Incidence Of Subcutaneous Emphysema Research Articles

Design and application of small-diameter closed thoracic drainage tube fixation following lung wedge resection: A randomised prospective study.

The use of indwelling closed thoracic drainage tubes in the wedge resection of the lungs is of great significance to postoperative recovery. However, there are potential risks. To explore the design feasibility and application effect of triple-buffer-system-fixed small-diameter (18 F) thoracic closed drainage tubes following lung wedge resection. A total of 136 patients with indwelling thoracic drainage tubes following pulmonary wedge resection were recruited, with 70 patients allocated to the control group and 66 to the experimental group. The drainage tube in the experimental group was fixed with the triple-buffer system, while that in the control group was fixed using the conventional lifting platform method. The incidence of unplanned extubation, the indwelling time of the drainage tube and the time and material costs, as well as information regarding any subcutaneous emphysema and skin tension blisters, were recorded following the operation. The pain and degree of comfort were assessed using a chi-square test and a rank sum t-test to compare the differences between the two groups. There were no statistically significant differences in terms of age, gender and sweating between the two groups. Compared with the control group, the unplanned extubation rate of the experimental group was lower (χ2= 8.513; P= 0.004), the indwelling time of the drainage tube was shorter (t= 2.108; P= 0.037), the cumulative material cost was lower (t= 3.778; P< 0.001), the time cost was also lower (Z= 2.717; P= 0.008), the degree of comfort was higher (Z= 2.752; P= 0.006), and the degree of pain was lower (Z= 4.019; P< 0.001). The incidence of subcutaneous emphysema was significantly lower in the experimental group than in the control group (χ2= 8.513; P= 0.004). The use of the triple-buffer system to fix small-diameter (18 F) thoracic closed drainage tubes can reduce the unplanned extubation rate, indwelling time of the drainage tube and the incidence of adverse reactions.

Using LAP PROTECTOR™ to prevent subcutaneous emphysema after robotic gastrectomy.

Subcutaneous emphysema (SE), a complication of robotic gastrectomy (RG), occurs when the gas used to establish pneumoperitoneum escapes and enters the soft tissue. SE typically does not result in major clinical problems, but massive SE can have life-threatening consequences. Hence, developing adequate preventive methods against postoperative SE is essential. We aimed to determine whether an existing protective device, the LAP PROTECTOR™ (LP), can be used to reduce the incidence of SE after RG. We analyzed the data of 194 patients who underwent RG at our hospital between August 2016 and December 2022. Since September 2021 (the 102nd patient), we have used the LP (FF0504; Hakko Medical, Hongo, Tokyo, Japan) at the trocar site, as this was expected to reduce the incidence of SE. The primary endpoint of this study was the efficacy of the LP in reducing the incidence of clinically relevant SE (defined as SE extending into the cervical area) a day after RG. Univariate analysis revealed that sex, body mass index (BMI), and LP usage differed significantly between patients with and without postoperative SE. Logistic regression analysis revealed that male sex (odds ratio [OR]: 0.22, 95% confidence interval [CI]: 0.15-0.72, P < 0.001), high BMI (OR: 0.13, 95% CI: 1.23-4.45, P = 0.009), and LP usage (OR: 0.11, 95% CI: 0.04-0.3, P < 0.001) were preventive factors independently associated with a lower incidence of clinically relevant SE. Placing an LP at the trocar site may be a safe and effective method of preventing SE after RG.

Emfisema Subkutis sebagai Komplikasi pada Pasien Covid-19 dengan Penggunaan Ventilasi Mekanik

Background. The incidence of subcutaneous emphysema in patients with severe pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus infection has been in the spotlight recently. Subcutaneous emphysema is a rare complication. With the increasing prevalence of subcutaneous emphysema in patients with confirmed coronavirus disease (COVID-19), it is necessary to know what factors can cause this and how to treat it. Case Description. Two patients, a man and a woman aged 50 and 70 years, diagnosed with COVID-19, came to the Emergency Room (IGD) of Bunda Menteng General Hospital, Jakarta, with symptoms of acute respiratory distress syndrome (ARDS). Both patients experienced severe shortness of breath with a respiratory rate above 30 times per minute. Then the two patients were treated in the intensive care Unit (ICU) isolation room and required mechanical ventilation assistance. After 3-4 days of mechanical ventilation treatment, subcutaneous emphysema develops, characterized by subcutaneous crepitus. After chest x-rays were carried out in both patients, the results were subcutaneous emphysema and pneumomediastinum. Several invasive procedures have been performed, such as subcutaneous insertion of an intravenous cannula, mediastinoscopy, and chest tube insertion. Conclusion. Complications of subcutaneous emphysema in COVID-19 patients are rare and require further research to determine the cause, where the infection is still the focus. With this case report, it is hoped that clinicians will pay more attention to the initial clinical findings of subcutaneous emphysema to reduce even more severe complications such as pneumothorax.

Subcutaneous Emphysema Risk Following Indwelling Pleural Catheter Insertion During Rigid Local Anesthetic Thoracoscopy: Via Thoracoscopy Port Versus Separate Incision Site.

Local anesthetic thoracoscopy (LAT) is important in the diagnosis of unilateral pleural effusions. Indwelling pleural catheters (IPC) can be inserted during LAT if a nonexpandable lung is suspected. Subcutaneous emphysema (SCE) is a known complication and is associated with increased morbidity and length of stay. It is unclear however if the incidence of SCE is affected if IPC is inserted through a separate incision to the LAT port. We aim to establish the incidence and grading of SCE when IPC is inserted during LAT and to determine if the site of IPC placement influences this. Retrospective analysis of LAT electronic records and radiology images over 8 years in a University Hospital. The incidence of SCE was assessed during admission and follow-up with the severity of SCE graded 0 to 4 (0 none; 1 at IPC site; 2 ipsilateral chest wall; 3 ipsilateral neck; 4 contralateral chest wall). 55 combined LAT and IPC procedures were performed. In 28 patients the IPC was inserted through the LAT port and in 27 the IPC was inserted in a separate intercostal space (ICS) to the LAT port. On day zero, the incidence of any SCE was lower if the IPC was inserted using a separate ICS to the LAT port compared with the same site as the LAT port( P =0.01). This was similarly reduced on discharge chest radiographs and subsequent follow-up. IPC insertion at LAT using a separate ICS to the LAT port is associated with a reduction in the incidence of SCE during admission and follow-up.

Subcutaneous Emphysema after Transurethral Resection of Bladder Tumor: A Rare Case Report and Review of the Literature

Abstract Transurethral resection of bladder tumors (TUR-BT) comprises the gold standard surgical approach for the management of the majority of bladder cancer cases, both for the diagnosis and treatment of these cases. Patients subjected to TUR-BT may present with various complications, such as gross hematuria, urinary infection, and postsurgical pain. The incidence of subcutaneous emphysema after TUR-BT is extremely rare and urologists should be aware of this extremely rare complication.

A New Traceless Technique for Cosmetic Closure of Minimally Invasive Incision and Chest Tube Fixation After Uniportal Video-Assisted Thoracoscopic Surgery.

BackgroundWith uniportal video-assisted thoracoscopic surgery (VATS) becoming mainstream, how to make the incision cosmetic has attracted much attention. This study aimed to introduce a new traceless method for cosmetic closure of the incision and a special procedure for chest tube fixation after uniportal VATS and to evaluate the feasibility, effectiveness, and safety of this new technique.MethodsIn this retrospective study, a total of 258 consecutive patients who underwent uniportal VATS were included. Among them, 127 patients were treated with a conventional method, and 131 patients were treated with a new method.ResultsPatients in the new method group had a significantly less incidence of subcutaneous emphysema after the chest tube was removed. The incidence of pneumothorax after the chest tube was removed and fat liquefaction of chest incision was not significantly different between the two groups. No differences in the incidence of pneumothorax after chest tube removal and fat liquefaction of postsurgical incision were found between the two groups. Additionally, there was also no significant difference in follow-up items.ConclusionsTaken together, our results showed that this new method for minimally invasive incision closure and chest tube fixation after uniportal VATS was as feasible, effective, and safe as the conventional one but more cosmetic.

Clinical evaluation of subcutaneous emphysema caused by dental treatments

ObjectiveSubcutaneous emphysema caused by dental treatment is uncommon. This study retrospectively investigated cases of dental treatment-induced subcutaneous emphysema. MethodsEleven patients were diagnosed with subcutaneous emphysema at our hospital between 2011 and 2021. We evaluated patient age, sex, medical history, origin tooth, dental procedure, cause, range, healing period, duration of antibiotic, and complication. The influence of patient age, extent of the emphysema, or dental procedure on the healing period was statistically analyzed. ResultsThe average patient age was 48.0 ± 20.0 years. The incidence of subcutaneous emphysema was not related to age but was more common in females. Of the 11 patients, 4 had subcutaneous emphysema that spread to the chest. Patients undergoing surgical procedures requiring an air turbine or electric handpiece seemed to be at the greatest risk of developing subcutaneous emphysema. The average healing period and duration with antibiotic treatment were 8.18 ± 1.78 days, and 10.09 ± 4.30 days, respectively. The statistical results showed a significant difference in the healing period between presence and absence of systemic medical history. ConclusionsThe results of this study suggests that subcutaneous emphysema occurs more frequently following surgical procedures requiring an air turbine or electric handpiece, and the presence or absence of systemic medical history affects the healing period.

Conservative management of subcutaneous emphysema and pneumomediastinum in a COVID-19 viral pneumonia patient-case report

In viral pneumonia, the incidence of subcutaneous emphysema and spontaneous pneumomediastinum are rare. But it can occur due to COVID-19 SARS (severe acute respiratory syndrome) corona infection. In this condition like COVID-19 disease the underlying pathology may be due to diffuse alveolar injury. High pressure levels in the alveoli can cause to the alveoli to rupture and ultimately to forms subcutaneous emphysema. We report one case of COVID-19 admitted in the hospital and later developed subcutaneous emphysema and pneumomediastinum without mechanical ventilation. He was managed conservatively without any intervention. 45 old male without co morbidities having post COVID-19 subcutaneous emphysema and pneumomediastinum developed without mechanical ventilation and he was managed conservatively without any surgical intervention. In COVID-19 viral pneumonia patients can develop subcutaneous emphysema without mechanical ventilation and should be careful for severe pneumomediastinum which can cause death. It can be managed conservatively in hemodynamic stable condition

Independent Predicting Factors for Subcutaneous Emphysema Associated with Robotic-Assisted Laparoscopic Radical Prostatectomy: A Retrospective Single-Center Study.

Objectives: Subcutaneous emphysema (SCE) is a complication associated with laparoscopic surgery. Severe SCE complicated by excessive hypercarbia may afford detrimental effects in surgical patients with cardiac dysfunction. Robotic-assisted laparoscopic radical prostatectomy (RALP) has several predisposing factors that contribute to SCE. The main purpose of our single-center retrospective study was to determine the preoperative and intraoperative predicting factors for SCE associated with RALP and to determine the actual incidence of SCE. Methods: In total, 229 adult male patients underwent standardized RALP for prostate cancer over the period of 1 May 2016 to 31 October 2018 at the Ehime University Hospital. We reviewed electronic clinical records for individual characteristics including age, body weight, height, coexisting disorders, preoperative ASA physical status, and the length of postoperative hospital stay. We also reviewed surgical and anesthetic records for the operation time, anesthetic method, and the partial pressure of end-tidal CO2 (PetCO2) during RALP. To determine the presence of SCE, we examined supine chest X-rays obtained after the completion of surgery. Results: We found 55 cases (24.0%) of SCE. Multiple logistic regression analysis showed that a BMI < 25 kg/m2 (OR: 3.0, 95% CI: 1.25–7.26) and a maximum value of PetCO2 of 46 mmHg or greater (OR: 23.3, 95% CI: 8.22–66.1) were independent predicting factors for SCE. Conclusion: These two predicting factors may be helpful to recognize the occurrence of SCE. Anesthesiologists should protect against SCE progression with the earlier detection of SCE for safe anesthetic management in patients undergoing RALP.

Subcutaneous emphysema and pneumomediastinum in patients with COVID-19 disease; case series from a tertiary care hospital in Pakistan

Since December 2019, the clinical symptoms of coronavirus disease 2019 (COVID-19) and its complications are evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema (SE). We report 10 patients of COVID-19, with SE and pneumomediastinum. The mean age of the patients was 59 ± 8 years (range, 23-75). Majority of them were men (80%), and common symptoms were dyspnoea (100%), fever (80%) and cough (80%). None of them had any underlying lung disorder. All patients had acute respiratory distress syndrome on admission, with a median PaO2/FiO2 ratio of 122.5. Eight out of ten patients had spontaneous pneumomediastinum on their initial chest x-ray in the emergency department. The median duration of assisted ventilation before the development of SE was 5.5 days (interquartile range, 5-10 days). The highest positive end-expiratory pressure (PEEP) was 10 cmH2O for patients recieving invasive mechanical ventilation, while 8 cmH2O was the average PEEP in patients who had developed subcutaneous emphysema on non-invasive ventilation. All patients received corticosteroids while six also received tocilizumab, and seven received convalescent plasma therapy, respectively. Seven patients died during their hospital stay. All patients either survivor or non-survivor had prolonged hospital stay with an average of 14 days (range 8-25 days). Our findings suggest that it is lung damage secondary to inflammatory response due to COVID-19 triggered by the use of positive pressure ventilation which resulted in this complication. We conclude that the development of spontaneous pneumomediastinum and SE whenever present, is associated with poor outcome in critically ill COVID-19 ARDS patients.

Incidence of Subcutaneous Emphysema in the Head, Neck and Thoracic Region of Intubated COVID-19 Patients: Our Experiences

Incidence of Subcutaneous Emphysema in the Head, Neck and Thoracic Region of Intubated COVID-19 Patients: Our Experiences

PD23-07 A MULTI-CENTER, PROSPECTIVE, RANDOMIZED, CONTROLLED STUDY TO EVALUATE THE SAFETY OF A VALVE-LESS TROCAR INSUFFLATION SYSTEM (AIRSEAL) VS. CONVENTIONAL INSUFFLATION FOR THE MANAGEMENT OF PNEUMOPERITONEUM DURING ROBOTIC PARTIAL NEPHRECTOMY

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology II (PD23)1 Apr 2020PD23-07 A MULTI-CENTER, PROSPECTIVE, RANDOMIZED, CONTROLLED STUDY TO EVALUATE THE SAFETY OF A VALVE-LESS TROCAR INSUFFLATION SYSTEM (AIRSEAL) VS. CONVENTIONAL INSUFFLATION FOR THE MANAGEMENT OF PNEUMOPERITONEUM DURING ROBOTIC PARTIAL NEPHRECTOMY Michael Stifelman*, Sam Bhayani, Robert Figenshau, and James Porter Michael Stifelman*Michael Stifelman* More articles by this author , Sam BhayaniSam Bhayani More articles by this author , Robert FigenshauRobert Figenshau More articles by this author , and James PorterJames Porter More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000873.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The use of valve-less insufflation is gaining significant popularity for robotic partial nephrectomy secondary to its ability to maintain a pneumoperitoneum during constant vigorous suction. This study evaluated a valve-less trocar system (AirSeal) compared with conventional insufflation and the effects of insufflation pressure on peri-operative safety outcomes. METHODS: Subjects from three institutions were randomized equally in a 1:1:1 ratio into three different study arms: AirSeal - 12mmHg pressure (AIS12); AIS - 15mmHg (AIS15); and Conventional Insufflation - 15mmHg (CIS15). The rate of subcutaneous emphysema (SE) constituted the primary safety endpoint and was identified by physical exam intraoperatively, post-operatively and chest x-ray (CXR). Secondary safety endpoints included: pneumothorax, and/or pneumomediastinum identified on post-operative CXR and post-operative shoulder pain measured via a Visual Analogue Scale (VAS) administered during predetermined times after surgery. RESULTS: A total of 198 patients were enrolled (n=66 in each study arm). There were no statistically significant differences in demographics including sex, ethnicity, age or BMI between the three groups. There was a statistically significant reduction in the rate of SE between AIS12 (15.25%) and CIS15 (30.9%) with a p value of 0.008. The incidence of pneumothorax was 0%, 5% and 5% for AIS12, AIS15 and CIS15, respectively (p=0.12). The incidence of pneumomediastinum was 6%, 12% and 11% for AIS12, AIS15 and CIS15, respectively (p=0.36). An 11.5% reduction in postoperative shoulder pain was seen in AIS12 vs. CIS15 ( p=.0.049) and 14% reduction in shoulder pain AIS15 vs. CIS15 ( p=0.01). Two patients randomized to CIS15 required conversion to AIS15 secondary to poor visualization and bleeding. CONCLUSIONS: This study demonstrates that utilizing AIS12 provides a significant reduction in the incidence of SE compared to CIS15 in patients undergoing robotic partial nephrectomy. In addition, the use of the Airseal system at both 12mmHg and 15mmHg reduces postoperative shoulder pain compared with conventional insufflation. This suggests that for patients undergoing robotic partial nephrectomy the use of AIS 12 provides the highest safety profile compared to CIS15. Source of Funding: Conmed © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e466-e466 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Stifelman* More articles by this author Sam Bhayani More articles by this author Robert Figenshau More articles by this author James Porter More articles by this author Expand All Advertisement PDF downloadLoading ...

MP26-16 COMPARISON OF VALVE-LESS AND STANDARD INSUFFLATION ON PNEUMOPERITONEUM-RELATED COMPLICATIONS IN ROBOTIC PARTIAL NEPHRECTOMY: A PROSPECTIVE RANDOMIZED TRIAL

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I1 Apr 2018MP26-16 COMPARISON OF VALVE-LESS AND STANDARD INSUFFLATION ON PNEUMOPERITONEUM-RELATED COMPLICATIONS IN ROBOTIC PARTIAL NEPHRECTOMY: A PROSPECTIVE RANDOMIZED TRIAL Tom Feng, Gerald Heulitt, Adel Islam, and James Porter Tom FengTom Feng More articles by this author , Gerald HeulittGerald Heulitt More articles by this author , Adel IslamAdel Islam More articles by this author , and James PorterJames Porter More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.874AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Data on the effects of valve-less insufflation (AirSeal) on the development of pneumoperitoneum-related complications, namely subcutaneous emphysema (SCE), are limited. We sought to compare the rates of SCE and other insufflation-related complications between AirSeal and standard insufflation systems as well as identify potential risk factors for development of SCE in patients undergoing robotic partial nephrectomy. METHODS A prospective randomized controlled trial was conducted during a 1.5 year period to compare insufflation-related complications in partial nephrectomy surgery by a single surgeon. Thirty-one patients were recruited for each group: AirSeal insufflation at 12 mmHg, AirSeal at 15 mmHg, and standard insufflation at 15 mmHg. Primary outcome assessed was rate of SCE. Secondary outcomes included rates of pneumothorax, pneumomediastinum, shoulder pain scores, overall pain scores, pain medication usage, insufflation time, recovery room time, and length of hospital stay. Predictors for SCE were assessed with univariate and multivariate logistic models. RESULTS 93 patients with similar baseline characteristics were randomized into the three insufflation groups. Incidence of subcutaneous emphysema was lower in the AirSeal 12mmHg group compared to standard (p=0.03). Shoulder pain was less in both AirSeal groups compared to standard, especially at 8 and 12 hours postoperatively. There was no difference between overall pain scores, morphine equivalent use, insufflation time, recovery room time, and length of hospital stay (all p>0.12). Univariate analysis shows positive smoking history (p=0.05) and insufflation with AirSeal at 12 mmHg (p=0.02) to be significant predictors for lower risk of developing SCE. When controlling for age, BMI, gender, smoking history, history of respiratory disease, and insufflation type, AirSeal at 12mmHg remained a significant predictor for decreased risk of SCE (p<0.001). CONCLUSIONS Compared to standard insufflation, AirSeal insufflation at 12mmHg was associated with reduced risk of developing subcutaneous emphysema in robotic partial nephrectomy. Furthermore, shoulder pain seems to be less in both the AirSeal groups compared to standard insufflation. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e343 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Tom Feng More articles by this author Gerald Heulitt More articles by this author Adel Islam More articles by this author James Porter More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Application of the coaxial smart drain in patients with a large air leak following anatomic lung resection: a prospective multicenter phase II analysis of efficacy and safety.

The presence of air leak following lung resection remains a frequent problem, which may prolong hospital stay and increase hospital costs. In the past, some studies documented the efficacy of soft and flexible chest tube in patients who underwent thoracic surgery. Nevertheless, safety in case of post-operative large air or liquid leak remains questionable. The objective of this study was to verify through a multicentre study the safety and the effectiveness of the coaxial chest tube in a consecutive series of selected patients who underwent anatomical pulmonary resection and with an active and large air leak. Between October 2016 and September 2017, data from patients submitted to anatomical lung resection with curative intent and operated in two Department of Thoracic Surgery of two different were prospectively collected. The inclusion criteria consisted in the presence of an air leak greater than 50 mL/min measured with a digital drainage system during the 3 postoperative hours. A descriptive statistic was used to report the incidence of complications assumed to be associated with the use of the coaxial drain. Forty-eight consecutive patients (27 males) submitted to lobectomy (37 patients: 77%) or anatomic segmentectomies (11 patients) were included in the analyses. Thirty-four operations (71%) were performed by video-assisted thoracic surgery (VATS). The median duration of chest tubes was 13 days [interquartile range (IQR), 4-19] and the median duration of air leak was 9 days (IQR, 2-17.5). No patient had undrained postoperative pleural effusion judged to require an additional chest tube placement. There were 12 (25%) cases of clinically or radiologically significant surgical emphysema; in none of these patients any additional procedure or re-operation was required, and they were treated conservatively by increasing the level of suction. Our experience with this novel Coaxial Drain was satisfactory with no clinically relevant complication caused using this drain, no need to insert additional drain or replace the existing one with another drain a duration of air leak and chest tubes as well as the incidence of subcutaneous emphysema that was in line with what observed in the daily practice in similar highly selected patients with large air leak.

Delayed subcutaneous emphysema in an acute weight loss female following robotic surgery

Robotic-assisted laparoscopy with the use of carbon dioxide (CO2) for insufflation is rapidly adopted procedure for gynecological surgery. Insufflation of the abdomen with CO2can potentially cause complications such as hypercarbia, subcutaneous emphysema (SE), pneumothorax, and pneumomediastinum. The incidence of SE ranges from 0.43% to 77%. Numerous potential mechanisms were proposed for the development of these complications. Several authors speculated that the surgical time, surgical ports, age, and peritoneal insufflation pressures are related to the development of these complications. These potentially lethal complications must be diagnosed and managed promptly. We experienced a case who developed delayed massive SE extended to neck and face after robotic ovarian cystectomy, it perhaps due to weaker tissues bonding fascial planes because she was acute weight loss within 1 month.

Systematic review of surgery for persistent pediatric tracheocutaneous fistula.

To compare the treatment outcomes and adverse event rates for primary closure compared to simple excision with healing by secondary intention for persistent tracheocutaneous fistula (TCF) in children. Systematic review. Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards. MEDLINE, Embase, Cochrane Library, and manual search were used to identify articles. Inclusion criteria were case series or comparative studies of surgery for persistent TCF in children under age 18 years. Exclusion criteria were age 18 years or older, duplicate patient series, case series with less than two patients, or case reports. Data were pooled using random effects meta-analysis to assess outcomes, adverse events, and comparative effectiveness. We identified 14 articles with 413 patients treated with excision with primary closure and 233 patients treated with excision with closure by secondary intention. Pooled success rates were 95.7% with primary closure (95% confidence interval [CI]: 93.1% to 97.4%) and 92.7% with secondary intention (95% CI: 88.4% to 95.4%). Subcutaneous emphysema or urgent airway problems were uncommon, occurring in 3.8% and 3.6% of patients, respectively. Five studies had data suitable for comparative meta-analysis, which showed no differences by closure technique for treatment success (P = .480), overall complications (P = .551), need for revision surgery (P = .624), or the incidence of subcutaneous emphysema or pneumothorax (P = .512), urgent airway problems (P = .126), wound infection (P = 1.00), or wound dehiscence or fistula (P = .818). There are no differences in the rates of success or complications with surgical closure of TCF in children, whether performed by primary closure or by secondary intention. Both techniques have high success rates with a low incidence of serious complications. Laryngoscope, 127:241-246, 2017.

Emphysematous Complications Following Third Molars Removal: Incidence among 10779 Surgeries and Report of Two Cases

Subcutaneous emphysema is a condition that results from introduction of air into soft tissues. In head and neck, it is commonly observed following fractures of paranasal sinuses. Less frequently, it may occur during surgical procedures for tooth removal, when air from dental hand-pieces is forced into surgical site. Depending on its extension, it may involve vital spaces such as mediastinum. This specific finding may induce life-threatening situations. The aim of this article is to establish the incidence of subcutaneous emphysema among 10,779 impacted third molar surgical procedures and report the cases in which such complications had occurred. In this retrospective study, data collected from 10,779 third molar extraction procedures performed at Piracicaba School of Dentistry were evaluated for the occurrence of subcutaneous emphysema. Two cases of subcutaneous emphysema (0.018%) occurred following extraction of impacted third molars. Both were associated with mandibular tooth and related to the use of dental air hand-piece. One of the cases involved submandibular and buccal spaces while the other involved buccal and canine spaces. Regression of emphysema occurred spontaneously and postoperative recovery was uneventful. Subcutaneous emphysema following impacted third molar extractions is rare and strongly associated with the use of air turbines. Follow-up and preservation are the treatments of choice, but clinicians should be aware about the possibility of microbial spreading through facial spaces.

Comparison of computer-driven weaning and physician-directed weaning from mechanical ventilation: a randomized prospective study

To evaluate if the computer-driven weaning (CDW) with a closed-loop knowledge-based system introduced in a ventilator is superior to physician-directed weaning (PDW) in difficult-to-wean patients in the intensive care unit (ICU). Sixty-two difficult-to-wean patients were randomized into 2 groups: weaning with Smart Care/PS (SC group, n = 32) or with synchronize intermittent mandatory ventilation add positive support ventilation (SP group, n = 30). In the SC group, the automated system titrated pressure support, conducted a spontaneous breathing trial and provided notification of success (separation potential). In the SP group, weaning from ventilators was carried out by gradually decreasing respiratory support. The length of mechanical ventilation and stay in ICU, the rate of ventilator-associated pneumonia (VAP), the retubing rate in 48 h, manual ventilator setting changes before extubation were compared between the 2 groups. In the SC group, the weaning time was (49 +/- 13) h, (67 +/- 37) h, and (254 +/- 96) h, respectively in patients with neuromuscular diseases, for post-operative respiratory support and patients with respiratory diseases; while in the SP group, the weaning time was (223 +/- 38) h, (106 +/- 34) h and (502 +/- 91) h, respectively; the difference between the 2 groups being statistically significant (chi(2) = 8.33, 4.77, 4.43, all P < 0.05). The time of stay in ICU was (9.0 +/- 1.7) d and (7.3 +/- 1.9) d in the SC group for patients with neuromuscular diseases and patients with post-operative respiratory support, respectively, while that was (20.8 +/- 5.1) d and (14.6 +/- 1.7) d in the SP group, respectively. Time of stay in ICU was significantly shorter in the SC group (chi2 = 6.74, 7.68, both P < 0.05). The number of manual ventilator setting changes was (5 +/- 1) times in the SC group, significantly less than that of the SP group (13 +/- 3, t = 2.73, P < 0.05). There were no significant differences between the SC and the SP groups in the rate of re-intubation, the rate of tracheotomy, the incidence of pneumothorax, the incidence of VAP and the incidence of subcutaneous emphysema. The CDW method used in patients with difficult weaning from ventilators was shown to shorten the weaning time, reduce stay in ICU, and decrease the need for manual adjustment of ventilators.

Carbon Dioxide Absorption During Laparoscopic Donor Nephrectomy: A Comparison Between Retroperitoneal and Transperitoneal Approaches

Aim Previous studies have suggested that retroperitoneal and transperitoneal approaches for laparoscopic donor nephrectomy are associated with variable carbon dioxide (CO 2) absorption, which can cause significant morbidity. The approach that results in greater CO 2 absorption is a matter of debate. We studied patients undergoing transperitoneal/retroperitoneal donor nephrectomy to determine relative CO 2 absorption, incidence of subcutaneous emphysema, pneumothorax, and pneumomediastinum, seeking to establish a correlation between the incidence of subcutaneous emphysema and CO 2 elimination. Materials and methods This was a prospective nonrandomized, single-center, two-arm clinical study of 60 kidney donors undergoing laparoscopic nephrectomy by transperitoneal ( n = 30) or retroperitoneal ( n = 30) approach. CO 2 elimination was calculated using end tidal CO 2, tidal volume, respiratory rate, and weight of the donor. We studied intraoperative CO 2 elimination and CO 2 retention-related morbidities. Results There was a significant increase in CO 2 elimination in the first 30 minutes of insufflation followed by a plateau for the remainder of procedure. There was no difference in CO 2 elimination in either procedure at any time interval. Patients with subcutaneous emphysema showed significantly greater CO 2 elimination, which decreased with desufflation. Conclusion CO 2 absorption during laparoscopy did not depend on the route of surgery. Subcutaneous emphysema was strongly and independently associated with a greater degree of CO 2 absorption during laparoscopic surgery.

Factors Influencing Development of Subcutaneous Carbon Dioxide Emphysema in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

There is a paucity of published data on the incidence of subcutaneous emphysema and the causative factors responsible for its occurrence during laparoscopic procedures. This study was undertaken to evaluate the incidence and factors associated with the occurrence of subcutaneous emphysema in patients undergoing a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. The prospective study included 100 patients who presented with a primary inguinal hernia and underwent an elective laparoscopic TEP hernia repair from November 2003 to May 2005. Various factors, including age, body mass index (BMI), type of hernia (i.e., unilateral or bilateral, indirect or direct), duration of surgery, and end-tidal carbon-dioxide tension (start and peak), were evaluated. A grading system was evolved to document clinically apparent subcutaneous emphysema immediately and at 6 and 24 hours after the surgical procedure. A BMI <25, longer operating time (especially >1 hour), and higher end-tidal carbon-dioxide tension (start, peak, and difference) were found to be significantly associated with the development of subcutaneous emphysema. Age and type of hernia -- unilateral versus bilateral, direct versus indirect -- were not found to be statistically significant factors. The incidence of subcutaneous emphysema in laparoscopic extraperitoneal hernia repairs is high and largely under-reported. Once it is noted, the progression of the surgical emphysema during this type of surgery can have serious complications (e.g., cardiovascular and hemodynamic disturbances) unless timely, appropriate measures are taken. Etiology of subcutaneous emphysema is multifactorial, with no single factor having a prominent association.