Posterior Packing Research Articles

Characteristics and treatment of epistaxis in nasopharyngeal carcinoma

ObjectivesTo analyze the risk factors and explore effective treatments for epistaxis in nasopharyngeal carcinoma (NPC) patients. MethodsFrom March 2006 to February 2020, 351 epistaxis patients visited our center and 195 patients meeting the inclusion criteria were enrolled in the study. Characteristics and treatments, including step-up hemostatic treatment (including medication, anterior ± posterior nostril packing, or further surgical hemostasis) and the CTPI emergency hemostasis method (including common carotid artery compression, tracheotomy / intubation, packing of nasal and nasopharynx, and interventional treatment), were analyzed. ResultsThe median total bleeding volume was 100.0 ml (range 20–4430 ml). 126 (64.6 %) and 69 (35.4 %) patients suffered from non-massive epistaxis and massive epistaxis. The 1-year overall survival (OS) rate was 60.1 % for patients with massive epistaxis and 97.3 % for those with non-massive epistaxis treated with step-up hemostatic treatment. Among patients with massive epistaxis, the 1-year OS rate was 80.0 % for those who received CTPI and 13.3 % for those who received step-up hemostatic treatment. ConclusionICA exposure and hemostasis failure was adverse prognostic factors for OS in NPC patients with epistaxis. The step-up hemostatic treatment is effective for controlling non-massive epistaxis. The CTPI emergency method might be an effective hemostasis treatment for NPC patients with massive epistaxis, especially those with PRNN and ICA exposure.

Angioembolism for the Management of Refractory Epistaxis

A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cauterization, posterior packing, ligation of external carotid artery or embolization. Here we report a case of bilateral posterior epistaxis in a 41 year old male patient with c/o spontaneous epistaxis from bilateral nostril. Digital Subtraction Angiography followed by Angioembolisation was done.

Endoscopic closure of the Eustachian tube orifice for refractory lateral skull base cerebrospinal fluid leak using autologous fat graft: illustrative case.

BACKGROUNDRhinorrhea due to lateral skull base cerebrospinal fluid (CSF) leaks can be a challenge to manage. Multiple strategies exist for treating CSF leaks in this region including direct repair, posterior Eustachian tube packing, and CSF diversion. Endonasal closure of the Eustachian tube has been reported using cerclage and mucosal flaps.OBSERVATIONSWe present the first reported case of endoscopic autologous fat packing of the Eustachian tube orifice to repair a CSF leak. In this case a 42-year-old woman who underwent middle fossa meningioma resection 20 years ago presented with refractory CSF rhinorrhea despite blind sac closure of the ear canal. This persisted after CSF diversion and only resolved after endoscopic endonasal Eustachian tube closure described herein.LESSONSThis technique is simple to perform with minimal risk of morbidity. Eustachian tube orifice fat packing may be particularly useful for patients with refractory CSF rhinorrhea with low CSF pressure.

Characteristics and Risk Factors of Recurrent Epistaxis in Geriatric Patients

Background and Objectives Recurrent epistaxis requiring emergency department (ED) visits results in increased morbidity in the elderly and associated with high health care costs. This study is to analyze the frequency and characteristics of epistaxis patients in the elderly and to find out the risk factors and effective treatment for recurrent epistaxis. Subjects and Method We studied retrospectively the clinical cases of 977 emergency patients and 155 patients, aged over 65, for the treatment of epistaxis during the last 10 years from January 2008 to January 2018. The group A, comprised of 95 patients (68.29%), was treated with an initial treatment. The group B, which comprised of 60 patients (38.71%), visited for re-bleeding following an initial treatment. Results Patients made 2 to 10 ED visits due to re-bleeding and 32 of the 60 patients (53.5%) visited twice. The electrocauterization was the most common (61.7%) for treatment method during rebleeding, followed by posterior packing (18.3%). The factors that increases the risk of recurrent epistaxis are anticoagulants, posterior epistaxis, anterior packing, inefficient ED packing. There was no correlation between comorbidities and rebleeding. Conclusion Accurate medical history taking of anticoagulants may enable personnel to provide more effective management of these patients. The most important factors in the failure of primary care were not being able to find the precise area of bleeding and ineffective packing during the initial treatment. Therefore, it is important that we must carefully check the areas using the endoscope to decrease the failure of initial treatment of epistaxis.

Management of Upper Airway Bleeding in Patients Hospitalized for SARS-COV2

Spontaneous epistaxis in patients with COVID-19 can represent a clinical challenge with respect to both the risk of contamination and the treatment options. Epistaxis (nosebleed) is a common condition overall but is relatively rare in adults and older patients. We herein present the data of 25 patients with COVID-19 who developed spontaneous epistaxis while hospitalized at Centro Médico Naval from March 2020 to April 2021. All patients received low-molecular-weight heparin during their hospital stay and required supplementary oxygen therapy either by a nasal cannula, continuous positive airway pressure or ventilatory mechanical support. In total, 12100 patients with laboratory confirmed SARS-CoV-2 infection were admitted to our hospital unit from 1 March to 31 April 2021. We only found 25 patients with epistaxis, All patients underwent anterior rhinoscopy. In all patients, the bleeding site was identified, controlled with cauterization with silver nitrate and absorbable hemostatic material. In patients with posterior epistaxis, the posterior packing was removed after 5 days. Nasal lubricants were prescribed in all patients after bleeding was controlled. All patients required suspension of anticoagulation after the bleeding event for 48 hours. Posterior, anterior and oropharyngeal epistaxis occurred in both sexes, in patients with comorbidities (Diabetes mellitus, hypertension, obesity) without statistical difference. In those patients who were on ventilatory mechanical support, they presented the same risk of epistaxis, however, with a small tendency to present greater anterior epistaxis, in the same way, those patients who presented anterior epistaxis had higher mortality.

Etiological characteristics and management of patients with epistaxis in Aksaray

Aim: Epistaxis is a common condition in humans, particularly in patients with hypertension, and is one of the most common presenting symptoms in ear, nose, and throat emergency consultation. The present study aimed to examine the treatment and hospitalization characteristics of the patients who presented with epistaxis in Aksaray city and to propose an optimized and updated protocol.Material and Methods: The present study retrospectively evaluated 758 patients who presented with epistaxis to the Training and Research Hospital in Aksaray between January 2016 and February 2020. The patients were analyzed in terms of age, sex, seasonal characteristics, hospitalization rates, pathogenesis of epistaxis, sites of bleeding, and treatments.Results: The study included 349 females (46.1%) and 409 males (53.9%); mean patient age was 60.9 ± 9.3 years (range: 3–89 years). The most common comorbidity was hypertension (47.3%), and the most common site of bleeding was the anterior region including the Kiesselbach’s plexus (88.2%). Nasal packing (58.5%) and electrocauterization (29.9%) were performed in most cases. The treatment success was defined as no instance of re-visit by the patients to the hospital due to nasal bleeding within 24 h after the procedure; the treatment was successful in 698 patients (92.1%).Conclusion: Most cases of epistaxis are successfully treated using endoscopic electrocauterization on an outpatient basis. Hospitalization is indicated if surgical intervention, posterior packing, or embolization is required and if deterioration of general condition is observed. The present study proposes an updated protocol optimized for the management of epistaxis.

Characteristics and treatment of patients with epistaxis over the last 5 years in Guangzhou

Background: Epistaxis is one of the most common emergencies in the department of otolaryngology, which gives a burden to the health care system. Objectives: This study aimed to investigate the patients’ characteristics of hospital admission with epistaxis and provide an optimized protocol. Methods: This study was a retrospective analysis of patients with epistaxis admitted to The Third Affiliated Hospital of Sun Yat-sen University in Guangzhou, China. The data were analyzed in terms of gender, age, seasonal differences, length and expenses of hospitalization, pathogenesis of epistaxis, primary medical management before hospital admission, bleeding sites, and treatment. Results: A total of 387 patients were included, which consisted of 270 males and 117 females with an average of 43 years. Most patients could be identified with underlying diseases, and the most commonly observed bleeding site was Little area (n = 164). Most patients received electrocauterization as a precision medical treatment (n = 288). The duration of hospitalization length ranged from a mean of 5.17–4.48 days, and the expenses of hospitalization ranged from a mean of RMB 4881–4951 yuan over the last 5 years. Conclusion: Most patients with epistaxis could be treated as outpatients by endoscopic electrocauterization, and hospitalization is indicated when patients need improvement of poor general condition, posterior packing, embolization, or surgery. This study enables to provide an optimized protocol for patient with epistaxis.

Epidemiologic and Outcome Analysis of Epistaxis in a Tertiary Care Center Emergency Department.

Background The association between hypertension and recurrent epistaxis is controversial. The objective of this study is to examine the factors associated with recurrent epistaxis visits to the emergency department (ED) and establish an otolaryngology (ENT [ear, nose, and throat]) consult algorithm to optimize treatment and minimize unnecessary consultation. Methods A retrospective review of 100 patients presenting to the ED for epistaxis requiring ENT consult from 2013 to 2018 was conducted. Patient demographics, comorbidities, epistaxis etiology, blood pressure measurements during admission, and treatment methods were analyzed. Patient charts were reviewed for ED admissions, complications, and procedures. A consult algorithm was subsequently devised and retrospectively applied to our cohort. Results Patients who required more than one ED visit for epistaxis were more often males (77.8% vs 49.3%, P = .01), required posterior packing (51.9% vs 17 .8%, P < .001), and had more comorbid hypertension (66.7% vs 38.4%, P = .01) compared to patients who had 1 visit. Compared to patients presenting during summer and fall (May–October), patients presenting during winter and spring (November–April) were more often treated for anterior epistaxis with Surgicel®/Surgifoam® rather than posterior nasal packing (57.4% vs 37.0%, P = .04). Application of our consult algorithm decreased consultation by 78% and liberated 58.5 hours of ENT resident time. Conclusion Patients with recurrent epistaxis tended to be male and had more comorbid hypertension. Further prospective studies are warranted to ascertain the factors associated with recurrent epistaxis. Our consult algorithm for epistaxis helped reduce unnecessary ENT consultation and facilitated reallocation of valuable resident work hours.

Intractable Epistaxis: Looking Beyond the Usual Sites

Intractable epistaxis is a challenge to manage and often requires multiple interventions, both medical and surgical. After anterior and posterior packing, many options exist on how to manage the patient. We performed a retrospective chart review of patients who presented to a private ear, nose, and throat practice with intractable epistaxis from January 2010 until July 2015.The clinical notes were reviewed, noting the demographic characteristics of the patients and the treatment plan that followed. In particular, we determined the site of bleeding that was documented. Of the 17 patients with intractable epistaxis identified, 5 had the site of bleeding documented and were included in the study. The documented areas that may have contributed to bleeding included the nasal olfactory region (n=3), nasal inferior meatus (n=1), and sphenoethmoid recess (n=1). After resuscitation and hematologic investigation, nasal endoscopy should be considered in patients with intractable epistaxis.

Principles of interventional treatment in epistaxis

Epistaxis is acommon ear, nose, and throat emergency, but rarely adirect cause for hospital admission. Patients who receive inpatient treatment usually suffer from recurrent posterior epistaxis. Despite otolaryngologic measures such as posterior packing or surgery, bleeding may recur or continue or the source may not be surgically accessible. For these patients, endovascular therapy is a real, sometimes the only, treatment option. In addition to idiopathic causes of posterior epistaxis, the cause may also be symptomatic. In this case, the cause must be identified and treatment adapted accordingly. Pre-embolization CT of the paranasal sinuses and CT-angiography is useful. These methods can reveal the cause and location of the hemorrhage as well as significant vessel variants, anatomic anomalies, or an unsuspected cause of epistaxis. Overall, with a good understanding of the dangerous anastomoses, endovascular therapy for posterior epistaxis has high success rates with alow periprocedural risk.

Etiology and management of nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma.

ObjectiveTo analyze the etiology of nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma (NPC) and evaluate the relevant management and rescue approaches.MethodsSeventeen cases of nasopharyngeal hemorrhage caused by radiotherapy of NPC, treated between January 2015 and March 2018, were retrospectively analyzed to study the etiology of nasopharyngeal hemorrhage. The management and rescue strategies, including anterior and posterior nostril packing, endoscopic nasopharynx electrocoagulation, and digital subtraction angiography embolization, were assessed for their effectiveness.ResultsNasopharynx hemorrhage after radiotherapy of NPC was mainly associated with erosion of the internal carotid artery or maxillary artery by the tumor. Among the 17 cases, 11 patients were treated by digital subtraction arterial angiography embolization, and 3 were treated by endoscopic nasopharynx electrocoagulation. Overall, 13 patients survived, while 4 died.ConclusionAnterior and posterior nostril packing, endoscopic nasopharynx electrocoagulation, and digital subtraction angiography embolization are suitable for treating nasopharyngeal hemorrhage. However, effective hemostasis depends on early identification of the bleeding vessels.

Comparison of endoscopic-guided silver nitrate cauterization and nasal packing in the treatment of epistaxis

Background: Epistaxis is a common disorder and often presents as an emergency. The management is challenging and various modalities of the treatment of epistaxis have been described. Nasal packing and silver nitrate chemical cautery are the commonest methods of treatment. However, there is no sufficient literature regarding the comparison of these two methods in the study area. The objective of this study is to compare endoscopic-guided silver nitrate cauterization with nasal packing in the treatment of epistaxis in our institution. Objective: To compare the endoscopic-guided silver nitrate cauterization with nasal packing in the treatment of epistaxis in our environment. Patients and Methods: This was a retrospective review of patients who presented with epistaxis at our clinic. The case notes of all patients with epistaxis who were managed with anterior packing (AP), posterior packing (PP), or endoscopic cauterization (EC) were selected. Patients with incomplete records were excluded. The information obtained included sociodemographic variables, clinical details, method of treatment, complications, and treatment outcome. The data were analyzed using SPSS version 20. Results: One hundred and twenty six patients were reviewed of which 70 (55.6%) were males and 56 (44.4%) females, within the age range of 5–80 years (mean age ± SD = 33.5 ± 17.9). The success rate of EC (93.5%) was higher compared to that of AP (68.3%) and PP (74.3%). The patients treated with EC had a statistically significant lower rate of recurrence (6.5%) compared with AP (31.1%) and PP (25.7%), respectively (P = 0.037). The mean hospital stay for patients treated with EC was significantly shorter (0.8 ± 0.6 days) compared to the group treated with AP (3.2 ± 0.9 days) and PP (6.2 ± 2.7 days), respectively (P = 0.000). Conclusion: Patients with epistaxis that underwent endoscopic-guided silver nitrate cauterization had better success rate, less complication, and shorter hospital stay than the group treated with nasal packing.

A clinical study of epistaxis

<p class="abstract"><strong>Background:</strong> Epistaxis is one the common emergencies in Oto-rhino-laryngology. It may occur in any age and in either gender. Cause of epistaxis range from simple self-limiting condition to more sinister malignancy which needs a radical approach. Hence, one should evaluate these patients appropriately and identify the cause to treat them accordingly. The present work was undertaken with the aim of studying the demographic profile of patients with epistaxis, its causes and management.</p><p class="abstract"><strong>Methods:</strong> The present study consisted of 60 patients who came with complaint of epistaxis. The patient’s detailed history was obtained. Detailed systemic examination and ENT examination was performed on patients in the study. Patients were investigated and treated as per the standard hospital protocol. </p><p class="abstract"><strong>Results:</strong> Out of the total 60 cases of epistaxis, 65% were males and 35% were females. Most of our cases were aged more than 50 years (31.7%) with mean age of 38.56 years. Most common etiology of epistaxis in present study was hypertension (20%), followed by acute rhino-sinusitis (15%). Commonest cause in children was deviated nasal septum and acute rhinosinusitis while in young adults, trauma was the common cause. Most common cause in elderly was hypertension. Medical management was done in most of the cases (65%) while anterior and posterior packing was done in 20% and 10% cases respectively. Three cases underwent electro-cauterization of bleeding point.</p><p><strong>Conclusions:</strong> Epistaxis can be seen in anyage. However the etiology of this condition varies with age. Understanding of the etiology helps in better evaluation and treatment of the case. </p>

Protocolo diagnóstico y terapéutico de la epistaxis

Epistaxis arise more often in the Kisselbach's submucous arterial plexus, which is located at both sides in the anterior part of the nasal septum. Significantly less often, the pinpoint bleeding is in the back of the nostril, normally in a zone irrigated by the Sphenopalatine artery that leads to the posterolateral side of the nostril by the hole of the same name. Anterior epistaxis, that can be self-limiting, usually are controlled by simple manoeuvres as cauterizing the bleeding vessel or anterior packing. However, epistaxis originated at the back of the nostril often occur in middle-aged or elderly patients, with associated pathology. In posterior epistaxis cases, they usually require the placement of a pneumo-packing and, possibily, endoscopic cauterizing or clipping under general anaesthesia of the bleeding vessel, placing frequently a conventional posterior packing. Some cases are resolved by arterial embolization.

Clinical analysis of delayed epistaxis after neuroendoscopic transnasal transsphenoidal surgery

Objective To investigate the clinical characteristics and treatment methods of delayed epistaxis after neuroendoscopic transnasal transsphenoidal surgery. Methods The clinical data of 14 patients with delayed epistaxis after neuroendoscopic transnasal transsphenoidal surgery were analyzed retrospectively. The clinical features and treatment of this complication were analyzed. Results The incidence of delayed epistaxis after procedure was 1.1% (14/1 224) in this group. Nine patients had nasal bleeding from 7 to 15 d after procedure; 2 had nasal bleeding at ≤2 d after procedure, and 3 had nasal bleeding from 3 to 4 weeks after procedure. The mean nasal bleeding time was 10.3 d after procedure. Of the 14 patients, 9 had active and permeating bleeding in nasal cavity, 4 had nasal hematorrhea, and 1 had nasal hematorrhea with shock and suffocation. Thirteen patients were sphenopalatine artery and its branch bleeding, and 1 was Littlehampton area bleeding. Nine patients used endoscopic surgery for electric coagulation hemostasis; 3 received transnasal endoscopic lower posterior naris packing hemostasis; and 1 underwent nasal packing hemostasis. One patient had asphyxia and caused respiratory arrest because of nasal hematorrhea. He showed a persistent vegetative state after cardiopulmonary resuscitation. The patients were followed up for more than 12 months (mean 15.3 months). Thirteen patients recovered well and no recurrent epistaxis occurred, one died of multiple organ failure at one month after procedure. Conclusions Delayed epistaxis is a rare complication of endoscopic transsphenoidal surgery. Early, timely, and correct individualized diagnosis and treatment can effectively control epistaxis and the prognosis is good. Key words: Neuroendoscopy; Postoperative hemorrhage; Delayed epistaxis; Endonasal transsphenoidal approach

Developing a laddered algorithm for the management of intractable epistaxis: a risk analysis.

For patients with epistaxis in whom initial interventions, such as anterior packing and cauterization, had failed, options including prolonged posterior packing, transnasal endoscopic sphenopalatine artery ligation (TESPAL), and embolization are available. However, it is unclear which interventions should be attempted and in which order. While cost-effectiveness analyses have suggested that TESPAL is the most responsible use of health care resources, physicians must also consider patient risk to maintain a patient-centered decision-making process. To quantify the risk associated with the management of intractable epistaxis. A risk analysis was performed using literature-reported probabilities of treatment failure and adverse event likelihoods in an emergency department and otolaryngology hospital admissions setting. The literature search included articles from 1980 to May 2014. The analysis was modeled for a 50-year-old man with no other medical comorbidities. Severities of complications were modeled based on Environmental Protection Agency recommendations, and health state utilities were monetized based on a willingness to pay $22 500 per quality-adjusted life-year. Six management strategies were developed using posterior packing, TESPAL, and embolization in various sequences (P, T, and E, respectively). Total risk associated with each algorithm quantified in US dollars. Algorithms involving posterior packing and TESPAL as first-line interventions were found to be similarly low risk. The lowest-risk approaches were P-T-E ($2437.99 [range, $1482.83-$6976.40]), T-P-E ($2840.65 [range, $1136.89-$8604.97]), and T-E-P ($2867.82 [range, $1141.05-$9833.96]). Embolization as a first-line treatment raised the total risk significantly owing to the risk of cerebrovascular events (E-T-P, $11 945.42 [range, $3911.43-$31 847.00]; and E-P-T, $11 945.71 [range, $3919.91-$31 767.66]). Laddered approaches using TESPAL and posterior packing appear to provide the lowest risk. Combining risk and cost-effectiveness perspectives, we recommend a laddered approach to intractable epistaxis with TESPAL first, followed by either embolization or posterior packing.

Arterial Embolization as a Treatment to Severe Epistaxis: A Case Report

Introduction: Epistaxis is a common condition and, fortunately, most cases resolve spontaneously. Only 6% of epistaxis cases require medical intervention. When initial measures, such as anterior and posterior packing of the nasal cavity, are unsuccessful in controlling the bleeding, interruption of the blood supply to the nasal cavity can be performed by transarterial embolization.

Intractable Epistaxis Due to Isolated Primary Telangiectasias

Epistaxis is the most common otolaryngologic emergency in the United States. Most cases are controlled with first-line measures, but intractable epistaxis can be a challenging clinical problem requiring posterior nasal packing and surgical or endovascular intervention. Bleeding from nasal telangiectasias is well known in hereditary hemorrhagic telangiectasia, but there are no reports in the literature of recurrent epistaxis due to isolated telangiectasias not associated with systemic disease. This report describes a series of cases in which intractable epistaxis due to isolated primary telangiectasias was effectively controlled with bipolar electrosurgery. We describe a patient with intractable epistaxis that had failed management with posterior packing and embolization. We also report a series of 16 cases of epistaxis, 6 of which were intractable, in adults without hereditary hemorrhagic telangiectasia who received treatment between 2009 and 2012. These cases reveal a common pattern of bleeding from telangiectasias on the anterior septum (8 cases [42%]), nasal sidewall (3 [16%]), inferior meatus (2 [10%]), posterior septum (2 [10%]), nasal floor (2 [10%]), middle turbinate (1 [5%]), and inferior turbinate (1 [5%]). Telangiectasias not associated with systemic disease are a previously unreported source of significant nasal bleeding that, when identified endoscopically, can be treated successfully with bipolar electrosurgery rather than with more invasive and costly surgical and endovascular measures.

Transcatheter Embolization in the Management of Epistaxis

A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cautery, posterior packing, surgical ligation, or embolization. Embolization has been used to treat epistaxis for more than 30 years and success can be achieved in approximately 90% of patients, with major complications occurring in approximately 2%. These excellent results require thorough knowledge of the regional anatomy, familiarity with the equipment and various agents used to achieve this type of embolization, as well as attention to detail and meticulous technique. There remains debate on several aspects of embolization, including the agent of choice, preferred size of the embolic, and the number of vessels to embolize. Advances in endoscopic surgery have evolved to the point that similar success rates for embolization and modern surgical techniques in treating epistaxis may be expected. This detailed review of pertinent vascular anatomy, embolization technique, and surgical alternatives should allow practitioners to formulate treatment algorithms that result in optimal outcomes at their institutions.

Progress in Radical Surgery for Malignant Pleural Mesothelioma

Aim: Stages I and II malignant pleural mesothelioma (MPM) can be satisfactorily treated with extended extrapleural pneumonectomy (EPP). We modified our diagnostic methods and surgical techniques to improve outcome. Methods: 74 patients were treated with EPP, 33 from 1988 to May 2000 (first group), and 41 from June 2000 to 2010 (second group) and all underwent thoracoscopy without mediastinoscopy or laparoscopy prior to EPP. We began to make changes in surgical management in group 2 (2000-2010). Staging was improved using 3D CT scan and Standard Uptake Values (SUV) provided by 2-(Fluorine-18)fluro-2-deoxy-D-glucose positron emission tomography (FDG PET) scan. Talc pleurodesis was used preoperatively in 15 cases. Double unilateral thoracotomy, performed on 24 patients, facilitated dissection of the diaphragm and made alterations in the reconstructive phase possible. Polytetrafluoroethylene (PTFE) prostheses were used instead of biological materials. In 10 cases the pericardium was not reconstructed on the left side after the previous negative experience of functional pericardial concretio that needed the prosthesis removal (Table 1). Topical thrombin was used to reduce postoperative complications whereas posterior prosthetic packing was used to prevent paraprosthetic evisceration and reduce postoperative bleeding. Results: Patients of group 2 experienced less morbidity. Fourteen of the 71 patients who survived beyond the immediate postoperative period lived at least 3 years. Potential positive prognostic factors were identified at follow-up. Conclusions: The innovations we adopted, especially the reconstruction procedures, improved the outcome for our series of patients who underwent extended EPP for MPM. Follow-up results suggest that the MIB-1 index, stage 1 disease, prosthetic diaphragmatic replacement, adjuvant radiotherapy and control are important positive prognostic factors.