Severe Aspiration Research Articles

Single centre analysis of perioperative complications in trans-oral robotic surgery for oropharyngeal carcinomas.

Trans Oral Robotic Surgery (TORS) is a modality in the management of oropharyngeal squamous cell carcinoma(OPSCC). This study was conducted to show the rates of peri-operative complications after TORS for OPSCC in our experience. Single centre retrospective analysis of consecutive OPSCC treated with TORS. The surgical complication severity was recorded according to Clavien-Dindo criteria (CDC). Eighty-seven OPSCC were operated with TORS. According to CDC, grade I, grade II and IIIb were registered in 8%, 4.6% and 11.5% of cases, respectively. The postoperative pain, registered with visual-analogue scale (VAS) score, was 8 ± 1.2 for the secondary healing wounds and 6.2 ± 1.5 for the flap reconstructions (p < 0.01). The impact on swallowing function was not significant between secondary healing and flap reconstructions(p = 0.96). Any major or life-threatening intraoperative complications have not been recorded. Only one patient had postoperative bleeding into the neck whilst 13.3% of patients had postoperative bleeding from the primary tumor. No total local or free flap failure were registered. The mean duration of tracheostomy use was 7.4 ± 2.6days, and nasogastric tube 14.3 ± 6.9days. Only one patient, who had also reconstruction with flap, experienced a postoperative severe dysphagia with severe aspiration, needing a permanent tracheostomy tube and percutaneous endoscopic gastrostomy feeding. TORS for OPSCC showed less morbidity, lower risk of severe complication and mortality. Thus, this treatment modality could be offered as first line treatment in selected cases.

Obstetric Outcomes Of Teenage Pregnancy Vs. Non-Teenage Pregnancy Patients.

Background:Teenage pregnancies contribute substantially to global health hazards, particularly in places like Khyber Pakhtunkhwa, Pakistan. Where social and economic conditions conspire to make unions between spouses early and their childbearing follows soon after. Despite initiatives to tackle this problem, restricted examination exists on the obstetric effects of adolescent pregnancies in this territory Objective This retrospective study analyzed obstetric outcomes and complications between teenage mothers aged 14 to 18 and older mothers aged 19 to 36 in Khyber Pakhtunkhwa, Pakistan. The aim was to compare risks between the two groups. Study design: a retrospective study. Place and duration of study. Department of Gynecology D.H.Q. Hospital Timarghra from 05 march 2021 to 05 February 2022 Material and Methods: A retrospective study was conducted in kpk, Pakistan, from Department of Gynecology D.H.Q. Hospital Timarghra from 05 march 2021 to 05 February 2022 all 14-18-year-olds who gave birth in the two hospitals had obstetric outcomes compared to non- adolescent women (19-36). chi-square and students' t-tests were used with a 0.05significance level. Results: out Of the 910 births, 128 (14.1%) non-teenage moms, teenage mothers had higher rates of serious anaemia (7.5 vs 4.1%), chorioamnionitis (2.6 vs 0.6%), and post-maturity (4.6 vs 1.8%) and meconium inhalation syndrome (6.5 vs 2.4%), respectively. Teenagers were less prone than adults to be overweight. Instrumental deliveries are more common in teenagers (7.1% vs 2.2%, p 0.01). Preterm birth, low birth weight babies, rds, and neonatal and foetal deaths did not vary substantially between the two groups. Conclusion: The results of this study showed that teenage pregnancies are associated with a higher risk of severe anaemia, chorioamnionitis, post maturity and meconium aspiration syndrome compared to non-teenage pregnancies. Preterm delivery, low birth weight infant, R.D.S., and fetal and perinatal death were not significantly different between the two groups. The results of this study suggest that teenage mothers need to be provided with appropriate obstetric care to reduce their risk of poor outcomes. Keywords: obstetric, outcomes, teenage, non-teenage, pregnancy, a retrospective study, Pakistan

Clinical characteristics and manometric findings of esophageal achalasia—a systematic review regarding differences among three subtypes

Esophageal achalasia is classified into three subtypes according to manometric findings. Since several factors, including clinical characteristics and treatment response, have been reported to differ among the subtypes, the underlying pathogenesis may also differ. However, a comprehensive understanding regarding the differences is still lacking. We therefore performed a systematic review of the differences among the three subtypes of achalasia to clarify the current level of comprehension. In terms of clinical features, type III, which is the least frequently diagnosed of the three subtypes, showed the oldest age and most severe symptoms, such as chest pain. In contrast, type I showed a higher prevalence of lung complications, and type II showed weight loss more frequently than the other types. Histopathologically, type I showed a high loss of ganglion cells in esophagus, and on a molecular basis, type III had elevated serum pro-inflammatory cytokine levels. In addition to peristalsis and the lower esophageal sphincter (LES) function, the upper esophageal sphincter (UES) function of achalasia has attracted attention, as an impaired UES function is associated with severe aspiration pneumonia, a fatal complication of achalasia. Previous studies have indicated that type II shows a higher UES pressure than the other subtypes, while an earlier decline in the UES function has been confirmed in type I. Differences in the treatment response are also crucial for managing achalasia patients. A number of studies have reported better responses in type II cases and less favorable responses in type III cases to pneumatic dilatation. These differences help shed light on the pathogenesis of achalasia and support its clinical management according to the subtype.

Evaluation and Comparison the Effectiveness of Remifentanil, Nitroglycerin, Esmolol, and Nitroglycerin + Esmolol on Blood Pressure And Heart Rate During Rhinoplasty Surgery

Background: Rhinoplasty is still one of the top five aesthetic surgeries performed and is considered one of the most challenging procedures in otorhinolaryngology surgery. Bleeding is one of the most important factors affecting an operation's success. The controlled hypotension method reduces bleeding; therefore, it provides a satisfying bloodless surgical field during operation. Objective: To evaluate and compare the effectiveness of (Remifentanil, Nitroglycerin, Esmolol, and Nitroglycerin + Esmolol) on hemodynamic parameters and the effectiveness of these drugs in providing a satisfactory bloodless surgical field during rhinoplasty surgery. Patients and Methods: 200 adults aged 20 to 45 years were randomly divided into four groups: Remifentanil (R), Nitroglycerin (N), Esmolol (E), Nitroglycerin + Esmolol (N+E). Systolic blood pressure, diastolic blood pressure, mean blood pressure, and heart rate (SBP, DBP, MBP, and HR) were recorded before anesthesia induction until the operation's end. The bleeding score and the visibility of the surgical field were rated by the surgeon as follows: (0) No bleeding, (1) Mild bleeding - no aspiration required, (2) Mild bleeding - intermittent aspiration is required, (3) Moderate bleeding - frequent aspiration is required, (4) Severe bleeding-constant aspiration is required, (5) Severe bleeding, operation stopped because of surgical field invisibility. Results: As a result, during operation, decreased values of (SBP, DBP, and MBP) were statistically significant in all groups. At the same time, the value of HR showed a statistically significant decrease in the (E) and (R) groups, while there was a statistically significant increase in the (N) and (N+ E) groups. Patients in the (E) and (R) groups had a statistically significantly lower bleeding score than the patients in the (N) and (N + E) groups. Conclusion: Patients had better Hemodynamic stability and surgical field visibility after applying Esmolol and Remifentanil. Keywords: Controlled hypotension, Rhinoplasty, Esmolol, Remifentanil, Nitroglycerin, and Nitroglycerin + Esmolol, Bleeding score, Surgical field visibility.

Evaluation and Comparison the Effectiveness of Remifentanil, Nitroglycerin, Esmolol, and Nitroglycerin + Esmolol on Blood Pressure And Heart Rate During Rhinoplasty Surgery

Background: Rhinoplasty is still one of the top five aesthetic surgeries performed and is considered one of the most challenging procedures in otorhinolaryngology surgery. Bleeding is one of the most important factors affecting an operation's success. The controlled hypotension method reduces bleeding; therefore, it provides a satisfying bloodless surgical field during operation.&#x0D; Objective: To evaluate and compare the effectiveness of (Remifentanil, Nitroglycerin, Esmolol, and Nitroglycerin + Esmolol) on hemodynamic parameters and the effectiveness of these drugs in providing a satisfactory bloodless surgical field during rhinoplasty surgery.&#x0D; Patients and Methods: 200 adults aged 20 to 45 years were randomly divided into four groups: Remifentanil (R), Nitroglycerin (N), Esmolol (E), Nitroglycerin + Esmolol (N+E). Systolic blood pressure, diastolic blood pressure, mean blood pressure, and heart rate (SBP, DBP, MBP, and HR) were recorded before anesthesia induction until the operation's end. The bleeding score and the visibility of the surgical field were rated by the surgeon as follows: (0) No bleeding, (1) Mild bleeding - no aspiration required, (2) Mild bleeding - intermittent aspiration is required, (3) Moderate bleeding - frequent aspiration is required, (4) Severe bleeding-constant aspiration is required, (5) Severe bleeding, operation stopped because of surgical field invisibility.&#x0D; Results: As a result, during operation, decreased values of (SBP, DBP, and MBP) were statistically significant in all groups. At the same time, the value of HR showed a statistically significant decrease in the (E) and (R) groups, while there was a statistically significant increase in the (N) and (N+ E) groups. Patients in the (E) and (R) groups had a statistically significantly lower bleeding score than the patients in the (N) and (N + E) groups.&#x0D; Conclusion: Patients had better Hemodynamic stability and surgical field visibility after applying Esmolol and Remifentanil.

OGBN V09 Laparoscopic Resection of Epiphrenic Diverticulum and Hellers Cardiomyotomy for achalasia

Abstract Background Epiphrenic diverticula are a rare form of diverticulum located in the distal oesophagus. Symptoms are varied as patients may be asymptomatic or present acutely with dysphagia and regurgitation. This video presentation is a case report and discussion of a patient requiring laparoscopic resection of an epiphrenic diverticulum and Hellers cardiomyotomy for concurrent achalasia. Methods The case of a 58 year old man is presented, who attended as an emergency with severe malnutrition and aspiration pneumonia secondary to dysphagia. Initial investigations included an upper GI endoscopy, barium swallow and CT scan which demonstrated a large oesophageal diverticulum and undiagnosed achalasia. Results The video presentation explores the operative technique used during this case in order to resect the epiphrenic diverticulum and perform a subsequent Hellers cardiomyotomy for achalasia. Conclusions Operative intervention was successful and the patient was discharged on day 2 post-operatively with no further complications. This video presentation stimulates further discussion regarding the management and operative technique utilised in epiphrenic diverticulae.

Radiography, CT‐angiography and post‐mortem findings in a foal with a congenital type 3 vascular ring anomaly

SummaryCongenital vascular ring anomalies (VRA) have been occasionally described in horses. To the authors' knowledge, this is the first case report providing radiographic and computed tomography (CT) findings of a congenital type 3 persistent right aortic arch (PRAA) in a foal. A 1.5 months old Franches‐Montagnes colt was presented for growth retardation with a history of mild intermittent bilateral nasal discharge occasionally containing milk and coughing since birth. Thoracic radiographs and ultrasound, oesophagoscopy, positive contrast oesophagography and CT angiography were performed. A final diagnosis of persistent right fourth aortic arch, with left ligamentum arteriosum and aberrant left subclavian artery (type 3 VRA) and subsequent aspiration pneumonia was achieved. Due to the poor physical condition, the presence of severe aspiration pneumonia and most importantly the lack of a surgical option for a type 3 VRA, the colt was euthanised and the post‐mortem examination confirmed the oesophagography and CT angiography findings.

Association of phase angle with muscle function and prognosis in patients with head and neck cancer undergoing chemoradiotherapy

ObjectivesThe aims of this study were to investigate the correlation of phase angle (PhA) with other parameters (e.g., muscle mass/quality/strength and physical function), assess the prognostic relevance of prechemoradiotherapy (CRT) PhA, and suggest a reference value of PhA in Asian patients with head and neck cancer (HNC). MethodsNinety-six patients with HNC who underwent CRT were divided into two groups— maintained-PhA group and low-PhA group—according to the PhA 25th percentile values by sex. Pretreatment PhA was measured using direct segmental multifrequency bioelectrical impedance analysis, and muscle quality was assessed using echo intensity in ultrasound images. Correlation of PhA with other parameters was investigated, and between-group differences with respect to adverse events, treatment interruption, and 3-y survival were assessed. ResultsPhA showed a positive correlation with isometric knee extension force (R = 0.710), handgrip strength (R = 0.649), skeletal muscle mass index (R = 0.620), and maximum gait speed (R = 0.543; P < 0.001). PhA showed a negative correlation with echo intensity (R = −0.439) and five times sit-to-stand test (R = −0.505; P < 0.01). The low-PhA group had a higher incidence of severe anemia (52% in low-PhA versus 17% in maintained-PhA), aspiration (17 versus 1%), radiotherapy interruption (17 versus 3%), and poor 3-y survival (47 versus 81%) than the maintained-PhA group (P < 0.05). ConclusionPhA was correlated with muscle mass/quality/strength, and physical function. Low PhA was associated with severe adverse events, treatment interruption, and shorter survival. These findings suggested that 4.6° for men and 4° for women may be useful as prognostic reference values in Asian patients with HNC.

Clinical features of severe meconium aspiration syndrome (MAS) and early predicting factors for severe MAS in neonates with meconium-stained amniotic fluid

To study the clinical features of severe meconium aspiration syndrome (MAS) and early predicting factors for the development of severe MAS in neonates with meconium-stained amniotic fluid (MSAF). A total of 295 neonates who were hospitalized due to Ⅲ° MSAF from January 2018 to December 2019 were enrolled as subjects. The neonates were classified to a non-MAS group (n=199), a mild/moderate MAS group (n=77), and a severe MAS group (n=19). A retrospective analysis was performed for general clinical data, blood gas parameters, infection indicators, and perinatal clinical data of the mother. The respiratory support regimens after birth were compared among the three groups. The receiver operating characteristic (ROC) curve and multivariate logistic regression analysis were used to investigate predicting factors for the development of severe MAS in neonates with MSAF. Among the 295 neonates with MSAF, 32.5% (96/295) experienced MAS, among whom 20% (19/96) had severe MAS. Compared with the mild/moderate MAS group and the non-MAS group, the severe MAS group had a significantly lower 5-minute Apgar score (P<0.05) and a significantly higher blood lactate level in the umbilical artery (P<0.05). Compared with the non-MAS group, the severe MAS group had a significantly higher level of interleukin-6 (IL-6) in peripheral blood at 1 hour after birth (P<0.017). In the severe MAS group, 79% (15/19) of the neonates were born inactive, among whom 13 underwent meconium suctioning, and 100% of the neonates started to receive mechanical ventilation within 24 hours. Peripheral blood IL-6 >39.02 pg/mL and white blood cell count (WBC) >30.345×109/L at 1 hour after birth were early predicting indicators for severe MAS in neonates with MSAF (P<0.05). Meconium suctioning cannot completely prevent the onset of severe MAS in neonates with MSAF. The neonates with severe MAS may develop severe respiratory distress and require mechanical ventilation early after birth. Close monitoring of blood lactate in the umbilical artery and peripheral blood IL-6 and WBC at 1 hour after birth may help with early prediction of the development and severity of MAS.

Safety and Clinical Benefits of Laryngeal Closure in Patients with Amyotrophic Lateral Sclerosis

This study evaluated the safety of laryngeal closure and post-surgical changes in swallowing function of patients with amyotrophic lateral sclerosis (ALS) and proposed an appropriate surgical strategy for patients with ALS. Clinical and surgical data of 26 consecutive patients with ALS who underwent laryngeal closure at Nagoya University Hospital in Japan between 2003 and 2020 were retrospectively analyzed. Changes in swallowing functions were evaluated before and approximately 1 month post-surgery using Neuromuscular Disease Swallowing Status Scale (NdSSS), and Functional Oral Intake Scale (FOIS). The median operation time was 126 min (range, 51–163 min), and the median intraoperative blood loss was 20 mL (range, 0–88 mL). Among the 26 ALS patients who underwent laryngeal closure, grade 1 (mild) complications occurred in three patients (12%); however, no severe complications were observed. After surgery, 25 patients (96%) maintained the swallowing function and only one patient (4%) had deteriorating NdSSS and FOIS scores. No patients were referred to our hospital due to severe aspiration pneumonia after the surgery. Two patients did not require a feeding tube after the surgery and returned to oral intake. Laryngeal closure may be a safe surgical procedure for preventing chronic aspiration and may also maintain swallowing function of patients with ALS. Further multicenter prospective studies using the gold standard videofluoroscopic swallowing examination are required to support our findings.

Accumulation of pathological Ataxin‐7 in the medulla leads to hypoglossal (XII) motor unit pathology

SCA7 is an autosomal dominant neurological disorder caused by a deleterious CAG repeat expansion in the coding region of the ataxin‐7 gene on chromosome 3. Patients with infantile SCA‐7 have the largest repeat expansion characterized by progressive loss of coordination, dysarthria, dysphagia, retinal degeneration and respiratory distress. These infants succumb to death due to severe hypotonia, aspiration pneumonia and respiratory failure. Our objective is to comprehensively analyze the underlying mechanisms that result in upper airway pathology which exacerbates respiratory insufficiency in SCA7. To do this, we will use an infantile SCA7 mouse model: SCA7266Q Knock‐in (KI) mouse. SCA7266Q KI mice exhibit progressive respiratory dysfunction along with irregular breathing and prolonged apneic events with a significant loss of hypoglossal (XII) motoneurons in the medulla. The XII motoneurons innervate the tongue to maintain the shape, stiffness and position of the tongue and regulate the upper airway patency. Therefore, we hypothesize that the expression of pathological ataxin‐7 in the medulla causes XII motor unit pathology leading to upper airway pathology. To confirm if the reduced number of motoneurons resulted in hypoglossal nerve pathology, we analyzed the efferent nerve output of the XII nerve of 9‐week‐old WT control and SCA72666Q KI mice during eupnea and hypercapnia (7% CO2). Later we performed post‐mortem histological analysis of the XII respiratory centers in the medulla and XII nerves. Specifically, we used immunohistochemistry to identify the cells that accumulate ataxin‐7 and we performed TUNEL assay to evaluate the extent of neurodegeneration in the XII motor pool. We analyzed the demyelination of the nerves by light microscopy and electron microscopy. To identify the cellular mechanisms involved in the XII pathology, we performed transcriptome analysis by bulk RNA sequencing of the medulla and confirmed the findings with qPCR.ResultsXII nerve efferent output is blunted at baseline and hypercapnic challenge in SCA7266QKI mice. There is increased TUNEL+ cells in the XII motor pool with intranuclear accumulation of ataxin‐7 in the astrocytes. Further, demyelination is present in the XII nerves in SCA7266QKI mice. RNA sequencing data of the medulla supports these findings and reveals diminished expression of the transcripts regulating the myelination pathway such as Plp1. There is also a significant decrease in activation of astrocytes with attenuated expression of neurotransmitter transporter such as Slc6a9 and Slc710 that are critical for breathing. In conclusion, intranuclear accumulation of ataxin‐7 in SCA7266QKI mice modulates transcription of astrocytes and influences different signaling pathways that result in neurodegeneration, demyelination, and decreased efferent XII nerve output. These findings are clinically relevant and emphasize the importance of neuropathology that results in dysphagia, aspiration pneumonia and respiratory failure in infantile SCA7.

SAVING AND EARLY DICHARGE OF A NEONATE WITH SEVERE MECONIUM ASPIRATION SYNDROME

Animal experiments have shown the resolution of radiological infiltrates of meconium aspiration syndrome (MAS) after using surfactant lavage. Intra-tracheal instillation of surfactant, as well as surfactant lavage, is studied in MAS. However, INSURE (INtubation, administration of SURfactant, Extubation) is never reported to have been used for meconium aspiration syndrome although it is used as the standard method of delivery of surfactant for respiratory distress syndrome. This is a case report of the use of INSURE technique for severe Meconium Aspiration syndrome. The baby was born at term gestational age to a primigravida mother by C-section for fetal distress. The baby was vigorous with chest retractions. Hence baby was supported with delivery room Continuous positive airway pressure (CPAP) and shifted to Neonatal Intensive Care Unit (NICU). In NICU, the baby was stabilized and given surfactant using the INSURE technique. Subsequently, a Chest X-ray showed clearing of lung infiltrates and drastically reduced oxygen requirement of the baby and the baby was discharged early to home.

Shamrock Lumbar Plexus Block for Hip Hemiarthroplasty in a High Risk Elderly Patient with Hip Fracture.

Hip fractures in the geriatric population are associated with high morbidity and mortality rate. Early surgical fixation is of major importance, as it is one of the factors that contribute to patient optimization. However, these patients usually present a high burden of comorbidities, including aortic stenosis that could affect their treatment. Despite major advances in anesthetic and surgical techniques, severe aortic stenosis remains an independent, important risk factor for patients undergoing anesthesia for noncardiac surgery. In these patients, general and/or neuraxial anesthesia should be avoided; peripheral nerve blockade is a viable option. This article presents a 96-year-old hip fracture patient with severe aortic stenosis and aspiration pneumonia that successfully underwent hip hemiarthroplasty under peripheral nerve blockade as sole anesthesia.

The story of the survival of a newborn with severe Meconium Aspiration Syndrome and cardiorespiratory arrest by using ECMO

Journal of the University of Ruhuna is published biannually as an online journal by University of Ruhuna. Research articles, Short communications, Research notes and Review articles in all fields of Science and Technology, Management and Social Sciences are accepted any time during the year to be considered for publication.

Evaluating dysphagia in infants with congenital heart disease using Fiberoptic Endoscopic Evaluation of Swallowing

ObjectiveDysphagia is common in infants with congenital heart disease (CHD). However, there is minimal published data regarding its management outside of the perioperative period. The objective of this study is to describe the role of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in the diagnosis and management of dysphagia in infants with CHD. MethodsInfants with CHD who underwent FEES exam for evaluation of swallowing dysfunction between February 2015 and February 2021 at a university-based, tertiary care urban pediatric hospital were studied. Demographic data, presenting symptoms, medical history, and dysphagia history were examined. The validated Dysphagia Outcome and Severity Scale (DOSS) was used to standardize and compare dysphagia severity. Results62 FEES exams were performed on 48 patients. All 48 patients were diagnosed with dysphagia and had a mean dysphagia severity score (DOSS) of 2.68. Patients with wet laryngeal congestion on presentation had worse mean DOSS score and were more likely to demonstrate aspiration on FEES exam (p < 0.01). There was no significant difference in mean DOSS or presence of aspiration when comparing infants who had cardiothoracic surgery, vocal cord paralysis, or lower respiratory tract illness with those who had not (p > 0.05). ConclusionA FEES exam is an effective and well-tolerated procedure for evaluating swallowing dysfunction in pediatric patients with CHD and its use reduces radiation exposure for this vulnerable population. Wet laryngeal congestion was found to be predictive of more severe dysphagia and aspiration. There is no significant association between severity of dysphagia or aspiration on FEES exam and history of cardiac surgery, vocal cord paralysis, or lower respiratory tract illness.

The clinical effects of high-frequency oscillatory ventilation in the treatment of neonatal severe meconium aspiration syndrome complicated with severe acute respiratory distress syndrome

ObjectiveTo explore the efficacy and safety of high-frequency oscillatory ventilation (HFOV) in the treatment of severe meconium aspiration syndrome (MAS) complicated with severe acute respiratory distress syndrome (ARDS).MethodsA total of 65 infants with severe MAS complicated with severe ARDS were included in the study. The clinical efficacy of treatment for the HFOV group (n = 31) and the conventional mechanical ventilation (CMV) group (n = 34) was retrospectively analysed. The partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (PaCO2), PaO2/fraction of inspired oxygen (FiO2), and oxygen index values before and at 6, 12, 24, 48, and 72 h after mechanical ventilation, the mechanical ventilation time, oxygen inhalation time, incidence of complications, and outcomes of the two groups were compared.ResultsAt 6, 12, 24, and 48 h after mechanical ventilation, the PaO2 in the HFOV group was significantly higher than in the CMV group, while the PaCO2 in the HFOV group was significantly lower than in the CMV group (P < 0.05). At 6, 12, 24, 48, and 72 h after mechanical ventilation, PaO2/FiO2 in the HFOV group was significantly higher than in the CMV group, and the OI in the HFOV group was significantly lower than in the CMV group (P < 0.05). Mechanical ventilation time, oxygen inhalation time, and the incidence of air leakage were significantly lower in the HFOV than in the CMV group (P < 0.05).ConclusionsOverall, HFOV can effectively improve lung ventilation and oxygenation function, shorten ventilator treatment time, and reduce the incidence rate of air leakage for neonatal MAS, making it a safe and effective treatment option.

Effects of Aspiration Prevention Surgery on the Dynamics of the Pharynx and Upper Esophageal Sphincter.

ObjectiveOral intake after aspiration prevention surgery (APS) is influenced by postoperative pharyngeal pressure and the dynamics of the upper esophageal sphincter (UES). We examined the effects of less invasive APS combined with UES relaxation techniques (laryngeal closure with cricopharyngeal myotomy [LC-CPM] and central-part laryngectomy [CPL]) on pharyngeal pressure and UES dynamics.Study DesignRetrospective, observational study.SettingSingle center.MethodsWe assessed the high-resolution pharyngeal manometric parameters of patients who underwent APS from 2018 to 2020. Then, we compared the effects of bilateral cricopharyngeal myotomy (combined with LC: LC-CPM group) and total cricoidectomy (CPL group) on both pharyngeal pressure and UES dynamics pre- and postoperatively.ResultsEighteen patients (median age, 68 years; 17 men [94%]) were enrolled. Primary diseases associated with severe aspiration were neuromuscular disorders in 13, stroke in 3, and others in 2 patients. Pharyngeal swallowing pressure did not significantly change before and after APS. UES resting pressure and UES relaxation duration were significantly reduced (P < .001) and prolonged (P < .001), respectively, after APS. Only the CPL group (8 patients: median 62 years, all men) showed an increase in the velopharyngeal closure integral after APS (P < .05). More prolonged UES relaxation duration was recognized postoperatively in the CPL group (P < .01) than in the LC-CPM group.ConclusionLess invasive APS minimally affects pharyngeal swallowing pressure, decreases UES resting pressure, and prolongs UES relaxation duration. CPL may be more effective for postoperative UES relaxation in patients with a short UES relaxation time.

What to do When Decompressive Gastrostomies and Jejunostomies are not Options? A Scoping Review of Transesophageal Gastrostomy Tubes for Advanced Malignancies

In advanced malignant bowel obstruction, decompressive gastrostomy tubes (GTs) may not be feasible due to ascites, peritoneal carcinomatosis, and altered gastric anatomy. Whereas nasogastric tubes (NGTs) allow temporary decompression, percutaneous transesophageal gastrostomy tubes (PTEGs) are an alternative method for long-term palliative decompression. This study performed a scoping review to determine outcomes with PTEG in advanced malignancies. A systematic literature search was performed to include all studies that reported the clinical results of PTEGs for malignancy. No language, national, or publication status restrictions were used. The analysis included 14 relevant studies with a total of 340 patients. In 11 studies, standard PTEGs were inserted with a rupture-free balloon's placement into the mouth or nose and esophageal puncture under fluoroscopy or ultrasound, followed by a guidewire into the stomach with placement of a single-lumen tube. Of 340 patients, 65 (19.1%) had minor complications, and 5 (2.1%) had significant complications, including bleeding and severe aspiration pneumonia. Of 171 patients, 169 with PTEGs (98.8%) reported relief of nasal discomfort from NGT and alleviation of obstructive symptoms. The one randomized controlled trial reported a significantly higher quality of life with PTEGs than with NGTs. When decompression for advanced malignancy is technically not feasible with a gastrostomy tube, the PTEG is a viable, safe option for palliation. The PTEG is associated with lower significant complication rates than the gastrostomy tube and significantly higher patient-derived outcomes than the NGT.

Surfactant Lung Lavage versus Standard Treatment for Meconium Aspiration Syndrome

Abstract Background: To evaluate diluted surfactant lung lavage as a therapy for severe meconium aspiration syndrome. Aim of Study: The aim of this study is to evaluate the efficacy and outcome of lung lavage using diluted surfactant compared to standard protocol for treatment of meconium aspiration syndrome. Patients and Methods: This was a prospective interven-tional study involved 24 patients with severe meconium aspiration syndrome divided into two equal groups one received the standard care in the form of high frequency ventilation and the second group received pulmonary lavage using diluted surfactant in addition to the standard care. Pulmonary lavage was done using of 15ml/kg of surfactant diluted to concentra-tion of 5mg of phospholipids/1ml of 0.9% NaCl divided into four equal aliquots. Results: On comparing both groups patients managed by pulmonary lavage using diluted surfactant showed significant improvement in PCO2 and mean airway pressure occurred 6 hours after lavage while improvement in PO2, oxygenation index and arterial-alveolar oxygen gradient occurred 24 hours after lavage. The duration of mechanical ventilation, oxygen therapy and hospital stay were shorter in the surfactant group. There was no difference between both groups in the incidence of complications, need for ECMO or death. Conclusion: Surfactant lung lavage is a safe and effective therapy for severe meconium aspiration syndrome.

Extracorporeal Membrane Oxygenation Rescue for Severe Aspiration Pneumonitis in Two Patients after Roux-en-y Gastric Bypass Procedure

Roux-en-y gastric bypass (RYGB) is one of the most common weight loss surgical procedures performed in the United States. Early post-operative small bowel obstruction is a rare but potentially morbid, complication of RYGB. We report two patients who underwent RYGB and required subsequent treatment for a post-operative small bowel obstruction. Their post-operative course was complicated by severe aspiration pneumonitis leading to hypoxemic respiratory failure requiring rescue with femoral veno-venous extracorporeal membrane oxygenation (V-V ECMO). Both patients were successfully extubated, weaned off V-V ECMO support, and discharged to home. These cases highlight the potential role of V-V ECMO for patients who have undergone RYGB and develop severe aspiration pneumonitis. They also highlight the need for cautionary use of gastrografin in RYGB patients. Early engagement of a multidisciplinary team experienced with adult ECMO is vital for favorable patient outcomes.