Surgical treatment of choanal atresia with transnasal endoscopic approach with stentless single side-hinged flap technique: 5 year retrospective analysis / Tratamento cirúrgico de atresia de coana com abordagem endoscópica transnasalcom técnica de retalho único e articulação lateral sem colocação de stent: análise retrospectiva de 5 anos

Abstract Introduction: Choanal atresia is a rare congenital malformation of the nasal cavity characterized by the complete obliteration of the posterior choanae. In 67% of cases choanal atresia is unilateral, affecting mainly (71%) the right nasal cavity. In contrast to the unilateral form, bilateral choanal atresia is a life-threatening condition often associated with respiratory distress with feeding and intermittent cyanosis exacerbated by crying. Surgical treatment remains the only therapeutic option. Objective: To report our experience in the use of a transnasal endoscopic approach with stentless single side-hinged flap technique for the surgical management of choanal atresia. Methods: A 5 year retrospective analysis of surgical outcomes of 18 patients treated for choanal atresia with a transnasal technique employing a single side-hinged flap without stent placement. All subjects were assessed preoperatively with a nasal endoscopy and a Maxillofacial computed tomography scan. Results: Ten males and eight females with a mean age at the time of surgery of 20.05 ± 11.32 years, underwent surgery for choanal atresia. Fifteen subjects (83.33%) had a bony while 3 (26.77%) a mixed bony-membranous atretic plate. Two and sixteen cases suffered from bilateral and unilateral choanal atresia respectively. No intra- and/or early postoperative complications were observed. Between 2 and 3 months after surgery two cases (11.11%) of partial restenosis were found. Only one of these presented a relapse of the nasal obstruction and was subsequently successfully repaired with a second endoscopic procedure. Conclusion: The surgical technique described follows the basic requirements of corrective surgery and allows good visualization, evaluation and treatment of the atretic plate and the posterior third of the septum, in order to create the new choanal opening. We believe that the use of a stent is not necessary, as recommended in case of other surgical techniques involving the use of more mucosal flaps.

Resumo Introdução: A atresia de coanas é uma malformação congênita rara da cavidade nasal caracterizada pela obliteração completa da coana posterior. Em 67% dos casos a atresia coanal é unilateral, acomete principalmente (71%) a cavidade nasal direita. Diferentemente da forma unilateral, a atresia coanal bilateral é uma condição com risco de vida, frequentemente associada a insuficiência respiratória à alimentação e cianose intermitente exacerbada pelo choro. O tratamento cirúrgico ainda é a única opção terapêutica. Objetivo: Relatar a nossa experiência no uso de uma abordagem endoscópica transnasal com a técnica de retalho articulado de um lado só sem colocação de stent para o tratamento cirúrgico da atresia coanal. Método: Análise retrospectiva de 5 anos dos desfechos cirúrgicos de 18 pacientes tratados para atresia coanal com uma técnica transnasal com um único retalho de articulação lateral, sem colocação de stent. Todos os indivíduos foram avaliados no pré-operatório com endoscopia nasal e um exame de tomografia computadorizada maxilofacial. Resultados: Dez homens e oito mulheres com idade média de 20,05 ± 11,32 anos à cirurgia foram submetidos a cirurgia para atresia de coanas. Quinze (83,33%) apresentavam placa atrésica óssea e três (26,77%) placa atrésica ósseo-membranosa mista. Dois e 16 casos tinham atresia coanal bilateral e unilateral, respectivamente. Não foram observadas complicações intra e/ou pós-operatórias precoces. Entre 2 e 3 meses após a cirurgia dois casos (11,11%) de restenose parcial foram identificados. Apenas um deles apresentou uma recidiva da obstrução nasal e, portanto, foi reparado com sucesso com um segundo procedimento endoscópico. Conclusão: A técnica cirúrgica descrita segue os requisitos básicos de cirurgia corretiva e possibilita boa visualização, avaliação e tratamento da placa atrésica e do terço posterior do septo, a fim de criar a nova abertura coanal. Pensamos que o uso de um stent não é necessário, tal como recomendado no caso de outras técnicas cirúrgicas que envolvem o uso de mais retalhos de mucosas.

Carotid artery stent angioplasty for treatment of internal carotid artery stenosis in the elderly: analysis on its efficacy and related factors of safety / 上海预防医学

Objective To study the efficacy and safety of carotid artery stenting(CAS) in elderly patients with internal carotid artery stenosis and its related factors.Methods Between January 2012 and July 2014,a total of 152 patients(over 65 years of age)with carotid artery stenosis were enrolled in this study,of whom 79 patients received drug treatment (control group) and 73 patients received CAS (intervention group).The two groups were followed up for one year.The patients'' scores of mRS(the modified Rankin Scale) and NIHSS(the National Institute of Health Stroke Scale) were observed and compared in the curative effect between the two groups.By means of logistic regression were analyzed the related safety factors in CAS treatment for elderly patients over 65 with extracranial stenosis of internal carotid artery.Results Both the median mRS (P<0.01) and NIHSS(P<0.05) scores were lower in intervention group than those in control group at 3,6 and 12 months follow-up,respectively.Thirty days after CAS,there occurred transient ischemic attack (TIA) in intervention group,whose incidence was significantly lower than that in control group (P<0.05).However,there was no statistical significant difference found between the two groups in the incidence of serious adverse events including TIA,cerebral hemorrhage,cerebral infarction and death(P>0.05)at one year follow-up.And logistic regression analysis showed that the previous history of cerebral infarction,residual stenosis or combined un-interferential cerebral arterial stenosis were all independent predictors of serious adverse events including TIA,cerebral infarction,cerebral hemorrhage,re-stenosis and death (P<0.05).Conclusion CAS is a safe and effective procedure for old patients with internal carotid artery stenosis.A history of cerebral infarction,combined un-interferential cerebral arterial stenosis or residual stenosis after CAS were all risk factors,which need to be effectively controlled before CAS.

Síndrome coronario agudo como manifestación clínica de la reestenosis intrastent / Acute coronary syndrome as a clinical presentation of in-stent re-stenosis

Antecedentes: La reestenosis intrastent (RES) es considerada responsable sólo de una mayor necesidad de reintervención. Sin embargo, se ha reportado que 30-60 por ciento de las RES se presentan como un síndrome coronario agudo (SCA). Objetivo: Conocer las incidencias de SCA como manifestación de RES y su relación con mortalidad. Método: Se analizaron pacientes que presentaron SCA como manifestación de RES y se compararon con los de presentación estable (ECE) respecto de la edad, factores de riesgo, evento clínico inicial que motivó la angioplastía coronaria (AC), stent utilizado y las características de la RES. Se comparó mortalidad a 30 días y alejada. Resultados: Entre 2006 y 2011, analizamos 210 pacientes con RES, de los cuales 68 (32 por ciento) se presentaron como SCA y 142 (68 por ciento) como ECE. La edad fue similar en ambos grupos (62,6 vs 62,7 años, NS). La prevalencia de diabetes fue 30 por ciento vs 22 por ciento (p=0,02), respectivamente, sin diferencias en otras características. Del grupo con SCA, 21 pacientes (31 por ciento) tuvieron un infarto con supradesnivel ST (SDST), 20 (29 por ciento) un infarto sin SDST y 27 (40 por ciento) una Angina Inestable (AI). La mortalidad a 30 días fue 2,9 por ciento vs 2,1 por ciento (NS), y la mortalidad alejada fue 12,2 por ciento vs 6,4 por ciento (p=0.4). No se identificaron predictores independientes para la presentación como SCA. Conclusion: El SCA con todas sus manifestaciones clínicas es una presentación frecuente de RES. Estos resultados sugieren que la RES no es una entidad benigna.

In-stent re-stenosis (ISR) has been associated with a high incidence of reintervention, but in addition some reports indicate that acute coronary syndromes (ACS) are a frequent clinical presentation. In this study of 210 patients with ISR we found that ACS was the presenting event in 31 percent of patients while a stable clinical event occurred in 69 per cent. In the ACS group 21 patients (31 percent) had an STEMI, 20 (29 percent) an NSTE-MI and 27 (40 per cent) patients presented with unstable angina. Comparing ACS vs SE groups, clinical characteristics were similar, except for diabetes which was more frequent in ACS (30 percent vs 22 percent, p=0,02). Thirty day mortality was 2,9 percent vs 2,1 per cent (p=ns) and long term mortality was 12,2 per cent vs 6,4 percent, respectively (p=0.18). In multivariate analysis, there were no independent predictors of an SCA presentation. In conclusion, ACS is a frequent clinical presentation of ISR and it is not always a benign condition.

Study on the changes of collagen content in the esophageal tissue after stenting / 中华消化内镜杂志

Objective To study the changes of collagen content in the esophageal tissue after stenting. Methods To select healthy adult dogs as experimental subjects.Esophageal stent was installed by the method of “autogenous fascia lata femoris transplantation and fixation",the dogs were killed at the end of 1,2,4 and 8 weeks,and the esophageal tissues with stent were taken out and studied by gross observation,light microscopy and electromicroscopy. The bulk density and distribution of collagen fiber were studied by special staining and computer technology.The content of P I CP and PⅢNP in restenosis tissue were measured by radio immunoassay(RIA).The contents of hydroxyproline and total amino acid(AA) in restenosis tissue were measured by amino acid analyser. Results At week 1 and 2 the inflammatory reaction occurred evidently in stenting esophagus with granulation and fibrosis,in some sites the esophageal tissue began to proliferate towards the lumen where the fibroblasts were in the state of active proliferation and secretion .The contents of hydroxyproline and total amino acid were significantly higher in the esophageal tissue within 1 and 2 weeks of stenting than those in normal esophagus.At week 4 and 8 esophageal lumen narrowed conspicuously,with a lot of fibrotic tissue and a little of inflammatory cells.The staining density of collagen elevated gradually within 4 weeks,there after the content of collagen was stabilized.The change of P I CP and PⅢNP accorded with that of collagen staining.The content of AA at week 4 increased significantly compared with that at week 2,its level was similar to that between 4 and 8 weeks. Conclusions Re-stenosis mainly expressed as fibrosis. At week 4,8 the fibrosis stabilized gradually with the lessening of inflammatory reaction. The content of collagen in re-stenosis tissue elevated within 4 weeks,and stablilized after week 4,it was in accordance with the pathological changes of re-stenosis.

Research on the relationship between functional changes of fibroblasts in local esophageal tissues and re-stenosis after stenting / 中华消化杂志

Objective Re stenosis is the common complication of stenting. This study was designed to investigate the functional changes of fibroblast in local re stenosis esophageal tissue after stenting and its relation to re stenosis. Methods Sixteen healthy adult dogs were divided into four groups. Esophageal stent was placed by means of “autogenous broad fascia transplantation and fixation”. At the end of 1,2,4 and 8 weeks,the dogs were killed, and the esophageal tissue with stent were taken out and analyzed by gross observation, light microscopy and electron microscopy. The expression of proliferation cell nuclear antigen (PCNA) and alpha smooth muscle actin (? SMA) in esophageal tissue at 1,2,4 and 8 weeks after stenting were studied by immunohistochemistry. The contents of hydroxyproline and gross amino acid(AA) in re stenosis tissue were measured by amino acid analysis. Results At week 1 and 2 the inflammatory reaction occurred evidently in stented esophagus, with granulation and fibrosis; in some places esophageal tissues began to proliferate towards the lumen. At week 1 some fibroblasts began to express PCNA and ? SMA, and at week 2 the expression augmented significantly. The content of hydroxyproline and AA was significantly higher in the esophageal tissues at 1 and 2 weeks after stenting than that in normal esophagus. At week 4 and 8 esophageal lumen became narrow conspicuously, with a lot of fibrotic tissue and few inflammatory cells. Only a few fibroblasts displayed the expression of PCNA instead of the expression of ? SMA at week 4. There was no expression of PCNA and ? SMA at week 8. The content of AA at week 4 increased significantly compared with that at week 2, and the level was similar between 4 and 8. Electron microscopy revealed that the fibroblasts were in the state of vigorous proliferation and secretion in esophageal tissue at week 2, and a lot of fibrotic tissue formed at week 8. Conclusions Re stenosis mainly expressed as granulation and fibrosis. At week 4 and 8 the fibrosis becomes stable gradually with the lessening of inflammatory reaction. Within 4 weeks of stenting fibroblast retains active proliferation and secretion, but after week 4 the function of fibroblasts gradually lessen or even lose.