2022 CAS Virtual Annual Meeting

The proceedings contain 63 papers. The topics discussed include: a retrospective study to optimize post-anesthetic recovery time after ambulatory lower limb orthopedic procedures at a tertiary care hospital in Canada;a virtual airway evaluation as good as the real thing?;airway management during in hospital cardiac arrest by a consultant led airway management team during the COVID-19 pandemic: a prospective and retrospective quality assurance project;prevention of cautery induced airway fire using saline filled endotracheal tube cuffs: a study in a trachea airway fire model;smart phone assisted retrograde illumination versus conventional laryngoscope illumination for orotracheal intubation: a prospective comparative trial;time to single lung isolation in massive pulmonary hemorrhage simulation using a novel bronchial blocker and traditional techniques;cannabinoid type 2 receptor activation ameliorates acute lung injury induced systemic inflammation;bleeding in patients with end-stage liver disease undergoing liver transplantation and fibrinogen level: a cohort study;endovascular Vena Cavae occlusion in right anterior mini-thoracoscopic approach for tricuspid valve in patients with previous cardiac surgery;and mesenchymal stem cell extracellular vesicles as a novel, regenerative nanotherapeutic for myocardial infarction: a preclinical systematic review.

Outcomes of coblation tonsillectomy versus bipolar electrocautery tonsillectomy in pediatric population

Background: Bipolar electrocautery tonsillectomy has been the preferred technique for many otolaryngologists, yet coblation tonsillectomy is gaining popularity in the current practice. This study aims at comparing both techniques in terms of pain, bleeding, and healing. Result(s): A total of 120 patients were randomly divided into two equal groups. Overall mean pain score associated with coblation tonsillectomy was statistically less than that caused by bipolar electrocautery throughout the follow-up period (p < 0.001). The difference in pain duration was statistically longer for the bipolar group. The incidence of postoperative hemorrhage-both reactionary and secondary-was statistically higher in the bipolar group. Coblation tonsillectomy showed statistically shorter duration of healing (p < 0.001). Conclusion(s): Coblation tonsillectomy is associated with less pain severity and shorter pain duration, fewer bleeding incidents, and more prompt healing.Copyright © 2022, The Author(s).

The use of monopolar diathermy in laparoscopic appendectomy, Is it really safe?

Background: There have been numerous techniques used in laparoscopic appendectomy (LA) to divide the mesoappendix, including LigaSure, Harmonic scalpel, clips, endoloop ligatures, Endo GIA staplers, and bipolar coagulation. However, few studies have investigated monopolar diathermy for mesoappendix division. Therefore, this study aimed to assess both its safety and efficacy in LA. Method(s): In this prospective non-randomized study, patients (n = 87) who underwent LA for acute appendicitis were included. The bipolar electrocautery was used for mesoappendix division in the first 33 patients (BC group), while the monopolar electrocautery was used in the next 54 patients (MC group). Result(s): The median operative time was significantly shorter in the MC group (42 min. vs 47 min. in BE group, p = 0.01). One patient converted to open surgery in the MC group due to uncontrollable bleeding. There were no significant differences between both groups regarding postoperative complications and hospital stay (p = 0.91, p = 0.13, respectively). Conclusion(s): Monopolar electrocautery is safe and effective for mesoappendix division in LP in comparison to bipolar electrocautery. However, larger and multicentric studies are required to validate our results.Copyright © 2023 The Authors

Successful treatment of viral warts with topical and intralesional cidofovir in an immunocompromised paediatric patient

Cidofovir is well described as an effective antiviral agent. It is reported to treat viral warts successfully in immunocompetent and immunocompromised individuals. Unfortunately, its use may be limited by the high cost and pain of treatment. We here report the successful treatment of multiple palmoplantar warts in an 8-year old male undergoing chemotherapy for relapsed acute lymphoblastic leukaemia. His most significant lesion was a 3 x 3 x 1.5 cm tumorous lesion on the central plantar forefoot that interfered with weight bearing. It had been resistant to over-the-counter treatments, cryotherapy, silver nitrate cautery, curettage and cautery, cantharadin and topical 5-fluorouracil. He was developing multiple satellite lesions and they had spread to the toes, the other foot and both hands, totalling more than 30 lesions. The first treatment session was during sedation for intrathecal chemotherapy. One millilitre of cidofovir (diluted to 15 mg mL-1) was instilled to the largest lesion (although solution was seen visibly escaping from the surface). The remainder of the vial was compounded to topical cidofovir 1% in Eucerin, which he applied once daily to remaining lesions. His postprocedure recovery was unremarkable, with no analgesia requirements or other complications. By the time of review 4 weeks later, the verruca that had received one session of intralesional treatment had completely resolved. Some of the smaller warts had shrunk in size. Despite reports of pain associated with intralesional cidofovir injections, our patient was keen for a repeated treatment to more lesions without sedation/anaesthetic. He tolerated the treatment of a number of remaining lesions without the need for topical or local anaesthesia. Treatments continued at 4-weekly intervals (to coincide with his chemotherapy regimen) with good response and no side-effects. After three treatment sessions most lesions had resolved with only some smaller lesions remaining. Unfortunately, his next treatments were suspended as he contracted COVID-19. In summary, we report the successful eradication of significant and widespread viral warts in an immunocompromised paediatric patient. Reports in patients under 10 years of age are scarce. We also confirm excellent tolerance of the procedure. Although the high cost of cidofovir may seem prohibitive, given that one vial could generate around 25 mL solution and 0.2-1 mL is needed per lesion, we would argue that it may be more costeffective than multiple sessions of other less/ineffective modalities. Furthermore, its antiviral mechanism of action is particularly beneficial in immunocompromised patients in comparison with other modalities, which require an efficient immune response in order to be successful.

Silver nitrate-induced skin inflammation mimicking surgical infection

Silver has been in medicine for hundreds of years and has proven antimicrobial properties. It was widely used until the Second World War, when antibiotics emerged. Silver nitrate (SN) sticks (75% silver nitrate and 25% potassium nitrate) are currently employed as a topical haemostatic agent for various cutaneous surgical procedures. In the initial phase of the COVID-19 pandemic, faced with a limited supply of personal protective equipment, we used SN stick haemostasis for several skin surgical procedures (including excisions). COVID-19-related guidance from the Trust recommended the avoidance of electrocautery owing to the generation of surgical plume;hence, SN stick haemostasis seemed a pragmatic option. Four female patients with a mean age of 67 years (range 48-75) presented with swelling, erythema and pain at the surgical site within a week of the procedure. Three had ellipse excisions for suspected melanoma and squamous cell carcinomas, and one had a shave excision for possible seborrhoeic keratosis. Postsurgical wound infection was suspected, but repeated microbiological swabs did not grow any pathogens. All patients failed to respond to broad-spectrum oral antibiotics, even after two courses. The inflammatory changes took up to 4 weeks to settle, with topical corticosteroids used for wound healing. On contact with moisture, SN sticks deliver free silver ions that form an eschar as they bind to the tissue and occlude vessels. The longer the tip contacts the tissue, the greater the degree of the resultant caustic action. It is widely used in clinical practice, especially wound care (overgranulation, epibole and delayed healing). A 2020 review found an increased incidence of postoperative pain along with pigmentary changes in surgical wounds treated with SN sticks vs. aluminium chloride hexahydrate and ferric subsulfate. In skin surgery, SN is used to cauterize superficial wounds after curettage and shave excision. It does not generate aerosol and, in a pandemic setting, this particular feature can be valuable. However, the potential to cause aseptic skin inflammation that mimics postoperative infection is noteworthy. There are no evidence-based guidelines for its use in dermatology. We believe that the SN is an effective haemostatic agent but can induce significant tissue inflammation in some patients, particularly if it is used in excisions when the cauterized tissue is closed. If SN-induced haemostasis for excision was to be adopted in clinical practice, our experience suggests that larger studies and guidelines are recommended.

Mechanical ventilation for COVID19 - new patient cluster in risk for postintubation tracheal stenosis

Introduction: Postintubation tracheal stenosis (PITS) is a rare complication of mechanical ventilation (MV). Risk factors for PITS include prolonged MV, reintubation and poor endotracheal tube cuff management, all of which are common in severe COVID19 patients during pandemic surges. Aims and objectives: to describe the patient characteristics and outcomes of PITS after MV for COVID19. Method(s): we conducted a retrospective review of all patients referred to our tertiary teaching hospital for endoscopic PITS treatment after COVID19 during 2021. Result(s): 60% of the 15 referred patients were female with a mean age of 60.1 years. Median duration of MV was 11.5 (8.5 - 16) days. 13.3% of patients were reintubated and 26.7% required tracheostomy during their ICU stay. 86.7% presented with stridor after a median of 32 (16.5-60) days after extubation with a further delay of 14 (2-42) days until the diagnosis of PITS. 73.3% had simple PITS with a mean diameter of 5.73+/-1.53 mm. 12 patients were successfully treated endoscopically with serial dilatation and electrocautery. Restenosis after treatment was observed in 66.7% of patients after a median of 30 (22.5-35) days. 5 patients required surgery while 2 patients required further endoscopic dilatation after surgery. Interestingly, 13 of the 15 patients were referred from a single tertiary hospital, after treatment in the same ICU. Conclusion(s): We observed an increase in referrals for PITS treatment during the study period with a cluster of patients from a single ICU. The high restenosis rate emphasizes the importance of multidisciplinary management as well as the prevention of PITS with high quality ICU care during the COVID19 pandemic.

A Case Report on Superior Mesenteric Artery Thrombosis in a Covid-19 Patient

INTRODUCTION: This case report discussed and reviewed an atypical presentation of COVID 19 involving superior mesenteric artery thrombosis with associated ischemic colitis. Thrombosis had been reported in up to 50 percent of patients with severe COVID -19. The pathophysiology of thrombosis in COVID 19 infection may include increasing blood viscosity and endothelial damage. DESCRIPTION: Case: A 59-year-old male with GERD, hiatal hernia, and diverticulitis was presented with ten days history of abdominal pain and vomiting, which later became coffee ground in nature. He was diagnosed with COVID 19 seven days before his presentation. Lab work showed hypokalemia with lactic acidosis, polycythemia, leukocytosis, thrombocytosis, and elevated D dimer. Esophagogastroduodenoscopy demonstrated actively bleeding Mallory Weiss tear successfully treated with bipolar circumactive probe cautery (BICAP). The patient's abdominal pain worsened, and a repeat CTA abdomen revealed a superior mesenteric artery thrombosis with thickening of the distal small bowel and ascending colon. Vascular surgery was consulted, and performed catheter-assisted tPA thrombolysis to the SMA. Atrial fibrillation, diverticulitis, and other possible causes were eliminated as etiologies. DISCUSSION: Acute mesenteric ischemia is a rare abdominal emergency. Due to rapid deterioration, early diagnosis and treatment are momentous for management. Severe abdominal pain and hematemesis are the keys to starting the evaluation. Initial investigation should include basic labs with a coagulation profile;the most common abnormalities are polycythemia, metabolic acidosis, lactic acidosis, and leukocytosis. CTA provides exquisite detail of the vascular anatomy and beneficial information regarding other bowel pathologies. After diagnosis, definitive management with fluid resuscitation, antibiotics, and IV high dose unfractionated heparin, if not contraindicated, should be initiated immediately. Recently, catheter-directed procedures for intravascular thrombectomy have been used with tPA. CONCLUSION(S): In our case, we attempted to emphasize the importance of a high index of suspicion with proper history, physical examination, and appropriate imaging for proper diagnosis and management of this life-threatening incident.

Candida nivariensis infection in South East Asia: Series of case reports from Selayang Hospital, Malaysia and South East Asia Region

Introduction: Candida nivariensis, first described from Spain in 2005 is an emerging fungal pathogen. Malaysia has cap-tured a total of 11 cases since its first reported here in 2014. Indonesia, Thailand, and Vietnam are among South East Asia countries that reported its occurrence too. Objective(s): The occurrence and characteristics of Candida nivariensis in South East Asia are studied. We would like to highlight two cases from Selayang Hospital, Malaysia that occurred during pandemic COVID-19 in 2020 and 2022. Case Description: In July 2020, a 60-year-old lady underlying poorly controlled diabetes mellitus, CKD stage V approach-ing ESRD, congestivecardiac failure, hypertension, and dyslipidemiawas diagnosed as complicated MSSAbacteremia secondary to right gluteal carbuncle.Appropriate antibiotics were commenced.Aggressive source control including incision and drainage, cauterization of right gluteal carbuncle, and multiple wound debridement for the infected gluteal wound was performed. She underwent a trephine sigmoid loop colostomy.Tracheostomy was done following prolong ventilation.Anidulafungin as empir-ical fungal coverage was commenced in ICU as she further deteriorated. Candida nivariensis was isolated later from her blood culture. In February 2022, a 74-year-old man underlying Diabetes mellitus, chronic kidney disease, hypertension, ischemic heart disease with two vessels disease stented, post-Whipple's procedure due to necrotizing pancreatitis in 2014 complicated with chronic abdominal pain with hyperalgesia admitted to the ward for acute right lacunar infarct with failed swallowing test and neurogenic bladder.His general condition deteriorated with worsening of biochemical and septic parameters.His blood culture grew C. nivariensis following which anidulafungin was started. No distant seeding and no signs of endophthalmitis. He then required mechanical ventilatory support complicated with multiorgan failure, leading to ICU admission. Method(s): For both cases, yeast isolates were subcultured on Sabouraud dextrose agar and CHROMagar. Matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-T OF MS) with molecular testing was performed for confirmation of isolates.Phylogenetic tree among isolates from Malaysia was analyzed.Antifungal susceptibility test (AFST) to study the minimum inhibitory concentration (MIC) among treatment options was performed using the e-test method. Result(s): Wide use of MALDI-T OF MS with molecular testing increased the detection rate of the species. Isolation sites in Malaysia and South East Asia region include blood culture, peritoneal fluid, high vaginal swab, and oropharyngeal swab. Risk factors namely immunocompromised status, indwelling vascular catheter, abdominal surgeries, renal failure or on dialy-sis support, polymicrobial usage, and prolonged stay in ICU. AFST established susceptibility towards fluconazole, high MIC to itraconazole and low MIC against amphotericin B, anidulafungin and voriconazole for both patients who unfortunately succumbed to their illness. Conclusion(s): Diagnosing C. nivariensis is challenging due to its closely related phylogenetic with C. glabrata, and C. bracarensis, thus molecular testing is vital. Inadequate antifungal coverage or delay of treatment could be detrimental to pa-tient's outcome. Continuous epidemiological surveillance is crucial to address this potential invasive fungal pathogen and to observe emerging of drug resistance.

Comparing Aerosol Generation in Human and Animal Tissues During Common Otolaryngology Procedures

Introduction: The SARS-CoV-2 pandemic has highlighted the need to understand the risk of infection that aerosolized particles pose to surgeons and clinical staff during otolaryngology procedures. The objective of our study is to determine whether hamster and human tissues generate similar amounts of aerosolized particles using common otolaryngology surgical techniques to establish the translational value of modeling aerosol generation in human tissue with animal models. Method(s): Drilling, electrocautery, and coblation were performed on human and hamster tissues. Particle size and concentration were measured during the surgical procedures using a scanning mobility particle sizer and an aerosol particle sizer (SMPS-APS) and GRIMM aerosol particle spectrometer. Result(s): SMPS-APS and GRIMM measurements detected at least 2-fold increases in aerosol concentrations compared with baseline during all procedures. Procedures performed on human and hamster tissues produced similar trends and order of magnitude of aerosol concentrations. Generally, hamster tissues produced higher aerosol concentrations compared with human tissues, and some of these differences were statistically significant. Mean particles sizes for all procedures were small (<200 nm), although statistically significant differences in particle size were identified between human and hamster tissues during coblation and drilling (P=.001 and P<.001, respectively). Conclusion(s): Aerosol-generating procedures performed on human and hamster tissue produce similar trends in aerosol particle concentrations and sizes, although we observed some differences between the two tissue types. Further studies should be performed to understand the clinical significance of these differences.

Prevalence, Recurrences, and COVID-19 Impact on Pediatric Epistaxis

Introduction: Pediatric epistaxis is highly prevalent, yet patient characteristics, frequency of office cauterizations, and outcomes have been minimally described. This study examined the epidemiology and prevalence of epistaxis and potential impact by COVID-19. Method(s): A retrospective summary was performed on all patients (0-18 years) seen/treated for epistaxis by pediatric otolaryngologists within a single health care system across northeast and southeast United States between January 1, 2013, and October 31, 2021. Demographics, geographics, medical history, and office and operating room cauterization were reviewed. Data were analyzed using chi2 and logistic regression. Result(s): Of 9770 unique patients, with 26,699 epistaxis encounters, 62% were male. Median age at first encounter was 8.5 years;50% of patients were White. Encounters were most frequent during the fall (September-November) and least frequent during winter (December-February) with no significant differences. The incidence of epistaxis has significantly increased since the onset of the COVID-19 pandemic (P<.001). Overall, 27% received a procedural intervention, 54% required more than a single visit. Logistic regression revealed age, ethnicity, and geographical region as independent predictors of receiving a procedure on the first encounter, with a model receiver-operating characteristic (ROC) curve with area=0.75 (95% CI, 0.73-0.76). Similarly, procedural intervention, history of allergies, and nasal steroid use were independent predictors of recurrent visits, with a model ROC curve with area=0.79 (95% CI, 0.78-0.80). Conclusion(s): The incidence of pediatric epistaxis is not significantly correlated with seasonality. However, there has been a significant increase in epistaxis encounters during the COVID-19 pandemic. Recurrent visits for pediatric epistaxis were significantly predicted by procedural intervention, allergies, and nasal steroid use.

EXTREMELY RARE CASE OF CARTILAGINOUS TUMOR IN THE POSTERIOR WALL OF THE TRACHEA

SESSION TITLE: Lung Cancer Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Tracheal tumor accounts for 0.4% of all tumors and only 10% of them are benign (1). We present, to our knowledge, the first case of a primary benign tracheal tumor with features of chondroid metaplasia arising from the posterior wall of the trachea. CASE PRESENTATION: 58-year-old male non—smoker with non-significant past medical history, presented to the Emergency department for COVID-19 pneumonia. CTA chest was done showing bilateral pulmonary embolism and a 12 mm polypoid tracheal mass arising from the posterior wall of the trachea extending into the lumen (Figure#1). The patient was asymptomatic prior to his COVID 19 infection;he denied any chest pain, hemoptysis, trauma, or prior intubation. After recovering from COVID-19, the patient was scheduled for an outpatient rigid bronchoscopy which revealed a tracheal polyp arising from the mid-distal posterior membranous trachea. (Figure#2). An electrocautery snare was used to simultaneously cut and cauterize the stalk using a lasso technique. The polyp was removed in its entirety without complication. Histopathology examination demonstrated a respiratory epithelium lined cyst with cartilaginous tissue, favoring chondroid metaplasia. DISCUSSION: Primary benign tracheal tumors with cartilaginous features are uncommon, especially in the posterior membrane of the trachea, which lacks cartilaginous support. Diagnosis of any benign tracheal tumor is usually delayed since most patients are asymptomatic. The majority of such tumors are found incidentally, as in this case. One of the most common benign tracheal tumors is hamartoma, which can have respiratory epithelium and cartilaginous tissue, however they do not have features of chondroid metaplasia, and are generally found in the lateral or anterior wall of the trachea. Furthermore, endobronchial lesions only account for 3% of all pulmonary hamartomas. (2) Reports of airway chondroid metaplasia are usually described in the larynx and are commonly associated with prior trauma or inflammation in the area which is not known to have occurred in this case (3). The histopathologic findings and unusual location of this tumor makes this case unique. CONCLUSIONS: The tracheal origin of this benign tumor, arising from the posterior membrane with cartilaginous features is extremely rare, and has not previously been described in the literature. Reference #1: Park CM, Goo JM, Lee HJ, Kim MA, Lee CH, Kang MJ. Tumors in the tracheobronchial tree: CT and FDG PET features. Radiographics. 2009 Jan-Feb;29(1):55-71. doi: 10.1148/rg.291085126. PMID: 19168836. Reference #2: Hurst IJ Jr, Nelson KG. Tracheal hamartoma. Chest. 1977 Nov;72(5):661-2. doi: 10.1378/chest.72.5.661. PMID: 913152. Reference #3: Orlandi A, Fratoni S, Hermann I, Spagnoli LG. Symptomatic laryngeal nodular chondrometaplasia: a clinicopathological study. J Clin Pathol. 2003 Dec;56(12):976-7. doi: 10.1136/jcp.56.12.976. PMID: 14645364;PMCID: PMC1770148. DISCLOSURES: No relevant relationships by Jorge Cedano Consultant relationship with Olympus America Please note: 8/1/21-present Added 04/18/2022 by Lucas Pitts, value=Consulting fee

Detection of SARS-CoV-2 Contamination in the Operating Room and Birthing Room Setting: Risks to Attending Health Care Workers

Objectives: The exposure risks to front-line health care workers (HCWs) who are in close proximity for prolonged periods of time, caring for COVID-19 patients undergoing surgery or obstetrical delivery, is unclear. Understanding of sample types that may harbour virus is important for evaluating risk. The objectives are as follows: to determine if SARS-CoV-2 viral RNA from patients with COVID-19 undergoing surgery or obstetrical delivery is present in: 1) the peritoneal cavity of males and females 2) the female reproductive tract, 3) the environment of the surgery or delivery suite (surgical instruments, equipment used, air or floors) and 4) inside the masks of the attending health care workers. Methods: In this cross-sectional study, conducted at 2 Toronto hospitals, 32 patients with COVID-19 underwent urgent surgery or obstetrical delivery and the presence of SARS-CoV-2 viral RNA in patient, environmental and air samples was identified by real time reverse transcriptase polymerase chain reaction. Air samples were collected using both active and passive sampling techniques. The primary outcome was the proportion of HCW masks positive for SARS-CoV-2 RNA. Results: SARS-CoV-2 RNA was detected in 20/332 (6%) patient and environmental samples collected: 4/24 (16.7%) patient, 5/60 (8.3%) floor, 1/5 (1.9%) air, 10/23 (43.5%) surgical instruments/equipment, 0/24 cautery filters and 0/143 (95% CI 0–0.026) inner surface of mask samples. Conclusions: While there is evidence of SARS-CoV-2 RNA in the surgical and obstetrical operative environment, the finding of no detectable virus inside the masks worn by the medical teams would suggest a low risk of infection for our health care workers using appropriate personal protective equipment. Keywords: SARS-CoV-2 viral RNA;PPE;exposure risk;health care workers;real time RT-PCR;environmental and air sampling;operating room exposure;delivery room exposure

Incidental Finding of a Tracheal Lipoma

Introduction: Primary tracheal tumors are rare with an incidence of 0.2/100,000 persons, accounting for 0.6% of all pulmonary tumors. Only 10-20% of these tumors are benign with the most common being recurrent respiratory papillomatosis. Other benign tracheobronchial tumors include hamartoma, fibroma, lipoma and hemangioma among others. Due to the slow growing nature of these tumors, patients may present with progressive exertional dyspnea, cough and recurrent pneumonia, though rarely these tumors are identified incidentally in asymptomatic patients. This case describes a patient with an who underwent successful resection with flexible bronchoscopy and snare electrocautery. Case Report: A 66-year-old male with a history of former tobacco use was admitted to the medical intensive care unit (ICU) in 11/2020 with COVID-19 pneumonia, and incidentally found to have a tracheal tumor noted on CT imaging. His ICU course was complicated by submassive pulmonary embolism, pneumothorax requiring chest tube, and acute hypoxemic respiratory failure requiring heated high-flow nasal cannula. He was successfully discharged to home after 4 weeks and evaluated in the ambulatory clinic for follow-up 2 months later. Review of his imaging from an outside facility demonstrated a 1-cm polypoid lesion arising from the right tracheal wall (Figure 1A). Pulmonary function testing demonstrated a moderate restrictive defect with normal flow-volume loops. He was referred to interventional pulmonology for further evaluation and management. Flexible bronchoscopy revealed a 50% partially obstructing polypoid mass 6-cm distal to the vocal cords (Figure 1B). The mass was excised using snare electrocautery with subsequent cryotherapy for destruction of abnormal tissue at the base of the lesion and argon plasma coagulation for hemostasis. Pathology revealed tracheal lipoma. Repeat flexible bronchoscopy 12 weeks later revealed no evidence of recurrence at the site of the previously resected tracheal lipoma (Figure 1C). Discussion: Among benign tracheobronchial tumors, lipoma is an extremely rare diagnosis representing only 3-9% of cases. Airway lipomas very rarely involve the trachea and are infrequently found incidentally in asymptomatic patients. Epidemiological risk factors are thought to include male gender, obesity, middle age, and smoking. Flexible tracheobronchoscopy remains the gold standard for diagnosis, also allowing for excisional treatment with electrocautery, cryotherapy, or laser therapy. Given the rare incidence of these tumors, follow-up evaluation is recommended, though to-date there are no reports of local recurrence after bronchoscopic treatment. This case highlights the importance for diagnostic evaluation of incidental tracheobronchial tumors given the rare incidence of benign diagnoses.

EUS-GUIDED GALLBLADDER DRAINAGE: A VALUABLE OPTION IN THE COVID-19 ERA

Background and aim: In the beginning of 2020 COVID-19 pandemic rapidly affected every country and overwhelmed many healthcare systems. In 2020 in northern Italy, the first western country to be affected, the prevalence was high and it brought a burden beyond the capacity of hospitals to manage, particularly in intensive care units (ICUs) [1]. This experience has shown that intensive care and ventilator support may be needed for extended durations. Patients experience consequences of severe respiratory illness and post-intensive care illness. Endoscopic procedures, such as endoscopic ultrasound-guided gallbladder transmural drainage (EUSGBD), can reduce surgical interventions, intensive care admissions, and longterm complications. In accordance with Tokyo guidelines, laparoscopic surgical cholecystectomy is the best treatment for acute cholecystitis (AC). Alternatives for high-risk patients must be considered, since morbidity and mortality are not negligible, and the traditional alternative is percutaneous trans-hepatic gallbladder drainage. EUS-GBD is efficient and safe, with a low rate of adverse events. A 2016 systematic review by Anderloni and others that evaluated stent outcomes showed pooled technical and clinical success rates in 98.6% and 94.4% of cases, respectively. Materials and methods: A 54-year-old man who had been admitted to a rehabilitation unit after prolonged ICU hospitalization for severe COVID-19 pneumonia, was referred to the surgical unit for AC and sepsis. Medical therapy could not improve his condition, and he rapidly worsened. Results: Due to his recent ICU admission, further intubation was strongly discouraged. Following multidisciplinary evaluation, he was moved to the endoscopy suite for drainage. EUS-GBD was achieved using a 10x15-mm electrocautery-enhanced lumen-apposing metal stent (Video 1). Up to now his follow-up is regular and after prolonged rehabilitation he can be considered for elective surgery. Conclusions: The patient didn't experience any symptom related to recurrent cholecystitis nor long term complications. EUS-GBD is a valuable option in order to reduce surgical interventions and intensive-care admissions. The Covid-19 pandemic has prompted further use of interventional endoscopic ultrasound as an alternative to surgery.

Day-case transurethral resection of bladder tumour (TURBT): A feasible approach in selected patients

Introduction & Objectives: Day-case Transurethral Resection of Bladder Tumour (TURBT) is currently only performed in 18% cases across the United Kingdom. Concerns exist regarding the quality of TURBT, early recurrence rate and the high-risk patient cohort that makes this approach less popular in some centers. The Primary Outcome was to determine 30-day readmission rate and 30-day morbidity using the Clavien-Dindo classification. The Secondary Outcomes were to determine patient cohort selection, quality of TURBT and early recurrence rate and to report patient feedback following day-case TURBT. Materials & Methods: A retrospective audit of day-case TURBTs in a District General Hospital (DGH) over 3 years pre-COVID19 (January 2017 - March 2020) was performed. We only included patients who underwent a TURBT and excluded any cystoscopy, biopsy or fulguration. A day-case TURBT pathway is in place, for postoperative recovery, instillation of intravesical chemotherapy postoperatively if required and re-admission for trial without catheter when indicated in the hospital. Case notes were reviewed manually. Feedback was obtained from patients who had new tumour TURBT in the last year using hospital patient feedback forms. Results: We included 77 patients who underwent TURBT in the day-case theatre, of these 5 patients required in-patient stay after the surgery. Of the remaining 72 discharged on the same day, 8 were re-admitted (11%) for Clavien-Dindo I complications. The mean age of the patients was 71 years (34-94 years);77% (59/77) were male;reported ASA scores were 3/77 ASA 1 (4%), 43/77 ASA 2 (56%), 28/77 ASA 3 (36%);30% (23/77) patients were on anticoagulants or antiplatelets;the average tumour size was 2cm (1mm – 5cm), 69% (53/77) were papillary in nature and 36/77 were newly diagnosed tumours (47%) and the remainder were recurrences or re-resections. Of the new tumours, 32/36 (89%) received mitomycin C as indicated. On final histology, muscle was present in specimen in 50/77 (65%). The readmission/failed discharge group had a higher rate of older patients, with higher ASA scores and longer operative times, however resection quality and tumour characteristics were not different from the day-case TURBTs. The recurrence rate at first check cystoscopy for the newly diagnosed tumours was 3% (1/36) while 1 patient had residual disease in a bladder diverticulum. All patients reported an overall positive experience. Conclusions: In the first of its kind audit patients reported outcomes after day-case TURBT, though readmission rate was relatively higher than previous reports in the literature, the overall patient experience was favorable and the outcomes of TURBT quality and early recurrence were satisfactory. The data obtained can provide guidance to employ better patient selection to reduce readmission rates. Hence, day-case TURBT can be a feasible option in appropriately selected patients, with a suitable pathway in place.

Epistaxis in the Sars-CoV-2 Era

Introduction Epistaxis was the third most common unscheduled ENT surgical intervention in Ireland in 2019. Otorhinolaryngologists are exposed to a high viral reservoir of Sars-CoV-2, as they are dealing with pathology in the upper respiratory tract. Risk analysis is required to minimise nosocomial transmission. Methods A prospective audit of epistaxis management in the outpatients at a tertiary hospital was undertaken pre pandemic. A retrospective review of patients records during the Sars-CoV-2 pandemic. Comparative analysis was utilised to assess outcomes. Results Pre Sars-CoV-2 analysis revealed 14 patients (70%) were manged with rigid endoscopy compared to one (5%) interpandemic. Cauterization treated 20 patients (100%) pre pandemic and four patients (20%) interpandemic. Nasal packing modality differed in that 13 patients (65%) were treated with Nasopore pre pandemic and 14 (70%) with Rapid Rhino interpandemic. This exhibited a paradigm shift in that 18 (90%) patients were managed conservatively with nasal packing interpandemic. Conclusion A paradigm shift in the management of Epistaxis during the pandemic has led to treatment which is less invasive, has less morbidity for the patient, requires less hospital admissions and lessens nosocomial transmission of the Sars-CoV-2. Further study is required given the advent of vaccines and development of various strains Sars-CoV-2.

Endoscopic sphenopalatine foramen cauterization is an effective treatment modification of endoscopic sphenopalatine artery ligation for intractable posterior epistaxis.

PURPOSE: Endoscopic sphenopalatine artery ligation (ESPAL) is known as an effective treatment for posterior epistaxis. Anatomical variations of the intranasal branching may result in long operative time and possible inadequate cauterization. A modification of ESPAL by cauterization at the sphenopalatine foramen (SPF), has been performed by our group. Our study assessed the clinical benefit of endoscopic sphenopalatine foramen cauterization (ESFC) and compared it to ESPAL. METHOD: A retrospective study was conducted. Patients who received ESFC for posterior epistaxis from 2016 to 2018 at a tertiary hospital were recruited. Middle meatal antrostomy was done. After ethmoidal crest was identified and nipped, pterygopalatine fossa was entered through the SPF. Sphenopalatine artery (SPA) and its branches within the SPF were cauterized without identification of any SPA distal branches in the nasal cavity. Patients receiving conventional ESPAL by the same surgeon were recruited and compared as control. Patients were followed-up for 3 months. Success rate, operative time, and complication were assessed. RESULTS: Thirty-four patients were identified. Recurrent epistaxis was absent in 90.0% and 100% of patients receiving ESPAL (9/10 patients) and ESFC (24/24 patients) respectively, p = 0.294. Median operative time was 115 and 60 min, respectively, p < 0.001. Ipsilateral hard palatal or anterior palatal numbness were found in one and three patients, respectively. All resolved spontaneously within 2 weeks. CONCLUSION: ESFC is effective in treating posterior epistaxis. It requires significantly less amount of time while the success rate was comparable to conventional ESPAL.