Pyogenic liver abscesses in liver transplant recipients versus non-transplant population. Outcome and risk factors of patient survival.

Pyogenic liver abscess (PLA) is a life-threatening infection in both liver transplant (LT) and non-LT patients. Several risk factors, such as benign and malignant hepatopancreatobiliary diseases and colorectal tumors have been associated with PLA in the non-LT population, and hepatic artery stricture/thrombosis, biliary stricture, and hepaticojejunostomy in the LT patients. The objective of this study is to compare the outcomes of patients with PLA in LT and non-LT patients and to determine the risk factors associated with patient survival. From January 2000 to November 2020, a total of 296 adult patients were diagnosed of PLA in our institution, of whom 26 patients had previously undergone liver transplantation (LTA group), whereas 263 patients corresponded to the non-LTA population. Seven patients with PLA who had undergone previous kidney transplantation were excluded from this retrospective study. Twenty-six patients out of 1503 LT developed PLA (incidence of 1.7%). Median age was significantly higher in non-LTA patients (p = .001). No significant differences were observed in therapy. PLA recurrence was significantly higher in LTA than in non-LTA (34.6% vs. 14.8%; p = .008). In-hospital mortality was greater in the LT group than in the non-LT group (19.2% vs. 9.1% p = .10) and was identified in multivariable analysis as a risk factor for mortality (p = .027). Mortality rate during follow-up did not show significant differences between the groups: 34.6% in LTA patients versus 26.2% in non-LTA patients (p = .10). The most common causes of mortality during follow-up were malignancies, Covid-19 infection, and neurologic disease. 1-, 3-, and 5-year actuarial patient survival rates were 87.0%, 64.1%, and 50.4%, respectively, in patients of LTA group, and 84.5%, 66.5%, and 51.0%, respectively, in patients with liver abscesses in non-LTA population (p = .53). In conclusion, LT was a risk factor for in hospital mortality, but not during long-term follow-up.

Safe oesophageal stent deployment using a checklist system instead of fluoroscopy.

BACKGROUND: Stenting is the management of choice for many benign and malignant oesophageal conditions and in the interest of safety stent insertion has traditionally been performed under fluoroscopic guidance. But this incurs additional expense, time, radiation risk and for the foreseeable future, an increased risk of Covid infection to patients and healthcare personnel. We describe a protocol that obviates the need for fluoroscopic guidance, relying instead on a systematic checklist to ensure safe positioning of the guidewire and the accurate positioning of the stent. The aim of this retrospective study was to review our experience of stent insertion employing a checklist system and compare our outcomes with outcomes using fluoroscopy in the literature. METHODS: We performed a retrospective review of a prospectively collected dataset of all patients undergoing oesophageal stent insertion between December 2007 and October 2019. The primary end points were patient safety parameters and complications of stent insertion. RESULTS: Total of 163 stents were deployed of which 93 (57%) were in males and the median age was 67.9 years (25-92 years). Partially covered self-expanding metallic stents (SEMS) were used in 80% of procedures (130/163). One hundred nineteen stents (73%) were for malignant strictures and 127 (78%) were deployed for strictures in the lower third of the oesophagus. There was no stent misplacement, injury, perforation or death associated with the procedure. Vomiting was the main post-operative complication (14%). Severe odynophagia necessitated stent removal in 3 patients. Stent migration occurred in 17 (10%) procedures with a mean time to stent migration of 6.4 weeks (range 1-20 weeks). CONCLUSIONS: Oesophageal stent placement without fluoroscopy is safe provided that a strict checklist is adhered to. The outcomes are comparable to the results of fluoroscopic stent placement in the literature, with considerable saving in time, cost, personnel, and risks of radiation and Covid exposure.

Tracheal Stenosis After Prolonged Intubation Due to COVID-19.

OBJECTIVES: The authors aimed to evaluate the characteristics and management outcomes of patients who developed tracheal stenosis after invasive mechanical ventilation (IMV) due to COVID-19. DESIGN, SETTING, AND PARTICIPANTS: The data of 7 patients with tracheal stenosis and 201 patients without tracheal stenosis after IMV due to COVID-19 between March 2020 and October 2021 were retrospectively analyzed. INTERVENTIONS: Flexible bronchoscopy was performed for the diagnosis of tracheal stenosis and the evaluation of the treatment's effectiveness, and rigid bronchoscopy was applied for the dilatation of tracheal stenosis. MEASUREMENTS AND MAIN RESULTS: In the follow-up period, tracheal stenosis was observed in 7 of 208 patients (2 women, 5 men; 3.3%). The patients were divided into 2 groups as patients with tracheal stenosis (n = 7) and patients without tracheal stenosis (n = 201). There were no statistically significant differences between the 2 groups in terms of age, sex, body mass index, and comorbidities (p > 0.05). The mean duration of IMV of the patients with tracheal stenosis was longer than patients without tracheal stenosis (27.9 ± 13 v 11.2 ± 9 days, p < 0.0001, respectively). Three (43%) of the stenoses were web-like and 4 (57%) of them were complex-type stenosis. The mean length of the stenoses was 1.81 ± 0.82 cm. Three of the patients were treated successfully with bronchoscopic dilatation, and 4 of them were treated with tracheal resection. CONCLUSIONS: Tracheal stenosis developed in 7 of 208 (3.3%) patients with COVID-19 who were treated with IMV. The most important characteristic of patients with tracheal stenosis was prolonged IMV support.

Comparison of the short-term outcomes of using DST and PPH staplers in the treatment of grade III and IV hemorrhoids.

Stapled hemorrhoidopexy has a few advantages such as less postoperative pain and faster recovery compared with conventional hemorrhoidectomy. There are two major devices used for stapled hemorrhoidopexy, PPH stapler (Ethicon EndoSurgery) and DST stapler (Covidien). This study was conducted to investigate the postoperative outcomes among patients with grade III and IV hemorrhoids who underwent hemorrhoidopexy with either of these two devices. A total of 242 consecutive patients underwent stapled hemorrhoidopexy with either PPH stapler (110 patients) or DST stapler (132 patients) at a single center in 2017. We performed a retrospective case-control study to compare the short-term postoperative outcomes and the complications between these two groups. After matching the cases in terms of age, gender, and the grade of hemorrhoids, there were 100 patients in each group (PPH versus DST). There were no significant differences in the postoperative visual analog scale (VAS) score and analgesic usage. Among complications, the incidence of anorectal stricture was significantly higher in the DST group (p = 0.02). Evaluation of the mucosal specimen showed that the total surface area, the muscle/mucosa ratio and the surface area of the muscle were also significantly higher in the DST group (p = 0.03). Further analysis of the DST group demonstrated that patients with anorectal stricture after surgery are younger than patients without anorectal stricture, and higher muscle/mucosa ratio (p = 0.03) and a higher surface area of the muscle (p = 0.03) also measured in the surgical specimen. The two devices provide similar outcomes of postoperative recovery. Patients who underwent DST stapled hemorrhoidopexy had a higher incidence rate of stricture, larger area of muscle excision, and higher muscle/mucosa ratio in the surgical specimen. Further investigation is warranted for a better understanding of the correlation between muscle excision and anorectal stricture.

Incidence of Laryngotracheal Lesions After Orotracheal Intubation in Coronavirus Disease Patients.

OBJECTIVES/HYPOTHESIS: To evaluate the incidence of lesions and severe sequelae and the risk factors for the development of laryngotracheal lesions after orotracheal intubation (OTI) in coronavirus disease (COVID-19) patients. STUDY DESIGN: Prospective cohort study. METHODS: In this prospective cohort study, we evaluated patients diagnosed with COVID-19 who were consecutively admitted to a tertiary hospital and required OTI from March 1, 2020 to October 31, 2020. Patients discharged were called for outpatient follow-up and endoscopic examination. RESULTS: A total of 1,357 patients diagnosed with COVID-19, as confirmed by nasal swab reverse transcription polymerase chain reaction, were admitted. OTI for mechanical ventilation was required in 421 patients (31%). Of the intubated patients, 172 (40.9%) were discharged and 249 (59.1%) died. Outpatient evaluation by videoendoscopy was performed in 95 patients (55.2%) approximately 100 days after extubation. Laryngotracheal lesions were observed in 38 patients (40%), with 17.9% diagnosed with laryngotracheal stenosis or unilateral immobility while 6.3% had severe stenosis (grades 3 and 4). The factors presenting statistical significance for the development of laryngotracheal lesions were the endotracheal tube (ETT) size; prone position over the OTI period; and the increased leukocyte count, d-dimer, prothrombin time (PT), and international normalized ratio (INR) on the day OTI was performed. CONCLUSIONS: The incidence of laryngotracheal lesion in COVID-19 patients is 40%, with 6.3% of them presenting with severe stenosis. There was a greater risk for the development of laryngotracheal lesions in patients using a larger ETT, kept in a prone position, presenting a greater inflammatory reaction (increased leukocyte count), or developing coagulation disorders (increased d-dimer, PT, and INR). LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1075-1081, 2022.

Long-term intubation and high rate of tracheostomy in COVID-19 patients might determine an unprecedented increase of airway stenoses: a call to action from the European Laryngological Society.

INTRODUCTION: The novel Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, may need intensive care unit (ICU) admission in up to 12% of all positive cases for massive interstitial pneumonia, with possible long-term endotracheal intubation for mechanical ventilation and subsequent tracheostomy. The most common airway-related complications of such ICU maneuvers are laryngotracheal granulomas, webs, stenosis, malacia and, less commonly, tracheal necrosis with tracheo-esophageal or tracheo-arterial fistulae. MATERIALS AND METHODS: This paper gathers the opinions of experts of the Laryngotracheal Stenosis Committee of the European Laryngological Society, with the aim of alerting the medical community about the possible rise in number of COVID-19-related laryngotracheal stenosis (LTS), and the aspiration of paving the way to a more rationale concentration of these cases within referral specialist airway centers. RESULTS: A range of prevention strategies, diagnostic work-up, and therapeutic approaches are reported and framed within the COVID-19 pandemic context. CONCLUSIONS: One of the most important roles of otolaryngologists when encountering airway-related signs and symptoms in patients with previous ICU hospitalization for COVID-19 is to maintain a high level of suspicion for LTS development, and share it with colleagues and other health care professionals. Such a condition requires specific expertise and should be comprehensively managed in tertiary referral centers.

Emergency presentation of iatrogenic airway stenosis following intubation in a patient with COVID-19 and its management.

A 59-year-old man presented to the emergency department with recent onset biphasic stridor, dyspnoea and increased work of breathing on the background of prolonged intubation for the novel COVID-19 2 months previously. Flexible laryngoscopy revealed bilateral vocal fold immobility with a soft tissue mass in the interarytenoid region. The patient's symptoms improved with oxygen therapy, nebulised epinephrine (5 mL; 1:10 000) and intravenous dexamethasone (3.3 mg). The following morning, the patient was taken to theatre, underwent suspension microlaryngoscopy and found to have bilateral fixation of the cricoarytenoid joints and a large granuloma in the interarytenoid area. He underwent cold steel resection of the granuloma and balloon dilatation between the arytenoids, with the hope of mobilising the joints. This failed and CO2 laser arytenoidectomy was performed on the left side. The stridor had resolved postoperatively, with normalisation of work of breathing and the patient was discharged home on the first postoperative day.