Safety of outpatient thyroidectomy: Review of the American College of Surgeons National Surgical Quality Improvement Program.

OBJECTIVES/HYPOTHESIS: To investigate national trends in admission status after thyroidectomy in the United States and to evaluate the factors associated with 30-day unplanned readmission and reoperation. STUDY DESIGN: Retrospective review of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) METHODS: The ACS-NSQIP database was queried for patients who underwent a partial or total thyroidectomy between 2005 and 2014. Outpatient surgery was defined as discharge on the day of surgery. Patient demographic information, unplanned hospital readmission, and reoperation were reviewed. Risk factors were identified using logistic regression modeling. RESULTS: A total of 76,604 cases met inclusion criteria as described above. There were 1,473 (1.9%) patients who underwent reoperation and 477 unplanned 30-day readmissions (1.4%) for procedures performed since 2012. There was a significant positive trend in the percentage of thyroidectomy (partial and total) patients who underwent outpatient procedures by year of operation (P < .001). Outpatient procedures were not more likely to have unplanned readmissions or reoperations. Independent patient risk factors for unplanned readmission and reoperation included current dialysis, chronic steroid use, unintentional weight loss, American Society of Anesthesiologists class 3 to 4, and active bleeding disorders. CONCLUSIONS: Over the past decade there has been a clear trend toward increasing outpatient thyroid surgery. Thyroidectomy performed as an outpatient was not found to be an independent risk factor for readmission or reoperation. Patients with serious medical comorbidities and active bleeding disorders are at increased risk of unplanned readmission or reoperation and should have their surgery performed on an inpatient basis. LEVEL OF EVIDENCE: 2c. Laryngoscope, 128:1249-1254, 2018.

Rate of regional nodal metastases of cutaneous squamous cell carcinoma in the immunosuppressed patient.

PURPOSE: Immunosuppressed solid organ transplant recipients (SOTRs) have an increased risk of developing cutaneous squamous cell carcinomas (cSCCs) with metastatic potential. This study sought to determine the rate of regional lymph node involvement in a large cohort of solid organ transplant patients with cutaneous head and neck squamous cell carcinoma. MATERIALS AND METHODS: A retrospective chart review was performed on solid organ transplant patients with head and neck cutaneous squamous cell carcinoma treated at a tertiary academic medical center from 2005 to 2015. RESULTS: 130 solid organ transplant patients underwent resection of 383 head and neck cutaneous squamous cell carcinomas. The average age of the patient was 63. Seven patients (5%) developed regional lymph node metastases (3 parotid, 4 cervical lymph nodes). The mean time from primary tumor resection to diagnosis of regional lymphatic disease was 6.7months. Six of these patients underwent definitive surgical resection followed by adjuvant radiation; one patient underwent definitive chemoradiation. 6 of the 7 patients died of disease progression with a mean survival of 15months. The average follow up time was 3years (minimum 6months). CONCLUSIONS: Solid organ transplant recipients with cutaneous squamous cell carcinoma of the head and neck develop regional lymph node metastasis at a rate of 5%. Regional lymph node metastasis in this population has a poor prognosis and requires aggressive management and surveillance.

Endoscopic Radiofrequency Ablation-Assisted Resection of Juvenile Nasopharyngeal Angiofibroma: Comparison with Traditional Endoscopic Technique.

OBJECTIVES: To evaluate the feasibility of radiofrequency surgical instrumentation for endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) and to test the hypothesis that endoscopic radiofrequency ablation-assisted (RFA) resection will have superior intraoperative and/or postoperative outcomes as compared with traditional endoscopic (TE) resection techniques. STUDY DESIGN: Case series with chart review. SETTING: Two tertiary care pediatric hospitals. SUBJECTS AND METHODS: Twenty-nine pediatric patients who underwent endoscopic transnasal resection of JNA from January 2000 to December 2014. RESULTS: Twenty-nine patients underwent RFA (n = 13) or TE (n = 16) JNA resection over the 15-year study period. Mean patient age was not statistically different between the 2 groups (P = .41); neither was their University of Pittsburgh Medical Center classification stage (P = .79). All patients underwent preoperative embolization. Mean operative times were not statistically different (P = .29). Mean intraoperative blood loss and the need for a transfusion were also not statistically different (P = .27 and .47, respectively). Length of hospital stay was not statistically different (P = .46). Recurrence rates did not differ between groups (P = .99) over a mean follow-up period of 2.3 years. CONCLUSION: There were no significant differences between RFA and TE resection in intraoperative or postoperative outcome parameters.

Surgical repair of nasal septal perforations: an update.

PURPOSE OF REVIEW: Nasal septal perforations can have a substantial impact on patient's nasal breathing and subsequent quality of life. Various surgical techniques have previously been described for the repair of these perforations. In this review, we examine the most recent literature evaluating surgical techniques for the repair of nasal septal perforations. RECENT FINDINGS: Twenty-seven studies evaluating 646 patients were included. None of these studies compared different surgical techniques. Four major categories of surgical techniques are described: multilayer, single layer, patch, and resection. Within these broad categories there is much heterogeneity in both the individual surgical technique and material used for reconstruction. However, the overall closure rate in all studies evaluated was 88%. SUMMARY: The diversity in surgical techniques demonstrated in this review would indicate that surgeons are not satisfied with the current surgical approaches for the repair of nasal septal perforations. However, the overall closure rates presented in this review are very favorable. Future comparative studies are needed to better evaluate these techniques.

Quality of life in acoustic neuroma patients.

OBJECTIVE: To examine the differences in quality of life for vestibular schwannoma patients undergoing conservative management, gamma knife, and surgery. PATIENTS: Vestibular schwannoma patients without a diagnosis of NF2. INTERVENTIONS: Vestibular schwannoma treatment or conservative management. MAIN OUTCOME MEASURES: Penn Acoustic Neuroma Quality of Life (PANQOL) survey scores (0-100). RESULTS: One hundred eighty-six patients (98 conservative, 49 gamma knife, 39 surgery) were included. Mean patient age (years) of the surgery group (49 ± 14) was significantly younger than both the conservative (58 ± 13) and gamma knife group (59 ± 12) (p < 0.001). Mean follow-up time was 2.6 years.Tumor size (mm) was found to be significantly different between the conservative (8 ± 4.8), gamma knife (18 ± 5.9), and surgery (22 ± 8.3) groups (p < 0.001). Speech recognition threshold and speech discrimination percentage were significantly better for the conservative group compared to the gamma knife or surgery groups (p < 0.001).The hearing domain scores seemed better for the conservative group (62 ± 26) when compared to the surgery group (47 ± 25). The general and total domain scores were similar for all treatment groups, whereas the quality-of-life scores for gamma knife and surgery were similar. CONCLUSION: Although surgery groups' significantly larger tumors and worse hearing were apparent in specific PANQOL domains, all patients achieved a similar general level of quality of life.

Treatment of a malignant peripheral nerve sheath tumor and its complications through a multidisciplinary approach.

The authors report the case of a 14-year-old girl with a residual malignant peripheral nerve sheath tumor after thoracotomy, chemotherapy, and radiation therapy. The residual tumor, which involved the intercostal muscles, aorta, and neural foramina of T4-10, was completely resected through a costotransversectomy and multiple hemilaminotomies with the patient in the prone position and was stabilized using a T1-12 pedicle screw fusion. Postoperatively, the patient developed several infections requiring multiple washouts and prolonged antibiotics. Thirty months after surgery, she developed a bronchocutaneous fistula. The hardware was removed, and a vascularized latissimus dorsi free flap was placed over the lung. She continued to have an air leak and presented 3 weeks later with a 40° left thoracic curve. She returned to the operating room for a T2-L2 fusion with a vascularized fibular graft. On postoperative Day 1, she underwent a bronchoscopy and had her left lower lobe airways occluded with multiple novel one-way endobronchial valves. She is now 5 years out from her tumor resection and 3 years out from her definitive fusion. She has no evidence of residual tumor, infection, or pseudarthrosis and continues to remain asymptomatic.