A multicenter study analyzing the impact of pre-existing comorbidities on laryngotracheal reconstruction (LTR) outcomes.

INTRODUCTION: Comorbidities such as chronic lung disease and gastroesophageal reflux (GERD), prematurity, and numerous other conditions may impact the success of LTR. Single-center studies are limited in terms of patient numbers and may be underpowered. OBJECTIVES: To analyze the impact of specific comorbidities on the operation-specific and overall surgical success of LTR in a large multicenter cohort and validate a predictive model for surgical success. METHODS: A large retrospective multicenter 10-year review was undertaken to validate the data of a previous single-center study (Wertz et al. Laryngoscope 2020) which identified specific predictive comorbidities which impacted LTR outcomes. A Monte Carlo simulation based on the previous data set suggested that 300-400 cases would be needed to optimize the statistical power of a Bayesian model developed from the single-center data to predict surgical success. An IRB-approved data-sharing agreement was executed for 4 large U.S. CENTERS: A virtual REDCap® data entry form inquired about patient characteristics that best predicted surgical success in the single-center model. These included demographics, surgical approaches, cardiac, airway, genetic, endocrine, musculoskeletal, gastrointestinal, and pulmonary comorbidities; details of the surgical procedures, and results of esophagogastroduodenoscopy (EGD), esophageal pH/impedance and flexible bronchoscopy with bronchioalveolar lavage (BAL) were included. Surgical success defined as successful decannulation or resolution of airway symptoms was recorded as single surgery success and overall success following open surgical revision surgery. Multivariate Bayesian analysis, logistical regression, and Kaplan-Meier analysis were performed. RESULTS: 542 patients were identified, including 165 from the single-center study and an additional 377 patients from the multicenter group. The median age was 36 months at the time of the most recent surgery. 70.9% of the LTRs were double-staged procedures. The overall success rate was 86.4% and operation-specific success rate was 69.2%. The specific comorbidities and aerodigestive test results that impacted success based on univariate analysis included staging, bronchiectasis, pulmonary hypertension, GERD, ASD, PDA, grade of stenosis, advanced levels of stenosis, Trisomy 21, MRSA, prior open surgery at another hospital, and gross appearance on EGD. Bayesian model averaging with backward selection was used to validate and refine a predictive model for surgical success with favorable receiver operating curve characteristics - AUC values of 0.827 for single surgery success and 0.797 for overall success. DISCUSSION: With over 500 patients reviewed, this was the largest multicenter study of LTR to date, which elucidated the impact of comorbidities on success with LTR and was able to improve upon the predictive modeling based on single-center data. Patient factors are most critical in the outcome of LTR. Stage and levels of stenosis, as well as pulmonary and GI conditions most strongly impact the likelihood of success. Future prospective case-control studies will be performed to further optimize the current model for outcome prediction and patient management.

Pediatric tonsillectomy: A short-term and long-term comparison of intracapsular versus extracapsular techniques.

OBJECTIVE: To review a cohort of over 2500 patients and investigate the short and long-term outcomes of intracapsular as compared to extracapsular tonsillectomy, and show if the complication rates are comparable between methods. STUDY DESIGN: A multicenter, retrospective chart review was conducted, evaluating pediatric tonsillectomies performed from 2004 to 2014. The electronic medical record was reviewed through December 2018, providing up to 14 years of follow-up data. SETTING: Two tertiary care, academic medical centers. SUBJECTS AND METHODS: A retrospective chart review was conducted to identify children undergoing tonsillectomy and adenotonsillectomy. A chart review was first performed of patients by a single surgeon (MEG) and then the analysis was repeated using enterprise data warehouse (EDW) to search for complications and interventions using International Classification of Diseases, ninth revision, (ICD-9) and Current Procedural Terminology (CPT) codes. The second surgeon's patients (JLC) patients were added to increase the cohort. Patients were excluded from the review of long-term outcomes if there was less than two-year follow-up. Short-term outcomes examined included rate of post-tonsillectomy hemorrhage and re-presentation for dehydration, while long-term outcomes included rates of peritonsillar abscess and tonsillar regrowth requiring revision tonsillectomy. RESULTS: A total of 2508 pediatric patients were identified who had undergone tonsillectomy or adenotonsillectomy. In 1456 (58.1%) of these patients, the intracapsular technique was used and in 1052 (41.9%) patients, the extracapsular technique was used. The mean documented follow-up time was 8.2 years. Thirty-five patients (1.4%) were identified with post-tonsillectomy hemorrhage, 2 of these patients (5.7%) with primary hemorrhage and 33 patients (94.3%) with secondary hemorrhage. 11 underwent intracapsular tonsillectomy and 24 underwent extracapsular tonsillectomy (p = 0.0042). The rate of post-tonsillectomy hemorrhage with intracapsular tonsillectomy was 0.76%, compared to 2.3% in the extracapsular group. Three patients (0.12%) undergoing intracapsular tonsillectomy required revision tonsillectomy; no patients in the extracapsular group required revision surgery. Three patients (0.12%) developed peritonsillar abscess post-operatively, two following intracapsular tonsillectomy and one following extracapsular tonsillectomy. CONCLUSION: This retrospective review comparing the intracapsular and extracapsular techniques for tonsillectomy provides further evidence of the benefits of this technique. It is worthwhile to continue offering intracapsular tonsillectomy to patients and their families during pre-operative discussions.