Swallowing rehabilitation of patients undergoing T-tube implantation for the treatment of laryngotracheal stenosis.

OBJECTIVE: Patients with laryngotracheal stenosis (LTS) often have dysphagia after laryngotracheal reconstruction with T-tube insertion, which affects the quality of life. The purpose of this study is to observe the effect of swallowing rehabilitation therapy on the improvement of quality of life in patients of otolaryngology-head and neck surgery with dysphagia undergoing T-tube implantation treatment through longitudinal study. METHODS: Thirty-eight patients with LTS who experienced dysphagia after laryngotracheal reconstruction and T-tube implantation were recruited. All patients received swallowing rehabilitation therapy. The assessment of swallowing function was performed using the 10-item Eating Assessment Tool (EAT-10), the 30 mL water swallow test (WST), and flexible endoscopic evaluation of swallow (FEES). RESULTS: After swallowing rehabilitation therapy, timing of swallowing, grade of dysphagia, performance on FEES and 30 mL WST, and EAT-10 score all improved. Thirty-eight patients successfully transitioned to oral feeding and were able to remove their nasogastric tubes without experiencing any complications, including aspiration pneumonia. CONCLUSION: For patients with LTS who experienced dysphagia after laryngotracheal reconstruction and T-tube implantation, swallowing rehabilitation therapy could improve swallowing function of the patients, so as to reduce the potential harm caused by the pain and complications of surgery experienced by patients.

Curative surgical treatment of common bile duct stones: Retrospective cohort study.

BACKGROUND: In the event of symptomatic common bile duct (CBD) stones with dilated CBD, one possible curative treatment option is stone extraction through choledocotomy associated with cholecystectomy. Endoscopic treatment is only reserved for residual stones at 6 weeks. The aim of this study was to evaluate the results from laparoscopic curative surgical treatment of CBD stones with dilated CBD. METHODS: This is a retrospective single-centered cohort study. All consecutive patients admitted for laparoscopic cholecystectomy with evidence of CBD stones with dilated CBD from January 2010 to December 2020 at our center were included. Success was defined by CBD clearance at 6 weeks. Need for additional procedures, such as endoscopic sphincterotomy, immediate, and end-of-procedure morbi-mortality as well as factors associated with procedure failure, were also studied. RESULTS: A total of 246 patients who received curative treatment were included in the study. The success rate for the curative treatment was 93.1% (229 patients). Immediate postoperative morbidity was 24.4% with a 5.3% reintervention rate. Immediate and 6-week postoperative mortality rates were zero and 0.4%, respectively. The mean length of stay was 11.3 days. Factors associated with procedure failure appeared to be the occurrence of an early postoperative complication and the need for readmission during the period between surgery and drain removal. CONCLUSION: This study indicates that laparoscopic curative surgical treatment for symptomatic CBD stones may be performed with acceptable results without routine need for additional procedures.

Syringo-Subarachnoid Shunt with Tube Versus T-Tube via the Dorsal Root Entry Zone Approach for Eccentric Syringomyelia.

OBJECTIVE: This study compared the clinical therapeutic efficacy of syringo-subarachnoid shunt placement with direct tube and T-tube via the dorsal root entry zone (DREZ) approach for treatment of eccentric syringomyelia. METHODS: A retrospective study was performed of 41 patients with idiopathic or secondary eccentric syringomyelia from November 2011 to December 2022. Syringo-subarachnoid shunt placement with direct tube or T-tube via the DREZ approach was performed. The modified Japanese Orthopaedic Association low back pain scale was used to investigate the severity of clinical symptoms. Magnetic resonance imaging was used to investigate therapeutic efficacy（reduction of the cavity volume by >10% was considered an improvement and 50% was considered a significant improvement). RESULTS: Incision length of the spinal cortex in the direct tube group was shorter than in the T-tube group (3.10 ± 0.28 cm vs. 5.03 ± 0.19 cm), with a significant difference between the 2 groups (t = -52.56, P < 0.001). Modified Japanese Orthopaedic Association score 3 months postoperatively was significantly better than the preoperative score in both the direct tube group（t = 40.954, P < 0.001） and the T-tube group（t = 24.769, P < 0.001）. Statistical comparison revealed there was no difference in imaging improvement between the direct tube group and T-tube group 3 months (χ2 = 0.20, P = 0.655) and 12 months (χ2 = 0.21, P = 0.647) postoperatively. CONCLUSIONS: Syringo-subarachnoid shunt placement with direct tube via the DREZ approach for treatment of eccentric syringomyelia is safer than with T-tube via the DREZ approach due to smaller incision length and less of a space-occupying effect with same therapeutic efficacy.

[Acute respiratory distress due to tracheostomy tube migration]. / Détresse respiratoire aiguë par migration d'une canule de trachéotomie.

Tracheostomy cannula care is of paramount importance in the daily management of tracheotomized patients. While some complications are commonplace, specific events can occur, often according to type of cannula. We herein report the case of a 71-year-old patient; following a lengthy stay in the intensive care unit, she had received a Safe T-Tube cannula designed to provide support in a stenotic trachea. At home, while suctioning her tracheal secretions, she suddenly experienced respiratory distress requiring a rapid intervention. On arrival, no seeable cannula was found, either in the tracheostomy or in the patient's immediate surroundings. Following her transfer to intensive care, a new cannula was inserted into the tracheostomy opening, enabling mechanical ventilation to begin and achieving rapid relief of dyspnea and improvement of the patient's overall condition. Bronchial fibroscopy was then performed, during which the Safe T-Tube cannula was found folded on itself in a supra-carinal intra-tracheal position. It was extracted and replaced by a cannula of the same model, which was sewn to the skin. Although rare and usually limited to flexible cannulas, this complication is potentially fatal. Generally speaking, when cannula obstruction is suspected, bronchial endoscopy in an intensive care setting is a vital necessity. It is not only the cornerstone of the diagnosis, but also of paramount importance in treatment taking into full account the mechanism of obstruction.

A modified procedure of T-tube maneuver to treat tracheal total obstruction involving ablative bronchoscopy sparing open surgical intervention.

Objectives: The study objectives were to test an innovative T-tube procedure involving ablative bronchoscopy for the treatment of total airway occlusion and to orchestrate a safe and nontraumatic maneuver to treat intricate subglottic stenosis amenable for substituting the conventional surgical intervention. Methods: This was an uncontrolled single-center cohort study on 1254 patients from January 2001 to June 2021. Patients underwent the modified T-tube procedure treatment for tracheal stenosis. Only 42 patients were included in the study because they had full records for subglottic total occlusion sitting tracheostomy. The ablative bronchoscopy, aided by a fixed suspending laryngoscope, was applied to retunnel their total airway occlusion. T-tube revision and removal were conducted under general anesthesia with laryngeal mask airway aid during follow-up. Results: The primary outcome was 90-day mortality. The secondary outcome was 90-day morbidity. The 42 patients included in the study had a mean age of 52.29 years (range, 9-84 years) with 22 men (52.38%). Their mean length of hospital stay was 13.67 days (range, 2-45 days). Their mean operation time was 73 minutes (range, 43-256 minutes). Their mean length of the tracheal stenosis was 2.8 cm (range, 0.8-6.3 cm). Outcomes were good in 29 patients (69.05%), satisfactory in 10 patients (23.81%), and considered failures in 3 patients (7.14%). A total of 16 patients (38.10%) underwent decannulation, and 3 patients (7.14%) were shifted to a Shiley tracheostomy. All 42 patients had a median follow-up of 6.2 years (range, 1.5-16.3 years). Conclusions: The modified T-tube procedure, which offered both resilience and versatility, improved the conventional technique in treating those patients experiencing total tracheal stenosis and who were unqualified for conventional open surgery.

T-tube implantation combined with cricoid cartilage reconstruction in the treatment of congenital laryngeal webs with subglottic stenosis.

OBJECTIVE: To discuss the presentation, evaluation, and management of congenital laryngeal webs with subglottic stenosis. METHODS: The clinical data of six children were retrospectively analyzed. RESULTS: The median age of these children who came to our hospital was 14 months (range 1-26 months). A tracheotomy was performed in all these six children. The median age of the patients who underwent tracheotomy was 4 months (range 1-11 months). The surgical method was T-tube implantation combined with cricoid cartilage reconstruction. The median age of these patients at the time of operation was 22 months (range 13-35 months). The T-tube remained in place for 3-8 months, with a median time of 6 months. The tracheal tubes in all these children were successfully removed. All patients were followed up for more than 2 years without recurrence. CONCLUSIONS: Children who have congenital laryngeal webs with subglottic stenosis required early tracheotomy. Open laryngoplasty combined with T-tube implantation and cricoid cartilage reconstruction may play a crucial role in the treatment of these children.

T­tube versus internal drainage tube in laparoscopic common bile duct exploration.

The 203 patients who underwent laparoscopic common bile duct exploration for choledocholithiasis were retrospectively analyzed. The patients were divided into internal drainage tube group (n=87) and T-tube group (n=116). Total bilirubin, direct bilirubin, alanine aminotransferase (AST), aspartate aminotransferase (ALT), the diameter of common bile duct, number of stones, operation time, intraoperative bleeding, postoperative hospital stay and postoperative complications were compared between the two groups. Possible influencing factors were selected as independent variables, and the operation mode was selected as the dependent variable for multifactor unconditional logistic regression analysis. There were no significant differences in the sex, age, total bilirubin, direct bilirubin, AST, ALT, operation time, intraoperative blood loss, postoperative hospital stay and postoperative biliary leaks between the two groups (P>0.05). The diameter of the common bile duct was smaller and the incidence of multiple stones in the common bile duct was lower in the internal drainage tube group compared with that in the T-tube group (P<0.05). The results of multifactor unconditional logistic regression analysis demonstrated that the diameter of the common bile duct and the number of stones in the common bile duct were associated with the operation mode as influencing factors. In conclusion, Patients with multiple stones in the common bile duct or with a wide diameter of the common bile duct are more likely to have T-tube placed rather than an internal drainage tube.

A Retrospective Study on the Three-Port Technique of Laparoscopic Common Bile Duct Exploration for the Management of Cholelithiasis and Choledocholithiasis.

Background: Laparoscopic cholecystectomy (LC) with laparoscopic common bile duct exploration (LCBDE) is convenient in treating cholelithiasis and choledocholithiasis due to its advantage of accelerated recovery. This retrospective study aimed to summarize the experience of cholelithiasis and choledocholithiasis treatment via three-port approach of LCBDE in Eastern China. Methods: Patients diagnosed with cholelithiasis and choledocholithiasis between July 2019 and October 2021 were included. Patients who received LC+LCBDE+primary suturing of the common bile duct (CBD) via a three-port approach were assigned to the LCBDE-P group, and those who received LC+LCBDE+T-tube drainage of CBD comprised the LCBDE-T group. The measurement data were compared between the two groups. P-values <0.05 indicated statistical significance. Results: A total of 88 patients were divided into two groups: LCBDE-P (n=50) and LCBDE-T (n=38). Multiple logistic regression analysis showed that LCBDE-P is associated with a shorter length of stay (OR=0.115, 95% CI: 0.040-0.329, P<0.001) and lower hospitalization costs (OR=0.120, 95% CI: 0.041-0.357, P<0.001). No significant differences between the two groups were detected in the operation time, intraoperative hemorrhage, clearance rate of CBD stones, postoperative liver function, and postoperative complications (P>0.05). Conclusion: The three-port approach of LCBDE is a safe and feasible strategy for managing cholelithiasis and choledocholithiasis. Compared to LCBDE-T, LCBDE-P reduces the length of hospital stay and medical costs during hospitalization.

The effectiveness of chest T-tube drainage in uniportal video-assisted thoracic surgery.

OBJECTIVES: Uniportal incision located at 4th or 5th intercostal space represents a problem for the correct drainage of distal areas of pleural cavity. The T-shaped tube can drain both the extremities of pleural space. In this study, we evaluated the effectiveness of T-chest tube compared to classic chest tube after uniportal video-assisted thoracic surgery. METHODS: We compared the effectiveness of T-tube and classic 28 CH chest drainage after different surgical procedures in uniportal video-assisted thoracic surgery: lobectomies, wedge resections and pleural and mediastinal biopsies. As primary end points, drained effusion and evidence of pneumothorax at postoperative day 1, subcutaneous emphysema, tube kinking, obstruction and necessity of repositioning or postoperative thoracentesis were considered. Pain at 6 and 24 h after surgery, pain at tube removal and mean hospitalization were analysed as secondary end points. RESULTS: A total of 109 patients were selected for the study, 51 included to the T-tube group while the other 58 ones to the control group with classic drainage. Patients with T-tube showed a significantly lower rate of pneumothorax (29.4% vs 63.8%; P < 0.001), tube kinking (5.9% vs 27.6%; P = 0.003) and need of repositioning (2.0% vs 12.1%; P = 0.043). No significant results were obtained in subcutaneous emphysema (P = 0.26), tube obstruction (P = 0.32), drained effusion (P = 0.11) and need of postoperative thoracentesis (P = 0.18). Patients with T-tube complained of <6 h after surgery (P < 0.001). Conversely, T-tube removal was reported to be more painful (P < 0.001). CONCLUSIONS: Chest T-tube can achieve significantly lower rate of postoperative pneumothorax, kinking and repositioning with less pain 6 hours after surgery compared to classic tube.

A Prospective Institutional Study on Aetiopathogenesis, Management and Complications of Laryngotracheal Stenosis.

The main purpose of this study is to evaluate and understand the clinical profile of patients presenting to an Indian tertiary care referral centre with Laryngotracheal Stenosis (LTS) and also to emphasise on the outcomes after treatment in these patients. This is a prospective observational study conducted at a tertiary care referral centre which included 18 patients diagnosed with LTS. All patients were evaluated clinically and radiologically to evaluate the degree of stenosis, site and length of the stenotic segment involved, intervened surgical procedure, intraoperative and postoperative complications following the procedure were all documented and taken into consideration. The data collected was analysed. The most common etiological cause of LTS was post intubation (77.8%). 61.5% among the 13 intubated patients had a history of intubation for more than 10 days. 83.3% of the cases had stenosis at the level of the subglottis and cervical trachea level. Post intubational airway stenosis is the most common cause of LTS. A precise assessment of the laryngotracheal complex is the cornerstone of LTS management. The choice of treatment depends on the location, severity, and length of stenosis, as well as on the patient's comorbidities, history of previous interventions, and on the expertise of the surgical team. Application of topical Mitomycin c during surgery reduces the incidence of granulations. Close postoperative follow up for a long time and the necessity of more than one intervention improves results and can spare patients the morbidity and mortality associated with acute airway obstruction.

Clinical Analysis of Laparoscopic Common Bile Duct Primary Suture and T-Tube Drainage in the Treatment of Common Bile Duct Stones.

Background: At present, T-tube drainage or primary suture for common bile duct stones is common management. Methods: The clinical data of 100 patients who underwent laparoscopic common bile duct exploration and T-tube drainage or primary suture for common bile duct stones from 2019 to 2021 were analyzed retrospectively, including 50 cases of primary suture and 50 cases of T-tube drainage. Results: The operation time and postoperative hospital stay of patients with primary suture were lower than those in T-tube drainage group (P < .05). There was no significant difference in the incidence of postoperative complications and hospitalization expenses between the two groups (P > .05). Conclusions: It has been suggested that the therapeutic effect of laparoscopic primary suture is better than that of T-tube drainage; although they have different indications, they should be selected according to the specific individual situation of patients.

Use of Silicon T-Tube for Subglottic Stenosis and Tracheal Stenosis.

Introduction: The management of subglottic and tracheal stenosis is challenging for any ENT surgeon. The treatment choice depends on the site, severity of stenosis, patient symptoms, and surgeon preferences. The various options for the management include endoscopic balloon dilatation, various types of laryngotracheoplasty, resection anastomosis, and insertion of a silicon T-tube. Compared to the above, silicon T-tube stenting is a better alternative, as it is a onetime procedure, easy to perform with fewer chances of complications. Shiann Yann lee technique is a form of laryngotracheoplasty with long-term stenting using silicon T-tube. This article analyzed our silicon T-Tube insertion result in patients with subglottic and tracheal stenosis using this technique. Materials and Methods: In this retrospective study, we included a total of 21 patients with subglottic and tracheal stenosis who underwent silicon T-Tube insertion. Data regarding the site of stenosis, procedure, complications, and outcome were analyzed. Results: Out of 21 patients, nine patients had subglottic stenosis (42.8%), 8 had cervical tracheal stenosis (38.09%), 3 had thoracic tracheal stenosis (14.28%), and 1 (4.7%) had combined subglottic and cervical tracheal stenosis. Out of 21 patients,7 (33.3%) have undergone successful removal of silicon T-Tube so far, one death due to medical reasons, and 13 patients (61.9%) are still on Silicon tube on regular follow-up. They are comfortable with the tube in situ. Conclusions: Silicon T-Tube for benign acquired laryngotracheal stenosis with Shiann Yann Lee's technique is effective, safe with less complication, and good acceptability and tolerance by the patient.

A comparison of the therapeutic outcomes between primary duct closure and T-tube drainage after laparoscopic common bile duct exploration: a single-centre retrospective study.

Introduction: In emergency surgery for acute obstruction of the common bile duct (CBD), primary duct closure (PC) of the CBD after laparoscopic common bile duct exploration (LCBDE) remains challenging. Aim: To explore the safety and effectiveness of this surgical method after LCBDE in patients with acute choledocholithiasis and discuss the feasibility of PC in the CBD. Material and methods: This retrospective study on surgical efficacy and safety involved 232 patients treated at The Third Affiliated Hospital of Soochow University between January 2015 and December 2019. These patients underwent LC + LCBDE for acute choledocholithiasis and were categorized into PC and T-tube drainage (TD) groups based on the method of closure of the CBD. The basic preoperative information, intraoperative situation, postoperative situation, and complications were analysed and compared between groups. Results: The baseline characteristics and preoperative information of patients between the 2 groups were balanced. Patients in the PC group had a shorter operation time (p < 0.001) and CBD suturing time (p < 0.001) than those in the TD group. In addition, compared with the TD group in postoperative situations, gastrointestinal recovery (p = 0.002), drainage removal (p < 0.001), and the length of postoperative hospital stay (p = 0.004) were markedly decreased in the PC group. In terms of intraoperative blood loss (p = 0.961), use of pipe washing (49.0 vs. 54.6%, p = 0.397), use of stone basket (50.0 vs. 42.3%, p = 0.243), use of electrohydraulic lithotripsy (1.0 vs. 3.1%, p = 0.525), postoperative liver function, and complications there was no significant difference between the PC and TD groups. No intraoperative transfusion and postoperative mortality occurred in either group. During 6 months of follow-up, only 1 patient showed biliary stricture in the PC group, and 2 and 4 patients in the PC and TD groups, respectively, showed residual stones. Conclusions: PC after LCBDE in acute choledocholithiasis patients displays better therapeutic outcomes than TD in some intraoperative and postoperative situations. PC of the CBD after LCBDE is a safe and effective therapeutic option in acute choledocholithiasis patients.

Is T-tube drainage no longer needed for laparoscopic common bile duct exploration? A retrospective analysis and literature review.

Introduction: Primary closure (PC) following laparoscopic common bile duct exploration (LCBDE) is increasingly becoming a safe and effective option for choledocholithiasis. However, whether T-tube drainage (TTD) is no longer needed for LCBDE remains under debate. Aim: To evaluate the safety and efficacy of PC and TTD following LCBDE, and discuss their indications for selection of the procedure, combined with a literature review. Material and methods: 826 consecutive patients who underwent LCBDE with PC or TTD at Shanghai Tenth People's Hospital were reviewed. The clinical data of postoperative outcomes were compared and analyzed. Propensity score matching (PSM) was used to adjust for potential baseline confounding. Results: Of these patients, 796 underwent PC and 30 underwent TTD. Twenty-eight (3.52%) cases occurred in bile leakage in PC, and all of them were treated successfully with conservative therapy. Additionally, there was no evidence of bile duct stricture and death in all PC cases. TTD was mainly performed in patients with a higher rate of cholangitis (50.00%), large stones (26.67%), impacted stones (23.33%) and laser lithotripsy (26.67%). After PSM, 23 cases with PC and TTD were included. In the PC group, the operative time, postoperative stay, hospital expenses and recurrence rate were significantly shorter or less than in the TTD group. However, there were no significant differences between the two groups in postoperative drainage time, complications, reoperations and bile duct stricture rate. Conclusions: PC following LCBDE is safe and effective for choledocholithiasis. TTD is a safe alternative method for bile duct closure in certain special cases, such as acute cholangitis, large stones, impacted stones, and laser lithotripsy.

Primary Closure vs T-Tube Drainage Following Open Choledochotomy for CBD (Common Bile Duct) Stones.

BACKGROUND: Choledocholithiasis affects 10%-15% of individuals with gallbladder stones. Approximately 7%-15% of cholecystectomy patients develop common bile duct (CBD) stones. It occurs more frequently in older age groups. It may result in a complete or partial blockage of the bile duct and present as pancreatitis or cholangitis due to gallstones. OBJECTIVE: The aim of this study was to compare the outcomes of primary closure of duct and T-tube drainage after open choledochotomy and to evaluate the effectiveness and safety of primary closure. MATERIAL AND METHODS: From January 2018 to December 2021, this descriptive study was carried out in the surgical department of the Hayatabad Medical Complex in Peshawar. In total, 60 patients who had open choledocholithotomy after a failed endoscopic extraction were included in this study. Of these, 30 (50%) patients got primary duct closure after choledochotomy, while 30 (50%) patients had T-tube insertion. RESULTS:  Among the total of 60 patients (primary closure: 30 and T-tube drainage: 30 patients), 10 (16%) were males, while 50 (84%) were female patients. The mean age was recorded as 45.9±13.9, and the mean hospital stay in days in both groups was 4.87±1.4 (T-tube: 5.24±1.50 and primary closure: 4.50±1.3). Complications developed in group A were a biliary leak in three (10%) patients, postoperative jaundice in two (6.5%) patients, wound infection in three (10%), intra-abdominal collection in three (10%) patients, and dislodgement of a tube in two (6.5%), while 17 (57%) patients had no complications developed. CONCLUSION:  If the duct is free of stones, as determined by preoperative choledochoscopy, primary closure of the common bile duct (CBD) is a safe, cost-effective procedure with less morbidity than regular T-tube drainage after open choledochotomy.

Application of a nurse-led transitional care programme for patients discharged with T-tubes after biliary surgery.

AIM: Nurse-led transitional care programmes (TCPs) have been shown to facilitate patient recovery in several illness settings, but its role among patients discharged with T-tubes remains uncertain. The aim of the study was to investigate the effects of a nurse-led TCP among patients discharged with T-tubes. DESIGN: This retrospective cohort study was conducted at a tertiary medical centre. METHODS: From January 2018 to December 2020, a total of 706 patients discharged with T-tubes after biliary surgery were included in the study. Patients were divided into a TCP group (n = 255) and a control group (n = 451) based on whether they participated in a TCP. The baseline characteristics, discharge readiness, self-care ability, transitional care quality and quality of life (QoL) were compared between the groups. RESULTS: Self-care ability and transitional care quality were significantly higher in the TCP group. Patients in the TCP group also exhibited improved QoL and satisfaction. The results suggest that the incorporation of a nurse-led TCP among patients discharged with T-tubes after biliary surgery is feasible and effective. No Patient or Public Contribution.

Endoscopic and Image Analysis of the Airway in Patients with Mucopolysaccharidosis Type IVA.

Mucopolysaccharidosis (MPS) is a hereditary disorder arising from lysosomal enzymes deficiency, with glycosaminoglycans (GAGs) storage in connective tissues and bones, which may compromise the airway. This retrospective study evaluated patients with MPS type IVA with airway obstruction detected via endoscopy and imaging modalities and the effects of surgical interventions based on symptoms. The data of 15 MPS type IVA patients (10 males, 5 females, mean age 17.8 years) were reviewed in detail. Fiberoptic bronchoscopy (FB) was used to distinguish adenotonsillar hypertrophy, prolapsed soft palate, secondary laryngomalacia, vocal cord granulation, cricoid thickness, tracheal stenosis, shape of tracheal lumen, nodular deposition, tracheal kinking, tracheomalacia with rigid tracheal wall, and bronchial collapse. Computed tomography (CT) helped to measure the deformed sternal angle, the cross-sectional area of the trachea, and its narrowest/widest ratio (NW ratio), while angiography with 3D reconstruction delineated tracheal torsion, kinking, or framework damage and external vascular compression of the trachea. The NW ratio correlated negatively with age (p < 0.01), showing that airway obstruction progressed gradually. Various types of airway surgery were performed to correct the respiratory dysfunction. MPS type IVA challenges the management of multifactorial airway obstruction. Preoperative airway evaluation with both FB and CT is strongly suggested to assess both intraluminal and extraluminal factors causing airway obstruction.

Developing a Tracheal Rendezvous Procedure for Complete High Subglottic Stenosis.

Complete subglottic stenosis is often managed with surgical resection. However, involvement of the high subglottis can limit candidacy for open resection, and there are few treatment options for these patients. We refined an endoscopic approach that evolved into a tracheal rendezvous technique with T-tube placement as an alternative to open surgical resection. Here, we present our series, technique, and outcomes. A retrospective review was performed to identify patients who underwent endoscopic management of complete high subglottic stenosis at the University of California San Diego. The surgical technique was initially a two-step staged procedure and was subsequently revised to a single-stage procedure with stenosis ablation, dilation, and insertion of a T-tube, which was completed in one day. Patients were seen at regular follow-up intervals for reassessment. Five patients were identified with complete stenosis not amenable to surgical resection. The average age of the cohort was 44.8 years. The etiology of stenosis in all patients was related to prolonged intubation and tracheostomy, and the average length of stenosis was 19.6 mm. Stenosis resection was accomplished via laser ablation and balloon dilation, and the average T-tube length was 50.3 mm. All patients were discharged on postoperative day one. Two patients developed airway crusting within the T-tube and required emergency department visits. Decannulation was attempted in three patients, although failed in two. Tracheal rendezvous is a safe and effective procedure for patients with grade IV subglottic stenosis. This provides a feasible endoscopic alternative to patients who are not candidates for open surgical resection, ye are motivated to have phonatory capacity.

Spontaneous perforation of the common bile duct in adults presenting as biliary peritonitis: a case report and literature review.

Spontaneous perforation of the common bile duct (SPCBD) is an exceptional disease, especially in adults. The cause is often idiopathic once trauma and choledochal cyst are excluded. Early diagnosis is often difficult because of its often-misleading appearance. Case presentation: The authors report the case of a 54-year-old man, a known case of type 2 diabetes mellitus, who presented to our emergency department for acute abdominal pain that had evolved for 2 days. Clinical findings and investigations: On physical examination, the patient had a fever of up to 38.5°C, and the abdomen was distended and generally tight. The abdominal computerized tomography scan confirms the presence of free fluid. In addition, the thickness of the gallbladder wall had increased in contrast with a resolved gallbladder distention. Because exploration failed to demonstrate the cause of ascites, the authors performed a diagnostic paracentesis, which revealing ascites with a dark yellow-green color, which implied bile leakage.After initial resuscitation, an emergent exploratory laparotomy was performed. The authors found biliary peritonitis secondary to SPCBD. After peritoneal lavage, the perforation was repaired over a T-tube. The postoperative course was uneventful. Histological findings were consistent with ulcerous acalculous cholecystitis. The patient was disease-free after a 3-month follow-up. Discussion: SPCBD is an uncommon condition in adults, and it is rarely reported in the literature. The pathogenesis of this disease is not clear and may be related to single or multiple factors. Usually, this disease is diagnosed in the postmortem. Early diagnosis and optimal surgical treatment are challenging. Conclusion: This present case highlighted the preoperative diagnostic difficulties of the SPCBD. Emergent surgical management should be instituted in the shortest time possible to reduce the high mortality.