The complimentary role of diagnostic and therapeutic endoscopy in foreign body aspiration in children.

OBJECTIVE: To review the importance and benefits of flexible bronchoscopy and rigid bronchoscopy in airway foreign body inhalation in children. Prompt diagnosis will lead to safer outcomes when both types of endoscopy are employed within the operating room setting. METHODS: Retrospective review of all cases of foreign body inhalation seen and treated in our Department between July 1986 and December 2010. RESULTS: Three-hundred and ten children were admitted to our Department from Pediatric Emergency Room for a suspected foreign body inhalation. All patients with suspected FB inhalation underwent bronchoscopy. Of 310 evaluations of tracheobronchial tree performed at our Department, 104 were negative, while an airway FB were observed and removed in 206 cases. CONCLUSIONS: Rigid bronchoscopy under general anesthesia is an extremely accurate surgical technique to identify, localize and remove airway foreign body. In our experience, flexible bronchoscopy under total intravenous sedation and topical anesthesia is very useful in doubtful cases to absolutely exclude the presence of foreign body in upper airway tracheobronchial tree.

Treatment of congenital subglottic hemangiomas: our experience compared with reports in the literature.

OBJECTIVE: To evaluate the outcome of our experience in the treatment of congenital subglottic hemangiomas. DESIGN: Retrospective review of records. SETTING: Airway tertiary care service. PATIENTS: From 1986 to 2006 we treated 39 pediatric patients affected by congenital subglottic hemangiomas. INTERVENTION: Therapeutic choice depended on presentation symptoms and grade of respiratory obstruction: 6 patients were primarily treated with only systemic steroids; 11 patients underwent intralesional corticosteroid injections followed by tracheal intubation and systemic steroid support; and 22 patients underwent primary diode laser treatment. MAIN OUTCOME MEASURE: The outcomes were evaluated according to 1 or more of the following criteria: resolution of symptoms, reduction of airway obstruction, the need and duration of intubation, tracheotomy decannulation, need of further treatments, and occurrence of complications. RESULTS: Patients treated with only systemic steroids showed a success rate of 50% (3 of 6); patients who underwent intralesional corticosteroid injections followed by tracheal intubation and systemic steroid support reached a positive result in 73% of cases (8 of 11). On the whole, 18% of patients treated with full-dose systemic steroids developed significant adverse effects (3 of 17). The success rate was 95% among patients treated with diode laser as primary treatment (21 of 22), with a complication rate of 9% (2 of 22). CONCLUSIONS: Endoscopic laser surgery is the therapeutic option that most approaches the objectives of securing the airway while using the least invasive method possible and reducing to a minimum the necessity and duration of intubation. On the basis of our experience, we believe that diode laser, owing to its physical and structural features, is the safest and most effective device for the treatment of congenital subglottic hemangiomas. Treatment with intralesional or systemic corticosteroids could have an adjuvant role.

Transoral kyphoplasty for tumors in C2.

BACKGROUND CONTEXT: The management of tumors of the C2 body remains controversial. In cancer patients, major procedures may be contraindicated, and nonoperative treatment could fail. PURPOSE: To describe a new surgical technique, the transoral kyphoplasty, that we performed in 3 cases of tumors in C2 after nonoperative treatment failure. STUDY DESIGN: Case series of three patients. PATIENT SAMPLE: Three patients from the senior author's practice. OUTCOME MEASURES: To reduce pain and avoid both C2 collapse and prolonged immobilization, transoral kyphoplasties were performed. METHODS: From February 2004 to January 2006, three cases of tumors in C2 did not show healing after nonoperative treatments. RESULTS: No complications and/or complaints were related to the procedure. There were no C2-related symptoms or neurological problems. The first patient died 8 months after surgery. The second and the third are alive with follow-ups of 2 years and 6 months, respectively. In all cases, cervical motion was restored, and patients are pain free, with no findings regarding pathologic mobility/instability on X-ray and computed tomography scan. CONCLUSIONS: Transoral kyphoplasty proved to be safe, quick, and effective in reducing pain and avoiding vertebral collapse in patients with tumors in C2 not responding to nonoperative treatment.

Endoscopic stapler-assisted Zenker's diverticulotomy: which is the best operative facility?

BACKGROUND: Despite great changes in treatment for Zenker's diverticulum, endoscopic stapler-assisted diverticulotomy (ESD) has not yet been included on the lists of possible day-case procedures, and determining the best operative facility is still a matter of debate. The aim of this article was to evaluate the safety and feasibility of endoscopic treatment for patients with Zenker's diverticulum on a planned 24-hour-stay basis. METHODS: We retrospectively reviewed cases in which patients were admitted to and operated on at the Department of Airway Endoscopic Surgery of the Padua University Hospital over a 5-year period (January 2000 to December 2004). RESULTS: We considered 106 consecutive ESDs performed on 86 patients (1.23 procedures/patient). All procedures were planned on a 24-hour-stay basis ("1-day surgery"). In no case was the endoscopic procedure aborted. The mean operative time was 14 minutes (range, 5-45 minutes). Neither perioperative mortality nor major complications occurred. Minor complications were noted in 3 cases (2.8%). The mean time taken to resume oral intake was 0.83 days (range, 0-1). The mean hospital stay was 1.06 days (range, 0-5). Ninety-nine patients (93.4%) were discharged within the 24 hours after surgery. In no case was readmission necessary. CONCLUSIONS: We believe that ESD is a suitable operation for 1-day surgery. This facility, in fact, ensures the same outcome and safety conditions as with the inpatient procedure, making it possible to rationalize health resource management, reduce hospital costs, and improve patient comfort. In selected cases, ESD could be performed on an outpatient basis.

Ethmoid osteoma with frontal and orbital extension: endoscopic removal and reconstruction.

Endoscopy provides a safe and effective way of treating craniofacial bony benign lesions. This approach permits not only complete removal of the tumour, but also reconstruction of the bony boundaries as necessary. Osteoma is a rare, osteogenic tumour that usually grows slowly and asymptomatically. It is the most frequent benign neoplasm of the nose and paranasal sinuses. Orbital extension is a rare event that can give rise to ocular signs and symptoms; in such a case treatment is mandatory, although debate persists regarding the optimal approach. We report the case of a bulky fronto-ethmo-orbital osteoma that was treated using an endoscopic trans-nasal approach. The medial wall of the orbit was repaired by means of an implant of porous polyethylene endoscopically positioned using an "underlay" technique. The surgical technique is described and the reasons for the endoscopic choice are also discussed. Fifteen days after the operation the patient reported complete resolution of craniofacial pain. Nasoendoscopy showed complete integration of the polyethylene implant in the healing tissue 4 weeks after surgery. A CT scan performed 6 months postoperatively showed good ventilation of the sinonasal cavity and effective reconstruction of the medial orbital wall.

Oesophageal diverticula.

Oesophageal diverticula are rare. They are most commonly seen at the pharyngo-oesophageal junction (Zenker's diverticula) or at the distal oesophagus (epiphrenic diverticula). In both cases they are caused by altered motility which results in abnormal intraluminal pressure and the pushing of the oesophageal mucosa through focal weaknesses of the muscular wall (pulsion diverticula). The established surgical treatment for these diverticula therefore consists of eliminating the functional obstruction causing the disease (myotomy), associated with resection of the diverticulum (diverticulectomy) or its suspension (diverticulopexy). Recently, the spread of minimally invasive surgery has also led the application of such techniques to the treatment of oesophageal diverticula. Endoscopic diverticulostomy with stapler, laser or coagulation, through a rigid or flexible endoscope, has been demonstrated to be a valid treatment for Zenker's diverticula-as an alternative to surgery-especially in high-risk patients. On the other hand, laparoscopic treatment of epiphrenic diverticula has recently been introduced with encouraging results. However, because the disease is rare, more experience is required in order to allow definitive conclusions.

Repair of a recurrent benign Tracheoesophageal fistula with a Gore-Tex membrane.

A case is reported of a recurrent postintubation tracheoesophageal fistula treated with the interposition of a Gore-Tex patch between the trachea and the esophagus.

Endoscopic treatment of upper airway and digestive tract lesions caused by caustic agents.

We present our experience in the endoscopic management of upper aerodigestive tract lesions caused by caustic agents. Between 1985 and 2000, 112 patients with upper airway and digestive tract lesions due to caustic agents were treated at the Airways Endoscopic Surgery Unit of Padua Hospital: 44 were male and 68 were female, and the median age was 42.6 years. A retrospective statistical analysis of our case series was made to evaluate the factors that most influenced the severity of injuries and the outcome of treatment. All of the patients underwent videoendoscopic assessment. In 79 cases, the patients came under our observation in the acute phase, whereas 33 presented a picture of chronic lesions. Acute lesions were classified into 3 grades. All acute grade 1 lesions healed spontaneously. In the 32 patients with grade 2 lesions, endoscopic treatment based on removal of necrotic tissue, dilations, and cleansing of abnormal fibrin adhesions resolved the disease in 30 cases (94%). Nine patients (43%) with acute grade 3 lesions developed severe chronic lesions that required subsequent treatments. Rigid endoscopy with diode laser-assisted radial lysis was performed in 32 patients with chronic cicatricial lesions and was successful in 30 cases (94%). We reiterate the need for a standardized multidisciplinary protocol for treating lesions caused by caustic agents and emphasize the essential role of airway and digestive canal videoendoscopy in the diagnosis and treatment of both the acute lesions and chronic cicatricial sequelae.

Benign tracheal and laryngotracheal stenosis: surgical treatment and results.

OBJECTIVES: Benign tracheal stenoses remain the most common indications for tracheal resection. We report lessons learned with surgical management of tracheal stenoses in a consecutive series of 65 patients from the beginning of our experience to date. METHODS: From December 1991 to January 2001 65 patients underwent primary tracheal and laryngotracheal resection and reconstruction for non-neoplastic stenoses. There were 39 males and 26 females with a median age of 33 years (range 14-74 years). There were 58 cases of postintubation and seven of idiopathic stenosis. A cervical approach was used in 60 patients, and a cervical incision with sternal split in four and with sternotomy in one. We performed 45 (69.2%) tracheal resections and 20 (30.8%) laryngotracheal resections. The length of resection ranged between 1.5 and 4 cm (median 2.5 cm). The range of resected rings was two to eight (median five). RESULTS: Fifty-four patients received a preoperative treatment. Preoperative procedures consisted of laser therapy (37), tracheostomy (38) and endotracheal prosthesis (16). We had major complications in eight patients (12.3%) and minor complications in 15 patients (23%). The most frequent complications were: temporary vocal cord dysfunction (eight patients), wound infection (five patients), anastomotic dehiscence (four patients), vocal cord paralysis (two patients), granulation tissue (two patients), deglutition dysfunction (one patient) and restenosis (one patient). Perioperative mortality was 1.5% (one patient). In classifying final results obtained, 54 patients achieved an excellent result, eight a good result and two satisfactory. CONCLUSIONS: The strategy for treatment of airway stenoses is now well established and leads to a high level of success with minimal or no sequelae. Meticulous preoperative assessment and preparation associated with a perfect surgical technique is mandatory to obtain good results. Preoperative treatments (laser and/or endotracheal prosthesis) could increase the extent of injury and the length of stenosis.