Prospective Audit and Review of Parathyroid Surgery in Rural Setting.

Primary hyperparathyroidism (PHPT) is a common condition associated with significant morbidity and mortality. Recently Endocrine multidisciplinary team (MDT) has greatly influenced the care of such patient and has helped in improving the outcome and reducing the complications related with surgery. We conducted a review of prospectively collected data of all consecutive parathyroidectomies carried out in our district general hospital between October 2016 and Jan 2020 by a single surgeon. The collected data include patient's characteristics, laboratory results, radiological findings and operative outcomes. There were 53 parathyroidectomies performed during this period for PHPT. Mean age of patients was 75 years. Our results demonstrated a reduction in post-operative PTH in 46 patients (92%). We have identified no cases of vocal cord palsy, significant neck haemorrhage or mortality. 6 patients had temporary hypocalcaemia and 2 patients had hungry bone syndrome. Patient selection and evaluation for parathyroidectomies under endocrine MDT has greatly influenced the outcome for our patients. We had low complication rate and surgery was done at a more convenient location for selected patients. We benefit from dedicated monthly parathyroid clinic and weekly endocrine multidisciplinary team meetings to assist with patient selection and optimisation. A team effort helps in reducing complications and improving outcomes. We feel that surgery can be provided safely and successfully in a district general hospital in rural settings.

Chronic esophageal dissection: Delayed diagnosis in a 15-year-old male.

Esophageal dissection is a rare condition, characterized by disruption of the submucosa from the muscular layer of the esophageal wall. It is commonly iatrogenic in etiology and patients typically present with acute onset dysphagia, odynophagia, and retrosternal pain. The condition can be diagnosed endoscopically; however, contrast swallow studies either with CT or fluoroscopy carry less risk and are the imaging investigations of choice for this condition. Patients are managed conservatively in the majority of cases. In this case report, we present a case of chronic esophageal dissection in a 15-year-old male who had undergone endoscopic removal of a foreign body from the esophagus several years prior. We discuss the clinical features, radiological diagnosis, and management of this condition.

Prematurity and associated future paediatric airway pathology: experience from a single tertiary paediatric ENT centre.

PURPOSE: Enhanced management of the pre-term patient has resulted in improved survival rates in increasingly premature patients. Although prematurity predisposes to congenital airway pathology, there is also increased risk of endotracheal intubation, and therefore acquired subglottic pathology. We sought to evaluate airway pathology in children outside the neonatal period with a history of prematurity to explore the relationship between prematurity and upper airway pathologies. METHODS: Data for patients undergoing elective microlaryngobronchoscopy (MLB) at our centre were collected prospectively over a 5-year period. Patients identified as premature were sub-classified by the grade of prematurity. RESULTS: 339 patients over 1 month of age underwent MLB, of which 56 (16.5%) were born prematurely. Of those with identified airway pathology, 49 (23.4%) were born prematurely, accounting for 32.6% of subglottic stenosis (n = 30), 24% of laryngomalacia (n = 13) and 19% of laryngeal cleft diagnoses (n = 16). 49 premature patients (87.5%) had one or more airway pathologies diagnosed. Multi-level airway pathology was seen in twelve premature infants (21.4%), demonstrating a statistically significant association (odds ratio 3.396; 95% CI 1.697-6.842; p value < 0.0016). Incidence of airway pathology, the severity of airway disease and multi-level airway pathology were not related to the grade of prematurity. CONCLUSIONS: Premature patients account for a significant proportion of the workload within our tertiary centre due to improving neonatal care and survival in pre-term infants. We suggest early paediatric ENT evaluation for ex-premature patients with symptoms of airway pathology, with a low threshold for MLB. Improving neonatal survival rates in ever-increasing prematurity will require the further provision of specialist paediatric ENT services to manage their ongoing care.

Review of 3-Dimensional Printing on Cranial Neurosurgery Simulation Training.

OBJECTIVE: Shorter working times, reduced operative exposure to complex procedures, and increased subspecialization have resulted in training constraints within most surgical fields. Simulation has been suggested as a possible means of acquiring new surgical skills without exposing patients to the surgeon's operative "learning curve." Here we review the potential impact of 3-dimensional printing on simulation and training within cranial neurosurgery and its implications for the future. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a comprehensive search of PubMed, OVID MEDLINE, Embase, and the Cochrane Database of Systematic Reviews was performed. RESULTS: In total, 31 studies relating to the use of 3-dimensional (3D) printing within neurosurgery, of which 16 were specifically related to simulation and training, were identified. The main impact of 3D printing on neurosurgical simulation training was within vascular surgery, where patient-specific replication of vascular anatomy and pathologies can aid surgeons in operative planning and clip placement for reconstruction of vascular anatomy. Models containing replicas of brain tumors have also been reconstructed and used for training purposes, with some providing realistic representations of skin, subcutaneous tissue, bone, dura, normal brain, and tumor tissue. CONCLUSION: 3D printing provides a unique means of directly replicating patient-specific pathologies. It can identify anatomic variation and provide a medium in which training models can be generated rapidly, allowing the trainee and experienced neurosurgeon to practice parts of operations preoperatively. Future studies are required to validate this technology in comparison with current simulators and show improved patient outcomes.

The Assessment of Distortion in Neurosurgical Image Overlay Projection.

BACKGROUND: Numerous studies have demonstrated the superiority of neuronavigation during neurosurgical procedures compared to non-neuronavigation-based procedures. Limitations to neuronavigation systems include the need for the surgeons to avert their gaze from the surgical field and the cost of the systems, especially for hospitals in developing countries. Overlay projection of imaging directly onto the patient allows localization of intracranial structures. A previous study using overlay projection demonstrated the accuracy of image coregistration for a lesion in the temporal region but did not assess image distortion when projecting onto other anatomical locations. Our aim is to quantify this distortion and establish which regions of the skull would be most suitable for overlay projection. METHODS: Using the difference in size of a square grid when projected onto an anatomically accurate model skull and a flat surface, from the same distance, we were able to calculate the degree of image distortion when projecting onto the skull from the anterior, posterior, superior, and lateral aspects. Measuring the size of a square when projected onto a flat surface from different distances allowed us to model change in lesion size when projecting a deep structure onto the skull surface. RESULTS: Using 2 mm as the upper limit for distortion, our results show that images can be accurately projected onto the majority (81.4%) of the surface of the skull. CONCLUSION: Our results support the use of image overlay projection in regions with ≤2 mm distortion to assist with localization of intracranial lesions at a fraction of the cost of existing methods.

New oral anti-coagulants: Implications for neurosurgery.

New oral anti-coagulants such as the direct thrombin inhibitor, Dabigatran, and the activated factor X inhibitors, Rivaroxaban and Apixaban, are rapidly gaining clinical popularity in North America and Europe following a number of seminal randomised control trials comparing their efficacy to Warfarin and Enoxaparin. In the coming years these agents are set to replace Warfarin use for the primary prevention of stroke in non-valvular atrial fibrillation, post-operative thromboprophylaxis and the treatment of deep vein thrombosis. The main trials have shown superior anti-coagulant effects over warfarin and low-molecular-weight heparin with the added benefits of lower bleeding complications (including intracranial haemorrhages) and no requirement for monitoring. Case reports are now appearing in the literature, highlighting some of the complications of their use, namely the lack of a uniform normalised anti-coagulation test and the paucity in clinical experience with reversing the anti-coagulant effects when emergent surgery is mandated. This review has been written for the neurosurgeon who will shortly be confronted with increasing numbers of patients taking new oral anti-coagulants and intracranial complications. Hospital clinicians will need to understand the pharmacokinetics of drug administration, the laboratory tests to measure the level of anti-coagulation and the treatment of patients who are therapeutically anti-coagulated and require urgent surgical intervention.