Recommendations regarding emergency head and neck procedures during coronavirus disease-2019.

The coronavirus disease-2019 (COVID-19) has spread globally and is considered a world health emergency. Healthcare professionals represent an important percentage of the infected population, with otolaryngologists and head and neck surgeons at particular risk. Elective procedures have been strongly discouraged, but urgent disorders still entail a hazardous setting. We performed a non-systematic review of the publications and guidelines regarding Head and Neck surgical emergencies management in the context of the COVID-19 pandemic. The literature describing management of the disease was also reviewed to adapt conventional treatment to the present circumstances. A concise and specific compilation of practical recommendations was made with the aim of improving management of emergencies involving the head and neck region, while offering a safe alternative for patients and healthcare providers. In addition, we have made a brief summary of how these recommendations were adapted based on our socio-economic background and available health resources.

La enfermedad del coronavirus-2019 (COVID-19) se ha extendido a nivel mundial y se considera una emergencia sanitaria mundial. Los profesionales sanitarios representan un porcentaje importante de la población infectada, y los otorrinolaringólogos y cirujanos de cabeza y cuello corren un riesgo especial. Se han desaconsejado enérgicamente los procedimientos electivos, pero los trastornos urgentes aún implican un entorno peligroso. Realizamos una revisión no sistemática de las publicaciones y guías sobre el manejo de emergencias quirúrgicas de cabeza y cuello en el contexto de la pandemia de COVID-19. También se revisó la literatura que describe el manejo de la enfermedad con el fin de adaptar el tratamiento convencional a las circunstancias actuales. Se realizó una recopilación concisa y específica de recomendaciones prácticas con el objetivo de mejorar el manejo de las emergencias que involucran la región de la cabeza y el cuello, al tiempo que ofrece una alternativa segura para los pacientes y los proveedores de atención médica. Además, hemos hecho un breve resumen de cómo se adaptaron estas recomendaciones en función de nuestros antecedentes socioeconómicos y los recursos de salud disponibles.

Head and neck sarcomas: treatment outcomes in a tertiary referral center in Argentina.

PURPOSE: To analyze the clinical findings, management, and results of oncological treatments and to identify prognostic factors in patients diagnosed with head and neck sarcoma. METHODS: We performed a retrospective analysis including 48 adult patients with primary head and neck sarcomas, treated between 2006 and 2018 in a referral center of Argentina. RESULTS: The median follow-up time was 44 months (range: 4-146 months). Five-year overall survival was 68%. On univariate analysis, radiation-induced sarcomas (p=0.038) had worse survival. Five-year disease-free survival was 58% and local recurrence at 2 years was 22.7%. On multivariate analysis, positive/close resection margins (p=0.031), radiation-induced sarcomas (p=0.037), and mandibular and oral cavity location (p=0.002) were independent prognostic factors associated to local recurrence and shorter disease-free survival. CONCLUSION: Head and neck sarcomas are a rare entity. Surgery is feasible in more than 80% of patients, with an acceptable overall and disease-free survival. Radiation-induced sarcomas, location in the mandible and oral cavity, and close margins were significant prognostic factors in our population.

Clear cell odontogenic carcinoma: a rare pathology with an innovative resolution.

Clear cell odontogenic carcinoma (CCOC) is an uncommon condition that has been considered malignant since 2005. The clinical presentation usually involves an asymptomatic swelling, which typically affects the anterior mandible in middle-aged women; it has neither clinical nor radiological defining features. Immunohistochemical analysis usually aids diagnosis, as clear cells are also associated with other clear cell carcinomas and benign tumors. Radical surgery is the gold standard of treatment and usually needs microsurgical reconstruction with bone transference for restoration of facial anatomy and adequate function.  We present the case of a young woman with CCOC whose tumor removal and reconstructive surgery were planned virtually and assisted by intraoperative navigation. The novelty of the reconstructive procedure was the replacement of the fibula cutting guides for intraoperative navigation of the osteotomies. We present a brief review of CCOC and the benefits of using computer-assisted surgery (CAS) in high-complexity cases like this one.

[Ectopic hyperparathyroidism. Detection of mediastinal localization]. / Hiperparatiroidismo ectópico. Detección de la localización mediastinal.

The ectopic parathyroid tissue is a frequent cause of recurrent hyperparathyroidism (HPT), accounting 16% in primary HPT and 14% in secondary cases. Although intrathoracic ectopic glands represent 25-35% of all ectopic cases, only 2% requires thoracic surgery. The aim of this study is to report a case series of patients with ectopic mediastinal HPT treated by thoracic approach in a private institution in Argentina. This is a retrospective analysis from January 2006 to June 2019. All patients diagnosed with ectopic hyperparathyroidism who required a thoracic surgical approach were included. During this period, 728 patients with primary HPT and secondary HPT were treated. Six with primary HPT and 3 with secondary HPT required a thoracic approach. Six video-assisted thoracoscopy surgeries (VATS) and 3 sternotomies were performed. None of them presented serious posoperative complications. Frozen section biopsy was used in all cases. iPTH was measured in 8 cases, with a mean drop of 65% after 15 minutes. Final pathology reports confirmed 5 adenomas and 4 hyperplasias. Our case series reported an incidence of 1.65% (12/728) mediastinal parathyroids, while 1.24% (9/728) received surgical treatment at our institution. Intraoperative frozen section and PTHi are useful to confirm the diagnosis and to avoid recurrences. Although VATS is a safe and efficient treatment option, it depends on surgical training and availability. In terms of diagnostic imaging resources, sestamibi remains the current gold standard. However, 18F-choline PET/CT may arise as a new diagnostic tool. The possibility of obtaining evidence-based conclusions requires studies with higher number of patients.

El tejido paratiroideo ectópico es una causa frecuente de recurrencia del hiperparatiroidismo (HPT) siendo de 16% en primarios y 14% en secundarios. La localización intratorácica representa el 20-35%, pero solo un 2% requiere una cirugía torácica. El objetivo fue analizar una cohorte de pacientes con diagnóstico de HPT mediastinal operados en un hospital de alta complejidad de Argentina. Se realizó un estudio retrospectivo de todos los operados por HPT entre enero de 2006 y julio 2019 en ese hospital. Se incluyeron aquellos que requirieron acceso torácico por HPT ectópico. En este período se trataron 728 pacientes con HPT primario y secundario. Seis con primario y 3 con secundario requirieron cirugía torácica. Se realizaron 6 videotoracoscopias (VATS) y 3 esternotomías, sin complicaciones graves. Se utilizó biopsia por congelación en todos y dosaje de paratohormona intraoperatoria (PTHi) en 8 casos, que descendió en promedio 65% respecto al valor basal. Se confirmaron 5 adenomas y 4 hiperplasias. La enfermedad paratiroi dea mediastinal representó el 1.65% (12/728), mientras que recibieron tratamiento quirúrgico en nuestra institución 1.24% (9/728). La biopsia por congelación y el descenso de PTHi resultan útiles para confirmar el foco y eventualmente disminuir el riesgo de recurrencia. La VATS es segura pero depende del entrenamiento y de la disponibilidad en el medio asistencial. Si bien el sestamibi es el método con mayor sensibilidad, se propone el uso de 18F-colina PET/TC ante la sospecha de HPT ectópico. La posibilidad de obtener conclusiones basadas en la evidencia requiere de estudios con mayor número de pacientes.

Hiperparatiroidismo ectópico: Detección de la localización mediastinal / Ectopic hyperparathyroidism. Detection of mediastinal localization

El tejido paratiroideo ectópico es una causa frecuente de recurrencia del hiperparatiroidismo (HPT) siendo de 16% en primarios y 14% en secundarios. La localización intratorácica representa el 20-35%, pero solo un 2% requiere una cirugía torácica. El objetivo fue analizar una cohorte de pacientes con diagnóstico de HPT mediastinal operados en un hospital de alta complejidad de Argentina. Se realizó un estudio retrospectivo de todos los operados por HPT entre enero de 2006 y julio 2019 en ese hospital. Se incluyeron aquellos que requirieron acceso torácico por HPT ectópico. En este período se trataron 728 pacientes con HPT primario y secundario. Seis con primario y 3 con secundario requirieron cirugía torácica. Se realizaron 6 videotoracoscopias (VATS) y 3 esternotomías, sin complicaciones graves. Se utilizó biopsia por congelación en todos y dosaje de paratohormona intraoperatoria (PTHi) en 8 casos, que descendió en promedio 65% respecto al valor basal. Se confirmaron 5 adenomas y 4 hiperplasias. La enfermedad paratiroi dea mediastinal representó el 1.65% (12/728), mientras que recibieron tratamiento quirúrgico en nuestra institución 1.24% (9/728). La biopsia por congelación y el descenso de PTHi resultan útiles para confirmar el foco y eventualmente disminuir el riesgo de recurrencia. La VATS es segura pero depende del entrenamiento y de la disponibilidad en el medio asistencial. Si bien el sestamibi es el método con mayor sensibilidad, se propone el uso de 18F-colina PET/TC ante la sospecha de HPT ectópico. La posibilidad de obtener conclusiones basadas en la evidencia requiere de estudios con mayor número de pacientes.

The ectopic parathyroid tissue is a frequent cause of recurrent hyperparathyroidism (HPT), accounting 16% in primary HPT and 14% in secondary cases. Although intrathoracic ectopic glands represent 25-35% of all ectopic cases, only 2% requires thoracic surgery. The aim of this study is to report a case series of patients with ectopic mediastinal HPT treated by thoracic approach in a private institution in Argentina. This is a retrospective analysis from January 2006 to June 2019. All patients diagnosed with ectopic hyperparathyroidism who required a thoracic surgical approach were included. During this period, 728 patients with primary HPT and secondary HPT were treated. Six with primary HPT and 3 with secondary HPT required a thoracic approach. Six video-assisted thoracoscopy surgeries (VATS) and 3 sternotomies were performed. None of them presented serious posoperative complications. Frozen section biopsy was used in all cases. iPTH was measured in 8 cases, with a mean drop of 65% after 15 minutes. Final pathology reports confirmed 5 adenomas and 4 hyperplasias. Our case series reported an incidence of 1.65% (12/728) mediastinal parathyroids, while 1.24% (9/728) received surgical treatment at our institution. Intraoperative frozen section and PTHi are useful to confirm the diagnosis and to avoid recurrences. Although VATS is a safe and efficient treatment option, it depends on surgical training and availability. In terms of diagnostic imaging resources, sestamibi remains the current gold standard. However, 18F-choline PET/CT may arise as a new diagnostic tool. The possibility of obtaining evidence-based conclusions requires studies with higher number of patients.

Head and Neck Tumors: Management of Primary Undifferentiated Pleomorphic Sarcoma.

INTRODUCTION: Sarcomas account for 1% of all tumors originated in the head and neck regions in adults. They constitute a heterogeneous group of tumors of mesenchymal origin with multiple histological variants. The undifferentiated pleomorphic sarcoma (UPS) subtype is the most frequent variant with an incidence range of 2.7-38%. MATERIALS AND METHODS: This retrospective case series was conducted on 11 patients who were diagnosed with UPS and treated in our institution in the last 11 years. RESULTS: According to the results, 26.8% of the sarcomas corresponded to UPS variant. Out of 11 patients, 5 cases were female. The median age of the participants was 58 years (range: 18-74 years). Seven and four patients were T1b and T2b, respectively. Ten patients had no metastasis at the moment of diagnosis. Six patients were categorized as intermediate-grade, and the remaining (n=5) were classified as high-grade. The most frequent location was the scalp (n=3). In the patients undergoing surgery, the mean follow-up duration was 52 months. Disease-free survival (DFS) rates were obtained at 70%, 50%, and 50% in the 1st, 3rd, and 5th years, respectively, with the mean DFS of 36 months. In addition, the overall survival rates in the 1st, 3rd, and 5th years were 100%, 100%, and 83%, respectively. CONCLUSION: The UPS represented the most common histological subtype in our series. They tend to be intermediate or high-grade tumors. An acceptable global survival rate justifies surgical treatment as the main therapeutic tool.

Reconstruction of Hind and Mid-Foot Defects after Melanoma Resection Using the Reverse Sural Flap: A Case Series.

Background Melanoma resection creates important soft tissues defects, which are difficult to manage when located on the weight-bearing heel and mid foot. There is little evidence on the use of the reverse-flow sural flap for this type of reconstruction. Objective This study reports our case series on the reconstructive management of the hind and mid-foot defects after melanoma resection using the reverse sural artery flap. Materials and Methods This is a retrospective study of four consecutive patients treated with resection of melanoma of the feet and reconstruction with reverse sural artery flap from 2006 to 2009. Results The mean age of the patients was 54 years, three were females, and one was male. Three of the defects were located on the weight-bearing heel, the other on the mid-foot dorsum. The melanomas were fully resected with wide margins. Three patients were reconstructed primarily, whereas one patient was reconstructed 4 weeks after the resective surgery. This series revealed 100% flap survival and there was no partial necrosis. Major complications were not observed. The four patients completely recovered the function of the affected limb. Conclusion The reverse sural flap is a viable option for the reconstruction of foot defects after melanoma resection.

Major liver resection as definitive treatment in post-cholecystectomy common bile duct injuries.

BACKGROUND: Common bile duct injuries (CBDI) are serious complications of cholecystectomies which are often associated with vascular involvement, meaning that their management represents a major challenge to the physician. We present our experience in major hepatectomy due to CBDI, highlighting indications, postoperative complications, and long-term outcomes. METHODS: From August 1993 to September 2013, 287 patients with CBDI were treated in our centre. In 15 patients of this group (5 %), a major hepatectomy was performed. Eleven patients presented E4 and four presented E5 injuries of Strasberg classification. Seven patients presented vascular involvement. In 12 patients, prior treatment attempts, either biliodigestive anastomosis, endoscopic or percutaneous drainage, was performed without success. The median time delay between lesional surgery and hepatectomy was 24 months. RESULTS: Right hepatectomy was performed in 10 patients and left hepatectomy in 5. Postoperative morbidity was 60 %. The incidence of serious complications (≥ grade IIIa of DC classification) was 40 %. There was no mortality in our study. The mean follow-up was 43.5 months and the overall survival was 100 %. Three patients had a single episode of ascendant cholangitis who were successfully treated with medical treatment. All other patients were asymptomatic during follow-up. No patients required further surgical procedures. CONCLUSION: In our series, major hepatectomy due to CBDI was a successful treatment with high rates of postoperative morbidity and excellent long-term outcomes which require a multidisciplinary approach in referral centres of HPB surgery.