A Case on Papillary Thyroid Carcinoma With Intraluminal Tracheal Extension: A Malaysian Experience and Literature Review.

Papillary thyroid carcinoma (PTC) is a common malignancy originating from the thyroid gland. In rare cases, it can invade the trachea, resulting in airway obstruction. Subsequent surgical planning may be complicated as the technique selected depends on a case-by-case basis. Here, we report a case of PTC with tracheal involvement and a literature review on the latest surgical options. A 56-year-old gentleman presented with an anterior neck swelling of 3 x 3 cm for 3 months. Flexible endoscopy showed irregular mass in the subglottic region. Subsequent aspiration for cytology confirmed a diagnosis of PTC. Neck contrast enhanced computed tomography showed an ill-defined lesion in the right thyroid (3.1 x 3.8 x 2.9 cm) with a subtle irregularity of the adjacent tracheal wall suggestive of infiltration. The findings indicated a clinical staging of cT4aN0M0 (Stage III) with Shin's staging of Stage IV. The patient underwent a total thyroidectomy and a single-stage partial cricoid-tracheal resection with anastomosis. There were no immediate post-operative complications reported. Unfortunately, the patient suffered from pulmonary embolism, which eventually resulted in his demise. A subsequent histopathology report confirmed the diagnosis of PTC. Surgical planning for such cases may be complicated. The risk of recurrent laryngeal nerve injury is increased as the site of resection is close to the nerve. Multiple intraoperative nerve monitoring systems may be required. Meticulous planning of intraoperative airway management is needed as a large intraluminal tumor may interfere with intubation. Generally, extensive tracheal invasion would require radical surgical approaches such as circumferential resection and total laryngectomy. Less extensive cases can be treated with shave excision or window resection. PTC with tracheal invasion is an uncommon condition, and surgical excision is indicated for cases with high Shin's staging.

A Miraculous Save: Gangrenous Bowel and Meckle's Diverticulum With Acute Superior Mesenteric Artery Thrombosis.

The superior mesenteric artery (SMA) is vital for parts of the small intestine and ascending colon. Thrombosis of this major artery is a severe and potentially fatal condition involving the occlusion of the arterial vascular supply, causing ischemia predisposing to gangrene. Meckel's diverticulum is a congenital outpouching in the lower part of the small intestine. The condition of gangrenous meckels diverticulum is, therefore, even more limited. This study presents a unique case of a 45-year-old male with coexisting features of SMA thrombus with acute small bowel intestinal obstruction. During the study, the patient was found to have sickle cell anemia with an AS pattern, which may have predisposed the formation of a thrombus. The patient underwent sequential management of active thrombus by thrombolysis first, followed by resection anastomosis for gangrenous bowel. With precise monitoring and therapeutic care, the patient made a remarkable recovery. The condition possesses a high mortality rate. Prompt recognition and timely intervention in this case are of utmost significance.

Surgery for tracheal and laryngotracheal stenosis: a historical case series.

OBJECTIVES: Benign (laryngo-)tracheal stenosis is a relatively rare pathology and its surgical treatment is performed only at few specialized centres. This study aims to investigate outcomes after (laryngo-)tracheal resection-anastomosis, to explore potential risk factors for postoperative complications and to assess whether, over a 33-year period, there were major changes in surgical indications, techniques or outcomes. METHODS: Retrospective, single-centre review of all consecutive patients who underwent tracheal or laryngo-tracheal resection/anastomosis for benign pathologies from 1990 to 2023. RESULTS: Overall, 211 patients underwent tracheal (149 patients, 70.6%) and laryngo-tracheal (62 patients, 29.4%) resection-anastomosis. Of these, 195 patients (93.8%) were affected by iatrogenic stenosis, while 13 (6.2%) suffered from idiopathic stenosis. The median length of stenosis was 25 mm (interquartile range 1-3, 20-30). The overall morbidity rate was 27.5%, while major morbidity occurred in 10.5% of cases. One patient (0.5%) died in the postoperative period. Glottic oedema (17 patients, 8.1%), granulations (12 patients, 5.7%) and restenosis (10 patients, 4.7%) were the main complications. The only independent risk factor for postoperative complications was the length of the resected airway (P = 0.019). In the latest half of the study period, an older median age was observed, and no patient with idiopathic tracheal stenosis underwent surgery. Postoperative outcomes were comparable between surgical eras. CONCLUSIONS: Surgical treatment of (laryngo-)tracheal stenosis is challenging and should be performed by specialized centres. In our experience, morbidity and mortality rates were satisfactory, and in most cases, patients could breathe without tracheostomy. The length of the stenosis was the most significant risk factor for postoperative complications.

Exploring the uncommon: A case report on localized peritonitis caused by ingested toothpick.

INTRODUCTION: Bowel perforation is a serious emergency. Occasionally, sharp objects like toothpicks can get stuck in narrow parts of the small intestine, potentially resulting in impaction, obstruction, or perforation. PRESENTATION OF CASE: A 20-year-old male arrived at our hospital's emergency department with sudden, severe abdominal pain persisting for 24 h. On examination, his abdomen showed tenderness, and bowel sounds were reduced. Contrast-enhanced computed tomography (CECT) indicated possible small intestine inflammation due to a foreign object and a diagnostic laparoscopy revealed a hyperemic terminal ileum. DISCUSSION: This case involves ileal perforation from an unnoticed toothpick ingestion. Detecting foreign object perforations is challenging, often leading to misdiagnoses and CT scans are the most effective for toothpick detection. Definitive diagnosis is through laparoscopy, and treatment varies between laparoscopic suturing to intestinal resection. CONCLUSION: Healthcare providers must consider toothpick ingestion in cases of acute abdominal symptoms to avert treatment delays and potential life-threatening outcomes.

Hemicricoidectomy with modified rotational thyro-crico-tracheal anastomosis: a newborn in the family of crico-tracheal resection and anastomosis techniques.

Objective: The aim of the present study is to describe our novel surgical technique of hemicricoidectomy and reconstruction with modified rotational thyro-crico-tracheal anastomosis for the treatment of non-squamous cell subglottic tumours. The procedure has been defined as Type E crico-tracheal resection and anastomosis (CTRA) following the University of Brescia (C)TRA classification introduced elsewhere. Methods: A detailed anatomical step-by-step dissection was reproduced and illustrated on a cadaveric laryngo-tracheal specimen. Moreover, oncological and functional outcomes of the first 5 patients who underwent Type E CTRA at our Institution between October 2016 and September 2022 are described. Results: Three patients underwent Type E CTRA for cricoid chondrosarcoma (CS) and 2 patients for subglottic adenoid cystic carcinoma (ACC). No post-operative complication was reported. All patients maintained intact oral intake and an intelligible voice at discharge. All but one patient with obstructive sleep apnoea hypopnea syndrome and lung comorbidity were successfully decannulated before discharge. At the last follow-up (April 2023), one patient experienced local recurrence of CS that was still amenable to conservative treatment by transoral debulking, while the remaining patients were free of disease. Conclusions: With the proper indications, Type E CTRA is a feasible and effective conservative surgical technique for selected non-squamous cell subglottic tumours.

Effect of da Vinci robot-assisted versus traditional thoracoscopic bronchial sleeve lobectomy.

OBJECTIVE: To analyze the short-term effect of Da Vinci robot-assisted thoracoscopic (RATS) bronchial sleeve lobectomy, so as to summarize its safety and effectiveness. METHODS: It was a retrospective single-center study with the inclusion of 22 cases receiving RATS lobectomy and 49 cases of traditional thoracoscopic surgery. Further comparison was performed focusing on the baseline characteristics and perioperative performance of the two groups. RESULTS: Compared with the traditional thoracoscopic surgery group, RATS group had more advantages in the number of lymph nodes dissected (P = 0.003), shorter postoperative length of stay in the hospital (P = 0.040), shorter drainage time (P = 0.022), reduced drainage volume (P = 0.001). Moreover, this study found for the first time that there was a shortening in the operation of sleeve lobectomy by using Da Vinci robot-assisted surgical system (P = 0.001). The operation cost of RATS group is more expensive (96000 ± 9100.782 vs 63000 ± 5102.563 yuan; P＜0.001). CONCLUSION: Compared with the traditional thoracoscopic bronchial sleeve lobectomy, RATS lobectomy shows advantages of higher operating sensitivity, shorter operation time, faster postoperative recovery, and more lymph nodes dissected. Collectively, RATS bronchial sleeve lobectomy is safe and effective in operation.

Comparing Resection and Primary Anastomosis versus Hartmann's Stoma on the Mortality and Morbidity of Gangrenous Sigmoid Volvulus: Systematic Review and Meta-Analysis.

Background: Gangrenous sigmoid volvulus has a significant impact on morbidity and mortality. This study was conducted to compare sigmoid resection and primary anastomosis (RPA) with sigmoid resection and end colostomy (Hartmann's procedure) for gangrenous sigmoid volvulus. Methods: A systematic review and meta-analysis study design was employed to summarize retrospective cohort, prospective cohort, and randomised control trial studies published from inception to march 31, 2023. Searching was performed on Medline, CINAHAL, Web of Science, Google Scholar, the Cochrane Library, and ClinicalTrials.gov to locate eligible articles. Data searching, selection and screening, quality assessment of the included articles, and data extraction were done by two separate reviewers. RevMan 5.4 software with a fixed-effect Mantel-Haenszel model and Stata version 14 were used to analyze the data. The protocol registered on PROSPERO registration website (CRD42023413367). Results: Ten cohort studies and one randomised control trial with 724 patients were found; all of them were rated as being of moderate quality. The overall mortality after RPA was 15% (95%CI: 11-19%), and after Hartmann's procedure it was 19% (95%CI: 15-23%). Resection and primary anastomosis (RPA) for gangrenous sigmoid volvulus had slightly lower mortality rate than stoma (OR=0.98(95%CI: 0.68-1.42), p=0.07, I2=43%), which had no statistically significant difference. Resection and primary anastomosis (RPA) had a slightly higher morbidity rate than Hartmann's procedure (OR=1.01(95%CI: 0.66-1.55), p=0.30, I2=18%), which had no statistically significant difference. Conclusion: Sigmoid resection and primary anastomosis (RPA) and Hartmann's procedure had no significant differences in mortality and morbidity for the treatment of gangrenous sigmoid volvulus. Choice of the intervention for gangrenous sigmoid volvulus should be individualized with consideration of different detrimental factors.

Richter's Type Recurrent Indirect Inguinal Hernia, an Extremely Rare Occurrence: A Case Report.

Background: Richter's type recurrent indirect inguinal hernia remains to be an extremely rare entity reported scarcely. It may present with grave complications in the absence of symptoms and signs of intestinal obstruction. The aim of this study is to report a rare case of Richter's hernia after a previously repaired indirect inguinal hernia. Case Presentation: A 31-year-old male farmer came up with complaints of colicky abdominal pain and two episodes of vomiting. He had a previous right inguinal surgery. A physical examination revealed a full abdomen with right inguinal tenderness and oblique surgical scar. Abdominal ultrasound showed a bowel segment entrapped in the deep inguinal ring of the inguinal canal. Right inguinal exploration was done, and the finding was a gangrenous Richter's type recurrent indirect inguinal hernia. The patient was discharged and improved on the seventh post-operative day after resection and anastomosis. Discussion: Richter's hernia is a rare form of hernia that occurs when the anti-mesenteric border of the bowel is partly trapped in a tight hernial ring. Its rarity, combined with the fact that it may present in the absence of typical symptoms and signs of intestinal obstruction and local physical findings, poses a diagnostic challenge which often end up with complications like gangrenous bowel at the time of diagnosis. Conclusion: Richter's hernia can occur in an extremely rare form as Richter's type recurrent indirect inguinal hernia. A high degree of suspicion, an early referral and timely imaging on the provider's side may prevent mortality and morbidity.

Twisted Mesenteric Leiomyoma Mimicking Acute Appendicitis.

Leiomyoma is a benign tumor of smooth muscles and can essentially arise from any part of the body that contains smooth muscles. It is more commonly found in the uterus, while those from the gastrointestinal tract are rare. The spectrum of clinical presentation is rather wide, from a vague abdominal discomfort or acute abdomen mimicking more common diagnoses such as acute appendicitis or acute gastroenteritis to features of intestinal obstruction and gastrointestinal bleeding. Here, we share our experience with a case of a young woman whose symptoms and signs were typical of acute appendicitis, which intraoperatively turned out to be a twisted mesenteric tumor located at 70 cm from duodenojejunal flexure. The tumor was managed by segmental resection and anastomosis. She had an uneventful recovery postoperatively, and histopathological examination of the surgical specimen was consistent with an infarcted mesenteric leiomyoma. The rarity of this entity mimicking appendicitis is highlighted, and should it never get twisted, it would have probably remained unnoticed for the rest of her life. In the current era of laparoscopy, it is always wise to never skip a thorough examination of the whole length of the small bowel in order to locate this type of pathology.

Post-intubation tracheal stenosis in pediatric age group: single-center experiences of 24 years.

BACKGROUND AND AIM: Post-intubation tracheal stenosis (PITS) is an iatrogenic injury that involves some patients. Given the importance of this issue and the referral of a significant number of children with tracheal stenosis to Masih Daneshvari Hospital in Tehran, Iran, the present study investigated tracheal stenosis following prolonged intubation in the pediatric age group. METHODS: In this observational retrospective study, from 1994 to 2018, the medical records of all children under 14 years of age with a history of PITS were reviewed. Demographic and clinical characteristics including signs and symptoms, the underlying condition that leads to intubation, duration of intubation, type of stenosis, and the therapeutic approach, type of surgery, and follow-up were collected and analyzed using SPSS. RESULTS: Among 161 patients with a mean age of 9.8 ± 4.2 years, 69% were male. The site of stenosis was limited to the trachea in 47% and others both trachea and subglottic area were involved. The most common cause of intubation was trauma. The most common symptoms were dyspnea and wheezing. Success rates of reconstruction were 93.75% in type I, 82.15% in type II, and 35.70% in type III. Among the 16 patients who underwent Type III surgery, decannulation was not performed in 11 patients. Traction in the anastomosis and complications were stated in 26 and 10% of the patients respectively, a mortality rate of 8.7% was also reported. CONCLUSION: In the case of endotracheal intubation, PITS should be considered in the differential diagnosis of dyspnea in children as well as adults.

Predictors of Anastomotic Complications After Resection and Anastomosis for Tracheal Stenosis.

Resection and anastomosis is an effective option for the management of complex tracheal stenosis, however, it's not without the complications. This study aims at evaluating various factors predicting anastomotic complications after trachea resection and anastomosis. This is a retrospective analysis of database from a dedicated thoracic surgical unit in New Delhi, India over 7 years. An analysis of demographic details, perioperative variables including complications were carried out. Analysis of various factors predicting anastomotic complications was performed. Out of 65 patients in the study, 49 (75.3%) were males and 16 (24.7%) were females. Median age of the patients was 31 years. Stenosis was cervical in 80%, cervico-thoracic in 15.4% and thoracic in 4.6% of patients. Median length of stenosis was 2.9 cm (1-4.2). 53 (81.6%) patients had some kind of preoperative intervention, where as rest 12 (18.4%) patients had no intervention at all. Out of 65 patients, 26 (40%) had crico-tracheal anastomosis while 39 (60%) had tracheo-tracheal anastomosis. Median length of resected tracheal segment was 3.3 cm (1-5). Overall complication rate (anastomotic + non-anastomotic) was 18.4% in which anastomosis related were in 4 (6.1%) patients. Resection of tracheal segment ≥ 3.5 cm, presence of diabetes mellitus and pre-operative use of corticosteroids were statistically significant factors for the onset of complications. Perioperative mortality rate was 1.5% (n = 1). Length of resection > 3.5 cm, presence of diabetes mellitus and pre-operative prolonged use of corticosteroids were significant predictors for the anastomotic complications.

Sigmoid volvulus in an adolescent female: A case report.

INTRODUCTION AND IMPORTANCE: Sigmoid volvulus is a rare cause of intestinal obstruction in children and adolescent population. It's considered a disease of the elderly with a widely varying incidence worldwide. It is more common in areas referred to as "volvulus belt" (Middle East, Africa, the Indian subcontinent, Turkey, and South America). CASE PRESENTATION: We report a 16-year-old female who underwent emergency laparotomy for intestinal obstruction. We found a twisted sigmoid volvulus in 3600 degree clockwise. The sigmoid colon was distended and edematous with no perforation or gangrene. Resection of the redundant colon was performed followed by primary anastomosis. CLINICAL DISCUSSION: Sigmoid volvulus remains an uncommon cause of intestinal obstruction among the adolescent age group. A high index of suspicion is necessary to reach a diagnosis and manage accordingly. Delay in diagnosis can lead to complications such as necrosis and perforation of the twisted colon. CONCLUSION: We present a rare cause of intestinal obstruction in a 16-year-old female due to sigmoid volvulus. Early diagnosis and management reduce morbidity and mortality.

Cecal volvulus in an adult male: A rare cause of intestinal obstruction: A case report.

INTRODUCTION AND IMPORTANCE: Cecal volvulus is uncommon cause of intestinal obstruction. It affects the ascending colon and the terminal part of the ileum which are twisted around the mesenteric pedicle. CASE PRESENTATION: We report the case of 37-year-old male who underwent emergency laparotomy for intestinal obstruction and found a twisted cecum with ileal knotting and anterior part of cecum necrosed. Resection of cecum and terminal ilium followed by end-to-end anastomosis of ileum to ascending colon were performed. CLINICAL DISCUSSION: Cecal volvulus remains an uncommon cause of intestinal obstruction with a surgical incidence of 2.8-7.1 cases per year per 1 million people. Delay in diagnosis can lead to complications such as necrosis and perforation of the cecum. CONCLUSION: We present a rare case of cecal volvulus in a 37-year-old male with necrosed part of the cecum without perforation. Early diagnosis and management can prevent perforation and reduce morbidity related to the cecal perforation.

Etiology and surgical management of pediatric acute colon perforation beyond the neonatal stage.

PURPOSE: Acute colon perforation is a pediatric surgical emergency. We aimed to analyze the different etiologies and clinical characteristics of acute non-traumatic colon perforation beyond the neonatal period and to identify surgical management and outcomes. METHODS: This retrospective study included 18 patients admitted with acute colon perforation and who received surgical treatment. RESULTS: Age of patients ranged between 1 month and 15 years. Five patients swallowed foreign objects (two swallowed magnets), two had colon perforation secondary to a malignant tumor (both colorectal adenocarcinoma) and two were iatrogenic (one prior colonoscopy, one air enema for intussusception). There was one perforation due to chemotherapy and Amyand's hernia respectively. The remaining seven patients had unknown etiologies; five of them were diagnosed with colitis. Fifteen (83.3 %) patients underwent open laparotomy, among which four attempted laparoscopy first. Three (16.7 %) patients underwent laparoscopic surgery. Fourteen (77.8 %) patients received simple suture repairs and four (22.2 %) received colonic resections and anastomosis. Four (22.2 %) patients received a protective diverting colostomy and three (16.7 %) received an ileostomy. CONCLUSIONS: There is a wide range of etiology besides necrotizing enterocolitis and trauma, but a significant portion of children present with unknown etiology. Type of surgery elected should be dependent on the patient's etiology, disease severity and experience of surgeons.

A Review of Normal Intestinal Healing, Intestinal Anastomosis, and the Pathophysiology and Treatment of Intestinal Dehiscence in Foreign Body Obstructions in Dogs.

Small intestinal anastomoses are commonly performed in veterinary medicine following resection of diseased or devitalized intestinal tissue. Traditionally, suture has been employed to anastomose intestinal ends. However, use of intestinal staplers has become increasingly popular due to the ability to produce a rapid anastomosis with purported superior healing properties. Under normal conditions, intestinal healing occurs in three phases: inflammatory, proliferative, and maturation. Dehiscence, a devastating consequence of intestinal anastomosis surgery, most often occurs during the inflammatory phase of healing where the biomechanical strength of the anastomosis is almost entirely dependent on the anastomotic technique (suture or staple line). The resulting septic peritonitis is associated with a staggering morbidity rate upwards of 85% secondary to the severe systemic aberrations and financial burden induced by septic peritonitis and requirement of a second surgery, respectively. Intraoperative and postoperative consideration of the multifactorial nature of dehiscence is required for successful patient management to mitigate recurrence. Moreover, intensive postoperative critical care management is necessitated and includes antibiotic and fluid therapy, vasopressor or colloidal support, and monitoring of the patient's fluid balance and cardiovascular status. An understanding of anastomotic techniques and their relation to intestinal healing will facilitate intraoperative decision-making and may minimize the occurrence of postoperative dehiscence.

Foreign body esophagus: Six years of silence.

Foreign body esophagus remains one of the common medical emergencies which may lead to significant morbidity and mortality. Sharp objects, batteries, and elderly with foreign body esophagus should be treated with emergent removal owing to the complications that might ensue. Endoscopic removal is the preferred choice of treatment but for large foreign body, sharp foreign body, and so on, rigid esophagoscopic removal might be more preferable. Foreign body esophagus though an obvious situation might at times be missed. It is important to make an early definitive diagnosis. We report a unique case of missed foreign body (denture) esophagus despite the obvious signs and symptoms. Definitive diagnosis was made only after 6 years due to the lack of definitive diagnostic procedures and expertise. The foreign body was impacted in the mucosal wall of the esophagus requiring Gastric resection and anastomosis (with McKeown procedure). With this we have tried to highlight the pitfalls in the diagnosis and management of foreign body esophagus. We report a case of a 55-year-old female who presented to the Emergency Room with history of progressive dysphagia and odynophagia for 6 years which was aggravated for the past 6 months. A radiological diagnosis was made. It was followed by a failed attempt of endoscopic removal which warranted the surgical removal of the foreign body.

Successful implementation of intestinal resection and anastomosis in non-human primates suggests the possibility of longitudinal intestinal research.

Intestinal biopsy is a basic experimental method for studying pathological changes in the intestinal tract during human immunodeficiency virus (HIV) infection. In this study, jejunal resection and anastomosis were successfully performed in 12 Chinese rhesus macaques ( Macaca mulatta). The sampled gut tissues were then examined by hematoxylin and eosin (H&E) staining, electron microscopy, flow cytometry, immunofluorescence detection, and RNA quality analysis to ensure suitability for histological, physiological, pathological, and immunological detection, as well as mechanistic analysis at the cellular and molecular level. Importantly, the surgery did not affect the ratio or number of immune cells in peripheral blood or the concentration of lipids, proteins, and vitamins in plasma, which are important indicators of nutritional status. Our results thus indicated that jejunal resection and anastomosis are feasible, and that immune homeostasis and intestinal barrier integrity are not altered by surgery. All macaques recovered well (except for one), with no postoperative complications. Therefore, this animal surgery may be applicable for longitudinal intestinal research related to diseases such as acquired immunodeficiency syndrome (AIDS).

Systematic review and meta-analysis comparing primary resection and anastomosis versus Hartmann's procedure for the management of acute perforated diverticulitis with generalised peritonitis.

BACKGROUND: Surgical strategies for acute perforated diverticulitis with generalised peritonitis remain controversial. This study aimed to meta-analyse trials comparing primary resection and anastomosis (PRA) to Hartmann's procedure (HP) for Hinchey III/IV diverticulitis. METHODS: A systematic literature search was conducted to identify observational studies and randomised control trials (RCTs) of patients with Hinchey III/IV diverticulitis undergoing sigmoidectomy that compared PRA to HP. The methodological quality of the included studies was assessed systematically (Newcastle-Ottawa, Jadad and Cochrane risk of bias scores) and a meta-analysis was performed. RESULTS: After removal of duplicates, 12 studies including 4 RCTs were identified. The analysis included 918 patients, of whom 367 (39.98%) underwent PRA. Both the initial stoma rate (risk ratio [RR] persistent stoma 0.43, 95% confidence interval [CI] 0.26, 0.71, p = 0.001; I2 = 99%, p < 0.0001) and the rate of permanent stoma after combining the first (emergency surgery) and second (stoma reversal) procedures were lower in the PRA group. There was no difference in in 30-day mortality; however, PRA resulted in a reduction in overall mortality as well as major complications after the initial operation (RR 0.67, 95% CI 0.46, 0.97, p = 0.03; I2 = 22%, p = 0.26), stoma reversal (RR 0.48, 95% CI 0.26, 0.92, p = 0.03; I2 = 0%, p = 0.58) and when combining both procedures (RR 0.67, 95% CI 0.51, 0.88, p = 0.005; I2 = 0%, heterogeneity p = 0.58). A subgroup analysis of stoma reversal rates using data from only RCTs were consistent (RR permanent stoma, 0.33, 95% CI 0.13, 0.85, p = 0.02; I2 = 77%, p = 0.004) with the findings of the overall analysis. CONCLUSIONS: This meta-analysis demonstrates that PRA used in the management of haemodynamically stable patients with Hinchey grade III/IV diverticulitis leads to a lower overall persistent stoma rate, with reduced morbidity compared with the traditional management.

Multicentric study applying the european laryngological society classification of benign laryngotracheal stenosis in adults treated by tracheal or cricotracheal resection and anastomosis.

OBJECTIVES/HYPOTHESIS: Introduction and widespread use of cricotracheal resection and anastomosis (CTRA) as routine treatment for high-grade benign laryngotracheal stenosis (LTS) led to the need for a new classification system that could accurately predict surgical outcomes by integrating crucial stenosis and patient-related information. In 2015, the European Laryngological Society (ELS) proposed a new classification for benign LTS. We retrospectively tested it in adults treated at three referral centers to assess its reliability in predicting surgical outcomes. STUDY DESIGN: Retrospective cohort study. METHODS: We included 166 adults treated by open tracheal resection and anastomosis (TRA) and CTRA procedures, restaged according to the ELS classification evaluating grade of stenosis (I-IV, Myer-Cotton), number of subsites involved, and presence of systemic comorbidities. We correlated these parameters with decannulation, number of retreatments, and complications. RESULTS: Final decannulation was predicted by a proposed ELS score ≥ IIIb, history of previous treatment, and length of resection (P < .05). Decannulation was achieved in 99% of patients without and in 88% of patients with surgical complications (P < .01). The incidence of surgical complications was related to the proposed ELS score (P < .01); an ELS score < IIIb showed a lower complication rate compared to patients with a ≥ IIIb score (32.8% vs. 57.7%, P < .01). Additional treatment was required in 73 (44%) patients (mean = 2.7 ± 2.2, range = 1-11). ELS score ≥ IIIb, length of resection, and occurrence of surgical complications predicted the number of such treatments (P < .05, P < .05, and P < .001, respectively). CONCLUSIONS: ELS classification of benign LTS is able to accurately predict success in adult TRA/CTRA procedures and may be helpful in choice of therapy and patient counseling. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:1640-1645, 2020.

[Analysis on operational safety of chronic radiation intestinal injury].

Objective: To investigate the safety and efficacy of surgical treatment for chronic radiation intestinal injury. Methods: A descriptive cohort study was performed. Clinical data of 73 patients with definite radiation history and diagnosed clinically as chronic radiation intestinal injury, undergoing operation at Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from January 1, 2012 to February 28, 2019, were reviewed and analyzed retrospectively. Patients did not undergo operation or only received adhesiolysis were excluded. All the patients had preoperative examination and overall evaluation of the disease. According to severity of intestinal obstruction and patients' diet, corresponding nutritional support and conservative treatment were given. Surgical methods: The one-stage bowel resection and anastomosis was the first choice for surgical treatment of chronic radiation intestinal injury. Patients with poor nutritional condition were given enterostomy and postoperative enteral nutrition and second-stage stoma closure and intestinal anastomosis if nutritional condition improved. For those who were unable to perform stoma closure, a permanent stoma should be performed. Patients with severe abdominal adhesion which was difficult to separate, enterostomy or bypass surgery after adhesiolysis would be the surgical choice. For patients with tumor metastasis or recurrence, enterostomy or bypass surgery should be selected. Observation parameters: the overall and major (Clavien-Dindo grades III to V) postoperative complication within 30 days after surgery or during hospitalization; mortality within postoperative 30 days; postoperative hospital stay; time to postoperative recovery of enteral nutrition; time to removal of drainage tube. Results: Of the 73 patients who had been enrolled in this study, 10 were male and 63 were female with median age of 54 (range, 34-80) years. Preoperative evaluation showed that 61 patients had intestinal stenosis, 63 had intestinal obstruction, 11 had intestinal perforation, 20 had intestinal fistula, 3 had intestinal bleeding, and 6 had abdominal abscess, of whom 64(87.7%) patients had multiple complications. Tumor recurrence or metastasis was found in 15 patients. A total of 65(89.0%) patients received preoperative nutritional support, of whom 35 received total parenteral nutrition and 30 received partial parenteral nutrition. The median preoperative nutritional support duration was 8.5 (range, 6.0-16.2) days. The rate of one-stage intestine resection was 69.9% (51/73), and one-stage enterostomy was 23.3% (17/73). In the 51 patients undergoing bowel resection, the average length of resected bowel was (50.3±49.1) cm. Among the 45 patients with intestinal anastomosis, 4 underwent manual anastomosis and 41 underwent stapled anastomosis; 36 underwent side-to-side anastomosis, 5 underwent end-to-side anastomosis, and 4 underwent end-to-end anastomosis. Eighty postoperative complications occurred in 39 patients and the overall postoperative complication rate was 53.4% (39/73), including 39 moderate to severe complications (Clavien-Dindo grade III-V) in 20 patients (27.4%, 20/73) and postoperative anastomotic leakage in 2 patients (2.7%, 2/73). The mortality within postoperative 30 days was 2.7% (2/73); both patients died of abdominal infection, septic shock, and multiple organ failure caused by anastomotic leakage. The median postoperative hospital stay was 13 (11, 23) days, the postoperative enteral nutrition time was (7.2±6.9) days and the postoperative drainage tube removal time was (6.3±4.2) days. Conclusions: Surgical treatment, especially one-stage anastomosis, is safe and feasible for chronic radiation intestine injury. Defining the extent of bowel resection, rational selection of the anatomic position of the anastomosis and perioperative nutritional support treatment are the key to reduce postoperative complications.