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Management of Enlarging tracheoesophageal fistula (TEF) with Voice Prosthesis in Laryngectomized Head and Neck Cancer Patients. Objectives: An enlarging TEF following voice prosthesis placement impacts patient quality of life, risks airway compromise, and can lead to aspiration pneumonia. Pharyngoesophageal strictures have previously been reported to be associated with TEF enlargement and leakage. We describe a series of patients with enlarging TEFs after Tracheoesophageal puncture (TEP) for voice prosthesis who required pharyngoesophageal reconstruction. Methods: Retrospective case series of laryngectomized H&N cancer patients with primary or secondary TEP who underwent surgical management for enlarging TEF site between 6/2016–11/2022. Results: Eight patients were included. The mean age was 62.8 years old. Seven patients had a history of hypothyroidism. Of seven with prior H&N radiation history, two had both historical and adjuvant radiation. Two of the eight TEPs were placed secondarily. Mean time from TEP to enlarging TEF diagnosis was 891.3 days. Radial forearm‐free flaps were used in five patients. Six had stenosis proximal to the TEF whereas one had distal stenosis and one had no evidence of stenosis. Mean length of stay was 12.3 days. Mean follow‐up was 400.4 days. Two required a second free flap for persistent fistula. Conclusion: Surgical reconstruction of enlarging TEFs due to TEP/VP placement is effective in combination with addressing underlying pharyngeal/esophageal stenosis contributing to TEF enlargement and leakage. Radial forearm‐free flaps have the additional benefit of a long vascular pedicle to access more distant and less‐irradiated recipient vessels. Many fistulae are resolved after the first flap reconstruction, but some may require subsequent reconstruction in case of failure. Level of Evidence: 4 Laryngoscope, 134:198–206, 2024 [ABSTRACT FROM AUTHOR]

Background: Head and neck osteosarcoma (HNOS) is a rare primary bone tumor with limited data to guide treatment approaches. Methods: The NCDB was used to identify patients diagnosed with HNOS. Kaplan–Meier and Cox multivariate regression were used to examine the impact of each treatment on overall survival (OS). Results: We identified 821 patients diagnosed with HNOS. Utilization of neoadjuvant chemotherapy + surgery increased from zero cases in 2004 to 24% of cases in 2016. Among surgically treated patients, 5‐year OS was 55.8% (CI: 51.7–60.1%). No difference was seen in OS between each treatment cohort on multivariate analysis. However, neoadjuvant chemotherapy + surgery + adjuvant chemotherapy had improved 18‐month survival compared to surgery alone (95.8% vs. 78.5%, p = 0.031). Conclusions: Our study demonstrated no survival benefit in perioperative chemotherapy or radiation therapy; however, short‐term survival improvement in patients receiving both neoadjuvant and adjuvant chemotherapy displays promise and requires further investigation. [ABSTRACT FROM AUTHOR]

The aim of this study is to evaluate the impact of transoral robotic surgery (TORS) compared to nonrobotic surgery (NRS) on overall survival in oropharyngeal squamous cell carcinoma (OPSCC). We performed a retrospective study of patients with HPV+ and HPV− OPSCC undergoing TORS or NRS with neck dissection using the National Cancer Database from the years 2010–2016. Among patients with OPSCC in our cohort, 3167 (58.1%) patients underwent NRS and 2288 (41.9%) underwent TORS. TORS patients demonstrated better overall survival than NRS patients (HPV+ patients: aHR 0.74, p = 0.02; HPV− patients: aHR 0.58, p < 0.01). Subsite analysis showed TORS was correlated with improved survival in base of tongue (BoT) primaries for both HPV+ (aHR 0.46, p = 0.01) and HPV− (aHR 0.42, p = 0.01) OPSCC. Compared to NRS, TORS is associated with improved overall survival for HPV+ and HPV− OPSCC, as well as greater overall survival for BoT primaries. [ABSTRACT FROM AUTHOR]

Objectives: To determine the prevalence of Sensorineural Hearing Loss (SNHL) attributable to Sickle Cell Disease (SCD) in the global pediatric population and to identify factors contributing to its severity.Study Design: Meta-analysis.Methods: We performed a comprehensive literature search for scientific articles in PubMed, Scopus, CINAHL, Web of Science, and the Cochrane Library that reported the incidence of hearing loss in populations under 18 years of age with excluding studies analyzing patients on iron chelation therapy, adults, or those without objective audiological analysis.Results: We identified 138 initial studies with 17 selected for analysis after applying the exclusion criteria. A total of 1,282 SCD patients and 553 controls were included in the meta-analysis. There was a statistically significant increase in the prevalence of SNHL in children with SCD compared to the general population with a cumulative risk ratio of 3.33.Conclusion: This is the first systematic investigation of the relationship between SCD and SNHL in pediatric patients across the globe. The increased prevalence of SNHL in the pediatric SCD population warrants future research into the predictors of SNHL severity and merits routine audiometric monitoring of SCD patients to reduce the social and developmental morbidity of hearing loss at a young age. PROSPERO Registration #: CRD42019132601. Laryngoscope, 131:1147-1156, 2021. [ABSTRACT FROM AUTHOR]

Byline: William E. Spangler, David P. Strum, Luis G. Vargas and Jerrold H. May In the face of increasing demands for services and tighter constraints on resources, medical centres are searching for ways to improve efficiencies and reduce costs. This paper describes the design and development of a system, called Resource Coordination for Surgical Services (RCSS), that is intended to help managers improve overall utilisation of surgical suites.

Byline: William E. Spangler, David P. Strum, Luis G. Vargas, Jerrold H. May This chapter explores cost reduction and capacity planning in surgical services. Classical operating suite (OR) utilisation is defined as the ratio of total OR time used to total OR time budgeted, but that definition of utilisation allows scheduling inefficiencies and costs to go undetected. Instead, a more accurate description of the overall use of resources can be achieved by dividing classical utilisation into under-utilisation and over-utilisation, and incorporating those measures within a minimal cost analysis model. The model, which was developed from a study of surgical case records collected over six years, indicates that the potential cost savings are significant.

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Notably, the authors highlight their evidence from a retrospective series with chart review of 35 patients with maxillofacial osteosarcomas, 24 of whom were treated with neoCT. Reply to Letter to the Editor regarding "Head and neck osteosarcomas: An analysis of treatment trends and survival outcomes in the United States (2004-2016)" While neoCT patients in our study were resected at a median of 10.2 (neoCT + Surgery) and 11.7 (neoCT +Surgery/Chemo) weeks following their first neoCT treatment, the NCDB does not record clinical or radiologic progression or response. [Extracted from the article]

This paper reviews the general problem of surgical scheduling. We organize the literature based on the time frame or planning horizon of the schedule into six categories: capacity planning, process reengineering/redesign, the surgical services portfolio, procedure duration estimation, schedule construction, and schedule execution, monitoring, and control. We survey past work and suggest topics for potential future research in each of those areas. [ABSTRACT FROM AUTHOR]

This research describes a constraint-based heuristic model of capacity segmentation for outpatient facilities used to estimate the effect of segmentation constraints on stakeholders. Growth of free-standing ambulatory surgery centres has been dramatic in recent years with institutions being urged by governments and insurers to segment inpatients (IP) and outpatients (OP) to reduce costs and improve services. Critics of segmentation argue it is a false economy to separate inpatients and outpatients since pooling of patients in large IP facilities offers economies of scale and opportunities for parallel processing, not to mention elimination of infrastructure. We implemented a constraint-based heuristic model of capacity segmentation for OP facilities and used it to estimate the effect of segmentation on stakeholders. [ABSTRACT FROM AUTHOR]

Minimum surgical times are positive and often large. The lognormal distribution has been proposed for modeling surgical data, and the three-parameter form of the lognormal, which includes a location parameter, should be appropriate for surgical data. We studied the goodness-of-fit performance, as measured by the Shapiro-Wilk p-value, of three estimators of the location parameter for the lognormal distribution, using a large data set of surgical times. Alternative models considered included the normal distribution and the two-parameter lognormal model, which sets the location parameter to zero. At least for samples with n> 30, data adequately fit by the normal had significantly smaller skewness than data not well fit by the normal, and data with larger relative minima (smallest order statistic divided by the mean) were better fit by a lognormal model. The rule "If the skewness of the data is greater than 0.35, use the three-parameter log- normal with the location parameter estimate proposed by Muralidhar & Zanakis (1992), otherwise, use the two-parameter model" works almost as well at specifying the lognor- mal model as more complex guidelines formulated by linear discriminant analysis and by tree induction. [ABSTRACT FROM AUTHOR]

The plans for Resource Coordination for Surgical Services system (RCSS) incorporate a distributed objectbase with a coordinating server. User-centered information screens are customized for each geographic location in surgical services. User interfaces are designed to mimic paper lists and worksheets used by health care providers. Patient-specific and site-specific data will be entered and maintained by providers at each geographic location, but also rebroadcast and displayed for all providers. Although RCSS is primarily a communications system, it will also support review of surgical utilization and operative scheduling. [ABSTRACT FROM PUBLISHER]

A letter to the editor is presented in response to the article "Observations on Surgical Demand Time Series: Detection and Resolution of Holiday Variance," in the September 2008 issue.

Introduction: Tracheostomy is a commonly performed procedure in Otolaryngology and can be performed in different settings. We evaluate patient characteristics and cost efficacy of tracheostomy at the bedside versus operating room (OR)., Materials and Methods: Retrospective chart review was performed for adult intensive care unit (ICU) patients who underwent tracheostomy from 2020 to 2023. Data and cost of procedures were analyzed using descriptive statistics., Results: One hundred and sixty-five patients were included. One hundred and thirty-four (81.2%) patients underwent bedside tracheostomy. Age, sex, and BMI were not significantly different. Average time from consult to procedure and operative time was significantly shorter (p = 0.03; 0.008). There were no differences in postoperative complications, 30-day mortality, ICU length of stay (LOS), or overall LOS. Tracheostomy at the bedside offered a 73.1% cost reduction compared with performed in the OR., Conclusion: Advantages of bedside tracheostomy include decreased operative time, time from consult to procedure, and cost reduction for the hospital system. We advocate for consideration of bedside tracheostomy when appropriate., (© 2024 Wiley Periodicals LLC.)

Background: Surgical scheduling is complicated by both naturally occurring and human-induced variability in the demand for surgical services. Surgical demand time series are decomposed into periodic, lagged, and linear trends with frequent occurrences of nonconstant variations in mean and variance. The authors used time series methods to model surgical demand time series in order to improve the scheduling of scarce surgical resources., Methods: With institutional approval, the authors studied 47,752 surgeries undertaken at a large academic medical center. They initially extracted periodic information from the time series using two frequency domain techniques: the harmonic F test and the multitaper test. They subsequently extracted lagged (correlated) behavior using a seasonal autoregressive integrated moving average model. Finally, they used moving variance filters on the residuals to identify variance in the time series that coincided with major US holidays., Results: Linear terms such as periodic cycles, trends, and daily and weekly lags explained 80% of the variance in the raw time series. In the residuals, the authors used moving variance filters to detect nonlinear variance artifacts that correlated with surgical activities on specific US holidays., Conclusions: After extracting linear terms, the remaining variance was attributable to a combination of nonlinear and unexplained random events. The authors used the term holiday variance to describe a specific nonlinear disturbance in surgical demand attributable to statutory US holidays. Resolving these holiday variances may assist in management and scheduling of scarce surgical personnel and resources.

Left ventricular (LV) contraction dyssynchrony is not easily quantified. We previously described a model for quantifying LV dyssynchrony that referenced regional amplitude and phase angles to global LV systole using esmolol-induced regional dyskinesis. We tested the hypothesis that our sine wave model and phase angle analysis of regional dyssynchrony in a canine model could also assess dyssynchrony of contraction during regional ischemia. Hence we compared intracoronary esmolol and matched regional ischemia in 10 anesthetized open-chest dogs. Regional and total LV volumes (conductance catheter), piezoelectric crystal shortening, and LV pressures were measured before, during, and after esmolol-induced apical dyskinesis and matched regional ischemia. We defined regional phase angle of contraction (alpha) as the relative distance, measured in degrees, that regional minimal volume differed from global end-systole. We also compared maximal stroke volume (SV), observed effective SV (that portion of regional SV contributing to total SV for each treatment), and calculated effective SV (total regional SV x cosine alpha). Dobutamine infusion increased homogeneity of regional alpha relative to baseline. Both esmolol and ischemia significantly delayed (P < 0.05) apical contraction as quantified by increased alpha (12.4 degrees +/- 28.1 degrees to 27.4 degrees +/- 30.4 degrees and 54.2 degrees +/- 32.6 degrees , respectively) (mean +/- sd) and decreased regional effective SV (4.7 +/- 2.5 mL to 3.6 +/- 2.2 mL and 4 +/- 2.5 mL, respectively) relative to baseline. Our study indicates that intracoronary esmolol and ischemia induced qualitatively similar mechanical effects on myocardial function and that a sine wave model to estimate regional effective SV is a sensitive method to detect and quantify regional dyssynchrony induced by ischemia. Potentially, phase angle and regional amplitude analyses may prove to be effective measures to identify and quantify the beneficial effects of resynchronization therapies on myocardial function.

Unlabelled: We studied the effect of systemic dobutamine infusion (4 microg. kg(-1). min(-1) IV) on regional wall motion abnormalities (RWMAs) in eight anesthetized open-chested dogs. We hypothesized that infusion of small doses of dobutamine would reduce RWMAs and improve global ventricular function. Apical RWMAs were induced by local intracoronary boluses of 9.0 mg esmolol. Phase angles, effective stroke volume (SV), maximum SV, stroke work, and segmental shortening were compared among four left ventricular (LV) regions (apical, papillary, chordal, and basal) during baseline, dobutamine, esmolol, and dobutamine-esmolol treatments. The minimal global LV volume was designated as 0 degrees, and the cardiac cycle was divided into 360 intervals. Regional phase angles were defined as the distance (in degrees) that regional minimum volume differed from global minimal LV volume (end-systole). RWMA decreased blood pressure (92 +/- 2 mm Hg to 84 +/- 3 mm Hg) and increased LV end-diastolic pressure (1.8 +/- 0.5 mm Hg to 4.2 +/- 0.8 mm Hg). RWMA delayed regional contraction (-2.9 degrees +/- 1.6 degrees to 52.3 degrees +/- 1.5 degrees ) and decreased effective SV (2.3 +/- 0.4 mL to 1.6 +/- 0.3 mL) in the affected apical region but did not decrease maximal SV. Systemic infusion of dobutamine restored global LV function but failed to eliminate RWMA, as evidenced by decreased apical synchrony, effective SV, and stroke work. We concluded that systemic dobutamine restored global LV function but failed to correct RWMA., Implications: We examined the effect of systemic dobutamine on regional wall motion abnormalities (RWMAs) induced by intracoronary esmolol infusion in eight anesthetized dogs. Esmolol dilated the heart and decreased regional synchrony of contraction. Dobutamine restored cardiac function but failed to correct the asynchrony of regional contraction caused by esmolol-induced RWMAs.