Claudio Vicini

European position paper on drug-induced sedation endoscopy (DISE)

BackgroundAlthough drug-induced sedation endoscopy (DISE) represents the most widespread diagnostic tool for upper airway endoscopic evaluation of snoring and obstructive sleep apnea hypopnea syndrome (OSAHS), many controversies exist about how to perform the sedation, the indications for DISE, and how to report DISE findings. The present position paper reports on a consensus as proposed by a group of European experts in the field of DISE after discussion during a recent dedicated meeting.MethodsThe authors have evaluated all the available evidence reported in the literature and have compared experience among various departments in leading European centers in order to provide a standardization of the DISE procedure and an in-depth insight in the main aspects of this technique.ResultsA proposal of the DISE procedure standardization has been achieved with a general agreement concerning the terminology, indications, contraindications, required preliminary examinations, setting, technical equipment required, staffing, local anesthesia and nasal decongestion, patient positioning, basis and special diagnostic maneuvers, and the applied sedation drugs and observation windows. Otherwise, no consensus has been reached on a scoring and classification system.ConclusionsAlthough consensus has been reached on several aspects of the DISE procedure, some topics remain open to future research, such as a better analysis of the importance of positional aspects during DISE and a further comparison of the differences in degree, level and pattern of upper airway collapse observed during DISE versus during natural sleep and awake endoscopy. Finally, a universally accepted scoring and classification system is lacking.

Transoral Robotic Tongue Base Resection in Obstructive Sleep Apnoea-Hypopnoea Syndrome: A Preliminary Report

Purpose of the Study:To evaluate the feasibility, tolerability and efficacy of tongue base management by means of transoral robotic surgery (TORS) in patients suffering from the obstructive sleep apnoea-hypopnoea syndrome (OSAHS) primarily related to hypertrophy of the tongue base. Procedure:Seventeen patients with OSAHS principally related to tongue base hypertrophy were managed by means of TORS (Intuitive da Vinci®). Patients with a minimum follow-up of 3 months were evaluated. Results: Ten patients [mean preoperative apnoea-hypopnoea index (AHI): 38.3 ± 23.5 SD] were included in the study. By means of robotic technology, the tongue base and the epiglottis could be managed. The postoperative polysomnographic results were fairly good (mean postoperative AHI: 20.6 ± 17.3 SD), and the functional results (pain, swallowing and quality of life) are very encouraging; altogether, complications were rare and of minor importance. Conclusions: Transoral robotic tongue base management in patients with OSAHS primarily related to tongue base hypertrophy is feasible and well tolerable. These preliminary results are encouraging and worthy of further evaluation.

Transoral robotic surgery of the tongue base in obstructive sleep Apnea‐Hypopnea syndrome: Anatomic considerations and clinical experience

The purpose of our work was to describe, through cadaveric dissection, the anatomy of the tongue base with a robotic perspective and to demonstrate the feasibility of this approach in case of tongue base hypertrophy in Obstructive Sleep Apnea‐Hypopnea Syndrome (OSAHS).

Surgery vs ventilation in adult severe obstructive sleep apnea syndrome

BACKGROUND AND PURPOSE Management of severe obstructive sleep apnea-hypopnea syndrome (OSAHS) is challenging and needs multidisciplinary cooperation. Ventilation is considered the gold standard of treatment in severe OSAHS. The aim of the study was to compare the therapeutical efficacy of a type of surgery (maxillomandibular advancement [MMA]) vs a ventilatory treatment modality (autotitrating positive airway pressure [APAP]). MATERIALS AND METHODS At the ENT Department of Forlì Hospital (University of Pavia), in strict cooperation with the Sleep Lab of the University of Bologna, a prospective randomized controlled trial was designed and performed. After fully informing them, 50 consecutive patients who have severe OSAHS were enrolled and randomized into a conservative (APAP) or surgical (MMA) section. Demographic, biometric, polysomnogram (PSG) and Epworth Sleepiness Scale profiles of the 2 groups were statistically not significantly different. RESULTS One year after surgery or continuous APAP treatment, both groups showed a remarkable improvement of mean Apnea-Hypopnea Index (AHI) and Epworth Sleepiness Scale levels; the degree of improvement was not statistically different. CONCLUSIONS Given the relatively small sample of subjects studied and the relatively brief follow-up, MMA proved to be a valuable alternative therapeutical tool in our adult and severe OSAHS patient group, with a success rate not inferior to APAP.

The nose oropharynx hypopharynx and larynx (NOHL) classification: a new system of diagnostic standardized examination for OSAHS patients.

The main pathological event of obstructive sleep apnea hypopnea syndrome (OSAHS) is the apneic collapse of the upper airways (UA). Frequently, UA collapse occurs at the same time at different section levels. Identifying the site and the dynamic pattern of obstruction is mandatory in therapeutical decision-making, and in particular if a surgical therapy option is taken into account. Nowadays, awake fiberoptic nasopharyngeal endoscopy represents the first level diagnostic technique to be performed in such patients, but recently, the drug-induced sleep endoscopy (DISE) has been introduced to overcome the limits of the awake nasopharyngeal endoscopy. Whatever diagnostic tool we decide to use, one of the main problems encountered is the standardization of the description of the sites and dynamic patterns of UA collapses. In this paper, the authors describe the NOHL classification, which could be applied during awake and sleep endoscopy, and allows a simple, quick, and effective evaluation of grade and patterns of UA collapse, suggesting its application, especially in therapeutical decision-making and in the analysis of surgical outcomes.

Sleep-related stridor due to dystonic vocal cord motion and neurogenic tachypnea/tachycardia in multiple system atrophy.

Sleep‐disordered breathing and sleep‐related motor phenomena are part of the clinical spectrum of multiple system atrophy (MSA). Stridor has been attributed to denervation of laryngeal muscles or instead to dystonic vocal cord motion. We studied 3 patients with nocturnal stridor in the setting of MSA. All patients underwent nocturnal videopolysomnography (VPSG) with breathing and heart rate, O2 saturation and intra‐esophageal pressure recordings, and simultaneous EMG recordings of the posterior cricoarytenoid, cricothyroid, and thyroarytenoid muscles and continuous vocal cord motion evaluation by means of fiberoptic laryngoscopy. VPSG/EMG and fiberoptic laryngoscopy documented normal vocal cord motion without denervation during wake and stridor only during sleep when hyperactivation of vocal cords adductors appeared in the absence of significant O2 desaturation. All patients had tachycardia and tachypnea and paradoxical breathing during sleep, erratic intercostalis and diaphragmatic EMG activity and Rem sleep behavior disorder. One of the patients had restless legs syndrome with periodic limb movement during sleep and excessive fragmentary hypnic myoclonus. In conclusion, our patients with MSA had nocturnal stridor due to sleep‐related laryngeal dystonia. Stridor was associated with other abnormal sleep‐related respiratory and motor disorders, suggesting an impairment of homeostatic brainstem integration in MSA.

Combined transoral robotic tongue base surgery and palate surgery in obstructive sleep apnea‐hypopnea syndrome: Expansion sphincter pharyngoplasty versus uvulopalatopharyngoplasty

Transoral robotic surgery (TORS) for obstructive sleep apnea‐hypopnea syndrome is a relatively young technique principally devised for managing apneas in the tongue base (TB) area and supraglottic larynx. This procedure is included in the so‐called “multilevel surgery” often including a palatal and nasal surgery.

Clinical Outcomes and Complications Associated with TORS for OSAHS: A Benchmark for Evaluating an Emerging Surgical Technology in a Targeted Application for Benign Disease

Background: The aim of this study was to create benchmarks for evaluating clinical outcomes and complications of transoral robotic surgeries (TORS) in a multicenter setting. Methods: 243 TORS for obstructive sleep apnea/hypopnea syndrome (OSAHS) operations, carried out between 2008 and 2012, were analyzed at 7 different centers. The average hospitalization was 3.5 days. The mean patient age was 50 ± 12 years, the average BMI at the time of the procedure was 28.53 ± 3.87 and the majority of the patients were men (81%). Results: The mean preoperative and postoperative apnea/hypopnea index was 43.0 ± 22.6 and 17.9 ± 18.4, respectively (p < 0.001). The mean preoperative and postoperative Epworth Sleepiness Scale score was 12.34 ± 5.19 and 5.7 ± 3.49, respectively (p < 0.001). The mean pre- and postoperative lowest O2 saturation was 79.5 ± 8.77 and 83.9 ± 6.38%, respectively (p < 0.001). Conclusions: Patients undergoing TORS as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation of success with minimal long-term morbidity.

Combined transoral transnasal robotic-assisted nasopharyngectomy: a cadaveric feasibility study.

Surgical management of the nasopharynx is complex. Both traditional and endoscopic transnasal techniques are demanding. Purely transoral robotic nasopharyngectomy has been described but it needs a palatal splitting and is performed with an inferior to superior perspective with a difficult vision of the upper regions. The aim of this study is to investigate a new robotic surgical setting, which is able to overcome the actual limits. The DaVinci Surgical System was used in two cadavers. Dissection was carried out through a combined transnasal–transoral approach and a purely transoral procedure. A complete nasopharyngectomy was performed with both settings. Working and setting times are comparable. The combined approach avoids palatal spitting and permits a more panoramic view of the surgical field with an easier dissection of the upper areas. A robotic palatal sparing nasopharyngectomy is feasible. The combined transnasal–transoral setting seems to offer significant advantages with respect to traditionally purely transoral procedures.

Operating room data management: improving efficiency and safety in a surgical block

BackgroundEuropean Healthcare Systems are facing a difficult period characterized by increasing costs and spending cuts due to economic problems. There is the urgent need for new tools which sustain Hospitals decision makers work. This project aimed to develop a data recording system of the surgical process of every patient within the operating theatre. The primary goal was to create a practical and easy data processing tool to give hospital managers, anesthesiologists and surgeons the information basis to increase operating theaters efficiency and patient safety.MethodsThe developed data analysis tool is embedded in an Oracle Business Intelligence Environment, which processes data to simple and understandable performance tachometers and tables. The underlying data analysis is based on scientific literature and the projects teams experience with tracked data. The system login is layered and different users have access to different data outputs depending on their professional needs. The system is divided in the tree profile types Manager, Anesthesiologist and Surgeon. Every profile includes subcategories where operators can access more detailed data analyses. The first data output screen shows general information and guides the user towards more detailed data analysis. The data recording system enabled the registration of 14.675 surgical operations performed from 2009 to 2011.ResultsRaw utilization increased from 44% in 2009 to 52% in 2011. The number of high complexity surgical procedures (≥120 minutes) has increased in certain units while decreased in others. The number of unscheduled procedures performed has been reduced (from 25% in 2009 to 14% in 2011) while maintaining the same percentage of surgical procedures. The number of overtime events decreased in 2010 (23%) and in 2011 (21%) compared to 2009 (28%) and the delays expressed in minutes are almost the same (mean 78 min). The direct link found between the complexity of surgical procedures, the number of unscheduled procedures and overtime show a positive impact of the project on OR management. Despite a consistency in the complexity of procedures (19% in 2009 and 21% in 2011), surgical groups have been successful in reducing the number of unscheduled procedures (from 25% in 2009 to 14% in 2011) and overtime (from 28% in 2009 to 21% in 2011).ConclusionsThe developed project gives healthcare managers, anesthesiologists and surgeons useful information to increase surgical theaters efficiency and patient safety. In difficult economic times is possible to develop something that is of some value to the patient and healthcare system too.