Ezequiel Barros

Impact of early elective tracheotomy in critically ill patients

INTRODUCTION Tracheotomy is one of the most frequent surgical procedures performed in critically ill patients hospitalized at intensive care units. The ideal timing for a tracheotomy is still controversial, despite decades of experience. OBJECTIVE To determine the impact of performing early tracheotomies in critically ill patients on duration of mechanical ventilation, intensive care unit stay, overall hospital stay, morbidity, and mortality. METHODS Retrospective and observational study of cases subjected to elective tracheotomy at one of the intensive care units of this hospital during five consecutive years. The patients were stratified into two groups: early tracheotomy group (tracheotomy performed from day one up to and including day seven of mechanical ventilation) and late tracheotomy group (tracheotomy performed after day seven). The outcomes of the groups were compared. RESULTS In the early tracheotomy group, there was a statistically significant reduction in duration of mechanical ventilation (6 days vs. 19 days; p<0.001), duration of intensive care unit stay (10 days vs. 28 days; p=0.001), and incidence of ventilator-associated pneumonia (1 case vs. 44 cases; p=0.001). CONCLUSION Early tracheotomy has a significant positive impact on critically ill patients hospitalized at this intensive care unit. These results support the tendency to balance the risk-benefit analysis in favor of early tracheotomy.

Surgical Approaches to Cerebellopontine Angle: A 17-Year Experience of Our Skull Base Team

Objectives: We give an overview of the current state of cerebellopontine angle (CPA) surgery, based on the recent evidence, and describe our center’s experience in surgical approaches to these lesions. Methods: Retrospective review of cases who underwent surgery for CPA lesions at our hospital during the past 17 years (1996-2013), with focus on the description of the currently most used technique-extended retrosigmoid. We also conducted a brief review of the literature on CPA surgery, comparing the different approaches, their indications and complications. Results: During this period, 203 patients underwent surgery for CPA. The most frequent indication was vestibular schwannoma (84.7%). Other indications were meningiomas (8.4%), epidermoids (1%), vestibular neurectomies (1.5%), arteriovenous malformations (1%), anterior inferior cerebellar artery–posterior inferior cerebellar artery aneurysms (1%), trigeminal microscopic decompression (0.5%), and other more rare tumors (2%). The most used approach was extended retrosigmoid (71.9%), followed by the translabyrinthine (26.1%) and middle fossa approach (2%). Until 2004, the most used approach was the translabyrinthine; after 2004, the most used was the extended retrosigmoid. Conclusions: Currently, the preferred surgical approach used by our team is the extended retrosigmoid, because it allows a complete exposition of sigmoid sinus from the transverse sinus to the jugular bulb, enhances CPA vision, avoids cerebellar retraction, and is a simple way to get a wide route to the CPA. It also allows good functional outcomes (hearing and facial nerve preservation) in most cases. However, indications for approaches depend on the size of the lesion, its location and the quality of preoperative hearing, as well as a necessary familiarity with all approaches.

Endoscopic Endonasal Transphenoidal Approach for Pituitary Adenomas: Outcomes of Our Center

Objectives: Report the results of a consecutive series of patients who underwent an endoscopic endonasal transphenoidal approach (EETA) for resection of a pituitary adenoma. Methods: A retrospective review of patients who underwent EETA at our center between 2010 and 2013, in a collaboration between head and neck surgeons and neurosurgeons, and a description of the technique used. Results: Nineteen patients underwent an EETA for removal of a pituitary adenoma. Decreased visual acuity or a visual field defect was the presenting complaint in 63.2% patients and headache in 26.3%. Nonfunctioning adenoma was the most frequent (52.6%). Sixteen (84.2%) patients had a macroadenoma (>1 cm) and 3 (15.8%) had a microadenoma (<1 cm). The overall postoperative cerebrospinal fluid leak rate was 5.3%. Other perioperative complications were epistaxis (5.3%), postsurgical hematoma (5.3%) with urgent evacuation, and meningitis (5.3%). The rate of gross total ressection was 70% in patients with nonfunctioning adenomas. The remission rate of secretory adenomas was 75%. Of the patients presenting with visual symptoms, 91.7% improved or normalized. Conclusions: EETA is an excellent alternative to other classic approaches for pituitary adenoma, providing similar results with less morbidity. It allows a better panoramic visualization of sellar and parasellar spaces and a better preservation of the normal anatomy and physiology of nasal cavity. This minimally invasive approach is now the standard of care in transasal pituitary surgery. Our outcomes, including remission and complication rates, are comparable with those reported in previous series of endoscopic and microscopic approaches.

Canal Wall-up Tympanomastoidectomy: Recurrence Factors

Objective: Canal wall-up tympanomastoidectomy is gaining popularity in the treatment for cholesteatoma. The choice remains controversial because of the significant recurrence rate of this disease. We aimed to analyze tympanomastoidectomy success rate, to establish eventual predictive factors for failure, and to evaluate the computed tomography (CT) scan’s value in this pathology. Method: We performed a retrospective cohort study regarding all patients submitted to tympanomastoidectomy for cholesteatoma at the otolaryngology department of Hospital São José, Lisbon, from January 1, 2005, to December 31, 2009. Clinical and demographic data were obtained from medical records. Results: One hundred nineteen patients were submitted to tympanomastoidectomy. In most cases, preoperative CT scans showed cholesteatoma in the attic (50%) and large extension of the disease (tegmen, semicircular or fallopian canal erosion in 51%), not always confirmed during surgery (75%). Sixty percent had a canal wall-down procedure. The overall postoperative air-bone gap was within 20 dB in 44%. Second-look surgery was performed in 24 patients: the overall recurrence rate was 23%, with conversion to canal wall-down procedure in 67%. Factors identified as related to failure: cholesteatoma in the sinus tympani (33%), scutum erosion (29%), and large extension of disease (40%). Conclusion: The recurrence rate was significant, despite the high percentage of canal wall-down procedures. Factors for failure remain uncertain and CT scans presented limited value in the diagnosis and evaluation of cholesteatoma, especially postoperatively. In the absence of better diagnostic procedures, we recommend second look surgery to control cholesteatoma’s recurrence.