Jeffrey M. Bumpous

Reduced postoperative infections with an immune-enhancing nutritional supplement†

Objectives/Hypothesis: Malnutrition is a significant risk factor for postoperative infections in patients undergoing oncologic surgery. This study was undertaken to determine if perioperative nutritional supplementation with an immune‐enhancing formula is superior to standard formula in the prevention of postoperative infectious complications. Study Design: This was a prospective, randomized, double‐blind trial comparing perioperative nutritional supplementation with Impact and standard nutritional formulas. Methods: Following stratification, 136 patients undergoing oncologic head and neck surgery were randomly assigned to one of four treatment groups: preoperative/postoperative Impact, postoperative Impact, preoperative/postoperative standard formula, and postoperative standard formula. Outcome measures included laboratory evaluations of nutritional status, infectious and wound healing complications, and duration of hospitalization. Statistical analysis was performed using ξ2 or two‐tailed Fisher Exact Tests, when appropriate. Results: Intent‐to‐treat (P = .02) and actual therapy (P = .04) analyses revealed a significant decrease in the incidence of postoperative infectious complications (all sites) in patients who received Impact. There was no significant difference in wound healing problems or duration of hospitalization. Postoperative measures of nutrition status demonstrated a higher serum albumin (P = .05) in patients who received Impact compared with standard formula. Conclusions: Compared with standard formula, perioperative nutritional supplementation with Impact significantly reduced the incidence of infectious complications. The length of hospitalization was significantly prolonged in patients with postoperative infections, suggesting potential cost savings with the use of immune‐enhancing formulas such as Impact. Key Words: Nutritional supplements, malnutrition, head and neck cancer.

Minimally invasive radioguided parathyroidectomy

Background: Minimally invasive radioguided parathyroidectomy (MIRP) combines technetium sestamibi scan, intraoperative gamma probe, methylene blue dye, and measurement of circulating parathyroid hormone (PTH) levels. Study Design: All patients presented with biochemically proved primary hyperparathyroidism. A technetium sestamibi scan was performed preoperatively. Technetium sestamibi and methylene blue dye (7.5 mg/kg) were administered IV on the day of operation. Operative dissection was directed by the gamma probe. Blood samples for PTH assay were obtained before and after excision of an abnormal gland. When an appropriate decrease in the PTH assay was obtained, the exploration was concluded. Persistent PTH elevation instigated further neck exploration. Results: Thirty-six consecutive patients were explored for untreated primary hyperparathyroidism and three for recurrent hyperparathyroidism. Hypercalcemia was corrected in all 39 patients. A single adenoma was found in 32 of 36 patients with untreated primary hyperparathyroidism, and a single abnormal gland was identified in all of those with recurrent hyperparathyroidism. Persistently elevated PTH prompted further exploration in two patients, identifying a second abnormal gland in one and hyperplasia in the other. Minor local complications occurred in 8% (3 of 39) of the patients. Forty-four percent (16 of 36) of the patients were discharged on the day of operation and 83% (30 of 36) within 23 hours after the initial neck exploration for primary hyperparathyroidism. Comparison of charges for MIRP with charges for “standard” neck exploration revealed lower costs with MIRP because of decreased duration of the operation, anesthesia, and hospital stay, and elimination of intraoperative histologic analysis. Conclusions: MIRP is a safe and effective procedure, resulting in the correction of hypercalcemia in all patients. The combination of intraoperative gamma probe and methylene blue dye allows rapid identification of the abnormal gland with minimal dissection through a small incision. PTH assay after excision provides biochemical confirmation that the abnormal gland has been removed. Most patients undergoing MIRP can be treated on an outpatient basis. Low postoperative complications, a small incision, and rapid return to normal activities resulted in very high patient acceptance of the procedure. (J Am Coll Surg 2000;191:24-31.

Neck Crepitance : Evaluation and Management of Suspected Upper Aerodigestive Tract Injury

Objective To determine safe criteria for the management of patients with crepitance of the neck.

Synovial cell sarcoma: diagnosis, treatment, and outcomes.

Objectives/Hypothesis Synovial cell sarcoma is a mesenchymal tumor predominantly of the lower extremities. Three percent of cases arise in the head and neck region. It is thought that head and neck synovial sarcoma has a better prognosis than tumors of the extremities. Our experience has demonstrated aggressive behavior of this neoplasm in the head and neck. This compelled us to compare our experience with other studies.

Patterns of maxillofacial injuries as a function of automobile restraint use.

Objective To determine the pattern and severity of maxillofacial injuries sustained in a motor vehicle accident (MVA) resulting from automobile restraint use.

Toxic metabolic encephalopathy after parathyroidectomy with methylene blue localization

OBJECTIVE: To determine the correlation between methylene blue use and toxic metabolic encephalopathy in patients undergoing surgery for primary hyperparathyroidism. STUDY DESIGN AND SETTING: A retrospective study of 193 patients was performed to collect demographic, perioperative, and postoperative data. Patients were divided into two groups: Group A (postoperative neurological sequelae) and Group B (no neurological sequelae). All data points were compared between the groups. RESULTS: Twelve of 193 patients were placed in Group A; 181 patients were placed in Group B. Ten patients in Group A were female, and 10 patients were older than 60 years. Of the patients in Group A, 100% were taking a serotonin reuptake inhibitor (SRI). In Group B, 8.8% of patients were taking an SRI. CONCLUSION: All the patients who experienced transient neurological events were taking an SRI. A correlation can be made between methylene blue infusion and SRI usage. SIGNIFICANCE: Patients taking SRIs may represent a high-risk group for postoperative neurological events when methylene blue is utilized.

Development of a Telehealth Intervention for Head and Neck Cancer Patients

Treatment for head and neck cancer precipitates a myriad of distressing symptoms. Patients may be isolated both physically and socially and may lack the self-efficacy to report problems and participate as partners in their care. The goal of this project was to design a telehealth intervention to address such isolation, develop patient self-efficacy, and improve symptom management during the treatment experience. Participatory action research and a review of the literature were used to develop electronically administered symptom management algorithms addressing all major symptoms experienced by patients undergoing treatment for head and neck cancers. Daily questions and related messages were then programmed into an easy-to-use telehealth messaging device, the Health Buddy(R). Clinician and patient acceptance, feasibility, and technology issues were measured. Using participatory action research is an effective means for developing electronic algorithms acceptable to both clinicians and patients. The use of a simple tele-messaging device as an adjunct to symptom management is feasible, affordable, and acceptable to patients. This telehealth intervention provides support and education to patients undergoing treatment for head and neck cancers.

Staging of Chronic Hyperplastic Rhinosinusitis: Treatment Strategies

In 1990 we reported an initial prospective study of 100 patients using a four-stage system for classification of chronic rhinosinusitis. Between January 1988 and July 1992, we used this system in staging an additional 1814 patients, on whom 2980 intranasal sphenoethmoidectomies were performed. In this staging system a protocol trial of medication was given for 2 weeks, followed by axial and coronal computed tomography. Medication consisted of a second-generation cephalosporin antibiotic, usually cefuroxime; a 4-day burst of intraoral steroids, usually prednisone; and an antihistamine decongestant if not contraindicated. The stages of chronic hyperplastic rhinosinusitis included the stages described in the 1990 report (i.e., stage I, single-focus disease; stage II, discontiguous disease throughout the ethmoid labyrinth; stage III, diffuse disease responsive to medication; and stage IV, diffuse disease unresponsive to or poorly responsive to medication). The results of this study have shown that the computed tomography staging system based on computed tomography extent of disease after medical therapy is a simple, easily remembered, and very effective modality for the classification of chronic sinusitis. This system provides a rationale for discussing and planning surgery with patients and physicians and is a convenient reference for the reporting of end results. More importantly, a linear relationship between disease stage and outcomes is demonstrated. This statistically highly significant feature of the staging system provides a firm basis for the production of outcomes after various treatment strategies, particularly ethmoidectomy and the treatment of sinusitis.

Microvessel Density in Head and Neck Squamous Cell Carcinoma Primary Tumors and Its Correlation with Clinical Staging Parameters

Objective: Our objective was to assess angiogenesis in head and neck squamous cell primary tumors and measure its correlation with tumor site and clinical and pathologic staging parameters.

Quality of life after treatment for advanced laryngeal and hypopharyngeal cancer.

Objectives To compare health‐related quality of life measures after treatment for advanced (stages III and IV) laryngeal and hypopharyngeal cancers.