Endoscopic Sinus Surgery

Endoscopic sinus surgery has revolutionized the field of otolaryngology and is now the surgical standard of care in treating most paranasal sinus disorders. A graduating otolaryngology resident must be proficient in performing endoscopic sinus surgery (ESS) to care for common sinonasal pathology. Thus, our goal with this chapter is to provide a systematic guide of ESS for surgeons at all stages of training. We discuss the indications for ESS, the thorough review of preoperative computed tomography, the intraoperative technique for ESS, as well as complications. We believe that careful review of this chapter will provide physicians with a comprehensive base to understand the concept of endoscopic sinus surgery and will allow them to develop their technique and skills as they continue to train. This review contains 5 figures, 5 tables, 34 references Keywords: Endoscopic Sinus Surgery, Surgical Education, Surgical Technique, Surgical Complications, Open Sinus Surgery Approaches

Endoscopic Sinus Surgery

Endoscopic sinus surgery has revolutionized the field of otolaryngology and is now the surgical standard of care in treating most paranasal sinus disorders. A graduating otolaryngology resident must be proficient in performing endoscopic sinus surgery (ESS) to care for common sinonasal pathology. Thus, our goal with this chapter is to provide a systematic guide of ESS for surgeons at all stages of training. We discuss the indications for ESS, the thorough review of preoperative computed tomography, the intraoperative technique for ESS, as well as complications. We believe that careful review of this chapter will provide physicians with a comprehensive base to understand the concept of endoscopic sinus surgery and will allow them to develop their technique and skills as they continue to train. This review contains 5 figures, 5 tables, 34 references Keywords: Endoscopic Sinus Surgery, Surgical Education, Surgical Technique, Surgical Complications, Open Sinus Surgery Approaches

Hymen Restoration: An Experience From a Moroccan Center

Background Hymenoplasty is one of the least described vulvovaginal procedures in plastic surgery without any surgical standard that attempts to restore the hymen’s ability to bleed during sexual intercourse on a couple’s wedding night. Objectives The objective of this study is to report outcomes from a Moroccan retrospective study of a series of 529 patients who underwent either a hymenorrhaphy or a hymenoplasty. Methods This was a retrospective study of 529 patients who underwent hymen restoration at a center in Morocco between April 2010 and April 2019. The data were collected according to the requirements of the center through preoperative and postoperative consultations, presential or phone post-coital interviews. The procedure consisted of suturing the edges of the hymen remnants using Vicryl 5-0, leaving a small opening in the newly reconstructed hymen. Two techniques – Hymenal Flap Hymenoplasty (HLH) and Vaginal Flap Hymenoplasty (HLV) – are used depending on the presence or absence of hymen remnants. Results A total of 529 patients were underwent hymen restoration, including 42% hymenorrhaphies, 58% hymenoplasties, 39% HLH, and 19% HLV. The mean age of the patients was 32 years. Of the 227 women who underwent a hymenorrhaphy, no failure was reported, and all the patients who had sexual intercourse within 15 days of the procedure experienced vaginal bleeding. Of the 99 hymenoplasties using vaginal flaps, only one failure was reported. Conclusions The techniques used in our cohort are safer and the complications are minor with general satisfaction of patients.

Pediatric Keratoplasty: The Success of a Tailor-Made Surgical Management

A Romanian 5-month-old girl was referred to our hospital after being diagnosed with congenital corneal opacities. She was sent in order to undergo penetrating keratoplasty (PKP) surgery on her left eye. The patient presented a natural tendency to esotropia. We took into account two different surgical techniques: PKP and lamellar keratoplasty. The latter was technically impossible to carry out because of the full-thickness corneal opacity. We conducted several tests to accurately obtain the patient’s preoperative parameters and specifically decide the details of the surgical technique to be applied. For each step of the surgical procedure we carefully compared the individual results in the literature in order to ensure a stable and lasting result. In addition to this, we used an innovative suture technique: nylon thread, interrupted suture, alternating 11-0/10-0 threads. Six months after the operation, the functional result obtained was 4–5/10, with recovery of the fixation. Pediatric PKP, therefore, cannot follow a surgical standard, but requires careful case-by-case evaluation from the pre- to the postoperative phase, with the aim of maximizing stable visual acuity.

868 Guideline for Discharge Opioid Prescription Management in Adult and Pediatric Burn Patients

Introduction Pediatric and adult burn survivors are at risk for chronic opioid dependency. Conversely, undertreatment of pain can negatively affect mental health and patient compliance. Overtreatment has arguably led to the current opioid legislation. Despite an opioid-limiting mandate, there has been little direction for streamlining prescribing practices and there has been no guideline established to facilitate prescribing practices for burn patients. We evaluated the efficacy of a standard opioid prescribing schedule (SOPS) for surgical patients admitted greater than four days, based on pain scores, in our adult and pediatric burn patients. Methods This was a retrospective review conducted between June 2018 to June 2019 of our prescribing practices compared to a newly established standardized prescribing schedule. All patients admitted to the burn center were included if they had a length of stay longer than 4 days, and were prescribed oxycodone doses between 0-60mg within the last 24 hours of their stay. The primary outcome was amount of oxycodone prescribed upon discharge compared to the doses they received within their last 24hrs before and after the SOPS was established. Results The year before the SOPS was developed, we prescribed an average of 140mg of oxycodone to our pediatric patients upon discharge, even when they used 0mg within 24 hours of discharge. We prescribed an average of 165mg of oxycodone to adult patients who required 0mg 24hrs prior to discharge. We prescribed an average of 200mg to adult patients who required 15mg. We prescribed an average of 235mg to adult patients who required 35mg. We prescribed 310mg to adult patients that required the maximum of 60mg within their last 24 hours. This represented 0% compliance. After adopting the surgical standard opioid prescribing schedule to determine doses, we became 87.5% complaint with all patients and saw no increased in readmissions for pain. Conclusions An institutional guideline for discharge opioid prescribing practices has reduced the number of opioid pills patients take home, and the risk for overtreatment. A Standardized Opioid Prescribing schedule for burn patients is feasible and merits further investigation. Applicability of Research to Practice This study demonstrates the benefits of a standardized prescribing schedule and its applicability to burn patients.

Surgical Approaches to Chronic Pancreatitis

Chronic pancreatitis is a progressive inflammatory disease resulting in permanent structural damage of the pancreas. It is mainly characterized by recurring epigastric pain and pancreatic insufficiency. In addition, progression of the disease might lead to additional complications, such as pseudocyst formation or development of pancreatic cancer. The medical and surgical treatment of chronic pancreatitis has changed significantly in the past decades. With regard to surgical management, pancreatic head resection has been shown to be a mainstay in the treatment of severe chronic pancreatitis because the pancreatic head mass is known to trigger the chronic inflammatory process. Over the years, organ-preserving procedures, such as the duodenum-preserving pancreatic head resection and the pylorus-preserving Whipple, have become the surgical standard and have led to major improvements in pain relief, preservation of pancreatic function, and quality of life of patients.