Surgical Technology International
43rd Edition
December 2023 - ISSN:1090-3941
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Bioabsorbable Temporizing Matrix (BTM): Not Just for Burns
Mark S. Granick, MD, Professor of Surgery, Ashley Ignatiuk, MD, Assistant Professor of Surgery, Edward S. Lee, MD, Associate Professor of Surgery, Rutgers New Jersey Medical School, Newark, NJ, James Yang, MD, St. Joseph’s Hospital, Paterson, NJ
1700
A skin substitute developed in Australia 2 decades ago for use in acute burns was recently introduced into the United States for the treatment of open wounds. This product has been shown to be very efficacious for coverage of debrided burn wounds. It consists of an inorganic synthetic woven layer that induces cellular ingrowth and deposition of interstitial tissue. It is covered by an attached silicone layer that seals the wound. The product is placed with the woven side directly on the wound. It is fixed in place and optimally covered by a negative pressure dressing for the first 5-10 days. Due to its synthetic composition, it is highly resistant to infection and can stay on the wound for as long as needed. The authors have used this matrix in a wide variety of complex reconstructions in 27 patients, consisting of 10 females and 17 males. Eleven had traumatic wounds of various etiologies (deep burns, crush injuries, Morell-Lavallee lesion, hand injuries, multiple trauma, open fractures, compartment syndromes and soft tissue avulsions). The following wounds were also treated with BTM: pressure ulcers, axillary hidradenitis, scalp wounds, severe facial acne keloidalis, Fournier’s gangrene, a diabetic foot ulcer, a chronic venous ulcer, a cutaneous pyoderma gangrenosum, a radiation ulcer with exposed Achilles tendon, a disfiguring scar from an old Dupytrens excision and a non-healing chemotherapy extravasation ulcer. Hand and leg wounds with exposed tendon achieved coverage without tethering. The scalp wounds developed a neodermis and were skin-grafted. A pyoderma gangrenosum patient with excessive slough and uncontrolled bleeding was temporarily immunosuppressed, aggressively debrided and covered with the matrix. Her bleeding resolved. She developed a neodermis, and had reduced symptoms. The Fournier’s patient had immediate skin-grafting of his penis and testicles, but the remaining extensive perineal and upper thigh wounds were treated with the matrix and healed without additional skin grafting. A hand patient with a forearm fasciotomy wound was covered with the matrix. As the swelling resolved the size of the defect decreased to the point that the wound was delaminated. The adjacent skin was elevated and used to cover the open area, achieving full closure. There were no complications attributed to the use of the matrix. Several patients healed secondarily with the silicone sheeting gradually peeling off. Seven patients have received or are awaiting skin grafts to be placed over the neodermis. Although this is an early review of the use of this synthetic matrix in the US, it comes with a positive legacy from Australia. The findings thus far indicate that there is a wide range of applications for this product well beyond burn care. Its safety record, resistance to infection and ease of use facilitate surgery.
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What Does Minimally Invasive Mitral Valve Surgery Really Mean? Defining Totally Endoscopic Mitral Valve Surgery Through Meta Analysis
Jessica Katsiroubas, MD, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, Emily Manin, BS, Cornell University, Manhattan, New York, Jake L. Rosen, BA, Thomas Jefferson University, Philadelphia, Pennsylvania , Yoona Choe, BA, MS , Keertana Jonnalagadda, BS, Rowan University, Stratford, New Jersey, Idy Ding, BA, Temple University, Philadelphia, Pennsylvania , T. Sloane Guy, MD, MBA, FACS, FACC, Department of Cardiac Surgery, Georgia Heart Institute, Gainesville, Georgia
1715
Introduction: Minimally invasive approaches to mitral valve surgery are being performed with increasing frequency; however, many of these procedures still involve rib spreading and large incisions. The heterogeneity of self-reported “minimally invasive” approaches limits analysis of outcomes. This review aims to formally define totally endoscopic mitral valve surgery (TEMVS) and assess outcomes.
Materials and Methods: A comprehensive literature search in Pub-Med, Cochrane Library, and EMBASE was used to find studies reporting outcomes on totally endoscopic mitral valve surgery. “Totally endoscopic” was defined as incisions less than 3cm and the avoidance of rib spreading. The primary outcome was 30-day mortality and secondary endpoints included postoperative myocardial infarction (MI), stroke, early reoperation, wound infection, renal failure, and prolonged ventilation. Perioperative patient characteristics were also recorded and analyzed.
Results: Thirty-three studies (6031 patients) were included in our meta-analysis. The 30-day mortality rate was 0.33%, p=0.88. The most frequent complications were early reoperation (2.12%, p=0.44) and prolonged ventilation (1.46% p=<0.01). Rates of MI, stroke, and renal failure were each less than 1%. Patient characteristics including age, body mass index (BMI), and ejection fractions were also analyzed.
Conclusions: We propose a formal definition of TEMVS, which is performed through incisions less than 3cm and without rib spreading. Thirty-day mortality and other adverse sequelae of TEMVS are uncommon.
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Cardiopulmonary Bypass Settings for the Prevention of Early Hypotension During CABG
Giuseppe Nasso, MD, PhD, Giuseppe Speziale, MD, PhD, Flavio Fiore, MD, Ignazio Condello, PhD, Anthea Hospital, GVM Care & Research, Bari, Italy, Francesco Bartolomucci, MD, Giovani Valenti, MD, Claudio Larosa, MD, Ospedale Lorenzo Bonomo, ASL BAT, Andria, Italy, Francesco Borrello, MD, Pugliese-Ciaccio Hospital, Catanzaro, Italy, Vincenzo Amodeo, MD, Ospedale Santa Maria degli Ungheresi, Polistena, Italy
1727
Background: Vasoplegic syndrome is a form of vasodilatory shock that can occur before, during or after cardiopulmonary bypass (CPB). We introduce a strategy to reduce the incidence of early hypotension phenomena during Coronary Artery Bypass Graft (CABG) procedures.
Materials and Methods: In this prospective cohort study, 100 patients underwent elective CABG with two perioperative CPB settings. The study group (50 patients) was managed with retrograde autologous priming (RAP), 3-minute stepwise for the institution of CPB, and pulsatile flow (PP). The control group (50 patients) was managed without RAP, with the rapid initiation of CPB, and non-pulsatile (NP) flow. The primary endpoints were MAP (mmHg), number of hypotensive phenomena (MAP < 50 mmHg for > 30 sec), the venous return volume on CPB (ml), the cardiac index (L/min/m2), hemoglobin (g/dL), indexed oxygen delivery (DO2i, ml/min/m2), the systemic vascular resistance index (SVRI, dynes s m2/cm5), number of 1-ml boluses of a vasoactive substance (norepinephrine), the positive fluid balance (ml), and the number of red blood cell units for transfusion.
Results: During CPB, the mean values in the study and control groups were as follows: MAP, 68± 7 vs 56 ± 7 (p-value, 0.0019); hypotensive phenomena, 3 ± 1 vs 8 ±2 (p-value, 0.019); venous return volume, 840±79 vs 1129 ±123 (p-value, 0.0017); cardiac index, 2.4 ± 0.4 vs 2.7 ±0.2 (p-value, 0.0023); hemoglobin, 9.13 ± 0.29 vs 7.8± 0.23 (p-value, 0.0001); DO2i, 301± 12 vs 276±23 (p-value, 0.0011); SVRI, 1879 ±280 vs 2210 ±140 (p-value, 0.0017); norepinephrine, 1±2 vs 8 ±3 (p-value, 0.0023); positive fluid balance, 750 ±212 vs 1450 ±220 (p-value, 0.005); and total number of red blood cell units for transfusion, 16 ±4.2 vs 27 ± 5.3 (p-value, 0.008).
Conclusions: In this prospective cohort study, during CPB, the study group showed a better preservation of MAP, SVRI, and DO2i, and a reduction of vasoconstrictor use in a CPB setting with the RAP technique, 3-minute stepwise for the initiation of CPB and pulsatile pump flow, compared to the control group. Further studies are needed to validate this perioperative approach to CPB.
Surgical Technique for Sphinkeeper® Implantation
Christopher Dawoud, MD, Moritz Daniel Felsenreich, MD, PhD, Associate Professor, Felix Harpain, MD, Stefan Riss, MD, FRCS, Associate Professor, Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Austria
1712
Fecal incontinence is a distressing condition characterized by the involuntary loss of solid and liquid stool and gas, It affects a significant proportion of the general population, with a reported prevalence ranging from 1% to 20%. Despite its considerable impact on quality of life, therapeutic options for fecal incontinence remain limited.
Current treatment modalities for fecal incontinence include conservative approaches such as dietary modifications, pelvic floor exercises, and pharmacotherapy. Surgical interventions, including sphincteroplasty or sacral nerve stimulation, may be considered in more severe cases.
Recently, THD Labs (THD S.p.A. Correggio (RE), Italy) introduced the Gatekeeper® as a novel device that supports the implantation of up to four solid prostheses into the intersphincteric groove. Early data were promising, with success rates above 50% and only a few perioperative complications.
Subsequently, Gatekeeper® was modified by increasing the length and number (up to 10) of prostheses, and renamed Sphinkeeper® (THD). With this device, nine to 10 small incisions measuring 2 mm are made at a distance of 2-3 cm from the anus. The intersphincteric space is accessed using the delivery system, and positioning is verified through endoanal ultrasound. This procedure is repeated for all 10 prostheses placed around the entire circumference. The Sphinkeeper® offers the potential to improve the management of fecal incontinence, and offers patients a less-invasive alternative to traditional surgical approaches.
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Gaseous Micro-Embolic Activity and Goal-Directed Perfusion Management in a Closed System for Cardiopulmonary Bypass and Minimally Invasive Extracorporeal Circulation during Coronary Artery Bypass Grafting
Ignazio Condello, PhD, Giuseppe Nasso, MD, PhD, Giuseppe Speziale, MD, PhD, Anthea Hospital, Bari, Italy, Kurt Staessens, PhD, UZ Brussels, Jette, Belgium
1721
Background: Cardiopulmonary bypass (CPB) techniques are becoming minimally invasive in clinical practice. The literature describes various extracorporeal techniques which seek to eliminate air-blood contact and reduce both hemodilution and the contact surface such as in Minimally invasive Extracorporeal Circulation (MiECC) and closed systems for CPB. However, the delivery of micro-embolic activity in the circuit and metabolic activity in terms of oxygen delivery for Goal-Directed Perfusion (GDP) management, in relation to the patient's blood volume and central venous pressure, have never been related and correlated. In this report, we present a cohort study that investigated these aspects between the closed SVR2000 System and modular MiECC (both from Eurosets SRL, Medolla, Italy).
Materials and Methods: Data were collected retrospectively and used to compare 60 consecutive patients who underwent isolated coronary artery bypass grafting (CABG) surgery by two surgeons using an SVR2000 oxygenator in 30 procedures, with a matched cohort of patients from the same period who underwent isolated CABG surgery by two other surgeons using a modular MiECC in 30 procedures. The primary endpoints collected were data on micro-embolic activity, including the number of gaseous micro-emboli in the circuit during the procedure, the mean maintenance value of oxygen delivery (DO2) and data relating to venous return volume and central venous pressure (CVP).
Results: During the CPB procedures, the following values were recorded for the closed SVR2000 and MiECC groups, respectively: the average number of gaseous micro-emboli (GME) in the venous line, 833 ± 23 vs 1221 ± 45 (p = 0.028); GME in the outlet of the pump, 375 ± 45 vs 429 ± 76 (p = 0.89; GME in the arterial line, 189 ± 36 vs 205 ± 27 (p = 0.92), and the volume of GME in the arterial line (mL), 0.32± 12 vs 0.49± 17 (p = 0.93). The mean Indexed Oxygen Delivery (DO2i) during cross-clamp (ml/min/m2) was 319 ±12 vs 278 ±9 (p = 0.0019), respectively. The maximum mean volume of venous return in the soft-shell venous reservoir (ml) was 1801 ±128 vs 824 ±192 (p = 0.038). The mean central venous pressure (CVP) during cross-clamp (mmHg) was 0 ± 2 vs 6 ± 2 (p = 0.019).
Conclusions: In this study, the results in the closed SVR2000 group were not statistically inferior to those in the modular MiECC group in terms of gaseous micro-embolic activity during CPB. Our analysis showed an important reduction of GME delivery in both systems. The closed SVR2000 group showed better management for GDP in terms of DO2i, associated with the flexibility of dynamic volume management and the absence of cavitation and regulation of the rate per minute and pump flow, which were reported in the MiECC group. The SVR2000 and modular MiECC systems were both safe and effective in perioperative practice without iatrogenic problems.
Using Software to Implant Orthopaedic Hardware: Surgeon Intraoperative Confidence Increased with Latest Technological Updates
Melanie Caba, MS, Laura Scholl, MS, Alexandra Valentino-Pfeil, MBA, Emily Hampp, PhD, Stryker Orthopaedics, Mahwah, New Jersey, Nipun Sodhi, MD, Long Island Jewish Medical Center, New York, New York, Jeremy Dubin, BA, Daniel Hameed, MD, Michael A. Mont, MD, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
1716
Background: Robotic-assisted total knee arthroplasty (TKA) has been associated with improved accuracy and precision of implant placement, protection of soft tissue, and improved patient-reported postoperative outcomes when compared to manual TKA techniques. Previous studies have highlighted the importance of surgical confidence throughout the learning curve when adopting robotic-assisted platforms. The purpose of this study was to evaluate the confidence and efficiencies of surgeons when utilizing computed tomography (CT)-based robotic TKA technology.
Materials and Methods: A cross-sectional, questionnaire-based study was conducted with 20 arthroplasty-trained surgeons with prior experience in both manual TKA and robotic-assisted TKA techniques. The surgeons completed an initial learning period, with new software, during various stages of their experience. The new TKA software upgrade builds on the prior software version with new features. A Net Promoter Score (NPS), the measurement of a respondent’s likelihood to recommend a product or service to others, was used during the analysis of survey questions. A NPS over 50 indicates a positive score.
Results: When compared to manual TKA techniques, 95% of surgeons reported that their overall intraoperative confidence increased with the new software upgrade for CT-based robotic technology and had an average rating of 8.9 out of 10 for their intraoperative confidence with the new software upgrade. Additionally, 100% of surgeons reported that they were more confident when performing intraoperative implant adjustments with the new software upgrade when compared to manual TKA. Surgeons determined that the overall use of the new software upgrade was intuitive (8.4 of 10 average rating) and were satisfied with the overall use of the new software upgrade (9 of 10 average rating). Also, surgeons reported that they would recommend the new software upgrade for CT-based robotic technology to colleagues (NPS of 85), as well as being used as a research tool (NPS of 85) or for a training and education tool in a fellowship program (NPS of 90).
Conclusion: As new technology continues to enter the field of orthopedics, it is important to ensure upgrades and advancements continue to serve surgeons and provide efficiencies in the operating room. For established robotic surgeons, the new robotic technology assessed in this study provided increased confidence when compared to manual TKA. Based on these results, the new software upgrade demonstrated value during various stages of a TKA procedure and is highly recommended for use by others in the field of orthopedics.
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Does Preoperative Statin Exposure Reduce Prosthetic Joint Infections and Revisions Following Total Joint Arthroplasty?
Oliver C. Sax, DO, MS, Zhongming Chen, MD, Sandeep S. Bains, MD, Danielle A. Jacobstein, Jeremy A. Dubin, BA, Daniel Hameed, MD, Mallory C. Moore, BS, Michael A. Mont, MD, James Nace, DO, Ronald E. Delanois, MD, Orthopaedic Attending, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, MD
1717
Introduction: The pleiotropic effects of statins extend beyond managing cardiovascular health and are suggested to modulate Staphylococcus aureus biofilm formation with prosthetic joint infection (PJI) reduction. However, a large analysis of statin use prior to total joint arthroplasty (TJA) to determine infection and revision risk is lacking. We specifically evaluated: 90-day to two-year (1) prosthetic joint infection (PJIs); (2) revisions; and (3) respective risk factors.
Materials and Methods: We queried a national, all-payer database for patients undergoing either TKA or THA between 2010–2020. Chronic statin exposure was defined as >3 prescriptions filled within one-year prior to TJA (statin users). A control cohort of patients undergoing TJA without history of statin use prior was identified (statin naïve). Cohorts were matched 1:1 based on demographics and comorbidities (TKA: n=579,136; THA: n=202,092). Multivariate logistic regression was performed to evaluate risk factors for PJIs and revisions.
Results: Among TKA recipients, statin users had lower incidence of PJIs at one year (0.36 vs. 0.39%) to two years (0.45 vs. 0.49%) compared to the statin naïve (all, p≤0.007). Similarly, statin users had lower incidence of one- to two-year revisions (all, p≤0.048). Among THA recipients, statin users had lower incidence of PJIs at 90 days (0.37 vs. 0.45%) to two years (2% vs. 2.14%) (all, p<0.001). Similar trends were observed for 90-day to two-year revisions (all, p≤0.022). Statin use was independently associated with decreased odds of PJIs and revisions by one year.
Conclusions: Statin use is associated with a reduced risk of PJIs and revisions from one to two years following TJA. It may be worthwhile to ensure patients take statin therapy if indicated for previously established cardiovascular guidelines.
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Predictors of Readmission and Reoperation Following Shoulder Arthroplasty in Patients Under 45 Years of Age
Luke C. Zappia, BS, Austen D. Katz, MD, Nicholas Sgaglione, MD, Northwell Health Long Island Jewish Medical Center, New Hyde Park, NY, Junho Song, MD, Mount Sinai Hospital, New York, NY
1688
Background: The use of shoulder arthroplasty has increased among all age groups, albeit most prominently in older patients. While previous studies have investigated predictors of short-term readmission and reoperation in the general population, there is a paucity of literature available on these in patients under 45 years of age. This study aimed to identify the predictors of 30-day readmission and reoperation following shoulder arthroplasty in patients under 45 years of age.
Methods: A retrospective query in the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2019 was used to identify patients who underwent primary reverse and anatomic total shoulder arthroplasty and hemiarthroplasty. Multivariate logistic regression was used to identify predictors of 30-day readmission and reoperation.
Results: A total of 530 patients were included. Multivariate regression revealed that Black race and Hispanic ethnicity were independent predictors of readmission. Functional dependence, hypertension requiring medication, and prolonged length of stay predicted reoperation. Finally, low hematocrit and prolonged length of stay predicted morbidity.
Discussion: Identifying and accounting for these risk factors for poor outcomes may help improve perioperative risk stratification. As a result, these findings have the potential to reduce healthcare costs associated with readmission and reoperation following shoulder arthroplasty in young patients. Our results also highlight the underlying disparities in healthcare outcomes among racial and ethnic groups that must be considered.
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Use of Topical Gaseous Nitric Oxide/Plasma Energy in the Treatment of Recalcitrant Wounds
Terry Treadwell, MD, FACS, FAAWC, Wound Care Solutions, LLC, Montgomery, AL
1707
Nitric oxide (NO) is involved in many biological functions and has been demonstrated to be important in wound healing. When delivered to a wound in its gaseous state, NO stimulates vasodilatation and angiogenesis, inhibits platelet and erythrocyte aggregation, reduces leukocyte adhesion, and is an important anti-inflammatory and antimicrobial agent.
Many patients with chronic and hard-to-heal wounds have a deficiency of NO in their tissues ,which may contribute to slow and even arrested healing. However, it has been difficult to use NO for treatment because of its short half-life, which is measured in seconds.
A recently developed device provides a way to generate NO and combine it with a stream of plasma energy, which extends its half-life to the point that it can provide a clinical effect. This device creates NO from the ambient air, and no other gases are needed. The combination of atmospheric oxygen and nitrogen at a high temperature generated by an electric arc results in NO and plasma energy (N2 + O2 = 2NO + 181 KJ energy). After generation, the NO/plasma energy-containing gas flow is cooled to 18–20°C, and NO is delivered to the tissues in a “dose” between 800 and 1000 ppm. When NO gas was combined with the plasma energy stream, the NO was found to penetrate intact skin or tissue up to 3cm to treat an underlying problem.
Studies have shown that NO/plasma energy therapy promotes healing. This report summarizes current applications of this unique approach in the treatment of chronic, hard-to-heal and infected wounds.
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Robotic Total Knee Arthroplasty is Associated with Earlier Return of Postoperative Range of Motion
Travis R. Weiner, BS, Emily D. Ferreri, BS, Nana O. Sarpong, MD, Associate Professor, Roshan P. Shah, MD, Associate Professor, H. John Cooper, MD, Associate Professor, Columbia University Medical Center, New York, New York
1724
Introduction: Postoperative range of motion (ROM) is an important measure for the functional outcome and overall success after total knee arthroplasty (TKA). While robotic knee systems have been shown to reduce pain and improve early function, the return of postoperative ROM specifically has not been adequately studied. The purpose of this study was to compare postoperative ROM in robotic and conventional TKA. We hypothesized that robotic TKA leads to an improvement in postoperative ROM.
Materials and Methods: A retrospective cohort study of 674 primary TKAs by a single surgeon between January 2018 and February 2023 was completed. Patients that did not have both a two-week follow up and eight-week follow up were excluded. Revision/conversion TKAs were excluded. The population was divided into two cohorts based on technique utilized: robotic versus conventional. Preoperative extension/flexion data, postoperative extension/flexion data at two-week and eight-week follow ups, and manipulation under anesthesia data were collected. ROM was defined as flexion minus extension. Chi-square tests were used to examine for differences between categorical variables and t-tests for continuous variables.
Results: A total of 307 robotic and 265 conventional knees were included. There were no differences in demographics, mean follow up, or preoperative ROM between groups. The robotic group had significantly more flexion (99.20° vs. 96.98°; p=0.034) and ROM (97.81° vs. 95.56°; p=0.047) at the two-week follow up. The loss in ROM at the two-week follow up from preoperative ROM was significantly less for the robotic group (-11.21° vs. -14.16°; p=0.031). There were no significant differences in extension at either follow up, in flexion at the eight-week follow up, or in ROM at the eight-week follow up.
Conclusion: Robotic TKA leads to an improvement in postoperative flexion and ROM when compared to preoperative ROM at two-week follow up. These findings could partially explain the quicker recovery associated with robotic TKA.
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Polymer versus Titanium Clips in Laparoscopic Cholecystectomy
Anna Malysz Oyola, DO, John Miller, MD,
Colston Edgerton, MD,
Adjunct Assistant Professor, William Hope, MD,
Adjunct Professor,
Novant Health New Hanover Regional Medical Center
Wilmington, NC
1730
Background: Surgical clips are commonly used during laparoscopic cholecystectomy for cystic duct and artery ligation. Titanium and polymer clips are the two most common types used for this indication. Given the cost-saving potential, design advantages, and decreased incidence of complications associated with polymer clips, we sought to study whether there is a clinically significant difference in outcome between polymer and titanium clips in laparoscopic cholecystectomy.
Methods: Fifty consecutive cases using polymer clips followed by 50 consecutive cases using metal clips over a 6-month period by residents under the direction of a single surgeon were retrospectively reviewed. The following outcomes were evaluated: incidence of bile leak, postoperative bleeding, need for additional procedures, hospital length of stay, and cost.
Results: We found that significantly more misfires occurred with the use of the polymer clips (n=17) than with the titanium clips (n=2, p<.001). Eight cases (16%) required opening of an additional polymer clip cartridge to complete the operation. Despite this additional expense, the total cost as it pertained to clip usage ($30.32 USD) was still lower than that using titanium clips ($139.17 USD). While these numbers were not statistically significant, three cases had bile leaks and required additional procedures, all of which were performed with metal clips. No postoperative bleeds were identified and there was no difference in hospital length of stay; most patients were discharged on the day of the procedure.
Conclusion: These findings demonstrate comparable clinical outcomes between laparoscopic cholecystectomies performed with polymer and titanium clips, though polymer clip usage carries a lower cost.
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What Drives the Material Costs of Total Knee Arthroplasty in the Operating Room?
Hannah L. Simmons, BS, Alison K. Klika, MSm Ignacio Pasqualini, MDm Pedro J. Rullán, MD, Robert M. Molloy, MD, Matthew E. Deren, MD, Joshua L. Tidd, BS, Nicolas S. Piuzzi, MD, Cleveland Clinic Foundation, Cleveland, Ohio
1703
Introduction: Approximately one-third of US healthcare spending is related to surgical care. Optimizing operating room (OR) spending is crucial, specifically for high-volume procedures like total knee arthroplasty (TKA). Therefore, the primary objective was to identify leading material drivers of cost for TKA procedures within the OR.
Materials and Methods: Patients who underwent a primary, elective TKA from 2018 to 2019 were included (n=8,672). Intraoperative cost details for each TKA patient were captured from the Vizient Clinical Database Resource Manager (CDB/RM) data. Each cost type was categorized into (1) implant, (2) disposables, (3) wound care, and (4) miscellaneous.
Results: 7,124 patients undergoing primary TKA were included. Implant-related costs accounted for 87.3% of cost, disposable materials covered 10.7%, and wound care products took 2%. The leading subcategories of implant costs were primary prosthetics (85.1%), revision prosthetics (9.9%), cement (2.8%), and implant instruments (1.7%). Within disposables, surgical products accounted for 81.3% of the cost, patient care products for 8.9%, medical apparel for 7.9%, and electrolytes for 1.8%. For an average individual TKA procedure, 86.4% (±4.4) of total cost went towards the implant, 10.7% (±3.4) towards disposable materials, and 1.6% (±1.4) to wound care products. Within the implant category, 92.5% (± 12.8) of costs were associated with primary implants, 13.3% (± 6.9) with instruments, and 2.5% (± 2.8) with cement.
Conclusions: The primary operative material expense category was costs associated with the TKA prosthesis and its fixation followed by disposable materials. A large amount of variation exists in the percent of the total cost for a given TKA procedure that can be attributed to each category.
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Evaluation of Lumbar Adhesiolysis Using a Radiofrequency Catheter During Epiduroscopy in the Treatment of Failed Back Surgery Syndrome (FBSS)
Roberto Gazzeri, MD, Susanna Tribuzi, MD, Felice Occhigrossi, MD, San Giovanni-Addolorata Hospital, Rome, Italy, Matteo Luigi Giuseppe Leoni, MD, Fabrizio Micheli, MD, Guglielmo da Saliceto Hospital, Piacenza, Italy
1714
Failed back surgery syndrome (FBSS) is a complication of spinal surgery that results in severe and disabling back/leg pain. Epiduroscopy is a percutaneous minimally invasive surgical technique used in the treatment of lumbar radicular pain that enables both direct visualization of epidural adhesions in patients with FBSS and the mechanical release of fibrotic scars in the epidural space. Although the use of a balloon catheter during epiduroscopy can usually remove adhesions between the dura and the vertebrae, in the thickest areas of fibrosis, the use of a catheter with a molecular quantum resonance radiofrequency generator may resect hard epidural fibrotic obstructions. The aim of this study was to evaluate the efficacy and safety of this radiofrequency catheter in the treatment of severe epidural fibrotic scars.
Ninety-three patients with FBSS were enrolled in this study. In 49 cases, a thick area of fibrosis was visualized during epiduroscopy and the use of a balloon catheter could not remove the fibrotic scars. In all of these cases, we used a molecular quantum resonance radiofrequency catheter to remove dense fibrotic areas. Intraoperatively during epiduroscopy, we could directly visualize lysis of the fibrotic scars. Immediately after the procedure and at 1-month and 6-month follow-up, the patients reported significant pain reduction. Pain reduction and patient satisfaction were also reported at 12 months in all but 5 cases.
This study found a clinically relevant reduction of pain at 1 and 6 months after epiduroscopy in patients with FBSS. The use of a radiofrequency catheter is safe and effective in resection of hard and thick epidural scars.
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The Use of Plant-Based Polysaccharide (PSP) Agents May Improve Early Outcomes Following Total Knee Arthroplasty—A Proof-of-Concept Study
Michael Ast, MD, Sean McMillan, DO, Virtua Health System, Cherry Hill, New Jersey, Emile-Victor Kuyl, BS, Dan Devine, BA, David Mayman, MD, Jason Blevins, MD, Brian Chalmers, MD, Hospital for Special Surgery, New York, New York, Elizabeth Ford, DO, Mohamed Albana, DO, Inspira Health Network, Vineland, New Jersey
1733
Our study sought to investigate the effects of a topical plant-based polysaccharide (PSP) as an adjunctive hemostat to minimize blood loss and improve early clinical outcomes in patients undergoing primary TKA. In this multi-center and randomized proof-of-concept study, 61 patients undergoing TKA were randomly assigned to one of two groups: A) intraoperative utilization of PSP (n=31) or B) no intervention (n=30). The primary outcomes were blood loss and change in hemoglobin, measured preoperatively and 24 hours postoperatively. Other endpoints included postoperative complications, Knee Society Score (KSS), knee range of motion (ROM), and thigh circumference. There was no difference in postoperative change of hemoglobin or calculated blood loss between the PSP and control groups. The PSP group achieved elevated flexion at two weeks (100.1° vs. 86.6°, p<0.05) and better change in KSS from preop to 90 days (29.5 vs. 22.4, p<0.05) than the controls. Some early postoperative outcomes were improved, which suggests a potential benefit of using PSP in primary TKA. However, the clinical significance of these differences warrants further investigation in a larger randomized trial.
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Advancements in Access for End-Stage Renal Disease and the Creation of Endovascular Fistulas
Jessica Katsiroubas, MD, Susan Basharkhah, MD, Kevin Leong, MD, New York Presbyterian-Brooklyn Methodist Hospital, Brooklyn, New York, Tara Lamb, BS, Drexel University College of Medicine, Philadelphia, Pennsylvania, Nicole Ilonzo, MD, Assistant Professor Weill Cornell Medicine, New York, New York
1657
The prevalence of end-stage renal disease has increased significantly since the 1980s, and the demand for successful, safe, and durable hemodialysis access is rising. Autogenous arteriovenous fistulas continue to be the gold standard modality for hemodialysis access. Biologic and synthetic grafts are used with comparable outcomes but are not without their own complications. Newer developments in hemodialysis access utilize endovascular technology, including dual catheter-based systems and thermal resistance devices, which are pushing the boundaries of fistula creation optimistically forward.
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Staple Line Reinforcement Using SEAMGUARD® versus Suture Over Sewing During Laparoscopic Sleeve Gastrectomy for Super Morbidly Obese Patients: A Prospective Randomized Clinical Trial
Hosam Elghadban, MD, Associate Professor, Ahmed Negm, MD, Professor, Mohamed Samir, MD, Associate Professor, Magdy Basheer, MD, Associate Professor, Ibrahim Dawoud, MD, Professor, Ashraf Shouma, MD, FRCS, Professor , Elsayed Abdallah, MD, Professor, Faculty of medicine Mansoura University, Mansoura, Egypt, Ahmed Taki-Eldin, MD, Assistant Professor, Faculty of medicine, Horus University-Egypt, New Damietta, Egypt
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Itroduction: Although theoretically a simple procedure, laparoscopic sleeve gastrectomy (LSG) can be followed by life-threatening complications. Early postoperative complications include staple line bleeding and leakage. Staple line reinforcement (SLR) has been used to decrease these complications. There are various methods for reinforcement of staple line such as suture over sewing, placing omental flap, using buttressing material, and spraying fibrin glue along the staple line. However, it is controversial whether SLR reduces the rate of staple line complications or not.
Materials and Methods: A prospective randomized clinical trial included 200 super morbidly obese patients randomized into two groups: Group 1 with reinforcement of the staple line by SEAMGUARD® (Gore Medical, Newark, Delaware) and Group 2 with reinforcement of the staple line using suture over sewing.
Results: The mean operative time was significantly shorter in Group 1 than Group 2 (62.6 ± 14.5 vs. 84.7 ±15.8 min, p=0.02). Intraoperative blood loss was significantly lower in Group 1 than Group 2 (17.1± 19.1 vs. 56.8 ± 27.9ml, p=0.00). Staple line hematomas were significantly higher in Group 2. There was no difference in postoperative bleeding between the two groups. No leak was reported in both groups. The cost was higher in Group 1.
Conclusion: Reinforcing the staple line in laparoscopic sleeve gastrectomy using suturing is equal to SEAMGUARD® in all aspects except shorter operative time and lower intraoperative blood loss with SEAMGUARD®.
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Postoperative Opioid Dependence in Patients Undergoing Either Total or Reverse Shoulder Arthroplasty for Proximal Humerus Fracture Fixation
Nayeem Baksh, BS, Qais Naziri, MD, MBA, Downstate Medical Center (SUNY), Brooklyn, New York, Scott Douglas, MD, Jeremy Dubin, BA, Sandeep S. Bains, MD, DC, MBA, Daniel Hameed, MD, Mallory C. Moore, BS, Michael A. Mont, MD, John V. Ingari, MD2, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: In elderly patients who have proximal humerus fractures, treatment commonly involves total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). Following these procedures, patients often require opioids for postoperative analgesia. This common scenario is of clinical and societal importance, as increased postoperative opioid usage has been shown to worsen outcomes and increase the likelihood for dependence. We aimed to compare postoperative opioid use in patients undergoing either TSA or RSA for fixation of their proximal humerus fracture. Specifically, we assessed: (1) postoperative opioid use at two, four, six, eight, and greater than eight weeks postoperatively; (2) aseptic revision rates at 90-days, one year, and two years postoperatively; and (3) periprosthetic joint infection (PJI) rates at 90-days, one year, and two years postoperatively between patients undergoing TSA or RSA for the surgical management of their proximal humerus fractures.
Materials and Methods: For this review, we queried a national all-payer database from October 1, 2015 to October 31, 2020 (n=1.5 million) for all patients who had a “proximal humerus fracture” diagnosis who underwent either TSA or RSA. There were two cohorts: patients undergoing TSA (n=731) and patients undergoing RSA (n=731). Bivariate Chi-square analyses.
Results: We found no differences (p>0.05) in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA after two weeks. There was not a significant difference in aseptic revision or PJI rates between the two cohorts (all p>0.05).
Conclusion: The evidence comparing opioid use in patients undergoing either TSA or RSA for proximal humerus fracture fixation is lacking. Our study specifically showed no differences in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA.
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Novel Uses of Indocyanine Green in Thoracic Surgery: A Review and Case Series
Justin A. Olivera, BS, Medical Student, Isaac Faith, MS, Medical Student, Albert Einstein College of Medicine, Bronx, NY, Osita Onugha, MD, MBA, Associate Professor of Thoracic Surgery, Charles Drew University, Los Angeles, CA
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Indocyanine green (ICG) is a water-soluble molecule that emits fluorescence in the near-infrared light spectrum. Due to its fluorescence properties, safety profile, and cost-effectiveness, ICG is used in minimally invasive surgery, enabling real-time visualization of structures during the operation. Until recently, its use was mainly limited to robotic surgery, which required specific technological setups to visualize the fluorescence. With recent technological advancements, however, similar capabilities can now be integrated into smaller laparoscopic instruments, broadening the accessibility and usefulness of ICG. In this article, we present various innovative applications of ICG in thoracic surgery, drawing from recent developments in the field and our own experiences. Specifically, we focus on the novel role of ICG in the evaluation of gastric conduit perfusion, lung nodule localization, and thoracic duct ligation.
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