1-week Postoperative Visit Research Articles

Metal Punch vs. Drill for Rotator Cuff Anchor Socket Creation; Cadaveric and Clinical Comparisons

BackgroundArthroscopic rotator cuff repair has been shown to decrease pain and increase function of certain rotator cuff tears. One potential source of pain is the technique used for bone tunnel creation in the humerus prior to suture anchor placement. This study compared the standard metal punch method to a continuous drilling method for tunnel creation prior to subsequent suture anchor placement. Our hypothesis was that the use of a drill would result in less bony trauma and therefore superior resolution of postoperative pain following rotator cuff repair. MethodsTunnels were created for six cadaveric (age: 50.83±3.25; male n=3; female n=3) shoulder humeri using a 4-anchor construct to mimic transosseous equivalent rotator cuff repair. Following suture fixation, μCT scans were performed for evaluation of peri-tunnel bone architecture. A tensile force was applied to the anchor through the suture material at a constant displacement rate of 1mm/s until ultimate failure of the construct. All statistical analyses were performed using SPSS (version 25; IBM, Armonk, NY, USA), and significance was set at p≤0.05. A total of 43 subjects between 18 and 80 years old were randomized into the study, with 22 in the drill group and 21 in the punch group. Following surgery, the first 5 patients in each cohort underwent MRI at the 2-week postoperative visit. Pain and other patient reported measures (PROMs) were assessed at all standard of care postoperative visits. Patient demographics and PROMs were assessed for significance within the groups using repeated ANOVA and unpaired t-test. A P-value of <0.05 was set for significance. ResultsPreclinical - There were no statistically significant differences (p>0.05) between punched and drilled anchors with respect to peri-socket bone architecture and material properties. Clinical – There were no statistically significant differences (p>0.05) between punch and drill cohorts for assessments of pain, function, or bone marrow lesion size. However, the punch cohort reported statistically significant and clinically meaningful reductions in pain scores at 2 weeks, 6 weeks, 3 months, and 6 months compared to preoperative scores (p<0.02), whereas the drill cohort reported statistically significant and clinically meaningful reductions in pain scores at 6 weeks, 3 months, and 6 months after surgery (p <0.05). Similarly, the punch cohort reported statistically significant reductions in PROMIS pain interference scores, which were within 1 standard deviation of the healthy adult control population, at 2 weeks, 6 weeks, 3 months, and 6 months compared to preoperative scores (p <0.05), whereas the drill cohort did not report statistically significant improvements in PROMIS PI scores until 3 months postoperatively and were not within 1 standard deviation of the healthy adult control population until 6 months after surgery. ConclusionPreclinical and clinical data suggest that it is reasonable to utilize either a punch or drill socket-creation method for suture anchor placement in arthroscopic rotator cuff repair, while considering the potential for earlier pain relief associated with the punch method.

Thymoma-associated paraneoplastic encephalitis resolved by robotic-assisted radical thymectomy: a case report

BackgroundWe present a rare case of autoimmune encephalitis associated with an incidentally discovered thymoma. Limited case reports exist of thymoma-associated paraneoplastic encephalitis. The unique clinical presentation and subsequent surgical intervention offer valuable insights into the management of similar cases.Case presentationA 41-year-old female presented with irritability, personality changes, fatigue, and seizures. Physical examination and bloodwork on first encounter were unremarkable. Neurological evaluation was done, and a brain magnetic resonance imaging (MRI) with and without contrast demonstrated numerous hyperintensity foci within bilateral cerebral cortices on T2-/FLAIR-weighted images affecting only the supratentorial brain, findings highly suggestive of encephalitis. A chest computed tomography (CT) revealed an anterior mediastinal mass compatible with a thymoma. Cerebrospinal fluid from a lumbar puncture was unremarkable. Paraneoplastic autoantibody evaluation was positive, and the patient was diagnosed with autoimmune encephalitis believed to be associated with an incidentally discovered thymoma. Given her rapid neurological deterioration, the thoracic surgery team was urgently consulted.Patient underwent robotic-assisted radical thymectomy with prompt resolution of symptoms. During her 2-week postoperative visit, she was neurologically intact with no residual deficits. Follow-up MRI at 6 months demonstrated resolution of abnormal signal intensities, with continued improvement noted 1-year post-operation. Chest CT scans at 6 and 12 months revealed no residual or recurrent thymic tissue.ConclusionsThis case illustrates the connection between thymoma and autoimmune neurological disorders like encephalitis. It emphasizes the significance of comprehensive neurological and oncological assessments for patients with unexplained neurological symptoms. Prompt diagnosis and treatment led to positive outcomes in this case, underscoring the potential for full recovery in similar cases.

Müller Muscle Conjunctival Resection: A Prospective Multicenter Comparison of Eyelid Height at the Immediate, 1-Week, and 3-Month Postoperative Time Points.

The primary objective was to document change in postoperative marginal reflex distance-1 (MRD1) after Müller muscle conjunctival resection surgery. The secondary objective was to identify predictors of change in postoperative MRD1. A multicenter prospective cohort study was performed on patients consecutively recruited for Müller muscle conjunctival resection. MRD1 was measured immediately after Müller muscle conjunctival resection, at the 1-week postoperative visit, and the ≥3-month postoperative visit. MRD1 at the immediate and 1-week time points were compared with MRD1 ≥3 months using descriptive statistics. Predictors of change in MRD1 were analyzed using multivariate regression analysis. A total of 150 patients (226 eyelids) were included. Regarding the immediate to ≥3-month interval, 53.8% of eyelids remained clinically similar (rise or fall ≤0.5 mm), 19.8% rose ≥1 mm, and 26.4% fell ≥1 mm. Regarding the 1-week to ≥3-month interval, 76.5% remained clinically similar, 17.3% rose ≥1 mm, and 6.2% fell ≥1 mm. No variable predicted change in MRD1 over either interval with both clinical and statistical significance. Immediate postoperative MRD1 is likely to reflect the late result in only 54% of cases. However, 1-week postoperative MRD1 is similar to the late result in 77% of cases and is highly unlikely (6%) to fall by the final visit. No variable significantly impacts change in postoperative MRD1.

Deferring Postoperative Follow‑Up Visits up to 4 Weeks After Uneventful Cataract Surgery in a Tertiary Level Eye Hospital: Protocol for a Prospective, Quantitative, Experimental Control Study.

Routine examination after cataract surgery, including a refraction test 4 to 6 weeks after surgery, is mandatory in most hospitals. In recent years, there has been growing interest in exploring alternative approaches to postoperative follow-up in cataract surgery patients due to the increasing number of cataract surgeries being performed, the limited availability of health care resources, and the need to optimize the use of health care services. We aim to compare postoperative visual outcomes after a day 0 examination in patients with 2 follow‑ups, one on day 7 and other on day 30, and patients with a single ophthalmic follow‑up between days 25 to 30. A prospective, quantitative, experimental control study will be carried out in Reiyukai Eiko Masunaga Eye Hospital, located in Banepa, Kavrepalanchok, Nepal. All patients undergoing cataract surgery meeting the inclusion and exclusion criteria irrespective of the type of surgery (small-incision cataract surgery or phacoemulsification) will be included in the study. The patients will be randomly assigned to 1 of 2 groups. Patients in group 1 will be examined on day 1, day 7, and day 30, whereas patients in group 2 will be examined on day 1 and once between days 25 to 30. The minimum clinically important difference (MCID) in our study will be set according to the improvement in the Snellen visual acuity chart. The study is expected to be completed within 6 to 8 months from the start of the project. Data analysis and report writing will be carried out in a 2-month period. Best-corrected visual acuity will be compared between the 2 groups to determine if the MCID is achieved. The cost-effectiveness of the new approach will also be analyzed. We aim to conclude that we can safely defer the 1-week postoperative follow-up visit in patients undergoing uncomplicated cataract surgery and that, moreover, we can reduce the patient load at the hospital and decrease patient expenses by decreasing the frequency of hospital visits. PRR1-10.2196/48616.

Single-Shot Versus Continuous Nerve Blocks for Pediatric Anterior Cruciate Ligament Reconstruction: Analgesic Efficacy and Postoperative Outcomes

Background: Regional anesthesia is often used to minimize postoperative pain, enable early mobilization, and improve patient/family satisfaction after ACL reconstruction. Little is known about the effects of nerve blocks on patient-reported outcomes and functional outcomes in pediatric ACL reconstruction. This study was performed to compare analgesic efficacy, isokinetic strength testing, and Patient-Reported Outcomes Measurement Information System (PROMIS) scores between single-shot femoral nerve block (SSNB) and femoral nerve catheter (FNC).Methods: Pediatric patients (<18 years old) who underwent primary ACL reconstruction at a tertiary care children's hospital between January 2018 and August 2019 were included. Patients were grouped based on their anesthesia technique (SSNB or FNC) and compared to identify differences in the occurrence of uncontrolled postoperative pain and opioid refills. PROMIS domain scores, active range of motion (AROM), and isokinetic strength testing at multiple timepoints up to 6 months postoperatively were also collected. Linear regression multiple imputation analysis was performed to account for variable outcome measure availability.Results: A total of 78 patients were included (SSNB:42; FNC:36). The groups had similar pain medication needs and pain scores at 1 week postoperatively. The FNC group had significantly longer in-room to incision times (P<0.001), were less likely to return to school by 1 week after surgery (P=0.03), and had lower mobility scores at the 1-week postoperative visit. Patients in the SSNB group had significantly weaker quadriceps function at 3 months (P=0.02), although this difference resolved by the 6-month visit. There were no cases of infection or neuropathy in either group.Conclusion: Our findings indicate that both FNC and SSNB are viable options with similar efficacy for postoperative pain management in pediatric ACL reconstruction. However, we did not find any evidence of superior analgesia with FNC. Additionally, FNC was associated with lower PROMIS mobility scores at 1 week, delayed return to school, and 30 minutes of additional time spent in the operating room. There were no significant differences between groups in terms of function and PROMIS scores at 6 months postoperatively.Level of Evidence: Level III, retrospective cohort studyKey Concepts•Femoral nerve catheter and single-shot femoral blocks are both viable management options for post-ACL reconstruction pain in children and adolescents.•We found that patients who received a femoral nerve block were less likely to return to school and had lower mobility scores at 1 week postoperatively and spent an additional 30 minutes in the operating room.•Both regional anesthesia techniques had similar PROMIS scores and functional outcomes at 6 months postoperatively.

Standard Opioid Prescribing in Pediatric and Adolescent Gynecology [ID: 1381154

INTRODUCTION: Enhanced Recovery After Surgery principles reduce opioid use postoperatively. There are no recommendations for optimal opioid dose prescribing for postoperative pain. The aim of this quality improvement project was to assess postoperative opioid use after pediatric gynecologic surgeries and establish standard opioid prescriptions across all surgeons based on procedural type. METHODS: Counseling on postoperative care including pain management was provided preoperatively and postoperatively. At the 2-week postoperative visit, patients were asked the number of opioid doses used and their pain control satisfaction. Baseline data were collected for 6 months with surgeons prescribing opioid doses via personal preference. After reviewing the prescribing practices and number of doses used, standard opioid doses were established with 10 doses provided for laparotomy with incision greater than or equal to 5 cm, 5 doses for laparoscopy or mini-laparotomy with incision(s) 4 cm or less, 5 doses for combined laparoscopic/vaginal approach, and 0 doses for vaginal cases. Data collection was repeated after implementation of standard opioid dose prescriptions. RESULTS: Complete data were recorded for 30 cases prior to implementation and 29 cases after implementation. Standard opioid dosing resulted in 30% decrease in total opioid doses (252–176 doses; P=.014) and 15% reduction in unused doses (162–137 doses). Forty-three percent of patients used no opioid doses. There was no significant difference in patient satisfaction (P=.014) in pain control. CONCLUSION: Application of standard opioid dose prescribing is feasible for common pediatric gynecologic surgeries without affecting patient satisfaction. This quality improvement project suggests further reduction in standard dose prescriptions is possible.

Opioid Usage After Hallux Valgus Correction Surgery.

Given the lack of objective data on opioid use and the difficulty of addressing a patient's postoperative pain, we sought to quantify patient's narcotic use after hallux valgus surgery. The purpose of our study was to determine the average quantity and type of postoperative opioids consumed after hallux valgus surgery and to assess potential predictive factors for increased opioid consumption. At the preoperative visit, patients were consented and completed a demographical questionnaire. Data were collected from the operative record, 2, 6, and 12-week postoperative visits. Type and number of pills prescribed were recorded as well as number of pills consumed at each postoperative visit. A logistic regression was performed to determine the average quantity consumed postoperatively and any statistically significant correlations. The average number of opioid pills collectively consumed at the 2-week and 12-week postoperative visit was 20 and 23, respectively. At the 2-week postoperative visit, only patient body mass index (BMI) showed a correlation with increased opioid use. Patients consumed an average of 23 of 40 (57.5%) narcotic pain pills prescribed after hallux valgus reconstruction surgery through the 12-week postoperative period. Owing to the opioid epidemic and potential for narcotic diversion, surgeons should counsel their patients on proper nonopioid postoperative pain management. II Therapeutic.

Laser Ablation of Pilonidal Sinus Disease: A Pilot Study.

Pilonidal disease is classically treated with wide local excision, although a number of minimally invasive approaches are currently under investigation. We aimed to determine the safety and feasibility of laser ablation of pilonidal sinus disease. Laser ablation provides a minimally invasive means of obliterating pilonidal sinus tracts without a need for excessive tract dilation. Laser ablation can be performed more than once on the same patient if necessary. This technique uses the NeoV V1470 Diode Laser (neoLaser Ltd, Caesarea, Israel) with a 2-mm probe. We performed laser ablation in adults and pediatric patients. We performed 27 laser ablation procedures in 25 patients, with a median operative time of 30 minutes. Eighty percent of patients reported either no pain or mild pain at the 2-week postoperative visit. The median time to return to work or school was 3 days. Eighty-eight percent of patients reported being satisfied or very satisfied with the procedure at their most recent follow-up (median, 6 mo). Eighty-two percent of patients were healed at 6 months. Laser ablation of pilonidal disease is safe and feasible. Patients experienced short recovery time and reported low levels of pain and high levels of satisfaction.

Graft Detachment after Descemet Membrane Endothelial Keratoplasty with and without Cataract Surgery.

To evaluate graft detachment after Descemet membrane endothelial keratoplasty (DMEK) in pseudophakic eyes and DMEK combined with cataract surgery (triple DMEK). Analysis of 3 single-center prospective cohort studies and 1 randomized controlled trial. Participants with Fuchs' endothelial corneal dystrophy. A validated neural network for image segmentation quantified graft detachment on anterior segment OCT (AS-OCT) images 3 days after DMEK and at the 2-week postoperative visit. Area and volume of graft detachment were compared between DMEK only and triple DMEK using generalized estimating equation models and adjusting for participant age and the size of the air bubble. Area and volume of DMEK graft detachment. Among 207 participants with 270 eyes included, 75 pseudophakic eyes had DMEK only and 195 eyes had triple DMEK. A total of 147 eyes had less than one third of detachment at day 3. In 139 of these eyes (95%), detachment was still less than one third at the 2-week scan, indicating that postoperative graft detachment at 2 weeks occurred mainly in eyes with early detachment. When superimposing all 3-dimensional maps from 2 weeks after surgery, the central graft was mainly attached and detachment was located at the graft margin. The mean area of graft detachment decreased from 28% in DMEK only and 38% in triple DMEK to 16% in DMEK only and 25% in triple DMEK at the 2-week postoperative visit. At 2 weeks, the mean area of detachment was 1.85-fold higher (95% confidence interval [CI], 1.34-2.56) and the mean volume was 2.41-fold higher (95% CI, 1.51-3.86) in triple DMEK compared with DMEK. A total of 46 eyes received rebubbling procedures, with 7 eyes (9%) in the DMEK group and 39 eyes (20%) in the triple DMEK group (adjusted risk ratio, 3.1; 95% CI, 1.3-7.1), indicating that rebubbling was more common in eyes undergoing triple DMEK. Automated segmentation of AS-OCT images allowed precise quantification of graft detachment over time and identified DMEK combined with cataract surgery as a risk factor. Frequency of operative follow-up might be guided by extent of detachment in the first postoperative days after DMEK.

Recovery from open osteocapsular débridement for primary elbow osteoarthritis is rapid and does not depend on preoperative motion.

Osteocapsular débridement is a surgical treatment for functionally limiting primary elbow osteoarthritis (PEOA). We hypothesized that postoperative improvement in range of motion (ROM) following elbow osteocapsular débridement could be grouped into predictable patterns. We also hypothesized that significant improvements in ROM frequently take place for up to 6 months after surgery. A retrospective chart review of patients who underwent open elbow débridement for PEOA was performed. Demographic information and surgical approach were recorded. ROM data were also collected at preoperative, intraoperative, and postoperative intervals of 2 weeks, 6 weeks, 3 months, and 6 months. Growth mixture modeling and latent class growth analysis were performed to identify groups of motion recovery trajectories, while Student's t-tests were performed to compare ROM data between intervals. Our study included 76 patients who underwent open elbow débridement (9 with a lateral approach, 55 medial, and 12 both) for PEOA. The mean preoperative arc of motion was 95°±22°. This improved to a mean final motion arc of 127°±11 at final follow-up, which was 92% of the mean intraoperative arc. The mean time to achieve final motion was 3 months, with 79% of patients achieving their final ROM arc by this point. Patients achieved an average of 85% of their final arc of motion by the 2-week postoperative visit (92% of final flexion and 61% of final extension). Growth mixture modeling and latent class growth analysis did not identify any statistically significant groupings for postoperative ROM progression trajectories. Arc of motion preoperatively, intraoperatively, and at 2 weeks postoperatively did not correlate with the final arc of motion. There were no characteristics or thresholds of motion which conferred a higher likelihood of achieving a better result postoperatively. ROM recovery after osteocapsular débridement for PEOA is not dependent on preoperative, intraoperative, or 2-week postoperative arcs of motion. Most of the ROM recovery occurs in the early postoperative period, with flexion restored preferentially faster than extension. The final arc of motion can be expected by 3 months postoperatively. This knowledge has potential benefit in affecting patients' personal time commitment to rehabilitation and the overall cost for therapy and splinting beyond the 3-month time point.

Shared decision-making for postoperative opioid prescribing and preoperative pain management education decreases excess opioid burden.

Managing postoperative pain requires an individualized approach in order to balance adequate pain control with risk of persistent opioid use and narcotic abuse associated with inappropriately outsized narcotic prescriptions. Shared decision-making has been proposed to address individual pain management needs. We report here the results of a quality improvement initiative instituting prescribing guidelines using shared decision-making and preoperative pain expectation and management education to decrease excess opioid pills after surgery and improve patient satisfaction. Pre-intervention prescribing habits were obtained by retrospective review perioperative pharmacy records for patients undergoing general surgeries in the 24months prior to initiation of intervention. Patients scheduled to undergo General Surgery procedures were given a survey at their preoperative visit. Preoperative education was performed by the surgical team as a part of the Informed Consent process using a standardized handout and patients were asked to choose the number of narcotic pills they wished to obtain within prescribing recommendations. Postoperative surveys were administered during or after their 2-week postoperative visit. 131 patients completed pre-intervention and post-intervention surveys. The average prescription size decreased from 12.29 oxycodone pills per surgery prior to institution of pathway to 6.80 pills per surgery after institution of pathway (p < 0.001). The percentage of unused pills after surgery decreased from an estimated 70.5% pre-intervention to 48.5% (p < 0.001) post-intervention. 61.1% of patients with excess pills returned or planned to return medication to the pharmacy with 16.8% of patients reporting alternative disposal of excess medication. Patient-reported satisfaction was higher with current surgery compared to prior surgeries (p < 0.001). Institution of procedure-specific prescribing recommendations and preoperative pain management education using shared decision-making between patient and provider decreases opioid excess burden, resulting in fewer unused narcotic pills entering the community. Furthermore, allowing patients to participate in decision-making with their provider results in increased patient satisfaction.

Single High-Dose Systemic Methylprednisolone Administered Preoperatively Improves Pain Control and Sleep Quality After Total Hip Arthroplasty: A Double-Blind, Randomized Controlled Trial

BackgroundThis study was performed to evaluate the efficacy of preoperative high-dose methylprednisolone on pain levels and sleep quality following primary total hip arthroplasty. Material and methodsA double-blind, randomized controlled trial was performed in adults underdoing total hip arthroplasty. A computer-generated, permuted-block randomization scheme with a 1:1 ratio between the intervention (125 mg methylprednisolone) and control groups (normal saline) was utilized. Patients underwent a similar preoperative and postoperative protocol. Pain was assessed using the visual analog scale (VAS). Sleep quality was assessed at the 2-week postoperative visit using the Pittsburgh Sleep Quality Index (PSQI). ResultsWith a total of 70 patients, 35 patients were included in the intervention and placebo groups. Hospital stay was significantly shorter in the intervention group (1.5 ± 0.7 vs 2.0 ± 0.5 days, P = .03). Preoperative pain levels were similar between groups, while satisfactory pain control was achieved in a significantly larger number of patients in the intervention group (18 vs 8 patients, P = .009). The intervention group was significantly more likely to have a good sleep quality than the placebo groups (74% vs 31%, P = .001). No significant differences were found between preoperative and postoperative blood sugar levels. We did not observe any cases of early postoperative wound complication, infection, or deep vein thrombosis among our patients. ConclusionIn this randomized controlled trial, preoperative administration of 125 mg of methylprednisolone was found to improve pain control, as measured by VAS, 24 hours after surgery, and sleep quality, as measured by PSQI, 2 weeks following surgery.

V05-05 REPAIR OF ENTERO-CONDUIT FISTULA USING ROBOT-ASSISTED LAPAROSCOPY

You have accessJournal of UrologyCME1 May 2022V05-05 REPAIR OF ENTERO-CONDUIT FISTULA USING ROBOT-ASSISTED LAPAROSCOPY Aeen Asghar, David Strauss, and Daniel Eun Aeen AsgharAeen Asghar More articles by this author , David StraussDavid Strauss More articles by this author , and Daniel EunDaniel Eun More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002579.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We present a case highlighting surgical management of an entero-conduit fistula (ECF), with robot-assisted laparoscopy (RAL). The patient is a 71-year-old male with a history of non-invasive high-grade urothelial carcinoma (UC) of the left distal ureter who underwent a RAL distal ureterectomy and ureteroneocystostomy and subsequent left RAL completion nephroureterectomy and eventual RAL radical cystoprostatectomy (RC) and intracorporeal ileal conduit (IC) diversion due to recurrence despite an induction course of intravesical BCG. Most recently, he developed metastatic disease to his right lung and underwent robot-assisted right lobectomy. Currently, the patient is disease-free. Nearly two years after RC, he presented with food particles and air per his urostomy. He also had a positive poppy seed test. Initially, pouchoscopy identified a pinpoint ECF tract at the proximal end of the IC. A 6-month trial of conservative management was unsuccessful with multiple episodes of pyelonephritis of his solitary right kidney requiring prophylactic antibiotics. Here, we demonstrate our approach to RAL ECF repair. METHODS: We began with pouchoscopy, which revealed a larger ECF, able to be cannulated by a 5 Fr open-ended catheter. Injection of contrast highlighted the ECF. A simultaneous pouchogram revealed reflux to the solitary right kidney. Access was obtained using a 5mm optical trocar without difficulty. We noted no significant intra-abdominal adhesions despite his past surgeries. Four 8mm robotic ports and a 5mm assistant port were used as outlined in the video. The ureteral anastomosis was easily identified, and further dissection revealed the ECF in proximity to the bowel-bowel anastomosis staple line. We upsized the left 8 mm robotic port to 12 mm to use a 45 mm robotic stapler. The ECF tract was stapled and oversewn using 4-0 silk sutures. Omentopexy and interposition flap was performed by mobilizing the omentum and fixating it in between the bowel and IC using 4-0 silk sutures to prevent recurrence. RESULTS: Operative console time was 98 minutes with 25 mL of blood loss. He was discharged on the same day. The red rubber catheter, which was secured to the IC, was removed at his 2-week post-operative visit. He remains symptom-free at the time of his 6 month follow up visit. CONCLUSIONS: First-line treatment of ECF is conservative management, with surgical repair reserved for rare failure. This case shows the feasibility of RAL ECF repair and revisions for urinary diversion-related complications. Additionally, it highlights a potential benefit of RAL given minimal adhesion development despite multiple prior major intra-abdominal surgeries done using the robotic approach. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e517 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aeen Asghar More articles by this author David Strauss More articles by this author Daniel Eun More articles by this author Expand All Advertisement PDF DownloadLoading ...

An Unusual Complication of Gluteal Fistula after Sacrospinous Ligament Suspension: A Case Report

Background: Sacrospinous ligament suspension (SSLS), also referred to as sacrospinous ligament fixation, is a well-established transvaginal procedure performed to treat apical prolapse. Serious complications are uncommon following SSLS, and mild infectious complications, such as cystitis, are most common. In this report, we present an uncommon case of gluteal fistula as a complication of this procedure. Case: A multiparous 48-year-old with a history of vaginal hysterectomy with bilateral salpingectomy, anterior and posterior colporrhaphy, and sacrospinous ligament suspension presented one year later with multiple emergency department visits for gluteal abscesses and continuous right gluteal drainage. MRI confirmed a gluteal fistula extending from the sacrum to the right gluteal fold and right piriformis muscle, thought to be caused by retained suture. The patient subsequently underwent an exam under anesthesia in which the reproduction of the vaginal dissection performed to place the SSLS sutures and probing of the fistula failed to expose any suture. The fistula was copiously irrigated with antibiotic solution, and on a 2-week postoperative visit, the fistula was noted to be completely healed. Conclusion: This is a rare case of gluteal fistula as a complication of SSLS procedure. In this case, the suspected retained suture causing the fistula was not identified; however, the fistula was still able to heal

Satisfactory Pain Management With Minimal Opioid Use After Arthroscopic Rotator Cuff Repair

PurposeTo evaluate patient use of opioids following arthroscopic rotator cuff repair, including the number of days and number of pills when used in combination with non-opioid medications and to determine whether patients were satisfied with their pain management and if variables such as age, sex, body mass index, duration of symptoms, anticipation of postoperative pain, preoperative opioid consumption, size of the rotator cuff tear, or anxiety/depression affected pain management.MethodsThis was a prospective cohort study of 117 prospectively enrolled patients older than the age of 18 years undergoing primary arthroscopic rotator cuff repair. All patients completed preoperative and 2-week postoperative questionnaires to assess their pain and satisfaction with pain management. Univariate and multivariate analyses were performed to evaluate the association of patient characteristics with satisfaction of pain control and amount/duration of opioids postoperatively.ResultsPatients required a median of 18 opioid pain pills or 135 morphine milligram equivalents (interquartiles, 6-35 pills) postoperatively over 6.9 ± 5.1 days. In total, 65% of patients took opioid pain medications for 7 days or fewer. On postoperative day 2, patients reported a VAS pain score of 6.6 ± 2.8 and at the 2-week postoperative visit, mean visual analog scale pain score was 3.5 ± 2.5. Differences in age, sex, body mass index, duration of symptoms, anticipation of postoperative pain, preoperative 2-item Patient Health Questionnaire, 2-item Pain Self-Efficacy Questionnaire, current opioid use, and surgical characteristics had no effect on, or association with, satisfaction with pain management postoperatively.ConclusionsFollowing arthroscopic rotator cuff repair, patients can achieve satisfactory pain control using a multimodal approach with a median of 18 opioid pills (range 6-35 pills) over 6.9 ± 5.1 days when used in combination with non-opioid pain medications. Overall, 74.4% of patients were satisfied with their postoperative pain management.Level of EvidenceLevel II; Prospective cohort study.

Laparoscopic Myomectomy: Surgical Tips and Tricks

<h3>Study Objective</h3> The objective of this video is to provide surgical and suturing tips for successful laparoscopic myomectomy of an enlarged fibroid uterus. <h3>Design</h3> Video case presentation. <h3>Setting</h3> The surgery in this video was performed in the operating room at an academic medical center. The patient was positioned in dorsal lithotomy position. Laparoscopic myomectomy and closure were completed using a 12mm umbilical port, a 12mm left lower quadrant port, a 5mm left upper quadrant port, and a 5mm right lower quadrant port. <h3>Patients or Participants</h3> The patient is a 38-yo G0 with symptomatic uterine fibroids including heavy menstrual bleeding and bulk symptoms, desiring future fertility. She had a preoperative pelvic MRI demonstrating a 15cm multifibroid uterus with 6 fibroids, the largest being a 7.5cm Type II-V fibroid at the uterine fundus. She's had a prior laparoscopic right salpingo-oophorectomy for an ovarian stromal tumor and reports that 2 small fibroids were also removed at that time. <h3>Interventions</h3> Laparoscopic enterolysis, laparoscopic myomectomy <h3>Measurements and Main Results</h3> This patient underwent an uncomplicated laparoscopic myomectomy. Total operative time was 201 minutes. Estimated blood loss was 100cc. Eight fibroids were removed, weighing 459g. The endometrial cavity was entered, and she will need a cesarean section with future deliveries. The patient was doing well at her 2-week post-operative visit with improvement in pelvic pain and bleeding. She will have an in-office flexible hysteroscopy 3 months post-op during the early proliferative phase prior to pursuing fertility goals. <h3>Conclusion</h3> Laparoscopic myomectomy of a large fibroid uterus can be successfully completed with minimal blood loss using the techniques described in this video. Closure of deep myometrial and endometrial defects can be done under good visualization utilizing ipsilateral ports for efficient suture placement and recovery.

Epidemiology and risk factors for loss to follow-up following operatively treated femur ballistic fractures

IntroductionEvidence regarding recommendations for treatment of ballistic fractures remains limited. This paucity of literature has largely been attributed to gunshot wound victims being a difficult population to study secondary to loss to follow-up. The purpose of this study was to examine the epidemiology of operatively treated ballistic femur fractures at our institution, the frequency of outpatient follow-up and risk factors for loss to follow-up. MethodsInpatient consults from 2013-2018 were queried for femoral gunshot wounds treated operatively. Cases without internal or external fixation were excluded from the study. Postoperative visits where a patient was hospitalized or had expired were excluded from the analysis. Demographic information, length of hospital stay, and operative characteristics were compared for different fixation methods and examined as risk factors for loss to follow-up. ResultsA total of 194 patients met inclusion criteria. The average age was 27 years old and 94% of the patients were male. Patient's stayed a median of 5 days post-operatively with patients treated with external fixation staying longer than internal fixation (14 days vs 5 days p=0.01). 9.3% of ballistic fractures had a concomitant vascular injury necessitating repair. 70.4% of patients attended their 2-week postoperative visit, 55.7% of patients attended their 6 week follow-up visit and 31.3% attended their 3 month follow-up visit. Risk factors for loss to follow-up at 3 month visit included younger age (p=0.028), decreased hospital length of stay (p=0.025) and intramedullary fixation (p=0.00015). Discussion and conclusionThis study reinforces the difficulty of studying ballistic fractures secondary to loss to follow-up. Younger age, shorter hospital stays and intramedullary fixation increased the risk for loss to follow-up at 3 months.

Relationship between ocular surface disease and patient’s satisfaction among cataract surgical patients in Nigeria

To determine the effect of clinical and cytological features of ocular surface disease on patient's satisfaction following small incision cataract surgery at a tertiary eye care centre. This is a prospective observational study of 70 consecutive consenting patients who underwent manual small incision cataract surgery(MSICS) at a tertiary eye care centre. All participants underwent ocular surface profile assessment using Schirmer I test (ST1), tear film break-up time (TBUT), conjunctival impression cytology (CIC) and ocular surface disease index (OSDI) at pre-operative visit, 1-week and 4-week post-operative visit. Patient's satisfaction with surgical outcome was evaluated at 6-week post-operative visit using a rating scale of 1 to 10. Data were analysed using IBM Statistical Package for the Social Sciences (SPSS) version 20.0 (IBM Corp., Armonk, NY USA). The mean age was 68 ± 9.4years with a male/female ratio of 1:1.1. The mean OSDI score decreased significantly (p < 0.001) from 33.1 ± 8.4 pre-operatively to 20.8 ± 7.4 four weeks after surgery. The TBUT was 12 ± 4.1s pre-operatively, but significantly reduced to 11.2 ± 3.9s (p < 0.001) at 4-week post-operative period. At 6 weeks, patients with normal CIC reduced from 53 (75.8%) pre-operatively to 8 (11.4%) (p < 0.001, z = -7.24). Fifty percent of patients with severe post-operative ocular surface disease reported dissatisfaction with their surgical outcome (p = 0.024). Manual small incision cataract surgery can significantly impair the ocular surface health profile of patients. The presence of ocular surface disease in patients pre-operatively can negatively impact their level of satisfaction with surgical outcome.

Case 287.

History A 60-year-old woman was diagnosed with a new right upper lobe stage I lung adenocarcinoma and underwent video-assisted thoracoscopic surgery (VATS) for right upper lobectomy. Her postoperative course was complicated by a large pneumothorax after chest tube removal on postoperative day 3. This was managed with repeat right-sided chest tube placement on the same day. The second chest tube was removed on postoperative day 8 without complications. A 2-week postoperative clinic visit was unremarkable. Postoperative chest radiographs on postoperative days 1, 3, and 8 (Fig 1a-1c) are provided. Subsequently, chest CT scanning was performed as part of routine 6-month postsurgical lung cancer surveillance follow-up (Figs 2, 3). The patient had no clinical complaints at routine follow-up. Physical examination revealed well-healed VATS scars in the chest wall. Laboratory results were within normal limits, including a normal white blood cell count of 6400/μL. Her surgical history included prior left upper lobectomy for remote left upper lobe stage IIIA adenocarcinoma and prior bilateral breast implantation for cosmesis. On the basis of chest CT findings, the patient was transferred from an outside institution.

Use of cryoanalgesia as a postoperative pain management for open pectus carinatum repair.

Cryoanalgesiahas shown to have safety and efficacy as an adjunct post-operative pain management for Nuss procedure. One retrospective study reported its efficacy for analgesia with the Ravitch procedure, with improved pain scores and decreased length of stay versus thoracic epidural. We describe our initial experience with the use of cryoanalgesiafor an open repair of pectus carinatum. We retrospectively reviewed the medical records of all patients who received cryoanalgesiaduring an open repair of pectus carinatum from 2016 to 2019 at our institution. We recorded pain scores at immediate post-operative and at 1-week follow up after hospital discharge. Length of stay and mean follow up time were also recorded. Five pediatric patients underwent open repair of pectus carinatum withcryoanalgesia. The median postoperative length of stay (LOS) was 1 (range 1-2) day. Only one patient reported a non-zero pain score during their hospitalization, and this was a 3 out of 10 in the post-analgesia care unit. At 1-week postoperative visit, all patients had apainscore of 0. Median follow up was 1 (0.5-2) year. No patients developed neuralgia. Cryoanalgesia is a safe and effective pain managementstrategy for pediatric patients undergoing open pectus carinatum repair.