Average Duration Of Procedure Research Articles

PO-02-056 REAL-TIME VIDEO ASSISTED THORACOSCOPIC SURGERY IN HIGH-RISK TRANSVENOUS LEAD EXTRACTION

Laceration injury to the superior vena cava (SVC) remains the most feared complication of transvenous lead extraction (TLE). Early recognition is crucial to prevent catastrophic complications. Use of real time video assisted thoracoscopic surgery (VATS) during high risk TLE can potentially be useful for prompt recognition of SVC injury. We describe the use of video assisted thorascopic surgery (VATS) guidance for complex transvenous lead extractions (TLE). We conducted a retrospective analysis of all patients that underwent TLE at our institution from September 2018 to November 2022. Our TLE protocol uses a risk stratification scheme of level 1, 2 and 3 based on perceived risk. Defibrillation leads with a dwell time of >10 years or presence of 3 leads with oldest lead >10 years qualify as level 3 TLE cases. All procedures are performed with surgical back up with the use of VAT via a right thoracoscopic approach in level 3 cases. During single lung ventilation, the surgeon places a camera port to provide visualization of the SVC and right atrium for direct visualization during the laser/mechanical sheath manipulation in the great vessels. Out of 41 patients that underwent TLE during the study period, 10 patients underwent concomitant right VATS. Mean age of cohort was 61.5 + 15.2 years and 70% were males. Mean BMI and LVEF was 28.8 + 7.9 & 28.5 + 5.9 % respectively. Indications for TLE included lead malfunction (50%), infection (40%) and removal of abandoned leads in 1 patient. Mean lead dwell time was 10.4 + 5.6 years. Laser sheath was used in all cases with 2 patients requiring use of additional mechanical sheaths. One case demonstrated externalized ICD coil and extraction was abandoned. A femoral approach with snaring was done in 1 patient. All patients had adequate visualization of the SVC via VATS during TLE. Average procedure duration was 134 + 79.1 minutes. There were no immediate procedural complications. VATS port was removed and a chest drain was placed which was removed on post operative day 1 in all patients. VATS allows for direct visualization of the venous structures, provides real time information regarding impending venous injury, and is feasible with minimal impact on procedural risk and length of stay.

A percutaneous ultrasound-guided iliotibial band release technique reduces surgical time and costs compared to an endoscopic technique.

External snapping hip is caused by the iliotibial band snapping from the greater trochanter during hip movement. The aim of this study was to compare a technique of ultrasound-guided iliotibial band release versus a similar endoscopic technique. An anatomical study was performed on 10 cadavers i.e. 20 hips. The same operator performed ultrasound-guided and endoscopic iliotibial band release on either side of each specimen. An independent operator performed an open control to verify the outcome measures. The primary outcome was iliotibial cutting percentage, defined as the ratio of the transversal cut distance and the width of the iliotibial at the most prominent portion of the great trochanter. Secondary outcomes included nerve injuries. The surgical time was assessed and disposable medical supplies costs were estimated. The average cutting percentage was 95% ± 8 by ultrasound, compared with 91% ± 11 by endoscopy (n.s.). No iatrogenic lesions were found, particularly nerve damage. The average duration of the ultrasound procedure was 12.3 minutes ± 6 compared to 21 minutes ± 10.7 for endoscopy (p=0.04), with a 3-fold decrease between the first and last procedure, regardless of the technique. The ultrasound procedure was 3 times less expensive in terms of disposable medical supplies (120.5€ versus 353.5€). This technique of ultrasound-guided iliotibial band release appears to be as effective and safe as a similar endoscopic technique. The surgical time is reasonable for a surgeon trained in ultrasound, with lower disposable supplies costs. A comparative clinical study is further needed to assess the actual benefits of each technique.

365 Awake Spine Surgery for Traditionally Poor Surgical Candidates: An Illustrative Cohort

INTRODUCTION: Annually, hundreds of thousands of patients undergo surgery for degenerative spine disease (DSD). This represents only a fraction of patients that present for surgical consideration. Procedures are often avoided due to comorbidities that make patients poor candidates for general anesthesia (GA) and its associated risks. With increasing interest in awake surgery under spinal anesthesia (SA), the authors have observed that SA may facilitate spine surgery in patients with relative contraindications to GA. METHODS: Case logs of a single surgeon were reviewed, and patients undergoing spine surgery with SA were identified. Within this group, patients were selected that were only able to receive surgery under SA due to their relative contraindications to GA. For this final cohort, the medical records were consulted to report demographic information, as well as patient outcomes. RESULTS: 8 patients were identified who were only able to receive lumbar spine surgery for DSD under SA due to their relative contraindications to GA. Comorbidities included octogenarian status, obesity, and chronic health conditions such as Parkinson’s and ischemic heart disease. The cohort was 25% female with a mean age of 72.9, a mean BMI of 30.1 kg/m2, and a mean ASA score of 3.0. The average procedure duration was 142.13 minutes. Mean time to ambulation was 23.18 hours and the average hospital length of stay was 1.67 days. The patients used an average of 28.69 morphine milligram equivalents for pain control in the operative and postoperative days. CONCLUSIONS: For patients with symptomatic, refractory DSD and relative contraindications to GA, SA may facilitate safe surgical intervention with excellent outcomes.

Endovascular Strategy for Inferior Vena Cava Thrombosis Secondary to Deep Venous Thrombosis of the Lower Extremities: Early Experience From Two Centres.

To evaluate the safety, feasibility and technical aspects of endovascular treatments for inferior vena cava (IVC) thrombosis secondary to deep venous thrombosis of the lower extremities. A retrospective study of patients from two centres who received endovascular treatment for IVC thrombosis from January 2015 to December 2020. Under the protection of the IVC filter, all lesions were treated with manual aspiration thrombectomy (MAT) followed by catheter-directed thrombolysis (CDT). Technical aspects, complications, IVC patency, Venous Clinical Severity Score (VCSS) score and Villalta score were recorded during the follow-up observation. Endovascular procedures including MAT and CDT were performed successfully in 36 patients (97.3%). The average duration of the endovascular procedure was 71minutes (range: 35-152min). To protect against fatal pulmonary artery embolism, 33 filters (91.7%) were deployed in the inferior renal IVC, while three patients (8.3%) received filter implantation in the retrohepatic IVC. No severe complications occurred during the procedure. In the follow-up observations, the cumulative primary and secondary patency rates in IVC were 95% and 100%, respectively. The patency rates for the iliac vein were as follows: a primary patency rate of 77% and a secondary patency rate of 85%. The average VCSS score was 5.9 ± 2.6, and the Villalta score was 3.9 ± 2.2. The rate of post thrombotic syndrome is 22% in our study as assessed by the villalta score (Villalta score>4). Endovascular treatment for IVC thrombosis secondary to DVT of the lower extremities is feasible, safe, and effective. This strategy alleviates venous insufficiency and results in a high patency rate in IVC.

Differences in Post Ablation Cardiac MRI Scar Between Radiofrequency and Cryoballoon Ablation: A DECAAF II Sub-analysis.

Pulmonary vein isolation (PVI) using radiofrequency (RF) and cryoballoon (Cryo) ablation are standard approaches for rhythm control in patients with symptomatic atrial fibrillation. Both strategies create scar in the left atrium (LA). There have been few studies investigating the difference in scar formation between patients undergoing RF and Cryo using cardiac magnetic resonance imaging (CMR). The current study is a sub-analysis of the control arm of the Delayed-Enhancement MRI Determinant of Successful Catheter Ablation of Atrial Fibrillation study (DECAAF II). The study was a multicenter, randomized, controlled, single blinded trial that evaluated atrial arrhythmia recurrence (AAR) between PVI alone and PVI plus CMR atrial fibrosis guided ablation. Pre-ablation CMR and 3-6-month post ablation CMR were obtained to assess baseline LA fibrosis and scar formation respectively. Of the 843 patients randomized in the DECAAF II trial, we analyzed the 408 patients in the primary analysis control arm that received standard PVI. Five patients received combined RF and Cryo ablations so were excluded from this sub-analysis. Of the 403 patients analyzed, 345 underwent RF and 58 Cryo. The average procedure duration was 146 minutes for RF and 103 minutes for Cryo (p = 0.001). The rate of AAR at ~15 months occurred in 151 (43.8%) patients in the RF group and 28 (48.3%) patients in the Cryo group (p = 0.62). On 3-month post CMR the RF arm had significantly more scar (8.8% vs. 6.4%, p = 0.001) compared to Cryo. Patients with ≥ 6.5% LA scar (p < 0.001) and ≥ 2.3% LA scar around the PV antra (p = 0.01) on 3-month post CMR had less AAR independent of ablation technique. Cryo caused a greater percentage of right and left pulmonary vein (PV) antral scar (p = 0.04, p = 0.02) and less non-PV antral scar (p = 0.009) compared to RF. On Cox regression Cryo patients free of AAR had a greater percentage of left PV antral scar (p = 0.01) and less non-PV antral scar (p = 0.004) compared to RF free of AAR. In this sub-analysis of the control arm of the DECAAF II trial, we observed that Cryo formed a greater percentage of PV antral scar and less non-PV antral scar compared to RF. Post ablation LA scar ≥ 6.5% predicted freedom from AAR, independent of ablation technique. These findings may have prognostic implications in ablation technique selection and freedom from AAR. This article is protected by copyright. All rights reserved.

Outcomes of a Colorectal Enhanced Recovery After Surgery Protocol Modified for a Diverse and Urban Community

IntroductionEnhanced recovery after surgery (ERAS) colorectal programs have been shown to improve the length of stay (LOS) without increasing hospital resource utilization at academic centers worldwide. A multidisciplinary ERAS protocol that includes preoperative, intraoperative, and postoperative management guidelines was recently implemented at our urban, racially diverse, and academically affiliated community hospital. A delivery option was provided to reduce barriers to care. Given our unique patient population, the objective of our study was to determine if improvements in outcomes were reproducible in our hospital. MethodsThis is a retrospective study of patients undergoing elective colectomy at New York-Presbyterian Queens Hospital between January 1, 2015, and December 31, 2020. Patient outcomes were compared between surgeries performed under standard practice (all colectomies prior to April 2017) and those performed after the implementation of the ERAS protocol. Demographic and perioperative data were abstracted from a prospectively derived database used to submit data to the National Surgical Quality Improvement Program. Additional data were obtained from chart review. ResultsSix hundred five elective colectomies were performed by 12 surgeons (range 1-228 cases) during the study period. Of these, 22 were performed open (41% followed ERAS), 467 were performed laparoscopically (57% followed ERAS), and 116 were performed robotically (74% followed ERAS). The average patient age was 64 y. Of which, 55% were male; 34% were Asian, 27% were non-Hispanic Caucasian, 27% were Hispanic, and 11% were Black or African American (all P-values > 0.05 for ERAS versus non-ERAS). Average duration of procedure was longer in the ERAS group (262 min versus 243 min, P = 0.04), although when stratified by procedure type, this relationship held true only for laparoscopic procedures. Hospital LOS was significantly shorter in the ERAS group (4.3 versus 5.4 d, P < 0.001) and this relationship held true for procedures performed both laparoscopically (4.2 versus 5.3 d, P = 0.01) and robotically (4.1 versus 5.1 d, P = 0.04). Of the ERAS group, patients who opted for delivery of ERAS components (n = 205) had the shortest LOS when compared to patients who picked up components (n = 91) or opted out of ERAS (n = 309) (4.1 versus 4.4 versus 5.2 d, P = 0.003). No significant differences were found for 30-d mortality, 30-d readmission, wound infection, or other postoperative complications (all P-values > 0.05). ConclusionsImplementation of an ERAS protocol in an urban, diverse, academically affiliated community hospital is associated with reductions in LOS for colectomies performed both laparoscopically and robotically. Facilitating ERAS compliance with a delivery option was also associated with improvements in hospital LOS. Preoperative nutrition supplementation was not associated with outcomes. No differences in mortality, readmission rates, or rates of postoperative complications were found.

5G-Based Telerobotic Ultrasound System Improves Access to Breast Examination in Rural and Remote Areas: A Prospective and Two-Scenario Study.

Ultrasound (US) plays an important role in the diagnosis and management of breast diseases; however, effective breast US screening is lacking in rural and remote areas. To alleviate this issue, we prospectively evaluated the clinical availability of 5G-based telerobotic US technology for breast examinations in rural and remote areas. Between September 2020 and March 2021, 63 patients underwent conventional and telerobotic US examinations in a rural island (Scenario A), while 20 patients underwent telerobotic US examination in a mobile car located in a remote county (Scenario B) in May 2021. The safety, duration, US image quality, consistency, and acceptability of the 5G-based telerobotic US were assessed. In Scenario A, the average duration of the telerobotic US procedure was longer than that of conventional US (10.3 ± 3.3 min vs. 7.6 ± 3.0 min, p = 0.017), but their average imaging scores were similar (4.86 vs. 4.90, p = 0.159). Two cases of gynecomastia, one of lactation mastitis, and one of postoperative breast effusion were diagnosed and 32 nodules were detected using the two US methods. There was good interobserver agreement between the US features and BI-RADS categories of the identical nodules (ICC = 0.795-1.000). In Scenario B, breast nodules were detected in 65% of the patients using telerobotic US. Its average duration was 10.1 ± 2.3 min, and the average imaging score was 4.85. Overall, 90.4% of the patients were willing to choose telerobotic US in the future, and tele-sonologists were satisfied with 85.5% of the examinations. The 5G-based telerobotic US system is feasible for providing effective breast examinations in rural and remote areas.

Efficacy and safety of remimazolam-based sedation for intensive care unit patients undergoing upper gastrointestinal endoscopy: a cohort study.

Remimazolam is a novel ultra-short-acting sedative, but its safety and adverse events (AEs) in high-risk patients in the intensive care unit (ICU) setting remain unknown. This was a single-center, retrospective study that compared remimazolam to propofol and midazolam in patients undergoing upper gastrointestinal endoscopy. The primary outcome was the incidence of treatment-related AEs. The secondary outcomes were the time to extubation, the length of ICU stay, and the average cost of sedative per case. Of the 88 patients analyzed, 47 were treated with remimazolam (mean dose, 7.90±4.84 mg), and 41 were treated with propofol (21.19±17.98 mg) or midazolam (3.08±2.17 mg). There was no statistically significant difference in the average duration of the endoscopic procedure (35.89±13.37 min vs. 44.51±21.68 min, P=0.133) or the time to extubation (15.00±9.75 h vs. 20.59±18.71 h, P=0.211) in the remimazolam group (group I) compared to the propofol or midazolam group (group II). ICU stays (5.40±2.93 d vs. 4.63±3.31 d, P=0.072) and treatment-related AEs (48.61% vs. 51.38%, P=0.056) were similar between groups. The average cost of sedative per case was significantly lower in the group I than in the group II (RMB 16.07±10.58 yuan vs. RMB 24.37±15.46 yuan, P=0.016). Remimazolam-based sedation was noninferior to the classic sedatives and had lower average cost per case, indicating that it may be used as a promising sedative for high-risk patients during endoscopic procedures in the ICU setting.

РЕЗУЛЬТАТЫ КОМБИНИРОВАННОЙ МИНИИНВАЗИВНОЙ ФЛЕБЭКТОМИИ И PRP-ТЕРАПИИ ПРИ СОЧЕТАНИИ ВАРИКОЗНОЙ БОЛЕЗНИ С ГОНАРТРОЗОМ

Objective: To analyze the results of combined minimally invasive phlebectomy (CMIP) with platelet-rich plasma (PRP) therapy for the treatment of chronic venous insufficiency (CVI) and knee osteoarthritis (KOA). Methods: The study analyzed the treatment results of 26 patients (11 men, 15 women, average age of 49.3±4.6 years) with CVI and KOA who underwent CMIP with PRP therapy. The patients' average body mass index (BMI) was 28.9±2.1 kg/m². It was observed that patients with CVI exhibited different grades of severity according to the Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification. Out of 26 patients, 7 (27%) were classified as CEAP class 2, 15 (58%) as class 3, and 4 (15%) as class 4. Isolated insufficiency of the great saphenous vein (GSV) and its tributaries was noted in 9 (35%) patients and the small saphenous vein (SSV) – in 2 (8%) patients. Of the 26 patients, 15 (58%) had combined insufficient GSV and SSV trunks and tributaries. All patients presented with bilateral saphenous vein insufficiency, predominantly on the left side in 19 (73%) cases and on the right side in 7 (27%) cases. Of 26 patients, 17 (65%) had insufficient tibial perforators. According to the Kellgren JH &amp; Lawrence JS classification of osteoarthritis (OA), 4 (15%) of the patients had grade I KOA, 14 (54%) had grade II, and 8 (31%) had grade III. Phlebological status was assessed visually and with duplex scanning (DS) of the venous system in the lower extremities. The knee joints were evaluated using the WOMAC Osteoarthritis Index. Results: The median total index on the WOMAC scale before treatment was 65.5 (61.0-74.0) points, including pain index – 14.0 (13.0-16.0) points, knee joint stiffness – 6.0 (5.0-6.0) points and joint functioning – 47.0 (45.0-49.0) points. All patients underwent CMIP as the first stage, followed by four sessions of PRP therapy, one per week as the second stage. The average duration of surgical procedures was 115.5±35.5 minutes, and patients stayed an average of 2.8±0.4 days in the hospital. There were no significant complications in any case. After the treatment, there was a substantial decrease in pain and stiffness and an improvement in knee joint function. Therapy was ineffective in 4 (15%) cases. The effectiveness of PRP therapy is lower when certain factors are present. These factors include an advanced stage of KOA with a longer duration of the degenerative process in the joint, chronic use of painkillers, and the combined insufficiency of the GSV and SSV trunks. There is a direct correlation between these factors and the low effectiveness of platelet-rich autologous plasma. Conclusion: In patients with CVI and KOA, performing CMIP and PRP therapy can significantly decrease pain and improve daily knee joint function. Keywords: Varicose veins, knee osteoarthritis, microphlebectomy, stripping, PRP therapy.

Guanti bianchi technique for resection of selected pituitary adenomas

IntroductionSince the introduction of the endoscopic endonasal approach (EEA) to skull base, the nasal phase has been a true challenge as it represents the moment of definition of the corridor, thus defining the instruments maneuverability at tumor removal phase. The longstanding cooperation between ENT and neurosurgeons have provided the possibility of creating adequate corridor with maximal respect toward nasal structures and mucosa. This sparked the idea of entering the sella as thieves, so we named “Guanti Bianchi” technique a lesser invasive variation of the approach for the removal of selected pituitary adenoma. Research QuestionThe purpose of this study is to present the preliminary results of “Guanti Bianchi” technique. Material and MethodsData from 17 patients undergoing “Guanti Bianchi” technique (out of 235 standard EEA) at our center, were retrospectively analysed. ASK Nasal-12, a quality-of-life instrument developed specifically to assess patient perception of nasal morbidity, was administered pre- and postoperatively. Results10 (59%) patients were men and 7 (41%) women. The mean age was 67.7 (range 35-88). The average duration of the surgical procedure was 71.17 minutes (range 45-100). GTR was achieved in all patients, no postoperative complications were observed. Baseline ASK Nasal-12 was near normal in all patients, 3/17 (17,6%) experienced transitory very mild symptoms without any worsening at 3 and 6 months. Discussion and ConclusionsThis minimally invasive technique does not require turbinectomy or carving of the nasoseptal flap, it alters the nasal mucosa as little as necessary, and it is quick and easy to perform.

Abstract 14457: Cardiac MRI Results Following RFA and Cryoballoon Ablation: DECAAF II Subanalysis

Introduction: Radiofrequency (RFA) and cryoballon ablation are standard approaches for rhythm control of atrial fibrillation. Both strategies involve scar formation of the left atrial tissue. To date there have been no studies using post ablation cardiac magnetic resonance imaging (MRI) to assess residual fibrosis and scar created by standard radiofrequency and cryoballoon ablation. Methods: The current study is a sub analysis of the control group of the Delayed-Enhancement MRI Determinant of Successful Catheter Ablation of Atrial Fibrillation trial (DECAAF II). This was a multicenter, randomized, controlled, single blindedtrial that evaluated atrial arrhythmia recurrence (AAR) between PVI alone and PVI plus fibrosis guided ablation. Baseline MRI and 3-month post ablation MRI were obtained to assess lesion and scar formation. Results: Of the 843 patients randomized in the trial, 428 patients were in the control arm that received standard PVI alone. Of those 428 patients, 367 patients (85.7%) underwent RFA and 61 (14.3%) underwent cryoballoon ablation. Average procedure duration was 147 minutes for RFA and 107 minutes for cryoballoon (p = 0.001). The rate of AAR at 451 days was 42.0% in the RFA group and 45.9% in the cryoballoon group (p = 0.66). At the 3-month post MRI the RFA arm had significantly more left atrial scar formation compared to cryoballoon arm (8.8% vs. 6.4%, p = 0.001). Also, the RFA arm had more covered fibrosis (3.6% vs. 2.9%, p = 0.02) and less non-covered fibrosis (14.9% vs. 17.2%, p = 0.05) compared to the cryoballoon arm. The amount of scar formation did not predict AAR (p = 0.07). Conclusions: In this subanalysis of the DECAAF II trial, there was no significant difference in the rate of AAR between RFA and cryoballoon ablation. However, RFA caused significantly more left atrial scar compared to cryoballoon ablation on 3-month post MRI.

7763 Hysteroscopic Morcellation (with Bigatti Shaver) Under Laparoscopic Guidance: A Novel Approach to Management of Caesarean Scar Pregnancy

<h3>Study Objective</h3> To present our experience in treating cases with caesarean scar pregnancy by hysteroscopic morcellation using Bigatti Shaver over a period of 1 year. <h3>Design</h3> Longitudinal prospective study for 1 year & follow up done till beta HCG level comes to normal. <h3>Setting</h3> Patients positioning in the OT table: Lithotomy position, 45-degree angle between OT table & patients elevated legs. 2 Endomat Select: one for irrigation & other for suction, RPM-2100, Irrigation: 200-250 ml/min, Pressure: 150mm of Hg <h3>Patients or Participants</h3> 10 women between age 22-35years presented to us in the OPD with caesarean scar pregnancy confirmed on their dating ultrasound. <h3>Interventions</h3> Pre operative investigations were done prior to surgery and under laparoscopy they were posted for surgical intervention - removal of scar pregnancy by Bigatti Shaver. <h3>Measurements and Main Results</h3> • No fertility desired by the patient further, so patient should be tubectomised • It should be done till 7 weeks of period of gestation • Myometrial thickness should be between 2 to 4 mm <h3>Results</h3> 1. None had any intra or post operative complications. 2. Average duration of procedure: less than half an hour & blood loss less than 100ml. 3. Serial Beta HCG from the day of discharge and weekly therefore done, which returned to non-pregnant levels by end of 4 weeks. <h3>Conclusion</h3> Hysteroscopic morcellation is a convenient and effective mode of management of caesarean scar pregnancy with excellent safety profile and patient satisfaction rates.

8741 Versius®, a Revolutionary Robotic Platform - First Endometriosis Surgical Trials in Brazil

<h3>Study Objective</h3> This study aims to assess a gynecological surgical team's early outcomes with the new Versius® platform in terms of safety and efficiency in minimally invasive gynecological operations. <h3>Design</h3> A prospective study that followed for 10 days endometriosis surgeries performed by the new robotic Versius® platform. <h3>Setting</h3> An operation room with space foi the surgeon console and of all base system units. All patients were positioned in the same way in dorsal decubitus. The trocar punctures followed the same techniques for the 4 robot arms. <h3>Patients or Participants</h3> 10 women with deep endometriosis. <h3>Interventions</h3> the first 10 cases of gynecological surgeries in the Americas using the platform Versius, performed by the same team in a private hospital in Sao Paulo, Brazil. <h3>Measurements and Main Results</h3> Ten robotic gynecological surgeries were conducted to treat endometriosis in individuals with an average age of 42 years and a BMI of 25.3. Six of the patients had severe endometriosis with an AAGL IV classification, whereas the other four had an AAGL II classification. Two of the instances were linked to hysterectomy, while one was linked to myomectomy. The average docking time was 24.7 minutes, while the average procedure duration was 93.7 minutes, and all procedures were without complications. Nine of the ten patients were discharged within 24 hours after the operation, and one was discharged within 48 hours. Collisions between the surgical arms were noticed throughout procedures, necessitating changes to the placement of the units or further "port-training" to establish a better fit and avoid collisions. All patients had the same standardization of trocar placement for the highest efficiency and best cosmetic result (pictures below). <h3>Conclusion</h3> CMR's Versius® system and the treatment of deep endometriosis surgery are encouraging, but additional cases should be monitored to measure learning curve time and improvements in the positioning of units to avoid collisions.

Minimally Invasive Surgical Decompression without Fusion for the Treatment of Lumbar Synovial Cysts: Feasibility and Long-Term Outcomes.

Lumbar synovial cysts (LSCs) can cause painful radiculopathy and sensory and/or motor deficits. Historically, first-line surgical treatment has been decompression with fusion. Recently, minimally invasive laminectomy without fusion has shown equal or superior results to traditional decompression and fusion methods. This study investigates the long-term efficacy of minimally invasive laminectomy without fusion in the treatment of LSC as it relates to the rate of subsequent fusion surgery. A retrospective review was performed over a 10-year period of patients undergoing minimally invasive laminectomy for symptomatic LSCs. The primary end point was the rate of revision surgery requiring fusion. Eighty-five patients with symptomatic LSCs underwent minimally invasive laminectomy alone January 2010-August 2020 at our institution. The most common location was L4-5 (72%). Preoperative imaging identified spondylolisthesis (grade 1) in 43 patients (57%), none of which was unstable on available dynamic radiographs. Average procedure duration was 93 minutes, with 78% of patients discharged home on the same day of surgery. Over 46 months of mean follow-up, 17 patients (20%) required 19 revision operations. Of those operations, 16 were spinal fusions (17.6%). Median time to fusion surgery was 36 months. There were no identifiable risk factors on multivariate regression analysis that predicted the need for fusion. Minimally invasive laminectomy is an effective first-line treatment for symptomatic LSCs and avoids the need for fusion in most treated patients. Of our patients, 18% required a fusion over 46 months, suggesting that further studies are required to guide patient selection.

COVID-19 and the duration of operating room procedures in Ontario: a population-based retrospective study.

Background:Studies have estimated that a large backlog of procedures was generated by emergency measures implemented in Ontario, Canada, at the onset of the COVID-19 pandemic, when nonessential and scheduled procedures were postponed. Understanding the impact of the COVID-19 pandemic on the time needed to perform a procedure may help to determine the resources needed to tackle the substantial backlog caused by the deferral of cases. The purpose of this study was to examine the duration of operating room (OR) procedures before and after the onset of the COVID-19 pandemic to inform planning around changes in required resources.Methods:A population-based, retrospective cohort study was conducted using Ontario Health Insurance Plan claims data and other administrative health care data from Apr. 1, 2019, to Sept. 30, 2020. Statistical analysis was conducted using multivariate regression, with procedure duration as the outcome variable.Results:Results showed that the average duration of nonelective procedures increased by 34 minutes during the COVID-19 period and by 19 minutes after the resumption of scheduled procedures. Controlling for physician, patient and hospital characteristics, and the procedure code submitted, procedure duration increased by 12 minutes in the nonelective COVID-19 period and by 5 minutes when scheduled procedures resumed, compared with the pre-COVID-19 period.Conclusion:Procedures may take longer in the COVID-19 period. This will affect wait times, which had already increased because of the deferral of procedures at the beginning of the pandemic, and will have an impact on Ontario’s ability to provide patients with timely care.

Application of difficult endotracheal intubation under fluoroscopy in otorhinolaryngology head and neck surgery.

Thyroid cancer, laryngeal cancer and retrosternal goiter are common diseases of head and neck, which often causes difficulty breathing and dyspnea. However, it is usually hard to use conventional methods to deal with this problem. The purpose of this study was to evaluate the safety and effectiveness of an interventional technique for difficult endotracheal intubation(DEI) caused by head and neck diseases. We retrospectively analyzed the clinical data of 35 patients who underwent an interventional technique for difficult endotracheal intubation and evaluated the efficacy of this approach and observe postoperative pulse oxygen saturation (SpO2), Hugh-Jones grade, and complications. The procedures were successfully completed in all patients who underwent DEI. The technical and clinical success rate of the procedures was 100%. The average procedure duration was 3.2 ± 1.1min (range 1-5min). The patients' postoperative SpO2 and Hugh-Jones grade improved, and dyspnea symptoms resolved. There were no serious EI-related complications. Interventional EI under fluoroscopy is a safe, simple, and fast method for accurate intubation and an effective method for DEI; furthermore, it allows for subsequent clinical treatment.

Variability in pediatric appendectomy: The association between disposable supply cost and procedure duration

BackgroundPediatric appendicitis accounts for a notable proportion of health care use and cost in the United States. To identify opportunities for cost savings during pediatric laparoscopic appendectomy, this study assessed whether surgeons' use of costlier disposable supplies correlated with procedure duration and patient outcomes. MethodsThis retrospective cross-sectional study assessed laparoscopic appendectomy for uncomplicated pediatric appendicitis at 2 tertiary-care academic hospitals. The cost of disposable surgical supplies, procedure duration, and patient outcomes were obtained from medical records. The correlation between average supply cost and procedure duration among surgeons was assessed using Pearson’s correlation coefficient. Associations between use of specific disposable supplies and supply cost or procedure duration were assessed using Student’s t tests. ResultsA total of 380 laparoscopic appendectomies were performed by 11 surgeons. Mean normalized supply cost varied between surgeons (range: 60.6%–151.1%) and was not correlated with procedure duration (R = 0.2951, P = .378). The use of energy-based sealing devices (76.7% increase, P < .001), staplers (38.4% increase, P < .001), endoscopic specimen pouches (45.3% increase, P < .001), and disposable ports (43.6% increase, P < .001) increased overall disposable supply cost. None of the disposable supplies in this analysis were associated with shorter procedures. Based on Medicaid reimbursement, the interquartile range of supply cost was 9.2% and 6.0% of hospital revenue at each site. ConclusionSurgeons varied in their use of disposable supplies for pediatric laparoscopic appendectomy, but the cost of supplies used did not influence outcomes. Incentivizing more judicious supply use may reduce costs related to pediatric appendicitis.

Surgical management of carpal tunnel syndrome with an open carpal tunnel release-our experience

Introduction: CTS (Carpal tunnel syndrome) is characterised by compression of the median nerve at the wrist joint and is quite common in orthopaedic practice. Surgical management with the release of the transverse carpal ligament is the most commonly performed modality of treatment and this study was performed to assess the functional outcome after the open release of the carpal tunnel.Methods: This study included 30 patients with CTS managed by open carpal tunnel release done between January 2014 to January 2017. The patients were evaluated for functional outcomes using the DASH (Disabilities of arm, shoulder and hand) and GSS (Global symptom score) scores. Results: There were 14 males and 16 females with the left wrist involvement seen more as compared to the right side. The patients age was a mean of 42.4 years (33-54 years). The average duration of the surgical procedure was 36 minutes (22-48 minutes) and the mean blood loss was 20.2 ml (18-28 ml). There was a good improvement in the DASH and the GSS scores postoperatively which were statistically significant. We were able to provide good functional outcomes to the patients with minimal complications. Conclusion: Open surgical carpal tunnel release facilitates release of the carpal ligament under direct visualization and hence complications such as iatrogenic median nerve injury which can be associated with minimally invasive methods can be avoided. It offers a good resolution of symptoms to the patients and provides a good functional outcome enabling a faster return to work-related activity and day-to-day living.

Robotic-assisted total knee arthroplasty: Is there a maximum level of efficiency for the operating surgeon?

AimsRecent studies have attempted to quantify the learning curve associated with integration of robotic technology into surgical practice, but to our knowledge, no study has demonstrated the number of cases needed to reach a steady state of maximum efficiency in operating times using robotic assisted technology. Patients and methodsThis was a retrospective analysis of 682 consecutive knees that underwent a robotic-assisted TKA for osteoarthritis by a single surgeon between 2017 and 2020. Procedure times (minutes), length of stay (LOS), and short-term postoperative complications and reoperations were analyzed to define trends. Time series analyses were used to identify the approximate time-point at which a maximum level of surgical operating speed was achieved. Analysis of Variance (ANOVA) and chi-square analyses then followed to compare average procedure duration, LOS, and complications across distinct moving groups of 50 procedures. ResultsTime series analyses suggest substantially improved times by the 50th procedure and reached a stable plateau between the 150th and 200th procedure. Average duration for the first 50 procedures was approximately 85 min, dropping to 69 min for procedures 51–100, 66 min for procedures 101–150, and then plateauing at approximately 61 min for procedures 151–682, demonstrating significant improvements in surgical efficiency at each 50-procedure interval (p < 0.05). There was no significant difference in LOS, readmissions, and reoperations with increasing groups of 50 procedures performed. ConclusionResults from this study will allow surgeons to better understand the implications of integrating robotic arm-assisted technology into their practice. Surgeons can expect significant improvement of their operative time following completion of at least 50 procedures, while likely reaching a maximum level of surgical efficiency between 151 and 200 procedures.

An innovative endoscopic management strategy for postoperative fistula after laparoscopic sleeve gastrectomy.

Postoperative fistula is a life-threatening complication that lacks a standard treatment strategy after laparoscopic sleeve gastrectomy (LSG). This observational study is the first to report the efficacy and safety of endoscopic full-thickness resection (EFTR) combined with purse-string sutures in treating this complication. The old fistula was resected by EFTR, cut radially, and then sutured with a purse-string. The primary endpoint was complete fistula closure within two months. Endoscopic procedure-related complications were also recorded. Eight of 788 LSG patients developed fistulas with an incidence of 1.01%, primarily under the gastroesophageal junction, and the average distance from the center of the fistula to the cardia was 30 ± 6.3mm. Two patients were cured by conservative treatment, and six received endoscopic sutures. The time from LSG to fistula diagnosis was 12.3 ± 14.4days. The time from fistula diagnosis to endoscopic repair was 43.8 ± 55.8days and 21.4 ± 10.0days after eliminating the data of first case. The average fistula size was 12 ± 10mm, the average endoscopic procedure duration was 40 ± 16min, and the average number of endoscopic procedures required was 1.6 ± 0.8. Five patients achieved the primary endpoint, and one patient refused a third endoscopic suture after two sutures. The endoscopy success rate was 83.3%. No endoscopic procedure-related complications occurred. EFTR combined with purse-string sutures is an innovative, safe, and effective endoscopic strategy for postoperative fistula after LSG, avoiding reoperation and allowing early oral feeding.