Decrease In Procedure Time Research Articles

A Comparative Evaluation of Real-Time Guided Dynamic Navigation and Conventional Techniques for Post Space Preparation During Post Endodontic Management: An In Vitro Study.

The three-dimensional (3D) dynamic navigation system (DNS; Navident, ClaroNav Technology, Toronto, ON) is a revolutionary technique in endodontics that offers superior precision and efficiency compared to existing techniques for post space preparation. The aim is to evaluate and contrast the efficacy and efficiency of the DNS with conventional post space preparation techniques. This assessment considers severalparameters, notably canal deviation (global coronal and apical deviation and angular deflection), duration of the procedure, and total volumetric loss of instrumented root canal and volumetric loss of instrumented root canal above 4 mm from the apex. Freshly extracted maxillary central incisors were chosen for this study. A total sample size of 60 (n) was included. The extracted teeth samples were divided into two groups: 3D DNS (group I; n = 30)and conventional techniques (group II; n = 30). The samples were taken, and 50% of the crown structure was reduced for post space preparation to ensure standardization between thetwo groups. The samples were root canal-treated and mounted in a 3D-printed maxillary cast. Preoperative micro-computed tomography (micro-CT) and cone-beam computed tomography (CBCT) were taken for both groups.For group I, post space preparation was conducted with the DNS, which provided comprehensive guidance. The procedure was stopped when post space preparation was 4 mm short of the apex, as indicated in the system display. For group II, post space preparation was done without the guidance of DNS. Time taken for the procedure was assessed using a timer; canal deviation was evaluated using CBCT analysis, and volumetric loss was estimated using micro-CT analysis. The dynamic navigation group achieves significantly more precise outcomes in post space preparation than the conventional technique. The DNS group has significantly lesser global coronal and apical deviation and angular deflection compared to the conventional group (p < 0.05). The DNS group has reduced the volumetric loss of instrumented root canals compared to the conventional group (p < 0.05). Furthermore, the DNS group requires significantlyless time than the conventional method, with a mean difference of about 10.567 minutes (p < 0.05). Implementing dynamic navigation improves precision in post space preparation, with a notable reduction in canal deviation and volumetric loss and a decrease in procedure time compared to the conventional method.

US/CT fusion imaging and virtual navigation to guide lumbar intradiscal oxygen-ozone therapy: a pilot study

Abstract Purpose To test the feasibility of US/CT fusion imaging to guide lumbar intradiscal O2/O3 therapy to treat discogenic degenerative low back pain due to lumbar disc herniation (LDH). Methods We retrospectively included consecutive patients affected by low back pain and/or sciatica due to LDH resistant to conservative therapies, who underwent to lumbar intradiscal O2/O3 injection under CT/US fusion imaging guidance (Fusion Group) and standard CT guidance (Control Group). For each procedure, we collected procedure operative time, room utilization time, number of CT passes, complications, and O2/O3 intradiscal diffusion adequacy. Technical success was defined as the ability to complete the procedure as initially planned to reach the disc. Technical efficacy was based on O2/O3 intradiscal diffusion adequacy, as demonstrated by the last CT scan. Results Six patients (4 males; mean age: 68 ± 15 years) were included in the Fusion group, six (4 males; mean age: 66 ± 12 years) in Control group. No complications were observed in both groups. In Fusion group we found significantly lower room utilization time (30 ± 6 min vs. 46 ± 10 min, p = 0.008), procedure operative time (14 ± 3 min vs. 24 ± 6 min, p = 0.008), and number of CT passes (2 [2,2] vs. 3 [3,3], p = 0.006) than in Control Group, respectively. Technical success and efficacy were 100% in both Groups. Conclusion CT/US fusion imaging seems to be a feasible and safe guidance for intradiscal O2/O3 injections, allowing decrease of procedure time and number of CT passes.

Accuracy and Potential Benefit of Ultraselective Invasive Coronary Angiography Guided by Computed Tomographic Coronary Angiography.

It is unknown whether computed tomographic coronary angiography (CTCA) can be used to perform ultraselective invasive coronary angiography (ICA) by only visualizing the abnormal coronary artery on CTCA and defer visualization of the normal contralateral coronary artery. This study assessed the accuracy of CTCA in patients with coronary artery disease (CAD) on CTCA limited to either the left (LCA) or right coronary artery (RCA) in predicting a contralateral coronary artery without abnormalities on CTCA determined to be normal by ICA. This retrospective analysis included patients with CAD limited to the LCA or RCA on CTCA. Primary endpoint was the accuracy of CTCA to predict a contralateral coronary artery without abnormalities on CTCA to be normal by ICA. Secondary endpoints were potential reductions in procedure time and radiation exposure if an ultraselective ICA approach would be used compared to standard ICA. In total, 202 patients were included. CTCA was correct in predicting a normal contralateral coronary artery in 201 of the 202 patients (99.5%). Deferring ICA of the normal contralateral coronary artery on CTCA resulted in a potential reduction in procedure time and dose area product of 4.22 ± 2.67 minutes (61 ± 16% reduction) and 1501 ± 1304 mGy•cm² (29 ± 13% reduction). In this retrospective study, CTCA was extremely accurate in predicting a normal contralateral coronary artery in patients with LCA- or RCA-limited CAD on CTCA. A potential CTCA-guided ultraselective ICA approach was feasible and would have led to a considerable decrease in procedure time and radiation exposure.

Microsurgical clipping of middle cerebral artery aneurysms: preoperative planning using virtual reality to reduce procedure time

The authors sought to evaluate the impact of virtual reality (VR) applications for preoperative planning and rehearsal on the total procedure time of microsurgical clipping of middle cerebral artery (MCA) ruptured and unruptured aneurysms compared with standard surgical planning. A retrospective review of 21 patients from 2016 to 2019 was conducted to determine the impact on the procedure time of MCA aneurysm clipping after implementing VR for preoperative planning and rehearsal. The control group consisted of patients whose procedures were planned with standard CTA and DSA scans (n = 11). The VR group consisted of patients whose procedures were planned with a patient-specific 360° VR (360VR) model (n = 10). The 360VR model was rendered using CTA and DSA data when available. Each patient was analyzed and scored with a case complexity (CC) 5-point grading scale accounting for aneurysm size, incorporation of M2 branches, and aspect ratio, with 1 being the least complex and 5 being the most complex. The mean procedure times were compared between the VR group and the control group, as were the mean CC score between the groups. Comorbidities and aneurysm conduction (ruptured vs unruptured) were also taken into consideration for the comparison. The mean CC scores for the control group and VR group were 2.45 ± 1.13 and 2.30 ± 0.48, respectively. CC was not significantly different between the two groups (p = 0.69). The mean procedure time was significantly lower for the VR group compared with the control group (247.80 minutes vs 328.27 minutes; p = 0.0115), particularly for the patients with a CC score of 2 (95% CI, p = 0.0064). A Charlson Comorbidity Index score was also calculated for each group, but no statistical significance was found (VR group, 2.8 vs control group, 1.8, p = 0.14). In this study, usage of 360VR models for planning the craniotomy and rehearsing with various clip sizes and configurations resulted in an 80-minute decrease in procedure time. These findings have suggested the potential of VR technology in improving surgical efficiency for aneurysm clipping procedures regardless of complexity, while making the procedure faster and safer.

Three-Dimensional Holographic Guidance, Navigation, and Control (3D-GNC) for Endograft Positioning in Porcine Aorta: Feasibility Comparison With 2-Dimensional X-Ray Fluoroscopy

Objectives Intraprocedural deployment of endovascular devices during complex aortic repair with 2-dimensional (2D) x-ray fluoroscopic guidance poses challenges in terms of accurate delivery system positioning and increased risk of x-ray radiation exposure with prolonged fluoroscopy times, particularly in unfavorable anatomy. The objective of this study was to assess feasibility of using an augmented reality (AR) system to position and orient a modified aortic endograft delivery system in comparison with standard fluoroscopy. Materials and Methods The 3-dimensional guidance, navigation, and control (3D-GNC) prototype system was developed for eventual integration with the Intra-Operative Positioning System (IOPS, Centerline Biomedical, Cleveland, OH) to project spatially registered 3D holographic representations of the subject-specific aorta for intraoperative guidance and coupled with an electromagnetically (EM) tracked delivery system for intravascular navigation. Numerical feedback for controlling the endograft landing zone distance and ostial alignment was holographically projected on the operative field. Visualization of the holograms was provided via a commercially available AR headset. A Zenith Spiral-Z AAA limb stent-graft was modified with a scallop, 6 degree-of-freedom EM sensor for tracking, and radiopaque markers for fluoroscopic visualization. In vivo, 10 interventionalists independently positioned and oriented the delivery system to the ostia of renal or visceral branch vessels in anesthetized swine via open femoral artery access using 3D-GNC and standard fluoroscopic guidance. Procedure time, fluoroscopy time, cumulative air kerma, and contrast material volume were recorded for each technique. Positioning and orientation accuracy was determined by measuring the target landing-zone distance error (δLZE) and the scallop-ostium angular alignment error (θSOE) using contrast-enhanced cone beam computed tomography imaging after each positioning for each technique. Mean, standard deviation, and standard error are reported for the performance variables, and Student’s t tests were used to evaluate statistically significant differences in performance mean values of 3D-GNC and fluoroscopy. Results Technical success for the use of 3D-GNC to orient and position the endovascular device at each renal-visceral branch ostium was 100%. 3D-GNC resulted in 56% decrease in procedure time in comparison with standard fluoroscopic guidance (p<0.001). The 3D-GNC system was used without fluoroscopy or contrast-dye administration. Positioning accuracy was comparable for both techniques (p=0.86), while overall orientation accuracy was improved with the 3D-GNC system by 41.5% (p=0.008). Conclusions The holographic 3D-GNC system demonstrated improved accuracy of aortic stent-graft positioning with significant reductions in fluoroscopy time, contrast-dye administration, and procedure time.

Mo1283 LEARNING CURVE OF TRANSORAL INCISIONLESS FUNDOPLICATION: A SINGLE ENDOSCOPIST EXPERIENCE

Transoral Incisionless Fundoplication (TIF) is a minimally invasive endoscopic technique proven to be safe and effective for treating Gastroesophageal Reflux Disease (GERD) in selected patients. The learning curve of this technique has not been studied. (1) To report the learning curve for TIF, by identifying a breakpoint or threshold number of procedures at which there is a significant decrease in procedure time, time taken per 2-set fastener placement and an increase in the valve circumference. Prospectively collected data on patients who had a TIF procedure at an academic medical center between September 2017 and November 2019 were analyzed. Routine pre-TIF work-up included upper endoscopy (EGD) with biopsies, cine-esophagram, high resolution esophageal manometry (HREM) and pH-monitoring. Patients who had prior per-oral endoscopic myotomy (POEM) were excluded. Learning curve analysis was done using STATA software v 15.1 and Power BI to calculate the threshold for learning assessed by time to reach specific endpoints of the TIF procedure. 51 patients (71% male, mean age 56.5±13.2 yr.) had TIF after testing confirmed appropriate criteria (ph-positive test, < 2cm hiatal hernia, Hill grade <=2, BMI< 35). Indications for TIF were refractory GERD (51%), laryngopharyngeal reflux disease (9%), failed Nissen fundoplication (9%) and GERD in PPI-averse patients (31%) (Table 1). Six (12%) patients had prior surgical fundoplication. All TIF procedures were performed by a single endoscopist after hands-on and supervised training. TIF was successfully completed in 50/51 (1 aborted due to technical failure) with no serious adverse events. Overall, mean procedure time was 56±15 minutes. Break point analysis revealed that the threshold procedure time was reached at 23 procedures, where time declined from 67±11 to 47±13 minutes (p<0.0001). The mean time to deploy set of 2 fasteners was 4.3±1.9 minutes and mean valve circumference was 285±24 degrees. The breakpoint analysis revealed that a threshold was reached at 18 procedures for both fastener deployment and valve wrap, with a decrease in the mean procedure time to deploy a set of 2 fasteners from 6.5±1.4 to 3.1± 0.8 minutes (p<0.0001) and an improvement in the mean valve circumference from 261±20 to 297±14 degrees (p<0.0001). There was a significant decrease in total procedure time and time to deploy 2-set fasteners as well as an improvement of the valve circumference with increased number of procedures (Figure 1). Our single-center analysis showed that the number of procedures needed for an endoscopist to achieve procedure times under 1-hour is 23 procedures. Furthermore, the number of procedures needed to achieve times under 4 minutes to deploy 2-set of fasteners and to achieve tighter valves is 18 procedures. Future larger studies are needed to validate these results.TIF learning curve breakpoint analysisView Large Image Figure ViewerDownload Hi-res image Download (PPT)

3:36 PM Abstract No. 340 Perioperative blood loss after preoperative prostatic artery embolization in patients undergoing simple prostatectomy: a propensity score matched study

To compare peri-operative blood loss in patients undergoing simple prostatectomy with and without preoperative prostatic artery embolization using propensity score matching. From September 2014 to July 2019, 56 patients (mean age, 67.4 ± 8.1 years) with prostatic hypertrophy resulting in severe lower urinary tract symptoms (LUTS). Twelve patients (66.8 ± 8.5 years) underwent preoperative embolization prior to prostatectomy. A retrospective chart review provided demographic data, medical history, pertinent labs (i.e., hemoglobin levels), procedural/operative information, surgical details (estimated blood loss (EBL), intraoperative transfusion), hospital course (length of stay, continuous bladder irrigation), and pathology. Ten patients (83%) underwent bilateral treatment. Two patients were treated unilaterally due to severe prostate artery stenosis. The mean EBL for patients without preoperative embolization was 548.9 ± 343.8 mL. The mean EBL for patients who underwent bilateral PAE was 250.0 ± 135.4 mL and unilateral PAE was 950 ± 70.7 mL. There was a significant difference in EBL between the no embolization and bilateral PAE group (P < 0.01). Twenty patients that underwent prostatectomy without preoperative embolization were selected for 2:1 Propensity Score Match Analysis based on age, race, surgery type, prostate gland size, and comorbidities. The mean EBL for these patients was 487.5, still statistically higher than the PAE group (P < 0.01). Propensity score match analysis also demonstrated a significant decrease in procedure time in patients who underwent preoperative PAE (P < 0.05). There were no differences in length of stay or perioperative transfusion requirements. For patients undergoing PAE, there were no complications related to the procedure. Preoperative PAE appears to be safe and may be effective in minimizing perioperative bleeding and procedure time. Unilateral treatment may not be sufficient in these cases.Tabled 12:1 MatchControlPAEPAge63.964.80.754RaceBlack10%20%0.516RaceHisp65%50%0.462RaceUnk25%30%0.787SurgType_Robot50%50%1.000PG.Size128.3112.30.137BPH15%10%0.703DM15%20%0.753HTN45%50%0.807HLD20%20%1.000CAD0%10%0.343Malignancy10%30%0.254 Open table in a new tab

Tu1106 EVALUATION OF THE LEARNING CURVE FOR TRANSORAL INCISIONLESS FUNDOPLICATION: A SINGLE CENTER EXPERIENCE

Transoral incisionless fundoplication (TIF) is an emerging technology, offering a minimally invasive option of the management of symptomatic reflux. We sought to define the learning curve associated with this procedure. Retrospective chart review was performed on patients who underwent TIF by a single therapeutic endoscopist between November 2016 and November 2017. Demographic information and pre- and post-procedure HRQL scores were collected. The TIF procedure involved insertion of the Esophyx device into the esophagus followed by deployment of H shaped fasteners across the distal esophagus and fundus of the stomach to create a 270-degree wrap and lengthening of the valve. Procedure times and number of fasteners per procedure were recorded and tested for structural break using STATA version 15.1. Fastener times were also measured by dividing procedure time by the number of fasteners, since there was variability in the number of fasteners applied in each procedure. Linear regression was performed to evaluate the association between fastener times and experience. There were a total of 14 patients who underwent TIF for management of symptomatic reflux during the study period with 4 males (28.6%). The average age of patients was 56.6±10.6 years. The average number of fasteners used was 17.8. Average procedure time was 42.7±8.3 minutes. There was no break point identified with structural break analysis. There was a linear decrease in procedure time with increased experience, but this was not statistically significant (p=0.0751). No break point was identified with average fastener time, but linear regression analysis showed that average clip time was negatively associated with experience (p=0.0096). As experience grows, more fasteners can be applied in a shorter period of time, suggesting that use of the device becomes less cumbersome over time. There were no complications associated with the procedure. Patients’ HRQL score significantly decreased from 31.8±11.4 pre-procedure to 3.2±2.8 post-procedure (p=0.0026). Our analysis suggests that increased experience with the TIF procedure improves efficiency with handling the EsophyX device. More fasteners can be deployed in shorter periods of time. The procedure is safe and effective at improving quality of life in patients with symptomatic reflux.

Single-center experience with complex abdominal aortic aneurysms treated by open or endovascular repair using fenestrated/branched endografts

ObjectiveThe objective of this study was to evaluate outcomes of patients with complex abdominal aortic aneurysms (cAAAs) treated with open repair (OR) or fenestrated/branched endovascular aneurysm repair (F/B-EVAR) from a single center. MethodsA retrospective analysis of consecutive patients with cAAAs treated electively by OR or F/B-EVAR between January 2010 and February 2017 was conducted. Demographics of the patients, cardiovascular risk factors, procedure time, number of vessels incorporated, radiation dose, estimated blood loss, intensive care unit (ICU) length of stay (LOS), and hospital LOS were recorded. End points included target vessel patency, aneurysm rupture, freedom from reintervention, and major adverse events (MAEs). ResultsDuring this period, 153 patients (OR, 69; F/B-EVAR, 84) underwent repair of cAAA. The majority were male (OR, 55; F/B-EVAR, 64), with a mean age of 75.8 ± 7.6 years (F/B-EVAR) and 71.2 ± 7.9 years (OR). Patients in the F/B-EVAR group were more likely to be American Society of Anesthesiologists class 3 and 4 (60% vs 0%; P < .001) and had a higher median Society for Vascular Surgery/American Association for Vascular Surgery comorbidity severity score (15 vs 7; P < .001). A total of 235 vessels were targeted in the F/B-EVAR group, with a technical success of 97.6%. Thirty-one patients in the OR group required concomitant renal artery revascularization. Transfusion requirements (100% vs 1.2%), MAEs (40.6% vs 13.1%), procedure length (304 minutes vs 140 minutes), estimated blood loss (2246 mL vs 165 mL), ICU LOS (3 days vs 1 day), and hospital LOS (7 days vs 2 days) were higher (P < .001) in the OR group compared with the F/B-EVAR group. The 30-day mortality was 2.9% and 2.4% (P = .84) in the OR group and F/B-EVAR group, respectively. Supraceliac clamp site was associated with increased incidence of postoperative renal insufficiency. A decrease in procedure time, contrast volume, fluoroscopy time, and fluoroscopy dose was noted in the F/B-EVAR group with increasing experience even as case complexity increased. More patients were discharged home after F/B-EVAR (97.6% vs 59.4%; P < .001). With a mean follow-up of 31 months (F/B-EVAR, 17 months; OR, 48 months), the rate of secondary intervention was 3.7% and 5.8% (P = NS) for F/B-EVAR and OR, respectively. Freedom from branch instability and reintervention was 99% (95% confidence interval, 96.2%-99.8%) and 96% (95% confidence interval, 87.1%-98.6%), respectively. ConclusionsResults of this “real-world” experience suggest that the use of F/B-EVAR for the treatment of cAAAs in high-risk surgical patients is safe and effective and has comparable short-term results to those of low-risk patients undergoing OR. Patients treated by F/B-EVAR had shorter ICU and hospital LOS, lower MAEs, and faster convalescence. A decrease in procedure time and radiation dose was noted as experience was gained, even as complexity increased.

Use of Peppermint Oil During Screening Colonoscopy to Improve Visibility

Introduction: Colonoscopy is the fundamental screening tool used to detect colorectal polyps and colorectal cancer. Many techniques are being developed to increase visualization and improve adenoma detection rate (ADR). Antispasmodic agents are used in intravenous form to inhibit peristalsis during colonoscopy. Limited data suggest beneficial effects of topical administration of peppermint oil, containing L-menthol, including diminished smooth muscle contraction, decreased endoscopic procedural time and improved ADR. We aimed to assess whether use of peppermint oil during screening colonoscopy improves visualization and increases patient satisfaction, as well as ADR. Methods: This was a randomized, double-blind, placebo-controlled study. Patients scheduled for screening colonoscopy were randomly assigned to either receive peppermint oil or placebo. Insertion of the colonoscope to the cecum was performed as standard practice and, once in the cecum, 50ml of peppermint oil solution or placebo containing normal saline was gently sprayed into the lumen. During withdrawal, the endoscopist graded colonic peristalsis, spasticity, and visibility while assessing for colon lesions. Quality measures including bowel preparation, withdrawal time and number of polyps removed were recorded. Additional data on demographics and procedural details were documented and analyzed. Statistical analysis was performed using Wilcoxon rank sum and Chi-square tests. Results: Preliminary data from 28 patients were analyzed. Thirteen patients were randomized to receive peppermint oil. Age, gender, and BMI were comparable between the two groups. Average Boston Bowel Preparation Score was overall excellent (mean 7.9 ±1.2 for drug vs 8.3 ±1.0 for placebo). Withdrawal time tended to be less in the group that received the drug (9.8 min vs. 10.9 min) with shorter overall procedure time (18.3 min vs 21.7 min, p= 0.56). With use of peppermint oil, ADR was 32.1% compared with 37.5% in controls (p=0.37). Assessment of spasticity, peristalsis and visualization did not differ in the two groups. Patient satisfaction evaluated by perception of pain and willingness to repeat the procedure was equally high in both groups. Conclusion: Our initial data on the use of peppermint oil in screening colonoscopy suggests no significant impact on peristalsis, patient satisfaction, or ADR. Decrease in procedure time may be a surrogate marker for improved visibility with additional patients currently being recruited to further explore our hypothesis.

US–Guided, Direct Puncture Retrograde Thoracic Duct Access, Lymphangiography, and Embolization: Feasibility and Efficacy

PurposeTo describe technical details, success rate, and advantages of direct puncture of the thoracic duct (TD) under direct ultrasound (US) guidance at venous insertion in the left neck. Materials and MethodsAll patients who underwent attempted thoracic duct embolization (TDE) via US-guided retrograde TD access in the left neck were retrospectively reviewed. Indications for lymphangiography were iatrogenic chyle leak, pulmonary lymphangiectasia, and plastic bronchitis. Ten patients with mean age 41.4 years (range, 21 d to 72 y) underwent US–guided TD access via the left neck. Technical details, procedural times, and clinical outcomes were evaluated. TD access time was defined as time from start of procedure to successful access of TD, and total procedural time was defined from start of procedure until TDE. ResultsAll attempts at TD access via the neck were successful. Technical and clinical success of TDE was 60%. There were no complications. Mean TD access time was 17 minutes (range, 2–47 min), and mean total procedure time was 49 minutes (range, 25-69 min). Mean follow-up time was 5.4 months (range, 3–10 months). ConclusionsTDE via US–guided access in the left neck is technically feasible and safe with a potential decrease in procedure time and elimination of oil-based contrast material.

A new strategy for difficult airway management with visual needle cricothyroidotomy: a manikin study

BackgroundConventional needle cricothyroidotomy uses blind manipulation. We investigated the feasibility and efficiency of a new visually guided needle cricothyroidotomy technique. MethodsA 0.9-mm microimaging fiber was delivered into a 14G needle to develop a visual puncture system. 10 inexperienced physicians were randomly assigned to perform 10 repeated needle cricothyroidotomy in each group with both conventional method and visual puncture in a manikin. Tracheal lumen puncture time and number of procedure-related complications were recorded. ResultsUnder visual guidance, the needle successfully reached the tracheal lumen. The anatomy of the upper and lower airways was acquired by further advancing the microimaging fiber into the tracheal lumen of the visual group. The tracheal lumen puncture time was significantly less in the visual group than in the conventional group (3.85 ± 1.54 vs. 9.84 ± 1.08 seconds, P < .001). Damage to the posterior tracheal wall was not observed in the visual group; however, 21% of manikins in the conventional group had procedure-related complications. ConclusionsOur results demonstrate that visual needle cricothyroidotomy is feasible, and may lead to a decrease in procedure time and procedure-related complications compared to the conventional procedure. In addition, this strategy may also provide useful information for diagnostic purposes; therefore, visual needle cricothyroidotomy may be a new strategy for the management of difficult airways in future care.

Does the Use of Blocking Screws Improve Radiological Outcomes Following Intramedullary Nailing of Distal Tibia Fractures?

ABSTRACTAimThe aim of this study is to assess whether the addition of blocking screws during intramedullary nailing of a distal tibia fracture improved the radiological outcome and prevented a loss of fracture alignment. As a secondary outcome, the time to radiographic union was compared to see if a more rigid bone-implant construct had an effect on healing.MethodsWe searched computerized records at a UK level 1 major trauma center. The joint alignment was measured on the immediate postoperative radiograph and compared to the most recent radiograph. We used a difference of 2° to indicate a progressive deformity.ResultsThirty patients were included. Twenty patients had no blocking screw and 10 patients had a blocking screw. Six patients had a difference in their coronal plane alignment of 2° or more (3/6 had no blocking screw). The results were analyzed and found to be not statistically significant (p = 0.82). The addition of a blocking screw has also been shown not to have an effect on the time to radiological union (RUST score greater or equal to 10).ConclusionWe use a 2.5-mm blocking wire to aid in fracture reduction prior to reaming or nail insertion and then remove the wire when the nail has been adequately locked. We no longer routinely replace the wire with a blocking screw and this could lead to a decrease in procedure time, cost, and radiation exposure.How to cite this articleFawdington RA, Lotfi N, Beaven A, et al. Does the Use of Blocking Screws Improve Radiological Outcomes Following Intramedullary Nailing of Distal Tibia Fractures? Strategies Trauma Limb Reconstr 2019;14(1):11–14.

VESS22. 24-Month Data From the BRAVISSIMO: A Large Scale Prospective Trial on Self-Expanding and Balloon-Expandable Stents for TASC A and B and TASC C and D Aortoiliac Lesions

Objectives: We assessed the effects of thoracic endovascular aortic repair (TEVAR) rehearsal with an endovascular surgical simulator in surgical trainees at different levels in training. Methods: Twelve trainees in three cohorts (student, postgraduate year [PGY]1-3, and PGY 4-7) were oriented to using the Simbionix AngioMentor simulator over four sessions. Likert scale qualitative analysis evaluated participant proficiency. Analysis of data included one-way analysis of variance and paired t-tests. Results: All groups had reduction of total procedure time (mean 537 6 148 seconds vs 269 6 66 seconds, first session vs fourth; confidence interval [CI], 195-341 seconds; P < .05) and fluoroscopy time (201 6 74 vs 110 6 37 seconds; CI, 51-132 seconds; P < .05) with case progression. Procedure time significantly decreased in students (551 6 84 vs 313 6 65 seconds; CI 189-287 seconds; P < .05) and PGY 1-3 (591 6 149 vs 264 6 29 seconds; CI, 113541 seconds;P< .02) had a significant decrease in procedure time. Fluoroscopy times were brief overall between individuals and groups and did not change significantly with case progression. Participants acquired proficiency after a few runs in almost every step of the procedure. Endograft sizing appeared to be the most challenging task by qualitative analysis. PGY 4-7 trainees had higher technical scores, but this was not statistically significant. Conclusions: Practice on endovascular surgical simulators can reduce overall procedure and fluoroscopy time, independent of trainee skill level or experience. Endovascular simulators can be effective tools in residency training and maintenance of proficiency. Further studies are needed to compare simulator performance with outcomes in real cases.

Learning curve of hysteroscopic placement of tubal sterilization microinserts in 15 gynecologists in the Netherlands

To evaluate the learning curve of hysteroscopic placement of tubal sterilization microinserts by gynecologists in the Netherlands. Prospective multicenter study (Canadian Task Force II-2). Ten community (teaching) hospitals in the Netherlands. A total of 631 women who underwent permanent sterilization by tubal microinserts. Hysteroscopic placement of tubal sterilization microinserts performed by 15 gynecologists experienced in performing operative hysteroscopy, starting from their very first placement. Effect of increasing experience in time on procedure time, pain score, successful bilateral placement, and complications. Bilateral successful placement with confirmation of adequate positioning at follow-up evaluation was achieved in 480 (76.1%) patients at first attempt and in 44 (7.0%) at second attempt. Median procedure time was 8.0 minutes (range: 3-40), and 31 (4.9%) patients were lost to follow-up evaluation. Gravidity showed to be a confounding factor and was consequently adjusted for. A learning curve was seen in a statistically significant decrease of procedure time with increasing experience. The decrease in procedure time extended to 11 to 15 cases and was followed by a plateau phase of the subsequent 60 cases. In contrast, pain scores, successful placement, and complication rate appeared not to improve with increasing experience. A learning curve for hysteroscopic tubal sterilization was seen for procedure time, but successful placement, pain score, and complication rate were not clearly influenced by increasing experience.

2D-fluoroscopic based navigation for Gamma 3 nail insertion versus conventional procedure- a feasibility study

BackgroundIntramedullary nailing is a standard surgical procedure for fixation of proximal femoral fractures, but is associated with considerable radiation exposure for controlling the implant placement, due to the percutaneous insertion technique.The aim of this study was the evaluation of potential benefits of 2D-fluoroscopic based navigation focused on the reduction of radiation exposure, a decrease of procedure time, as well as an increase of accuracy for Gamma3 nail insertions.MethodsTwenty randomized Gamma3 nail insertions were performed in non-fractured synthetic femora according to the manufactures operation guidelines (group I) or with use of a 2D-fluoroscopic based navigation system (group II). Time of different steps of the procedure and the radiation exposure were measured, as well as the accuracy evaluated in postoperative CT scans.Results and discussionAll Gamma3 nails were placed without any technical problems. Independent of the used procedure, the overall operating time (group I: 584 ± 99.2 sec; group II: 662 ± 64.9 sec; p=0.06) and accuracy of the final nail-positions were equivalent, but the radiation exposure was significantly reduced (92% reduction in fluoroscopic images and 91% reduction in fluoroscopic time, p< 0.01), using the 2D fluoroscopic based navigation procedure.Conclusions2D-fluoroscopic based navigation for Gamma3 nail insertion facilitates a relevant reduction of radiation exposure with equivalent accuracy of the final implant position and no prolonged operating time. This promising procedure modification is independent of different cephalomedullary implant manufacturers and specific implant designs, but needs to be evaluated in further clinical settings.

Comparison of a 6.5, 10, and 15 mm cryoablation catheter-tip for the treatment of common atrial flutter

Only a few studies have investigated the effect of large tip sizes for catheter-based cryoablation (cryo). This study evaluates the safety and efficacy of cryo of the cavotricuspid isthmus (CTI) using three cryocatheter-tip sizes. Forty-five consecutive patients with common atrial flutter (AFL) underwent cryo of the CTI using a 6.5, a 10, or a novel 15 mm catheter-tip. Single applications of 3 min were delivered at each site along the CTI. Baseline characteristics of the three groups were comparable. The overall acute success rate was 89% and there was no difference with respect to the tip electrode size (P > 0.05). Fewer applications were required for a 10 mm (6 ± 2, range 3-7) and a 15 mm (6 ± 1, range 4-8) compared with a 6.5 mm catheter-tip (8 ± 3, range 4-14; P < 0.05). Procedure time was significantly shorter with the largest tip electrode (89 ± 26 min vs. 132 ± 28 min (6.5 mm tip), P < 0.05). No complications occurred. After a mean follow-up of 51 ± 5 months, 43 patients (96%) were without recurrence of AFL. A large (10 or 15 mm) cryoablation catheter-tip requires significantly fewer applications to create bidirectional CTI block compared with a 6.5 mm tip. A significant decrease in procedure time with preservation of the overall safety and efficacy supports the preference of a 15 over a 6.5 mm catheter-tip for cryoablation of AFL.

A learning curve for endoscopic submucosal dissection of gastric epithelial neoplasms

Endoscopic submucosal dissection (ESD) has become a widely accepted method for treating gastrointestinal neoplasms. The objective of our study was to assess the learning curve for ESD of gastric epithelial neoplasms. Clinicopathological data were retrospectively collected from 383 ESD procedures for gastric epithelial neoplasms that were performed over a 5-year period. Thirteen endoscopists were involved as operators during this period. In study 1, the performance of the two principal operators was assessed every 25 patients. In study 2, the performance of all 13 operators was assessed according to their experience. In study 1, the caseloads of the two principal operators were 188 and 118 ESD procedures. There were no significant differences found between successive groups of 25 patients with regard to en-bloc resection rate and bleeding and perforation complication rates. The size of the lesions and the resected specimen diameter increased significantly as the number of treated cases increased, whereas the average procedure time decreased significantly. In study 2, the operators' caseloads ranged from 1 to 188 cases, with 11/13 operators having experience of fewer than 30 cases. There was no significant difference in treatment efficacy and complication rates between the operators throughout the study period. The lesions were mainly located in the lower part of the stomach in the procedures performed by the 11 less experienced endoscopists. The procedure times shortened as experience in the method increased. Constant rates of both treatment efficacy and complications were achieved over a 5-year period of experience with ESD. A decrease in procedure time was found to be a marker of proficiency in this technique.

Evaluation of minimally invasive percutaneous CT-controlled ventriculostomy in patients with severe head trauma

Evaluation of percutaneous CT-controlled ventriculostomy (PCV) in patients with severe traumatic brain injury to measure intracranial pressure as a component of early clinical care. A consecutive series of 52 interventions with PCV was prospectively analyzed with regard to technical success, procedural time, time from the initial cranial computed tomography (CCT) until procedure and transfer to the intensive care unit (ICU). Additionally, the data was compared with a retrospective control group of 12 patients with 13 procedures of conventional burr-hole ventriculostomy (OP-ICP). The PCV was successful in all cases (52 of 52; 95% CI 94–100%). In 1 case a minor hemorrhage into the ipsilateral lateral ventricle was observed on CT scans due to an initially unsuccessful puncture (95% CI 0–6%). No infections occurred (95% CI 0–6%). In the control group with OP-ICP one catheter infection and one unsuccessful catheter placement occurred (each 8%, 95% CI 0–20%). The PCV led to a significant decrease of procedure time from 45±11 min (OP-ICP) to 20±12 min (PCV). The interval from the initial CCT until procedure (PCV 28±11 min, OP-ICP 78±33 min) and transfer to the ICU (PCV 69±34 min, OP-ICP 138±34 min) could also be significantly reduced (each with p<0.05, Mann-Whitney U-test). Percutaneous CT-controlled ventriculostomy is a safe and efficient method for ICP catheter placement during initial trauma room management. It significantly reduces the time of initial trauma room treatment.