Innovative Surgical Techniques Research Articles

Randomized Controlled Trials in Pancreatic Surgery - an Update

This review provides a summary of important, completed and published clinical trials, together with interesting and important running RCTs in pancreatic surgery.Randomised controlled studies (RCT) are one of the most important sources of new evidence for the treatment of cancer patients. This is particularly the case for pancreas surgery, where complications are comparatively common and serious and innovative surgical techniques and peri-interventional innovations are needed that could reduce morbidity and mortality. Although there are many very different methodological challenges in performing surgical RCTs, large surgical RCTs of high scientific quality have been completed during the last 10 years.

Diagnosis and Treatment of Lumbar Giant Cell Tumor of the Spine: Update on Current Management Strategies.

(1) Background: Giant Cell Tumor of the spine remains a difficult tumor to treat. Recent advances in adjuvant therapy such as denosumab and innovations in surgical technique in the last 5 years have given providers new options for treatment after a successful diagnosis of the tumor. (2) Methods: Articles published between 1927 and 2021 were selected from PubMed and Scopus searches using key words “Giant Cell Tumor” AND “Lumbar Spine” AND “Treatment”. Relevant articles were reviewed and selected by the authors. (3) Results: A total of 191 articles were discovered. Complete en bloc spondylectomy remains the most definitive treatment option; however, this surgery is challenging and carries a high rate of complication. New adjuvant therapies including denosumab offer a viable alternative to surgery. (4) En bloc spondylectomy remains the gold standard treatment for Giant Cell Tumor of the spine with the lowest published recurrence rate. The use of (neo)adjuvant denosumab improves recurrence rates. More data are needed to determine if denosumab alone is a viable standalone definitive treatment.

Fertility and Sterility top videos of 2020

To objectively grade all video publications in Fertility and Sterility during 2020 and compile a list of the top 5 surgical videos. Descriptive presentation of the 5 highest scoring video publications from Fertility and Sterility in 2020 SETTING: Not applicable. Not applicable. J.F., Z.K., J.P.P., and S.R.L. acted as independent reviewers of all video publications. A standardized scoring method was used to score all videos. Up to 5 points were awarded for each of the following categories: scientific merit or clinical relevance of the topic, the clarity of the video, the use of innovative surgical technique, and video editing or the use of marking tools on the video to highlight the important features or surgical landmarks. This allowed a maximum score of 20 for each video. The numbers of YouTube views and likes were used as a tiebreaker if ≥2 videos scored similarly. The interclass coefficient from a 2-way random-effects model was calculated to assess for agreement between the 4 independent reviewers. A total of 20 videos were published in Fertility and Sterility during 2020. After averaging scores from all 4 reviewers, a list of top 5 videos was created (Table1). The overall interclass coefficient for the 4 reviews was 0.77 (95% confidence interval, 0.56-0.89). An overall substantial agreement was noted among the 4 reviewers. Five videos particularly stood out within the competitive peer reviewed publications. The subject matter of these videos ranged from complex surgical procedures, including transvaginal natural orifice surgery and advanced endometriosis to basic embryology laboratory topics that covered trophectoderm biopsy and novel intracytoplasmic sperm injection techniques.

Unfolding falciform folds and their consequences - To touch or not to touch.

Background:Falciform folds are congenital tractional retinal folds due to strong contractile forces and hyperextensibility of retina resulting in temporal dragging of the macula and often associated with familial exudative vitreoretinopathy and retinal detachment (RD). Retinologists are reluctant to treat these entities in view of their poor visual recovery.Purpose:To describe a novel surgical technique to unfold the falciform folds.Synopsis:This video demonstrates innovative surgical techniques to remove both pre-retinal and sub-retinal adhesions and unfold these folds, managing its consequences and visual recovery. We describe cases of congenital falciform folds with poor visual acuity, where we did vitrectomy, membrane adhesion removal, peeling of the internal limiting membrane (ILM) the macula, mechanical stretching of the folded retina by Tanno scraper or Finesse flex loop, then sub-retinal injection of balanced salt solution (BSS) by 38 gauge sub-retinal needle o create multiple blebs around the folded retina and finally sulphur hexafluoride tamponade. Post-operative macular hole with RD can be a complication. When this falciform fold is complicated by RD, there is risk of intraoperative subretinal migration of infusion cannula and therefore the need for peripheral relaxing retinectomy for redundant retinal fold as well as silicone oil as endotamponade. Vision improved in all our patients after the surgery.Highlights:Both long-standing pre-retinal adhesions as well as sub-retinal adhesions are responsible for he tformation of congenital falciform folds. For pre-retinal adhesions, vitrectomy with removal of all the adhesions along with peeling of the sticky ILM and then mechanical stretching of folded retina by Tanno scraper or Finesse flex loop are necessary. To remove sub-retinal adhesions, sub-retinal injection of BSS is necessary to stretch the folded retina from behind, but it should be done away from the retina to avoid formation of macular hole.Online Video Link: https://youtu.be/9h8IE3abKIM

Oncological surgery in the interdisciplinary context-On the way to personalized medicine

Oncological surgery is adiscipline which closely interacts with other clinical partners and remains in many cases the cornerstone of acurative treatment of solid tumors. Due to the progress in the field of systemic tumor treatment as well as innovations in surgical techniques, the indications in oncological surgery are also changing, such as extended indications for patients with oligometastatic disease. Surgery of metastases has long been established for colorectal cancer and is being further tested for other entities, such as pancreatic and gastric cancer, within randomized controlled clinical trials (e.g. RENAISSANCE and METAPANC). Anew challenge is the handling of a clinical complete remission after total neoadjuvant therapy, for example in locally advanced rectal cancer or in esophageal cancer. Here, organ and function preservation are increasingly propagated but should only be performed within clinical trials until stratification enables the identification of patients in whom this concept is oncologically safe. The personalized use of oncological surgery is dependent on the patient, the tumor and on the total multimodal concept.

Breast Cancer-Related Lymphedema: A Review of Management and Innovative Surgical Techniques

Lymphedema is one of the most feared complications of breast cancer treatment. The objective of this article is to review the basic workup, staging, and diagnostic criteria for lymphedema and to discuss non-surgical and surgical treatments, with a focus on breast-cancer related lymphedema. Non-surgical treatment consists of intensive physical therapy including manual lymphatic drainage via massage, daily compression wraps, and exercises to prevent scarring and increase mobility. Surgical intervention is considered when non-surgical treatment is ineffective or more recently as a preventive measure. Surgical interventions, used once lymphedema has developed, include 1) lympho-venous bypass, which is the anastomosis of lymphatic vessels distal to the site of dermal backflow to neighboring venules to shunt lymphatic drainage away from the area of lymphatic injury; 2) vascularized lymph node transplant, in which lymph nodes are harvested from a donor site with their supporting artery and vein and transferred to the affected recipient site; and 3) debulking procedures including liposuction and direct excision. Preventive surgical interventions include 1) lymphatic microsurgical preventive healing approach, known as LYMPHA, which also utilizes lympho-venous anastomoses but at the time of lymph node dissection to anastomose lymphatic channels transected during lymph node dissection with adjacent veins to preserve lymphatic drainage of the arm; and 2) axillary reverse mapping, which involves tracer or dye injection within the ipsilateral arm before axillary surgery so that the breast surgeons are able to delineate nodal drainage and therefore attempt to spare nodes specific to arm tissue provided they are not the sentinel lymph node. Patient selection is critical for these procedures, and requires a multi-disciplinary approach.

Regenerative peripheral nerve interfaces (RPNIs): current status and future direction

Despite significant advancements in neuroprosthetic control strategies, current peripheral nerve interfacing techniques are limited in their ability to facilitate accurate and reliable long-term control. The regenerative peripheral nerve interface (RPNI) is a biologically stable bioamplifier of efferent motor action potentials with demonstrated long-term stability. This innovative, straightforward, and reproducible surgical technique has shown enormous potential in improving prosthetic control for individuals with upper limb amputations. The RPNI consists of an autologous free muscle graft secured around the end of a transected peripheral nerve or individual fascicles within a residual limb. This construct facilitates EMG signal transduction from the residual peripheral nerve to a neuroprosthetic device using indwelling bipolar electrodes on the muscle surface. This review article focuses on the development of the RPNI and its use for intuitive and enhanced prosthetic control and sensory feedback. In addition, this article also highlights the use of RPNIs for the prevention and treatment of postamputation pain.

Repositioning of buccal corticotomy: An innovative surgical technique for removal of lingually placed cyst

Repositioning of buccal corticotomy: An innovative surgical technique for removal of lingually placed cyst

Surgical Innovations to Restore Function in Pediatric Peripheral Nerve Conditions.

Peripheral nerve injuries in children can result in devastating lifelong deficits. Because of the time-sensitive nature of muscle viability and the limited speed of nerve regeneration, early recognition and treatment of nerve injuries are essential to restore function. Innovative surgical techniques have been developed to combat the regenerative length and speed; these include nerve transfers. Nerve transfers involve transferring a healthy, expendable donor nerve to an injured nerve to restore movement and sensation. Nerve transfers are frequently used to treat children affected by conditions, including UE trauma, brachial plexus birth injury, and acute flaccid myelitis. Pediatricians play an important role in the outcomes of children with these conditions through early diagnosis and timely referrals. With this review, we aim to provide awareness of state-of-the-art surgical treatment options that significantly improve the function of children with traumatic nerve injuries, brachial plexus birth injury, and acute flaccid myelitis.

Advances in Pancreatic Ductal Adenocarcinoma Treatment.

Simple SummaryPancreatic cancer remains one of the most challenging malignancies to treat with standard approaches. Emerging treatment approaches incorporating innovative surgical techniques and novel systemic therapies may help to improve outcomes for pancreas cancer patients. Although immunotherapy has proven to be less effective for the treatment of pancreas cancer relative to more immunogenic tumor types, multiple immune system stimulating agents are under active investigation for pancreatic ductal adenocarcinoma, either alone or in combination with other therapeutic agents. The tumor microenvironment of pancreatic cancer is also an attractive therapeutic target given that it is believed to be highly immunosuppressive and encapsulated by a dense stroma. This review article aims to summarize pre-clinical and clinical studies, including ongoing clinical trials, which attempt to incorporate novel treatment approaches for pancreas cancer. Emerging treatment approaches may help to significantly improve outcomes for this tough to treat disease.Pancreatic Ductal Adenocarcinoma (PDAC) is one of the deadliest malignancies among all cancers. Despite curative intent, surgery and the use of standard cytotoxic chemotherapy and radiation therapy, PDAC remains treatment-resistant. In recent years, more contemporary treatment modalities such as immunotherapy via checkpoint inhibition have shown some promise in many other malignancies, yet PDAC still eludes an effective curative treatment. In investigating these phenomena, research has suggested that the significant desmoplastic and adaptive tumor microenvironment (TME) of PDAC promote the proliferation of immunosuppressive cells and act as major obstacles to treatment efficacy. In this review, we explore challenges associated with the treatment of PDAC, including its unique immunosuppressive TME. This review examines the role of surgery in PDAC, recent advances in surgical approaches and surgical optimization. We further focus on advances in immunotherapeutic approaches, including checkpoint inhibition, CD40 agonists, and discuss promising immune-based future strategies, such as therapeutic neoantigen cancer vaccines as means of overcoming the resistance mechanisms which underly the dense stroma and immune milieu of PDAC. We also explore unique signaling, TME and stromal targeting via novel small molecule inhibitors, which target KRAS, FAK, CCR2/CCR5, CXCR4, PARP and cancer-associated fibroblasts. This review also explores the most promising strategy for advancement in treatment of pancreatic cancer by reviewing contemporary combinatorial approaches in efforts to overcome the treatment refractory nature of PDAC.

Have urinary function outcomes after radical prostatectomy improved over the past decade?

Changes in surgical technique and postoperative care that target improvements in functional outcomes are widespread in the literature. Radical prostatectomy (RP) is one such procedure that has seen multiple advances over the past decade. The objective of this study was to leverage RP as an index case to determine whether practice changes over time produced observable improvements in patient-reported outcomes. This study analyzed patients undergoing RP by experienced surgeons at a tertiary care center with prospectively maintained patient-reported outcome data from 2008 to 2019. Four patient-reported urinary function outcomes at 6 and 12 months after RP were defined with a validated instrument: good urinary function (domain score ≥ 17), no incontinence (0 pads per day), social continence (≤1 pad per day), and severe incontinence (≥3 pads per day). Multivariable logistic regressions evaluated changes in outcomes based on the surgical date. Among 3945 patients meeting the inclusion criteria, excellent urinary outcomes were reported throughout the decade but without consistent observable improvements over time. Specifically, there were no improvements in good urinary function at 12 months (P = .087) based on the surgical date, and there were countervailing effects on no incontinence (worsening; P = .005) versus severe incontinence (improving; P = .003). Neither approach (open, laparoscopic, or robotic), nor nerve sparing, nor membranous urethral length mediated changes in outcomes. In a decade with multiple advances in surgical and postoperative care, there was evidence of improvements in severe incontinence, but no measurable improvements across 3 other urinary outcomes. Although worsening disease factors could contribute to the stable observed outcomes, a more systematic approach to evaluating techniques and implementing patient selection and postoperative care advances is needed. Although there have been advances in radical prostatectomy over the past decade, consistent observable improvements in postoperative incontinence were not reported by patients. To improve urinary function outcomes beyond the current high standard, the approach to studying innovations in surgical technique needs to be changed, and further development of other aspects of prostatectomy care is needed.

Recurrent Paravaginal Abscess: An Unusual Presentation of a Distal Ectopic Ureteral Remnant after Prior Nephrectomy

Study Objective Describe a patient with OHVIRA syndrome and demonstrate the surgical technique used to treat her paravaginal abscess and remnant ectopic ureter. Design Video case-presentation. Setting Academic hospital. Patients or Participants Single patient. Interventions Surgery. Measurements and Main Results We describe a patient who initially presented at the onset of menarche with cyclic abdominopelvic pain. She was diagnosed with uterine didelphys with obstructed right hemivagina. She underwent a vaginoplasty, which was followed by postoperative urinary incontinence. Further work-up indicated a dysplastic right kidney with ectopic ureter to the right vaginal sidewall, correlating with diagnosis of OHVIRA syndrome. She then represented at 21 years old with chronic vaginal drainage. She underwent an extensive evaluation including imaging as well diagnostic procedures, including: cystovaginoscopy, hysteroscopy and laparoscopy. She was tested for sexually transmitted diseases, put on multiple courses of antibiotics, and had two drains placed with recurrence of drainage. When she finally presented to our facility, there was concern for abscess secondary to remnant distal ectopic ureter into the vagina. She underwent an office examination and vaginoscopy, confirming drainage from a right vaginal ostium. She was counseled and ultimately underwent a robotic assisted laparoscopic excision of paravaginal abscess and remnant of distal right ectopic ureter. She did well postoperatively. Interval CT scan on post-operative day 15 demonstrated fluid collection, which was drained by interventional radiology. The fluid collection resolved, drain removed and she has had no further recurrence of drainage. Conclusion This is an unusual presentation of a recurrent paravaginal abscess in the setting of prior partial right ectopic ureterectomy. We describe the innovative and successful surgical technique used to identify and excise the paravaginal abscess and distal ectopic ureter. Highlighting this patient's unique anatomy and the importance of complete resection of an ectopic ureter to the vagina at the time of nephrectomy due to potential risk of ascending chronic infection and abscess formation. Describe a patient with OHVIRA syndrome and demonstrate the surgical technique used to treat her paravaginal abscess and remnant ectopic ureter. Video case-presentation. Academic hospital. Single patient. Surgery. We describe a patient who initially presented at the onset of menarche with cyclic abdominopelvic pain. She was diagnosed with uterine didelphys with obstructed right hemivagina. She underwent a vaginoplasty, which was followed by postoperative urinary incontinence. Further work-up indicated a dysplastic right kidney with ectopic ureter to the right vaginal sidewall, correlating with diagnosis of OHVIRA syndrome. She then represented at 21 years old with chronic vaginal drainage. She underwent an extensive evaluation including imaging as well diagnostic procedures, including: cystovaginoscopy, hysteroscopy and laparoscopy. She was tested for sexually transmitted diseases, put on multiple courses of antibiotics, and had two drains placed with recurrence of drainage. When she finally presented to our facility, there was concern for abscess secondary to remnant distal ectopic ureter into the vagina. She underwent an office examination and vaginoscopy, confirming drainage from a right vaginal ostium. She was counseled and ultimately underwent a robotic assisted laparoscopic excision of paravaginal abscess and remnant of distal right ectopic ureter. She did well postoperatively. Interval CT scan on post-operative day 15 demonstrated fluid collection, which was drained by interventional radiology. The fluid collection resolved, drain removed and she has had no further recurrence of drainage. This is an unusual presentation of a recurrent paravaginal abscess in the setting of prior partial right ectopic ureterectomy. We describe the innovative and successful surgical technique used to identify and excise the paravaginal abscess and distal ectopic ureter. Highlighting this patient's unique anatomy and the importance of complete resection of an ectopic ureter to the vagina at the time of nephrectomy due to potential risk of ascending chronic infection and abscess formation.

1045 Summarising the Reporting of Regulatory Procedures in Robotic Cholecystectomy: A Systematic Review and Narrative Synthesis

Abstract Introduction Robotic cholecystectomy (RC) represents the most recent innovation in the management of gallstones. Whilst RC is becoming increasingly widespread, the evidence base surrounding its introduction has not been characterised. When evaluating innovative surgical techniques, adherence to regulatory and governance procedures is essential in maintaining patient safety. This study aims to appraise the reporting of studies of RC, focussing on regulatory procedures. Method Systematic searches identified all published studies reporting RC. Data collection was based on the IDEAL (Idea, Development, Exploration, Assessment, Long-term follow-up) framework, and included general study characteristics, governance approvals, trial registration, study funding, conflicts of interests, and information communicated to patients. Results Systematic searches identified 1425 abstracts. Of the 90 full-text papers included, only three were randomised controlled trials. The majority (71%) were single-centre studies. Conflicts of interest were common, with 11 (12%) studies funded by the robot manufacturer, and 23 (26%) reporting conflicts related to authors. Ethical approval was confirmed in 51 (57%) studies; four reported prior registration with a register. Only forty-two studies (47%) documented obtaining patient consent for study participation. Only four documented discussions regarding the innovative nature of RC. In ten, modifications to the robot or technique were described, but it was not apparent if patients were informed of these. Conclusions This comprehensive review highlights multiple deficiencies in the reporting of regulatory procedures in the evaluation of RC. Improved reporting is required in studies of RC to ensure transparency, interpretability, and the safe, evidence-based adoption of new technologies into clinical practice.

Preoperative Ozaki technique measures on tridimensional engineered root

BackgroundThe aortic valve neocuspidalization (AVNeo) is an innovative surgical technique aiming at the reconstruction of the aortic valve using autologous pericardium. One of the main criticisms to AVNeo is the longer duration of the aortic clamping time (ACT) as compared to standard aortic valve replacement due to the sizing of the valve neocusps. MethodsWe retrospectively enrolled 30 consecutives patients underwent AVNeo. For each patient we developed a 3D aortic root model (ARM) based on CT-scan datasets. We retrospectively compared the leaflets measurements performed during surgery with those obtained on the corresponding ARMs. ResultsIn 100% of cases no difference between the in vitro and in vivo measurements exceeded the acceptable error limit of 2 ​mm. The correlation of each single in vitro versus in vivo measurements demonstrates a strong coincidence between the two different methods of sizing (r ​> ​0,9, p ​< ​.0001). By analyzing the data considering the annulus perimeter and not the single cusp size, the perfect coincidence was to be found in 89.9% with a slight acceptable discrepancy (2 ​mm on total) in the remaining 10.1%. Conclusions3D-ARMs, printed from CT-scan, represent a reproducible process to obtain overlapping cusp sizes compared to those measured in-vivo, possibly reducing the ACT.

Use of micro-grafts in a chronic infected open wound after limb amputation in a cat

In human medicine, skin grafting is an innovative surgical technique widely used in reconstructive surgery to repair skin loss. This case evaluated the effectiveness of a treatment with dermal micro-grafting obtained through the Rigenera&lt;sup&gt;®&lt;/sup&gt; technology in a chronic open wound resulting from a suture dehiscence of a limb amputation in a cat. Significant differences were observed between the aesthetic aspects of the injury using traditional treatments (cleaning and curettage) and the regenerative technology. The results showed that the healing periods were significantly reduced after the Rigenera&lt;sup&gt;®&lt;/sup&gt; treatment and that, moreover, a perfect skin status and a complete reduction in the wound area (100%) were achieved in one month. Given these results, Rigenera&lt;sup&gt;®&lt;/sup&gt; has proven to be a simple yet highly effective method in the treatment of inactivated chronic wounds.

Biological Characterization of Human Autologous Pericardium Treated with the Ozaki Procedure for Aortic Valve Reconstruction.

Background: The Ozaki procedure is an innovative surgical technique aiming at reconstructing aortic valves with human autologous pericardium. Even if this procedure is widely used, a comprehensive biological characterization of the glutaraldehyde (GA)-fixed pericardial tissue is still missing. Methods: Morphological analysis was performed to assess the general organization of pericardium subjected to the Ozaki procedure (post-Ozaki) in comparison to native tissue (pre-Ozaki). The effect of GA treatment on cell viability and nuclear morphology was then investigated in whole biopsies and a cytotoxicity assay was executed to assess the biocompatibility of pericardium. Finally, human umbilical vein endothelial cells were seeded on post-Ozaki samples to evaluate the influence of GA in modulating the endothelialization ability in vitro and the production of pro-inflammatory mediators. Results: The Ozaki procedure alters the arrangement of collagen and elastic fibers in the extracellular matrix and results in a significant reduction in cell viability compared to native tissue. GA treatment, however, is not cytotoxic to murine fibroblasts as compared to a commercially available bovine pericardium membrane. In addition, in in vitro experiments of endothelial cell adhesion, no difference in the inflammatory mediators with respect to the commercial patch was found. Conclusions: The Ozaki procedure, despite alteration of ECM organization and cell devitalization, allows for the establishment of a noncytotoxic environment in which endothelial cell repopulation occurs.

Regional Anesthetic Approaches for Postoperative Analgesia Following Vertebral Body Tethering: A Case Series.

Vertebral body tethering (VBT) is an innovative surgical technique used to treat juvenile and adolescent idiopathic scoliosis. The optimal anesthetic technique, including the preferred management of postoperative pain, is not known. In this case series, we describe 3 patients with adolescent idiopathic scoliosis who received either continuous erector spinae plane block (ESPB) catheters or intercostal liposomal bupivacaine for postoperative pain management after bilateral VBT via minithoracotomy.

Patient-specific 3D-printed cutting guides for high oblique sagittal osteotomy-an innovative surgical technique for nerve preservation in orthognathic surgery.

Bilateral sagittal split osteotomy (BSSO) of the mandible according to Obwegeser/Dal Pont is considered to be gold standard in orthognathic surgery. Frequently reported complications of BSSO are injuries of the mandibular nerve resulting in paresthesia/anesthesia as well as inadequate mandibular bone fracturing (‘bad split’). High oblique sagittal osteotomy (HOSO) was introduced to overcome these complications. We present an innovative HOSO modification using patient-specific 3D-printed cutting guides positioned on the outside of the ascending mandibular ramus and fixed in the incisura semilunaris, precisely marking the optimal height and angle of the osteotomy. Advantages are a decreased operation time due to the simplicity of this less invasive procedure, a potentially reduced frequency of mandibular nerve damage and bad splits as well as a lower bleeding risk.

Safe implementation of robotic-assisted minimally invasive direct coronary artery bypass: application of learning curves and cumulative sum analysis.

BackgroundLearning curves are inevitably encountered when first implementing an innovative and complex surgical technique. Nevertheless, a cluster of failures or complications should be detected early, but not deter learning, to ensure safe implementation. Here, we aimed to examine the presence and impact of learning curves on outcome after robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB).MethodsA retrospective analysis of the first 300 RA-MIDCAB surgeries between July 2015 and December 2020 was performed. Learning curves were obtained via logarithmic regression for surgical time. Cumulative sum (CUSUM) analysis was performed for (I) major complications including MI, stroke, repeat revascularization, and mortality, and (II) other complications, including prolonged ventilation, pneumonia, pleura puncture, lung herniation, pericarditis, pleuritis, arrhythmia, wound complications, and delirium. Expected and unacceptable rates were set at 12% and 20%, respectively, for major complications, and at 40% and 60% for other complications, based on historical data in conventional coronary artery bypass grafting (CABG).ResultsDemographic characteristics did not differ between terciles, except for more smokers in the first tercile, and less hypercholesterolemia and more complex procedures in the third tercile. The mean surgical time for all operations was 258±81 minutes, ranging from 127 to 821 minutes. A learning curve was only observed in the first tercile. Subgroup analysis revealed that this learning curve was only observed for procedures consisting of single internal mammary artery (SIMA) with 1 or 2 distal anastomoses but not with bilateral internal mammary arteries (BIMA) or more than 2 distal anastomoses. CUSUM analysis showed that the cumulative rate of major and other complications never crossed the lines for unacceptable rates. Rather, the lower 95% confidence boundary was crossed after 50 cases, indicating improvement in safety.ConclusionsThese results suggest that integration of RA-MIDCAB in the surgical landscape can be safely achieved and complication rates can quickly be reduced below those expected in traditional CABG. Collective experience plays a key role in overcoming the learning curve when more complex procedures and cases are introduced.

Trends in Surgical Glaucoma Treatment in Germany Between 2006 and 2018.

Background/AimsSurgical procedures in ophthalmology underlie variations over different time periods and are strongly dependent on the technical process and the invention of innovative surgical techniques. Especially, in glaucoma surgery a lot of surgical devices and techniques have been introduced during the last years. Until now, the use of these newer techniques has not been shown on a robust data basis. We herein present the numbers of different types of glaucoma surgeries performed at German hospitals between 2006 and 2018.Methods and DesignThe quality reports of hospitals in Germany from 2006 to 2018 were analyzed concerning all procedural codes for glaucoma surgery and intervention. Especially, the change in usage of “classical” and “modern” surgical techniques (MIGS: “minimally invasive glaucoma surgery”) or devices was compared.ResultsThe number of glaucoma procedures performed increased by 75% from 27,811 in 2006 to 48,794 in 2018. Absolute numbers of trabeculectomies, goniotomies, ab externo trabeculotomies and to a certain level cyclodestructive procedures decreased during the examined years while use of MIGS has increased in absolute and relative numbers since 2012. From 2015 a strong increase in the usage of XEN implants could be seen. Drainage implants (such as Baerveldt/Ahmed) showed stable absolute numbers over the time period covered. Absolute numbers of laser trabeculoplasty peaked in 2014 and decreased afterwards. Iridotomies and iridectomies increased by 120%/248% over the whole period.ConclusionOur data show a trend towards the modern surgical options and especially MIGS during the recent years. Classical procedures showed a decrease in total numbers emphasized from 2013. These numbers confirm the assumption that modern glaucoma surgery is becoming more and more popular and established in German hospitals.