Surgical Skin Marker Research Articles

Clinical Issues-June 2020.

Perioperative personnel with cold sores Key words: herpes labialis, herpes simplex virus type 1 (HSV-1), cold sore, infection transmission, surgical mask. Documenting the use of bone wax Key words: bone wax, documentation, implant, medical device, electronic health record (EHR). Using sterile surgical skin markers on veins Key words: skin marker, isopropyl alcohol, gentian violet, methylene blue, vein. Documenting solutions used to prepare tissue for implantation Key words: documentation, preparing tissue, processing tissue, solutions, implantation. Defining fire Key words: fire, oxidation, chemical reaction, sentinel event.

Evaluation of a sterile surgical skin marker to indicate the optimal vein for venepuncture in the blood donation setting.

Phlebotomy is a central task for blood donation; however, not all blood donors have veins that are easy to see or feel. This study aimed to determine whether use of a surgical skin marker to highlight the donors' vein location and direction prior to venepuncture increased blood donation success. All blood donors who participated in this study were eligible to donate according to Australian guidelines. Ten donor centres with phlebotomy success rates <95% were selected. A randomized cluster trial design assigned five sites to test the skin marking device and five sites as controls. Single-use sterile Gentian violet skin marker pens were used to mark donors' veins. Phlebotomy site skin bacterial load after using the skin marking device was tested on a subset of 100 donors. Phlebotomy success rates and donor adverse events were recorded. Of the control donors, 6993 had successful phlebotomies and 225 failed. Of the skin marker donors, 6998 had successful phlebotomies and 248 failed. No statistically significant differences in phlebotomy success were found between the two groups (OR: 0·91, 96·4% CI [96·0, 96·8], P-value 0·348). The use of skin marker pens did not increase overall phlebotomy success rate. There was no increase in phlebotomy site skin bacterial load, and amendments to standard skin disinfection techniques were not required. Blood donors were not concerned about the pen mark on their arms. Generally, staff indicated that the markers may be valuable to assist with phlebotomies for donors with difficult or deep veins.

Association Between Surgical Skin Markings in Dermoscopic Images and Diagnostic Performance of a Deep Learning Convolutional Neural Network for Melanoma Recognition

Deep learning convolutional neural networks (CNNs) have shown a performance at the level of dermatologists in the diagnosis of melanoma. Accordingly, further exploring the potential limitations of CNN technology before broadly applying it is of special interest. To investigate the association between gentian violet surgical skin markings in dermoscopic images and the diagnostic performance of a CNN approved for use as a medical device in the European market. A cross-sectional analysis was conducted from August 1, 2018, to November 30, 2018, using a CNN architecture trained with more than 120 000 dermoscopic images of skin neoplasms and corresponding diagnoses. The association of gentian violet skin markings in dermoscopic images with the performance of the CNN was investigated in 3 image sets of 130 melanocytic lesions each (107 benign nevi, 23 melanomas). The same lesions were sequentially imaged with and without the application of a gentian violet surgical skin marker and then evaluated by the CNN for their probability of being a melanoma. In addition, the markings were removed by manually cropping the dermoscopic images to focus on the melanocytic lesion. Sensitivity, specificity, and area under the curve (AUC) of the receiver operating characteristic (ROC) curve for the CNN's diagnostic classification in unmarked, marked, and cropped images. In all, 130 melanocytic lesions (107 benign nevi and 23 melanomas) were imaged. In unmarked lesions, the CNN achieved a sensitivity of 95.7% (95% CI, 79%-99.2%) and a specificity of 84.1% (95% CI, 76.0%-89.8%). The ROC AUC was 0.969. In marked lesions, an increase in melanoma probability scores was observed that resulted in a sensitivity of 100% (95% CI, 85.7%-100%) and a significantly reduced specificity of 45.8% (95% CI, 36.7%-55.2%, P < .001). The ROC AUC was 0.922. Cropping images led to the highest sensitivity of 100% (95% CI, 85.7%-100%), specificity of 97.2% (95% CI, 92.1%-99.0%), and ROC AUC of 0.993. Heat maps created by vanilla gradient descent backpropagation indicated that the blue markings were associated with the increased false-positive rate. This study's findings suggest that skin markings significantly interfered with the CNN's correct diagnosis of nevi by increasing the melanoma probability scores and consequently the false-positive rate. A predominance of skin markings in melanoma training images may have induced the CNN's association of markings with a melanoma diagnosis. Accordingly, these findings suggest that skin markings should be avoided in dermoscopic images intended for analysis by a CNN. German Clinical Trial Register (DRKS) Identifier: DRKS00013570.

Standard Surgical Skin Markers Should Be Avoided for Intraoperative Vein Graft Marking during Cardiac and Peripheral Bypass Operations.

One cause of early graft failure following coronary and peripheral vein grafting is kinking or mechanical twisting of the conduit. The blind tunneling necessitated in peripheral bypasses can lead to this consequence (1). In coronary artery bypass grafting (CABG), grafts to the posterior branches of the right or circumflex coronary arteries are placed to the back of the heart and are generally the longest aortocoronary grafts. These grafts are particularly prone to twisting and kinking. Additionally, single vein grafts to two or more coronary branches (“sequential vein grafts”) present special challenges with respect to maintenance of proper alignment (2, 3). The coronary vein graft failure rate at 1 year in the PRoject of Ex vivo Vein graft ENgineering via Transfection IV (PREVENT IV) cohort was 25%, suggesting that early graft failure is a significant problem (4, 5). The incidence of vein graft failure due to twisting or kinking is not well studied, though some reports estimate that obstructing lesions, including but not limited to twisting or kinking, account for 15–25% of early (<1 year) graft failures (6–8). Preparation and preservation techniques have advanced the field of solid organ allotransplantation, but vein graft failure rates suggest room for improvement in the handling of saphenous vein (SV) harvested for autotransplantation. Interventions for ex vivo graft treatment, including appropriate choice of preservation solution and minimization of manual pressure distension via chemical vasodilators such as papaverine, have been proposed (9–12). Additionally, the “no-touch” technique has emerged as a method of minimizing detrimental handling of graft during harvest with adventitial preservation (4, 13–15). Marking of the SV graft using a surgical skin marker in an “off-label” fashion represents another such preparation technique and is the most commonly employed method of preventing graft torsion (16). This marking allows for the maintenance of continuous alignment along the length of the vein in the same longitudinal plane. These lines provide a visible guide for surgeons to use during conduit routing and tunneling to avoid mechanical obstructions related to vein alignment (17). While operating rooms have adapted less traumatic methods of vein harvest, preservation, and distension, surgical skin marker use remains ubiquitous as the primary method to maintain graft orientation. The use of surgical skin markers during graft preparation is toxic to the tissue and impairs physiologic function (16). We argue that the data support avoidance of standard surgical skin markers for marking on vascular tissue; We further contend that brilliant blue FCF (for coloring food) may represent a viable alternative dye for intraoperative graft marking.

Source investigation of two outbreaks of skin and soft tissue infection by Mycobacterium abscessus subsp. abscessus in Venezuela.

Outbreaks of soft tissue or skin infection due to non-tuberculous mycobacteria are reported frequently in scientific journals but in general the infection source in these outbreaks remains unknown. In Venezuela, in two distinct outbreaks, one after breast augmentation surgery and another after hydrolipoclasy therapy, 16 patients contracted a soft tissue infection due to Mycobacterium abscessus subsp. abscessus. Searching for the possible environmental infection sources in these outbreaks, initially the tap water (in the hydrolipoclasy therapy outbreak) and a surgical skin marker (in the breast implant surgery outbreak), were identified as the infection sources. Molecular typing of the strains with a variable number tandem repeat typing assay confirmed the tap water as the infection source but the molecular typing technique excluded the skin marker. We discuss the results and make a call for the implementation of stringent hygiene and disinfection guidelines for cosmetic procedures in Venezuela.

An Optimized Preparation Technique for Saphenous Vein Graft

An Optimized Preparation Technique for Saphenous Vein Graft

Brilliant blue FCF is a nontoxic dye for saphenous vein graft marking that abrogates response to injury

Injury to saphenous vein grafts during surgical preparation may contribute to the subsequent development of intimal hyperplasia, the primary cause of graft failure. Surgical skin markers currently used for vascular marking contain gentian violet and isopropanol, which damage tissue and impair physiologic functions. Brilliant blue FCF (FCF) is a nontoxic dye alternative that may also ameliorate preparation-induced injury. Porcine saphenous vein (PSV) was used to evaluate the effect of FCF on physiologic responses in a muscle bath. Cytotoxicity of FCF was measured using human umbilical venous smooth muscle cells. Effect of FCF on the development of intimal hyperplasia was evaluated in organ culture using PSV. Intracellular calcium fluxes and contractile responses were measured in response to agonists and inhibitors in rat aorta and human saphenous vein. Marking with FCF did not impair smooth muscle contractile responses and restored stretch injury-induced loss in smooth muscle contractility of PSV. Gentian violet has cytotoxic effects on human umbilical venous smooth muscle cells, whereas FCF is nontoxic. FCF inhibited intimal thickening in PSV in organ culture. Contraction induced by 2'(3')-O-(4-benzoylbenzoyl)adenosine 5'-triphosphate and intracellular calcium flux were inhibited by FCF, oxidized adenosine triphosphate, KN-62, and brilliant blue G, suggesting that FCF may inhibit the purinergic receptor P2X7. Our studies indicated that FCF is a nontoxic marking dye for vein grafts that ameliorates vein graft injury and prevents intimal thickening, possibly due to P2X7 receptor inhibition. FCF represents a nontoxic alternative for vein graft marking and a potentially therapeutic approach to enhance outcome in autologous transplantation of human saphenous vein into the coronary and peripheral arterial circulation.

Brilliant blue FCF as an alternative dye for saphenous vein graft marking: effect on conduit function.

Surgical skin markers are used off-label to mark human saphenous veins (HSVs) to maintain orientation before implantation as aortocoronary or peripheral arterial bypass grafts. These surgical skin markers impair functional responses of the HSV tissue. To investigate the effect of brilliant blue dye 1 (brilliant blue FCF [for food coloring]; hereinafter, FCF) as a nontoxic alternative marking dye and to determine whether FCF has pharmacological properties. Segments of HSVs were collected in university hospitals from patients undergoing coronary artery bypass grafting procedures immediately after harvest (unmanipulated) or after typical intraoperative surgical graft preparation (after manipulation). Rat inferior venae cavae were used to determine the pharmacological properties and cellular targets of FCF. Endothelial and smooth muscle functional responses were determined in a muscle bath, and intimal thickening in HSVs was determined after 14 days in organ culture. Contractile responses were measured in force and converted to stress. Smooth muscle function was expressed as maximal responses to potassium chloride depolarization contractions. Endothelial function was defined as the percentage of relaxation of maximal agonist-induced contraction. Neointimal thickness was measured by histomorphometric analysis. Human saphenous veins stored in the presence of FCF had no loss of endothelial or smooth muscle function. Unmanipulated HSVs preserved in the presence of FCF demonstrated a significant increase in endothelial-dependent relaxation (mean [SEM], 25.2% [6.4%] vs 30.2% [6.7%]; P = .02). Application of FCF to functionally nonviable tissue significantly enhanced the smooth muscle responses (mean [SEM], 0.018 [0.004] × 10⁵ N/m² vs 0.057 [0.016] × 10⁵ N/m²; P = .05). Treatment with FCF reduced intimal thickness in organ culture (mean [SEM], -17.5% [2.1%] for unmanipulated HSVs vs -27.9% [3.7%] for HSVs after manipulation; P < .001). In rat inferior venae cavae, FCF inhibited the contraction induced by the P2X7 receptor agonist 2'(3')-O-(4-benzoyl)benzoyl-adenosine-5'-triphosphate (mean [SEM], 14.8% [2.2%] vs 6.5% [1.8%]; P = .02) to an extent similar to the P2X7 receptor antagonist oxidized adenosine triphosphate (mean [SEM], 5.0% [0.9%]; P < .02 vs control) or the pannexin hemichannel inhibitor probenecid (mean [SEM], 7.3% [1.6%] and 4.7% [0.9%] for 0.5mM and 2mM, respectively; P < .05). Treatment with FCF did not impair endothelial or smooth muscle function in HSVs. Brilliant blue FCF enhanced endothelial-dependent relaxation, restored smooth muscle function, and prevented intimal hyperplasia in HSVs in organ culture. These pharmacological properties of FCF may be due to P2X7 receptor or pannexin channel inhibition. Brilliant blue FCF is an alternative, nontoxic marking dye that may improve HSV conduit function and decrease intimal hyperplasia.

Correlations between displacements of GTV, surgical clips, and skin markers in external-beam partial breast irradiation:a study based on 4DCT

Objective To investigate the correlations between the displacements of surgical clips,skin markers and the gross tumor volume (GTV) delineated by surgical clip and seroma based on fourdimensional computed tomography (4DCT) during normal breathing.Methods On each of the 10 respiratory phases of 4DCT with 15 patients of breast cancer,the surgical cavity,which was defined as GTV and formed by both surgical clips and seroma,all surgical clips in the cavity,and skin markers on the skin were delineated by the same radiation oncologist.The center displacements of GTV,selected boundary surgical clips and skin markers in the left-right (LR),anterior-posterior (AP),and superior-inferior (SI) directions were recorded and analyzed by Pearson method.Results In the AP direction,there was a positive correlation between the displacements of the GTV and the inner clip (r =0.643,P =O.013).In the SI direction,the displacement of GTV was positively correlated with those of the lower clip and the skin marker at anterior body midline (r =0.857 and 0.643,P =0.002 and 0.013).In the LR and AP directions,there was a positive correlation between the displacements of the outer clip and the ipsilateral skin marker (r =0.757 and 0.697,P =0.001 and 0.025),but they were negatively correlated with each other in the SI direction (r =-0.647,P =0.043).In the AP direction,there was a positive correlation between the displacements of the inner clip and the skin marker at the anterior body midline (r =0.738,P =0.015).Conclusions The correlations between the displacement of GTV delineated by surgical clips and seroma and the displacements of surgical slips and skin markers vary under different conditions,and so does the correlation between the displacements of surgical clips and skin markers. Key words: Tomography, X-ray computed, four-dimensional; Metal clips ; Seroma; Skin-marker; Displacement

Abstract 204: Brilliant Blue FCF is an Alternative Vein Marking Dye That Restores Functional Viability in Human Saphenous Vien Graft

Objective The human saphenous vein (HSV) is the most effective conduit for infrainguinal peripheral bypass grafting. Optimal vein graft preparation is critical to vein graft patency. Graft marking using surgical skin markers is detrimental to endothelial and smooth muscle function of the graft. The objective of this study was to evaluate the effect of FD&amp;C Brilliant Blue No. 1 (FCF) as an alternative for vein graft marking. Methods Segments of HSV were collected after typical harvest and graft preparation. The tissues were cut into rings and either left unmarked or marked with FCF (2.6 mM). The functional viability of the rings was determined in a muscle bath. Results Marking with FCF did not impair contractility of the smooth muscle (Figure 1A). Contractility was restored in HSV segments that had no functional contractile responses after harvest and preparation (Figure 1B). To determine the mechanism of this protective effect of FCF, purinergic receptors were activated with BzATP with and without pre-incubation with FCF (50μM) or a purinergic receptor antagonist (oATP, control) and the rise in [Ca 2+ ] i was measured. FCF and oATP reduced the BZATP-evoked rise in [Ca 2+ ] i (Figure 1C), suggesting that the salutary effects of FCF were due to inhibition of a P2X or P2Y receptor. Conclusions FCF is a non-toxic alternative to surgical skin markers that antagonizes purinergic receptors in HSV. FCF restored functional viability to injured vascular smooth muscle. FCF may protect HSV against injury-elicited ‘danger’ signals such as extracellular ATP that is released during injury-induced preparation.

Concentration modulated skin marker for radiotherapy treatment planning process

Background and purposeFor conformal radiotherapy, it is feasible to achieve high accuracy in contouring the outline of the target volume in treatment planning process. In contouring process, target volume is occasionally defined by means of either surgical clips or skin marker during patient anatomical data acquisition. Treatment planning systems are predicting invalid radiation dose distributions by using surgical clips and skin marker within the patient. Purpose of this study is the production of new skin marker which affects less dose distributions of electron beam. Materials and methodsThe influences of lead and commercial markers on dose calculations in a 3D treatment planning systems were investigated in terms of electron beam energy and dose profile depth. Dose deviation with commercial marker was observed to smaller than lead marker. However this dose deviation was still at big value. In order to reduce of this value, barium sulfate suspension and ultrasound gel were mixed with different volumetric ratio. With the purpose of acception the most suitable marker for radiation therapy, obtained new suspensions were investigated in terms of visibility and dose deviation. ResultsB:G/1:10 marker was determined to cause optimum visibility and the lowest dose deviation on dose calculations in terms of electron beam energy and dose profile depth. ConclusionsAppropriate marker, mixture of substances such as barium sulfate suspension and ultrasound gel can be produced. This marker is both ease of usage and practical and economical. Each clinic can prepare marker which is peculiar to suspension with different concentration of substance for specific visibility. But, it should be taken into account resultant dose deviation to beam calculation depending on barium sulfate concentration.

Surgical Skin Markers Impair Human Saphenous Vein Graft Smooth Muscle and Endothelial Function

Marking human saphenous vein graft (HSV) with a surgical skin marker to prevent twisting on implantation is a common practice in peripheral and coronary artery bypass procedures. This study is designed to examine the effects of surgical skin markers on the HSV smooth muscle and endothelial functional responses. De-identified HSV remnants were collected during peripheral and coronary artery bypass procedures. Physiologic responses of the HSV were measured using a muscle bath. Veins that were marked with surgical skin markers intraoperatively generated significantly less contractile force to depolarizing KCl (110 mM) and receptor-mediated contractile agonists than unmarked HSV, suggesting that surgical skin markers impaired HSV smooth muscle contractility. To directly access the effects of chemical components in the surgical skin markers, unmarked HSV was exposed to isopropyl alcohol (a solvent commonly used in surgical skin markers) or methylene blue (a dye). Smooth muscle contractility was significantly reduced by isopropyl alcohol and methylene blue. Endothelial-dependent relaxation to carbachol was significantly reduced after exposure to surgical skin markers. Our data demonstrated that marking HSV with surgical skin markers reduces smooth muscle and endothelial functional viability.

Vein marking through ultrasound coupling gel

It is now common practice to mark the course of the long saphenous vein by duplex scanning prior to in situ or reversed vein bypass grafting. This poses the problem of how best to mark its course durably in the presence of the ultrasound coupling gel on the skin. Blind to two observers, 11 commonly available marking pens were applied to the skin through ultrasound coupling gel, the gel was removed and the skin cleaned using a spirit-based antiseptic solution. The observers then rated the pens in order of performance. We recommend "Pilot Super Color Marker", "Artline 70" and "Edding 3020 Surgical Skin Marker" for preoperative vein mapping. These pens allow rapid marking of the saphenous or other veins through ultrasound coupling gel at the time of duplex scanning, and the marks persist after surgical preparation of the skin.