Two-surgeon Team Research Articles

Surgical Observations From the First 120 Cases of Subretinal Gene Therapy for Inherited Retinal Diseases.

To report surgical observations formulated during the first 120 cases of subretinal gene therapy in patients with inherited retinal degenerations (IRDs). A two-surgeon team compiled surgical observations and formulated surgical pearls based on the consecutive cases of subretinal viral vector injection in patients enrolled in clinical trials focusing on choroideremia, achromatopsia, and RP GTPase regulator associated retinitis pigmentosa, as well as patients with retinal pigment epithelium-specific-65-kDa (RPE65) associated Leber congenital amaurosis receiving Food and Drug Administration-approved voretigene neparvovec-rzyl therapy. One hundred twenty subretinal surgeries were performed by a two-surgeon team. Key anatomical features pertinent to surgical management were noted and are described in this article. Surgical decision making for successful subretinal administration of viral vectors and management of potential surgical challenges were formulated. Lessons learned during subretinal gene therapy cases may be helpful to other surgeons entering clinical trials or performing postapproval gene therapy administration. Surgical pearls outlined in this article may also be helpful for other targeted subretinal therapies, such as cellular transplantation or retinal prosthesis implantation.

Accuracy and outcomes of virtual surgical planning and 3D-printed guides for osseous free flap reconstruction of mandibular osteoradionecrosis

ObjectivesVirtual surgical planning, 3D-printed osteotomy guides and preoperatively-bent or custom-milled mandibular reconstruction plate (VSP/3Dprinted-guide/plate) have been shown to ease intraoperative decision making and reduce operative time. Few studies have examined outcomes of VSP/3Dprinted-guide/plate specifically for mandibular osteoradionecrosis (mORN) cases, which pose unique challenges. We aimed to examine reconstruction accuracy, functional outcomes, and postoperative complications following osseous-free-flap reconstruction with VSP/3Dprinted-guide/plate for mORN. Materials and methodsSingle academic medical center retrospective case series of ORN-related osseous-free-flap mandibular reconstructions with VSP/3Dprinted-guide/plate between January 2015 and March 2021. Most cases were performed by the same two-surgeon team. Outcomes include reconstruction accuracy (assessed by 3D-overlay computer models with cephalometric and donor-bone segment length measurements), complications and function. ResultsTwenty-six cases were identified with a mean follow-up of 85 weeks. Most patients were male (69 %); mean age was 64 years. 3D-model-overlay demonstrated minimal deviation between planned and actual reconstruction among 18 evaluable cases: intercondylar distance = 1.46 mm (SD 2.4); intergonial distance = 1.82 mm (SD 2.0); anterior-posterior distance = 2.14 mm (SD 1.9); gonial angle = 3.33 degrees (SD 2.4). Mean change donor-bone segment length inferiorly 4.39 mm (SD 4.3) and superiorly 3.43 mm (SD 4.0). Complications: returned to operating room (N = 2), minor primary/neck site infection/dehiscence (N = 11). Function improved postoperatively: 20/21 (95 %) cases with preoperative pain, resolved; 13/20 (65 %) with preoperative trismus, improved; 21/24 (87 %) with preoperative malocclusion/jaw malignment, improved. ConclusionsThis is the largest series of VSP/3Dprinted-guide/plate surgery for mORN to date. Mandibular reconstruction for ORN is aided by VSP/3Dprinted-guide/plate with accurate results, acceptable complications, and improved function.

Microvascular Breast Reconstruction in the Era of Value-Based Care: Use of a Cosurgeon Is Associated with Reduced Costs, Improved Outcomes, and Added Value.

Reducing complications while controlling costs is a central tenet of value-based health care. Bilateral microvascular breast reconstruction is a long operation with a relatively high complication rate. Using a two-surgeon team has been shown to improve safety in bilateral microvascular breast reconstruction; however, its impact on cost and efficiency has not been robustly studied. The authors hypothesized that a cosurgeon for bilateral microvascular breast reconstruction is safe, effective, and associated with reduced costs. The authors retrospectively reviewed all patients who underwent bilateral microvascular breast reconstruction with either a single surgeon or surgeon/cosurgeon team over an 18-month period. Charges were converted to costs using the authors' institutional cost-to-charge ratio. Surgeon opportunity costs were estimated using time-driven activity-based costing. Propensity scoring controlled for baseline characteristics between the two groups. A locally weighted logistic regression model analyzed the cosurgeon's impact on outcomes and costs. The authors included 150 bilateral microvascular breast reconstructions (60 single-surgeon and 90 surgeon/cosurgeon reconstructions) with a median follow-up of 15 months. After matching, the presence of a cosurgeon was associated with a significantly reduced mean operative duration (change in operative duration, -107 minutes; p < 0.001) and cost (change in total cost, -$1101.50; p < 0.001), which was even more pronounced when surgeon/cosurgeon teams worked together frequently (change in operative duration, -132 minutes; change in total cost, -$1389; p = 0.007). The weighted logistic regression models identified that a cosurgeon was protective against breast-site complications and trended toward reduced overall and major complication rates. The practice of using a of cosurgeon appears to be associated with reduced costs and improved outcomes, thereby potentially adding value to bilateral microvascular breast reconstruction. Therapeutic, III.

Surgical Treatment of Developmental Spondylolisthesis: Contemporary Series With a Two-Surgeon Team

Study DesignRetrospective case series. ObjectivesTo report operative outcomes of contemporary surgical treatment of spondylolisthesis in the pediatric population. Summary of Background DataSurgical treatment of developmental spondylolisthesis is controversial, with limited data on complication and reoperation rates. MethodsA retrospective study followed pediatric patients with either L5–S1 high-grade spondylolisthesis (HGS) or L5–S1 symptomatic low-grade spondylolisthesis (LGS) for a minimum of two years. All patients underwent a contemporary, single-stage decompression, partial reduction, and posterior instrumented fusion (DRPF) or in situ stabilization by a combined orthopedic and neurosurgeon team at a single institution during 2005–2015. Clinical examination and radiographic data were collected preoperatively and at discharge, 1 year, 2 years, and terminal visit (defined as the last follow-up at >2 years). ResultsThirty-four patients (79% HGS), mean (±standard deviation) age at surgery 13.5 (±3.3) years, were followed for 4.8 (±2.3) years. The patients who underwent DRPF (n = 26) had mean lumbosacral angle increase from 79.8° (±20.8) to 92.5° (±16.1) (p < .001) and mean listhesis reduce from 63.2% (±21.9) to 26.0% (±20.1) (p < .001). Preoperatively, 18 (53%) had neurologic symptoms. At one- and two-year follow-up, new or residual neurologic symptoms were present in four patients (12%) (p < .001). Postoperative symptoms were not significantly related to amount of reduction. Sixteen (47%) underwent reoperation at an average of 24.8 months, 10 for planned prominent instrumentation removal, and 6 for true complications. ConclusionsSurgical reduction and decompression of spondylolisthesis in the pediatric population restores spinopelvic alignment. We found no evidence that a greater amount of reduction was associated with a higher incidence of postoperative complications. However, patients should be advised that prominent instrumentation may require future removal. Although previous reports suggest complication rates and permanent neurologic sequelae in up to 20% after operative treatment of spondylolisthesis, our results suggest that a contemporary approach with a two-surgeon team may provide improved results. Level of EvidenceLevel IV.

The Effect of Two Attending Surgeons on the Outcomes of Posterior Spine Fusion in Children With Cerebral Palsy

BackgroundPosterior spinal fusion (PSF) in children with cerebral palsy (CP) carries a high risk of complications and morbidity. The purpose of this study is to investigate the impact of using two attending surgeons on blood loss, operative time, and complications in this fragile population. MethodsThis was a prospective, matched cohort analysis of patients with CP who underwent PSF with two attending surgeons. These were matched with a control group that had a single-surgeon team, assisted by a senior resident or PA. The groups were compared using paired Student t tests and chi-square tests. Results50 patients were included in the study (25 study and 25 matched controls), determined by our power analysis. There was no statistical difference in the mean age, preoperative major curve angle, major curve angle correction, or use of antifibrinolytics. The two-surgeon group decreased surgical time from 5.25 to 3.3 hours (p = .000002), and estimated blood loss from 1,238 to 865 mL (p = .009). The complication rate decreased from 33% to 8% (p=.034). Length of stay was also decreased from 6.5 days to 5.35 (p = .02). ConclusionsAlthough confounding variables were present, this study demonstrates that the use of a two-surgeon team during spinal surgery for patients with cerebral palsy could have a role in reducing operative time, blood loss, complication rates, and hospital length of stay. Overall, these factors and any improved operating room efficiencies may lead to lasting improved patient outcomes. Level of EvidenceLevel III, retrospective, comparative study.

Current practices in microvascular reconstruction in otolaryngology–head and neck surgery

Despite major advances in the field of head and neck microvascular free tissue transfer (MFTT) over the past several decades, there are no standardized perioperative regimens for the care of patients undergoing free flap reconstructive surgery, and continued variation in practice exists. This study aimed to report current trends in the field of MFTT performed by otolaryngologists, including surgeon training, institutional operative practices, and perioperative management. Cross-sectional survey. A survey of Accreditation Council for Graduate Medical Education-accredited residency programs and American Head and Neck Society fellowship sites was conducted. Seventy-one (62.8%) programs responded, with 67 (94.4%) routinely performing MFTT and 23 (32.4%) having a dedicated microvascular fellowship program. Of institutions performing MFTT, 66 (98.5%) reported the use of a two-surgeon team, most commonly both otolaryngologists (76.3%). Institutional MFTT volumes and donor site frequency are reported. Postoperative care includes routine admission to the intensive care unit (75.2%), step-down unit (15.0%), or general care floor (8.1%). Postoperative flap monitoring practices, including modalities, personnel, and timing/frequency show institutional variation. Despite differences in postoperative monitoring regimen and management (sedation, anticoagulation, antibiotic use), surgeon-reported measures of flap success rate (95.7%, standard deviation [SD] 4.7%) and complication rate (6.8%, SD 2.4%) show little difference across institutions. Many elements of MFTT perioperative care show continued variation at an institutional level. There is a notable shift toward the two-team approach within otolaryngology. Self-reported flap complication and success rates showed no significant differences based on perioperative care and monitoring regimen. Further study of perioperative practices should focus on standardization of care to improve overall outcomes in this complex patient population. NA Laryngoscope, 129:138-145, 2019.

The IDEAL prospective development study format for reporting surgical innovations. An illustrative case study of robotic oesophagectomy

BackgroundThe early development of innovative surgical procedures is usually reported as retrospective case series, wasting opportunities to provide useful information and introducing bias. We present a report of an innovative procedure in development, using the Prospective Development Study (PDS) format recommended by the IDEAL Collaboration. MethodsWe report the development of robotically assisted oesophagectomy by a two-surgeon team from the first robotic case onwards. Key outcomes (blood loss, robotic operating time, lymph node yield, length of stay and complications) are prospectively reported for each patient sequentially. Reasons for rejecting cases for robotic surgery are explained. All changes to technique or indication are highlighted, showing when they occurred and explaining why they were instituted. ResultsThe first robotic oesophagectomy was attempted in December 2009. Subsequently 55 oesophagectomies were undertaken, 34 using the robot and 21 without it. Seven deliberate changes in technique occurred during the series. Nodal yield increased markedly after adopting formal mediastinal node dissection and clipping of the thoracic duct. No obvious trends were noted in other outcomes. The robot facilitated Intra-thoracic anastomosis, but mediastinal node dissection showed no advantages due to loss of haptic sensation. Complication rates, R0 rates and nodal yield were considered acceptable. DiscussionPresenting the development experience in this way improved the clarity of transmission of the main learning points for other surgeons, eliminated bias from selective reporting and explained other types of selection bias. The IDEAL Prospective Development Study has clear advantages over standard case series format for presenting uncontrolled early study data from innovative procedures.

Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis in Children

This study was designed to evaluate the results of restorative proctocolectomy with distal rectal mucosectomy and ileal pouch-anal anastomosis in children. This study is a retrospective review of 100 consecutively referred children (<18 years old) who underwent reconstruction with a J-pouch of ileum and preservation of the transitional anorectal epithelium by the same two-surgeon team. Temporary diverting ileostomy was used. The main outcome measures were daytime and nocturnal fecal continence, bowel movements per day, and complications including pouchitis, ileoanal stricture, or postoperative small-bowel obstruction. Average age of the 100 children (48 males/52 females) was 13.2 years (range, 2.95-17.99). All 25 children with familial adenomatous polyposis had proctocolectomy and reconstruction performed simultaneously. Of 75 children with ulcerative colitis, 50 (67%) had their colectomy followed by reconstruction after an interval ranging from 2 months to 4.4 years. Median postoperative follow-up was 2.6 years. Daytime fecal continence was achieved in 98 children, although 4 reported rare accidents. Nighttime continence was achieved in 93 children, of whom 14 reported rare accidents. The average frequency of bowel movements was 5.43/day (+/-2.22). Only one child with polyposis had pouchitis. Of 75 children with ulcerative colitis, 35 had symptoms consistent with pouchitis; of these 35 children, 10 required prolonged treatment. The most frequent postoperative complication was ileoanal stricture requiring operative dilatation and/or anoplasty (18 children). Bowel obstruction requiring surgery occurred in 18 children. One child eventually required pouchectomy for probable Crohn's disease. Excellent results can be achieved with restorative proctocolectomy in children with respect to fecal continence and stool frequency. However, with ulcerative colitis, a substantial risk of pouchitis remains.

Two-surgeon versus single-surgeon radical cystectomy and urinary diversion: Impact on patient outcomes and costs

Objectives To examine the difference in charges and outcomes between patients who underwent radical cystectomy and urinary diversion by a team of two surgeons versus a single surgeon. Methods A total of 63 patients with bladder cancer who underwent the procedures were retrospectively analyzed. Two surgeons sequentially performed the cystectomy and ileal conduit (IC, n = 17) or neobladder (NBL, n = 18) or a single surgeon performed both the cystectomy and IC (n = 21) or NBL (n = 7). Procedure-related charges, hospital charges, operating room time, length of stay, and complications were compared between the two groups. Results For the IC patients, the two-surgeon team had 60% greater mean surgeon charges ( P <0.0001), 23% lower mean anesthesia charges ( P <0.0001), 121 minutes shorter operating room time ( P = 0.001), and 30% lower operating room charges ( P = 0.001). For the NBL patients, the two-surgeon team had 32% greater surgeon charges ( P <0.0001), 22% lower anesthesia charges ( P = 0.003), 149 minutes shorter operating room time ( P <0.0001), and 41% less operating room charges ( P <0.0001). No differences were found in total hospital charges. The NBL patients who underwent surgery by two surgeons had a longer length of stay ( P = 0.008). No differences were found in complications between the groups. Conclusions For IC patients, our data showed no differences in the average overall charges, whether a two-surgeon team or a single surgeon performed the procedure. Additional reductions in hospital charges could offset the greater physician charges in the NBL patients and allow full realization of the benefit from the shorter operative time with the two-surgeon team.

Minimal blood loss in patients undergoing radical retropubic prostatectomy.

The objective of this study was to evaluate blood loss in patients undergoing radical retropubic prostatectomy. Blood loss and operating time were evaluated in a series of 197 consecutive patients with prostate cancer who underwent radical retropubic prostatectomy by a two-surgeon team. The patients were positioned supine with the table flexed and the patient in about 35 degrees Trendelenburg position. Results were compared with those recorded for an earlier series of 40 patients operated in the supine position alone. The influence of parameters that might affect blood loss (peridural and hypotensive anesthesia, bilateral hypogastric artery clamping) was assessed in multivariate analyses. Since adoption of a Trendelenburg position with flexion of the hips, the mean intraoperative blood loss has decreased by 80%, to a low level of 260 cc; and transfusions have become exceptional (0.5%). The decrease in blood loss correlated with a decrease in operating time, which was reduced to an average of 90 minutes. Whereas epidural anesthesia decreased blood loss by a modest 27%, intraoperative blood pressure, bilateral hypogastric artery clamping, and nerve sparing had little or no significant effect. Patient position and the surgical skill of a two-man team can virtually eliminate the risk of blood loss during radical retropubic prostatectomy. There is thus no need always to resort to other procedures or to preoperative autologous blood donation.