In regard to Wu and Vapiwala et al Meyer, Joshua E; Dilling, Thomas J; Amdur, Robert J ...
International journal of radiation oncology, biology, physics,
03/2016, Letnik:
94, Številka:
4
Journal Article
Background Intraoperative pain during Mohs micrographic surgery (MMS) has not been characterized. However, many patients report postoperative pain on the day of MMS. Objective We sought to determine ...if patients experience pain during their MMS visit. Methods In phase I of this study, patients were asked to report intraoperative pain level using the verbal numerical rating scale (0-10) at discharge. In phase II, pain levels were assessed before each Mohs layer and at discharge, to determine whether pain was experienced throughout the day. Results Pain was reported at some point during the MMS day for 32.8% of patients (n = 98). The mean pain number reported was 3.7 (range 1-8) out of 10. Pain was more commonly reported by patients who spent a longer time in the office, had 3 or more Mohs layers, and had a flap or graft repair. Patients most frequently reported pain with surgical sites of the periorbital area and nose. Limitations Time between Mohs layers was not measured. There was nonstandardized use of intraoperative local anesthesia volume and oral pain medications. Conclusion Some patients experience pain during MMS. However, the majority of patients report a low level of pain. Additional preventative measures could be considered in patients at higher risk.
Background With the US Food and Drug Administration approval of the TAG thoracic device, more thoracic pathologies are being treated using endovascular techniques. Although endovascular abdominal and ...thoracic aortic repairs have some apparent similarities, there are substantive anatomic, pathologic, and technical differences that could impact perioperative outcomes. The purpose of this study is to identify these differences. Methods During a 5-year period, 121 endovascular thoracic aortic repairs (TEVAR) and 450 abdominal aortic repairs (EVAR) were performed at a single institution. Preoperative, intraoperative, and early postoperative data were prospectively collected and retrospectively reviewed. Aggregate outcome measures were compared between the two cohorts, with statistical significance achieved at P < .05. Results The mean age of patients undergoing EVAR was 72.8 ± 8.3 compared with 68.3 ± 13.9 for TEVAR ( P = .02). More women underwent TEVAR (30.6% vs 11.1%, P < .001). Aneurysms undergoing TEVAR were larger than those for EVAR (62.0 mm vs 58.3 mm, P = .01). Intraoperatively, EVAR required 26.2 minutes of fluoroscopy compared with 22.1 minutes for TEVAR ( P < .001). The amount of contrast used was higher in TEVAR (133.6 mL vs 93.6 mL, P < .001). The mean procedure times were 164 minutes for EVAR and 115 minutes for TEVAR ( P < .001). Iliac conduits were required in 46 patients (10.2%) undergoing EVAR, and in 24 (19.8%) undergoing TEVAR ( P = .007). The 30-day or in-hospital mortality was 2.0% for EVAR and 5.0% for TEVAR ( P = NS). The median length of stay was longer for TEVAR (3 days vs 2 days, P = .034). There were 54 postoperative complications in 36 TEVAR patients (29.8%), including 13 neurologic (10.7%), 8 renal (6.6%), 7 pulmonary (5.8%), 6 ischemic (5.0), and 5 (4.1%) hemorrhagic events. Among the EVAR group, 136 (30.2%) patients had postoperative complications, which included 45 ischemic (10.0%), 34 wound (7.6%), 22 renal (4.9%), 12 cardiac (2.7%), 8 pulmonary (1.8%), 5 gastrointestinal (1.1%), and 4 neurologic (0.9%) events. Conclusions A relatively higher proportion of women underwent TEVAR than EVAR, and this was reflected in the greater need for iliac conduits to accommodate the larger delivery catheters of the thoracic devices. Intraoperative imaging techniques were also different, and TEVAR required higher contrast volumes despite shorter overall procedure times. The incidence of strokes and spinal cord ischemia was also higher during TEVAR. Despite apparent similarities of devices and techniques, EVAR and TEVAR are fundamentally different procedures with different perioperative outcomes.
Background Although a large proportion of patients with traumatic thoracic aortic injury die before undergoing definitive repair, those who survive still face ongoing risk of death and morbidity. ...Endovascular therapy may offer a minimally invasive alternative in the repair of the aortic injury. Study Design We reviewed our experience with endovascular repair of traumatic aortic injuries using medical records, imaging studies, and a prospectively maintained endovascular and institutional trauma database. Results Twenty-two patients underwent thoracic endovascular repair (TEVAR) of traumatic aortic injuries over 44 months. The mean (SD) age was 34 ± 12 years and 68% were men. Among the 16 patients registered with our trauma database, the mean Injury Severity Score was 33 ± 16 (range, 13 to 45). All injuries were sustained from blunt trauma; 95% of patients had nonaortic thoracic injuries, and 64% and 55% had extremity and abdominal injuries, respectively. Intraoperatively, 91% were repaired under general anesthesia, the mean procedure time was 80 ± 52 minutes, and mean blood loss was 219 ± 72 mL. The mean fluoroscopy time was 13 ± 5 minutes and contrast volume 98 ± 23 mL. Twenty-one patients (95%) required coverage of the left subclavian artery to achieve an adequate proximal landing zone. There were no in-hospital or 30-day deaths. The median length of stay was 8 days (range, 1 to 62 days), and 11 (50%) patients were able to be discharged home (versus to another extended care facility). At a mean followup of 7.7 months (range, 0 to 40 months) there were 2 patients (9%) who required endograft-related reintervention at 1 and 6 months. One was an access-related complication, and the second was complete device collapse with acute aortic occlusion, resulting in the patient's death. Conclusions Although patients who undergo endovascular repair of traumatic thoracic aortic transections typically have significant concomitant injuries, the procedure itself is well tolerated and can be performed rapidly with minimal blood loss and contrast administration. But close followup is necessary given the risk of late complications.
Controlled hypotension is sometimes necessary for accurate endograft deployment and adjunctive ballooning and stenting near the arch and proximal descending thoracic aorta. This article describes a ...technique in which a compliant occlusion balloon inflated in the right atrium is used to occlude the inflow from the inferior vena cava and reduce the cardiac preload. This reliably and effectively induces systemic hypotension to any desired level and is also able to be rapidly reversed. The technique has been used in 11 cases of thoracic endovascular aortic repairs with complete success and no procedure-related complications.
Objectives Failure to conform to the arch (“bird-beaking”) can lead to endoleak and graft collapse after thoracic endovascular aortic repair. We report the first United States experience with the new ...TX2 Pro-Form (Cook Inc, Bloomington, Ind), a novel delivery system that became commercially available in October 2009, designed to enhance circumferential apposition of the TX2 thoracic endograft to the arch. Methods This was a single-institution retrospective study. Endograft-to-arch conformance was quantitatively analyzed using intraoperative angiograms of consecutive, reverse chronologic cohorts of TX2 Pro-Form, TX2 Z-Trak (prior delivery system; Cook), and Gore TAG (W.L. Gore and Assoc, Flagstaff, Ariz). Only native aortic arch deployments in zones 2 and 3 were included. Results During a 6-week period, 20 Pro-Form cases were performed, of which 17 patients met inclusion criteria. These were compared with 17 Z-Trak and 17 TAG patients. Endografts were successfully delivered to their intended proximal landing zones in all 51 patients. A higher proportion of dissections were treated in the Z-Trak (65%) and TAG (76%) patients ( P = .03), but similar rates of zone 2/3 deployments ( P = .30). Despite the mean arch angle being greatest for the Pro-Form patients (90° vs 74° vs 71°, P = .18), the mean separation between the leading endograft edge and the aortic wall along the inner curvature of the arch was significantly less (1.4 vs 4.1 vs 5.7 mm; P = .0002), with complete apposition achieved in 65% of Pro-Form patients (18% Z-Trak, 6% TAG, P < .0001). This resulted in the lowest reduction in aortic luminal diameter at the proximal landing zone (5.5% vs 13.4% vs 19.3%; P = .0006) compared with Z-Trak and TAG. Rates of type Ia endoleak were similar ( P = .38). Conclusions The Pro-Form delivery system significantly improves endograft conformation to the arch, resulting in minimum bird-beaking even in severely angulated anatomies.
To compare the efficacy of simulation-based training between the Mimic dV- Trainer and traditional dry lab da Vinci robot training.
A prospective randomized study analyzing the performance of 20 ...robotics-naive participants. Participants were enrolled in an online da Vinci Intuitive Surgical didactic training module, followed by training in use of the da Vinci standard surgical robot. Spatial ability tests were performed as well. Participants were randomly assigned to 1 of 2 training conditions: performance of 3 Fundamentals of Laparoscopic Surgery dry lab tasks using the da Vinci or performance of 4 dV-Trainer tasks. Participants in both groups performed all tasks to empirically establish proficiency criterion. Participants then performed the transfer task, a cystotomy closure using the daVinci robot on a live animal (swine) model. The performance of robotic tasks was blindly assessed by a panel of experienced surgeons using objective tracking data and using the validated Global Evaluative Assessment of Robotic Surgery (GEARS), a structured assessment tool.
No statistically significant difference in surgeon performance was found between the 2 training conditions, dV-Trainer and da Vinci robot. Analysis of a 95% confidence interval for the difference in means (-0.803 to 0.543) indicated that the 2 methods are unlikely to differ to an extent that would be clinically meaningful.
Based on the results of this study, a curriculum on the dV- Trainer was shown to be comparable to traditional da Vinci robot training. Therefore, we have identified that training on a virtual reality system may be an alternative to live animal training for future robotic surgeons.
Surgical repair of proximal right subclavian artery aneurysms can be difficult. They typically require a combined mediastinal exposure to control the innominate and right common carotid arteries and ...a supra- or infraclavicular exposure for distal control, with either a segmental resection and bypass or a bifurcated reconstruction. In this report, we present four cases utilizing a single-stage, hybrid technique combining an endovascular stent graft and an extra-anatomical bypass to repair proximal right subclavian artery aneurysms without the need for mediastinal exposure or extensive surgical reconstruction. There were no deaths and two minor neurologic events.
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