Gastric peroral endoscopic myotomy for management of refractory gastroparesis in patients with gastric neurostimulator devices: a multicenter retrospective case control study.

BACKGROUND AND AIMS: Gastric neurostimulation (GNS) and gastric peroral myotomy (G-POEM), therapies for refractory gastroparesis, are associated with suboptimal outcomes. We studied the role of G-POEM as a salvage therapy in patients with refractory symptoms after GNS implantation. METHODS: This was a multicenter, retrospective, matched case-control study. Consecutive patients with a GNS device and who underwent G-POEM as a salvage therapy for clinical failure (cases) and patients without GNS implantation and who underwent G-POEM for refractory gastroparesis (control) between October 2018 and August 2021 were included. The primary outcome was clinical success after G-POEM. RESULTS: A total of 123 patients (mean age 45.7 ± 14.7 years; 88 female subjects [72%]) underwent G-POEM therapy during the study: 41 cases and 82 controls. Clinical success was achieved in 66% in the case group and 65% in the control group (P = .311), during a median total clinical follow-up time of 11.8 (interquartile range, 2.4-6.3) months. In the case group, the mean Gastroparesis Cardinal Symptom Index score decreased from 2.8 ± 1.8 to 1.5 ± 1.9 (P = .024), and gastric retention at 4 hours improved from 45% ± 25.8% to 16.6% ± 13.1% (P = .06). The mean delta improvement in the subscales of nausea/vomiting (1.3 ± .6 vs .9 ± 1.1, P = .044) and bloating (1.6 ± 1.3 vs 1.2 ± 1.4, P = .041) were significantly higher in cases than in controls. CONCLUSIONS: Among patients with refractory symptoms after GNS, G-POEM can be a reasonable salvage therapy to provide further symptomatic relief with evidence of a potential additive effect of both G-POEM and GNS.

Effect of neuromuscular blockade reversal on post-operative urinary retention following inguinal herniorrhaphy.

PURPOSE: This study aims to define the risk of post-operative urinary retention (POUR) following inguinal hernia repair in those that received sugammadex compared to anticholinesterase. METHODS: Adults undergoing inguinal herniorrhaphy from January 2019 to July 2022 with at least 30-day follow-up receiving rocuronium or edrophonium and reversed with an anticholinesterase or sugammadex were included. 1-to-2 propensity score matched models were fitted to evaluate the treatment of effect of sugammadex vs. anticholinesterase on POUR, adjusting for patient comorbidities, ASA class, wound class, operative laterality, urgency of case, and open versus minimally invasive repair. RESULTS: 3345 patients were included in this study with 1101 (32.9%) receiving sugammadex for neuromuscular blockade reversal. The 30-day rate of POUR was 2.8%; 1.4% in the sugammadex and 4.4% in the anticholinesterase group. After propensity score matching, patients receiving sugammadex had significantly lower risk of POUR compared to anticholinesterase overall (OR 0.340, p < 0.001, 95% CI 0.198-0.585), in open (OR 0.296, p = 0.013, 95% CI 0.113-0.775) and minimally invasive cases (OR 0.36, p = 0.002, 95% CI 0.188-0.693), unilateral (OR 0.371, p = 0.001, 95% CI 0.203-0.681) and bilateral repairs (OR 0.25, p = 0.025, 95% CI 0.074-0.838), elective (OR 0.329, p < 0.001, 95% CI 0.185-0.584) and clean cases (OR 0.312, p < 0.001, 95% CI 0.176-0.553). CONCLUSIONS: The incidence of 30-day new onset POUR was 2.8%. Sugammadex was associated with significantly lower risk of POUR after inguinal herniorrhaphy compared to anticholinesterase overall and when stratifying by operative modality, laterality, and wound class.

Ultrasound evaluation of sinus fluid levels in swine during microgravity conditions.

BACKGROUND: Acute rhinosinusitis is a common problem that could occur in space secondary to absence of gravity-dependent drainage or odontogenic or external sources of infection. The purpose of this study was to determine the efficacy of ultrasound to determine sinus fluid distribution levels in swine and to assess the accuracy of ultrasound in the animal during normal and microgravity conditions. METHODS: Anesthetized swine had a catheter placed through a frontal bone window to allow aliquots of a viscous solution to be injected at 1 G (N = 4) or during brief microgravity parabolic flights (N = 4). Ultrasound examinations were performed with a high frequency probe during baseline and fluid-induced conditions. RESULTS: There was a consistent air-fluid level interface seen on ultrasound examination with the injection of 1 ml of fluid during 1-G conditions. Microgravity conditions caused the rapid (< 10 s) dissolution of the air-fluid level associated with dispersion of the fluid to the walIs of the sinus cavity in a uniform fashion. The air-fluid interface was recreated with return to 1 G. CONCLUSIONS: Ultrasound is a reliable diagnostic test for assessing fluid levels; these experiments demonstrate the technique can be used during microgravity conditions with attention to altered fluid behavior in the absence of gravity.

The learning curve of laparoendoscopic single-site (LESS) cholecystectomy: definable, short, and safe.

BACKGROUND: The applications of laparoendoscopic single-site (LESS) surgery, including cholecystectomy, are occurring quickly, although little is generally known about issues associated with the learning curve of this new technique including operative time, conversion rates, and safety. STUDY DESIGN: We prospectively followed all patients undergoing LESS cholecystectomy, and compared operations undertaken at our institutions in cohorts of 25 patients with respect to operative times, conversion rates, and complications. RESULTS: One-hundred fifty patients of mean age 46 years underwent LESS cholecystectomy. No significant differences in operative times were demonstrable between any of the 25-patient cohorts operated on at our institution. A significant reduction in operative times (p < 0.001) after completion of 75 LESS procedures was, however, identified with the experience of a single surgeon. No significant reduction in the number of procedures requiring an additional trocar(s) or conversion to open operations was observed after completion of 25 LESS cholecystectomies. Complication rates were low, and not significantly different between any 25-patient cohorts. CONCLUSIONS: For surgeons proficient with multi-incision laparoscopic cholecystectomy, the learning curve for LESS cholecystectomy begins near proficiency. Operative complications and conversions were infrequent and unchanged across successive 25-patient cohorts, and were similar to those reported for multi-incision laparoscopic cholecystectomy after the learning curve.

Ultrasonographic evaluation of sinusitis during microgravity in a novel animal model.

OBJECTIVES: To develop an animal model of rhinosinusitis in microgravity, to characterize the behavior of intracavitary fluid in microgravity, and to assess the accuracy of ultrasonographic (US) diagnosis in microgravity. DESIGN: An animal model of acute sinusitis was developed in anesthetized swine by creating a window into a frontal sinus to allow unilateral catheter placement and injection of fluid. We performed US examinations in normal and microgravity environments on control and sinusitis conditions and recorded these for later interpretation. SETTING: Henry Ford Hospital and the National Aeronautics and Space Administration (NASA) Microgravity Research Facility in Houston, Texas. SUBJECTS: Ground (normal-gravity) experiments were conducted on anesthetized swine (n = 4) at Henry Ford Hospital before the microgravity experiments (n = 4) conducted in the NASA Microgravity Research Facility. MAIN OUTCOME MEASURE: Ultrasound visualization of fluid cavity. RESULTS: Results of bilateral US examinations before fluid injection demonstrated typical air-filled sinuses. After unilateral injection of 1 mL of fluid, a consistent air-fluid interface was observed on the catheterized side at ground conditions. Microgravity conditions caused the rapid (<10-second) dissolution of the air-fluid interface, associated with uniform dispersion of the fluid to the walls of the sinus. The air-fluid interface reformed on return to normal gravity. CONCLUSIONS: The US appearance of fluid in nasal sinuses during microgravity is characterized in the large animal model. On the introduction of microgravity, the typical air-fluid interface disassociates, and fluid lining the sinus can be observed. Such fluid behavior can be used to develop diagnostic criteria for acute bacterial rhinosinusitis in the microgravity environment.

Bone marrow-derived mesenchymal stromal cells accelerate wound healing in the rat.

Bone marrow-derived mesenchymal stromal cells (BMSCs) are multipotential stem cells capable of differentiation into numerous cell types, including fibroblasts, cartilage, bone, muscle, and brain cells. BMSCs also secrete a large number of growth factors and cytokines that are critical to the repair of injured tissues. Because of the extraordinary plasticity and the ability of syngeneic or allogeneic BMSCs to secrete tissue-repair factors, we investigated the therapeutic efficacy of BMSCs for healing of fascial and cutaneous incisional wounds in Sprague-Dawley rats. Systemic administration of syngeneic BMSCs (2 x 10(6)) once daily for 4 days or a single treatment with 5 x 10(6) BMSCs 24 hours after wounding significantly increased the wound bursting strength of fascial and cutaneous wounds on days 7 and 14 postwounding. Wound healing was also significantly improved following injection of BMSCs locally at the wound site. Furthermore, allogeneic BMSCs were as efficient as syngeneic BMSCs in promoting wound healing. Administration of BMSCs labeled with iron oxides/1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanine perchlorate fluorescent dye revealed that systemically administered BMSCs engraft to the wound. The increase in the tensile strength of wounds treated with BMSCs was associated with increased production of collagen in the wound. In addition, BMSC treatment caused more rapid histologic maturation of wounds compared with untreated wounds. These data suggest that cell therapy with BMSCs has the potential to augment healing of surgical and cutaneous wounds.

Ocular examination for trauma; clinical ultrasound aboard the International Space Station.

BACKGROUND: Ultrasound imaging is a successful modality in a broad variety of diagnostic applications including trauma. Ultrasound has been shown to be accurate when performed by non-radiologist physicians; recent reports have suggested that non-physicians can perform limited ultrasound examinations. A multipurpose ultrasound system is installed on the International Space Station (ISS) as a component of the Human Research Facility (HRF). This report documents the first ocular ultrasound examination conducted in space, which demonstrated the capability to assess physiologic alterations or pathology including trauma during long-duration space flight. METHODS: An ISS crewmember with minimal sonography training was remotely guided by an imaging expert from Mission Control Center (MCC) through a comprehensive ultrasound examination of the eye. A multipurpose ultrasound imager was used in conjunction with a space-to-ground video downlink and two-way audio. Reference cards with topological reference points, hardware controls, and target images were used to facilitate the examination. Multiple views of the eye structures were obtained through a closed eyelid. Pupillary response to light was demonstrated by modifying the light exposure of the contralateral eye. RESULTS: A crewmember on the ISS was able to complete a comprehensive ocular examination using B- and M-mode ultrasonography with remote guidance from an expert in the MCC. Multiple anteroposterior, oblique, and coronal views of the eye clearly demonstrated the anatomic structures of both segments of the globe. The iris and pupil were readily visualized with probe manipulation. Pupillary diameter was assessed in real time in B- and M-mode displays. The anatomic detail and fidelity of ultrasound video were excellent and could be used to answer a variety of clinical and space physiologic questions. CONCLUSIONS: A comprehensive, high-quality ultrasound examination of the eye was performed with a multipurpose imager aboard the ISS by a non-expert operator using remote guidance. Ocular ultrasound images were of diagnostic quality despite the 2-second communication latency and the unconventional setting of a weightless spacecraft environment. The remote guidance techniques developed to facilitate this successful NASA research experiment will support wider applications of ultrasound for remote medicine on Earth including the assessment of pupillary reactions in patients with severe craniofacial trauma and swelling.

Evaluation of shoulder integrity in space: first report of musculoskeletal US on the International Space Station.

Investigative procedures were approved by Henry Ford Human Investigation Committee and NASA Johnson Space Center Committee for Protection of Human Subjects. Informed consent was obtained. Authors evaluated ability of nonphysician crewmember to obtain diagnostic-quality musculoskeletal ultrasonographic (US) data of the shoulder by following a just-in-time training algorithm and using real-time remote guidance aboard the International Space Station (ISS). ISS Expedition-9 crewmembers attended a 2.5-hour didactic and hands-on US training session 4 months before launch. Aboard the ISS, they completed a 1-hour computer-based Onboard Proficiency Enhancement program 7 days before examination. Crewmembers did not receive specific training in shoulder anatomy or shoulder US techniques. Evaluation of astronaut shoulder integrity was done by using a Human Research Facility US system. Crew used special positioning techniques for subject and operator to facilitate US in microgravity environment. Common anatomic reference points aided initial probe placement. Real-time US video of shoulder was transmitted to remote experienced sonologists in Telescience Center at Johnson Space Center. Probe manipulation and equipment adjustments were guided with verbal commands from remote sonologists to astronaut operators to complete rotator cuff evaluation. Comprehensive US of crewmember's shoulder included transverse and longitudinal images of biceps and supraspinatus tendons and articular cartilage surface. Total examination time required to guide astronaut operator to acquire necessary images was approximately 15 minutes. Multiple arm and probe positions were used to acquire dynamic video images that were of excellent quality to allow evaluation of shoulder integrity. Postsession download and analysis of high-fidelity US images collected onboard demonstrated additional anatomic detail that could be used to exclude subtle injury. Musculoskeletal US can be performed in space by minimally trained operators by using remote guidance. This technique can be used to evaluate shoulder integrity in symptomatic crewmembers after strenuous extravehicular activities or to monitor microgravity-associated changes in musculoskeletal anatomy. Just-in-time training, combined with remote experienced physician guidance, may provide a useful approach to complex medical tasks performed by nonexperienced personnel in a variety of remote settings, including current and future space programs.