Implementation of an Enhanced Recovery After Surgery Protocol for Cranial Vault Remodeling Procedures.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been implemented across surgical disciplines, including cranial vault remodeling for craniosynostosis. The authors aim to describe the implementation of an ERAS protocol for cranial vault remodeling procedures performed for patients with craniosynostosis at a tertiary care hospital. DESCRIPTION: Institutional review board approval was received. All patients undergoing a cranial remodeling procedure for craniosynostosis at the authors' institution over a 10-year period were collected (n = 168). Patient and craniosynostosis demographics were collected as well as operative details. Primary outcome measures were intensive care unit length of stay (ICU LOS) and narcotic usage. Chi squared and independent t-tests were employed to determine significance. A significance value of 0.05 was utilized. RESULTS: During the time examined, there were 168 primary cranial vault remodeling procedures performed at the authors' institution - all of which were included in the analysis. Use of the ERAS protocol was associated with decreased initial 24-hour morphine equivalent usage (p < 0.01) and decreased total morphine equivalent usage (p < 0.01). Patients using the ERAS protocol experienced a shorter ICU LOS (p < 0.01), but the total hospital length of stay was unchanged. CONCLUSION: This study reiterates the benefit of developing and implementing an ERAS protocol for patients undergoing cranial vault remodeling procedures. The protocol resulted in an overall decreased ICU LOS and a decrease in narcotic use. This has implications for ways to maximize hospital reimbursement for these procedures, as well as potentially improve outcomes.

Dr. ChatGPT: Utilizing Artificial Intelligence in Surgical Education.

OBJECTIVE: This study sought to explore the unexamined capabilities of ChatGPT in describing the surgical steps of a specialized operation, the Fisher cleft lip repair. DESIGN: A chat log within ChatGPT was created to generate the procedural steps of a cleft lip repair utilizing the Fisher technique. A board certified craniomaxillofacial (CMF) surgeon then wrote the Fisher repair in his own words blinded to the ChatGPT response. Using both responses, a voluntary survey questionnaire was distributed to residents of plastic and reconstructive surgery (PRS), general surgery (GS), internal medicine (IM), and medical students at our institution in a blinded study. SETTING: Authors collected information from residents (PRS, GS, IM) and medical students at one institution. MAIN OUTCOME MEASURES: Primary outcome measures included understanding, preference, and author identification of the procedural prompts. RESULTS: Results show PRS residents were able to detect more inaccuracies of the ChatGPT response as well as prefer the CMF surgeon's prompt in performing the surgery. Residents with less expertise in the procedure not only failed to detect who wrote what procedure, but preferred the ChatGPT response in explaining the concept and chose it to perform the surgery. CONCLUSIONS: In applications to surgical education, ChatGPT was found to be effective in generating easy to understand procedural steps that can be followed by medical personnel of all specialties. However, it does not have expert capabilities to provide the minute detail of measurements and specific anatomy required to perform medical procedures.

A Cost and Metric Comparison of Disposable Negative-Pressure Wound Therapy Systems.

BACKGROUND: Disposable NPWT (dNPWT), a form of negative-pressure wound therapy, has been shown to be both outcome- and cost-effective for small to medium-sized wounds or closed incisions compared to traditional NPWT systems. When choosing a dNPWT system, multiple factors should be evaluated, including the wound size, wound type, estimated exudate production, and required days of therapy. If the device is not optimized for use in a particular patient, a much higher overall cost can be expected. METHODS: A web-based search, manufacturer website review and communication, and list price-based cost analysis was performed for currently available dNPWT systems. These systems differ with respect to cost, degree of negative pressure, canister size, number of dressings included, and recommended days of therapy. RESULTS: The results showed that 3M™ KCI devices (3M™ KCI, St. Paul, MN) cost about 6x more per day than non-KCI devices, and the V.A.C.® Via and Prevena™ Plus Customizable Incision Management System (both 3M KCI) cost over $180 per day of use. The no-canister Pico 14™ (Smith+Nephew, Watford, UK) is the most cost-effective dNPWT option, with an overall cost of $25.00 per day, but is limited to low exudate-producing wounds, such as closed incisions. At $25.67 per day, the UNO 15 (Genadyne Biotechnologies, Hicksville, NY) is the most cost-effective dNPWT option that still includes a replaceable canister system. CONCLUSION: We present a cost and metric comparison of currently available dNPWT systems. Despite significant differences in the cost of treatment with each dNPWT device, there has been limited research on their relative efficacies.

Targeted muscle reinnervation: a brief history of a promising procedure for effective management of amputation pain.

Each year, 27.5% of the 150 000 people in the United States who require lower extremity amputation experience significant postoperative complications, including pain, infection, and need for reoperation. Postamputation pain, including RLP and PLP, is debilitating. While the causes of such pain remain unknown, neuroma formation following sensory nerve transection is believed to be a major contributor. Various techniques exist for management of a symptomatic neuroma, but few data exist on which technique is superior. Furthermore, there are few data on primary prevention of neuroma formation following injury or intentional transection. The TMR technique shows promise for both management of PLP and RLP and prevention of neuroma formation. Following amputation, transected sensory nerves are coapted to nearby motor nerve supplying remaining extremity musculature. Not only does this procedure generate increased myoelectric signals for improved prosthesis control, TMR appears to neurophysiologically alter sensory nerves, preventing formation of painful sensory neuromas. The sole RCT to date evaluating the efficacy of TMR showed statistically significant reduction in PLP. TMR is not limited to use in the setting of major limb amputation. It has also been used in the setting of post-mastectomy pain, abdominal wall neuromas, digital amputations, and headache surgeries. This article reviews the origin of TMR and provides a brief description of histologic changes following the procedure, as well as current data regarding the efficacy of TMR with regard to postoperative pain relief. It also seeks to provide a concise, comprehensive resource for providers to facilitate better discussions with patients about treatment options.

Utilization of the Labial Flap in Anterior Palatal Fistula Repair.

Background: Palatal fistulas are the most common postoperative complications in primary cleft palate surgery, with incidence rates ranging from 10% to 30%. Functional indications for repair include food regurgitating from the nose, food impaction resulting in malodor, and hypernasality with speech. Anterior palatal fistulas (APFs), in particular, present difficult reconstructive cases due to lack of available local tissue. Here, we describe a case series of 3 patients who underwent APF repair with a random pattern labial flap. Methods: The 3 patients included in this report underwent surgical repair of APF. The size of defects measured 2 × 1cm, 2.5 × 1.5cm, and 3 × 2cm. In each case, the labial flap was elevated on the free border of the superior lip mucosa and advanced through the alveolar cleft to cover the oral layer of the fistula. After 3 weeks, the proximal part of the pedicled flap was incised and inset to the alveolar ridge. Results: From 2020 through 2021, 2 lip flaps were successful in providing full coverage to the oral fistula. In one patient, a 3-year-old who did not cooperate with postoperative care, one of the flaps dehisced before division. Conclusions: APFs are common postoperative complications in patients with primary palate repairs and present difficult reconstructions due to lack of local tissue flaps. Here, we describe a 2-stage method in which a random pattern labial flap is used to provide oral fistula coverage. We recommend this procedure when multiple prior traditional attempts at closure have been unsuccessful and the patient can comply with postoperative care.

Location, Location, Location: The Geographic Impact of Medical School on the Plastic Surgery Match.

BACKGROUND: This resident application cycle posed academic leadership and applicants with an unprecedented challenge: how to virtually match applicants to mutually beneficial programs. The authors sought to refer to previous years' data, specifically geographic trends, to better inform both program directors and applicants. The authors hypothesized that geography, as it pertains to the transition from medical school to residency, impacts match patterns. METHODS: The study was designed as a cross-sectional analysis including all current integrated plastic surgery residents. The independent websites of all accredited integrated plastic surgery programs were then queried for the desired demographic resident information. Additionally, as an illustrative endpoint, geospatial heat maps were generated to better understand geographic trends. RESULTS: All (n = 78) integrated plastic surgery programs and 953 residents were included in the study. Nearly half (47.2%) of current residents remain in the same geographic region in which they obtained their medical degree, with 26% and 17% remaining in the same state and institution, respectively. Students within all regions (North, South, Midwest, West) were more likely to stay within that region for residency (OR 2.59, 2.39, 2.09, 3.80, respectively). Students attending medical schools with affiliated integrated plastic surgery residencies have matched to programs with significantly higher Doximity rankings (p < 0.0001). CONCLUSIONS: Matched integrated plastic surgery applicants are more likely to continue their training at institutions in closer geographic proximity to their medical schools. Students graduating from medical schools without affiliated integrated plastic surgery programs appear to be at a disadvantage during the match process.

Four Columns of the Thorax: Operative Decision-Making in the Setting of Complete Bony Instability.

Thoracic skeletal injury is a common outcome of motor vehicle accidents. Skeletal reconstruction is guided by anatomic and physiologic variables dictated by the injury complex. Here we describe a report of a patient who sustained complex trauma to the thorax leading to complete thoracic dissociation. Clinical and operative decision-making is discussed to inform the reader of a proposed ordered protocol and considerations for operative intervention and reconstruction.

Isolation and characterization of mesenchymal stem cells in orthopaedics and the emergence of compact bone mesenchymal stem cells as a promising surgical adjunct.

The potential clinical and economic impact of mesenchymal stem cell (MSC) therapy is immense. MSCs act through multiple pathways: (1) as "trophic" cells, secreting various factors that are immunomodulatory, anti-inflammatory, anti-apoptotic, proangiogenic, proliferative, and chemoattractive; (2) in conjunction with cells native to the tissue they reside in to enhance differentiation of surrounding cells to facilitate tissue regrowth. Researchers have developed methods for the extraction and expansion of MSCs from animal and human tissues. While many sources of MSCs exist, including adipose tissue and iliac crest bone graft, compact bone (CB) MSCs have shown great potential for use in orthopaedic surgery. CB MSCs exert powerful immunomodulatory effects in addition to demonstrating excellent regenerative capacity for use in filling boney defects. CB MSCs have been shown to have enhanced response to hypoxic conditions when compared with other forms of MSCs. More work is needed to continue to characterize the potential applications for CB MSCs in orthopaedic trauma.

Self-renewing Monolayer of Primary Colonic or Rectal Epithelial Cells.

BACKGROUND & AIMS: Three-dimensional organoid culture has fundamentally changed the in vitro study of intestinal biology enabling novel assays; however, its use is limited because of an inaccessible luminal compartment and challenges to data gathering in a three-dimensional hydrogel matrix. Long-lived, self-renewing 2-dimensional (2-D) tissue cultured from primary colon cells has not been accomplished. METHODS: The surface matrix and chemical factors that sustain 2-D mouse colonic and human rectal epithelial cell monolayers with cell repertoires comparable to that in vivo were identified. RESULTS: The monolayers formed organoids or colonoids when placed in standard Matrigel culture. As with the colonoids, the monolayers exhibited compartmentalization of proliferative and differentiated cells, with proliferative cells located near the peripheral edges of growing monolayers and differentiated cells predominated in the central regions. Screening of 77 dietary compounds and metabolites revealed altered proliferation or differentiation of the murine colonic epithelium. When exposed to a subset of the compound library, murine organoids exhibited similar responses to that of the monolayer but with differences that were likely attributable to the inaccessible organoid lumen. The response of the human primary epithelium to a compound subset was distinct from that of both the murine primary epithelium and human tumor cells. CONCLUSIONS: This study demonstrates that a self-renewing 2-D murine and human monolayer derived from primary cells can serve as a physiologically relevant assay system for study of stem cell renewal and differentiation and for compound screening. The platform holds transformative potential for personalized and precision medicine and can be applied to emerging areas of disease modeling and microbiome studies.

In Vitro Generation of Mouse Colon Crypts.

Organoid culture has had a significant impact on in vitro studies of the intestinal epithelium; however, the exquisite architecture, luminal accessibility, and lineage compartmentalization found in vivo has not been recapitulated in the organoid systems. We have used a microengineered platform with suitable extracellular matrix contacts and stiffness to generate a self-renewing mouse colonic epithelium that replicates key architectural and physiological functions found in vivo, including a surface lined with polarized crypts. Chemical gradients applied to the basal-luminal axis compartmentalized the stem/progenitor cells and promoted appropriate lineage differentiation along the in vitro crypt axis so that the tissue possessed a crypt stem cell niche as well as a layer of differentiated cells covering the luminal surface. This new approach combining microengineered scaffolds, native chemical gradients, and biophysical cues to control primary epithelium ex vivo can serve as a highly functional and physiologically relevant in vitro tissue model.

Rational Design of a Dephosphorylation-Resistant Reporter Enables Single-Cell Measurement of Tyrosine Kinase Activity.

Although peptide-based reporters of protein tyrosine kinase (PTK) activity have been used to study PTK enzymology in vitro, the application of these reporters to intracellular conditions is compromised by their dephosphorylation, preventing PTK activity measurements. Nonproteinogenic amino acids may be utilized to rationally design selective peptidic ligands by accessing greater chemical and structural diversity than is available using the native amino acids. We describe a peptidic reporter that, upon phosphorylation by the epidermal growth factor receptor (EGFR), is resistant to dephosphorylation both in vitro and in cellulo. The reporter contains a conformationally constrained phosphorylatable moiety (7-(S)-hydroxy-1,2,3,4-tetrahydroisoquinoline-3-carboxylic acid) in the place of L-tyrosine and is efficiently phosphorylated in A431 epidermoid carcinoma cells. Dephosphorylation of the reporter occurs 3 orders of magnitude more slowly compared with that of the conventional tyrosine-containing reporter.