Asunto(s)
Neoplasias de Cabeza y Cuello/cirugía , Hemostasis Quirúrgica/instrumentación , Cirugía de Mohs/métodos , Hemorragia Posoperatoria/prevención & control , Neoplasias Cutáneas/cirugía , Craneotomía/instrumentación , Neoplasias de Cabeza y Cuello/diagnóstico , Humanos , Cirugía de Mohs/efectos adversos , Cirugía de Mohs/instrumentación , Hemorragia Posoperatoria/etiología , Cuero Cabelludo/patología , Cuero Cabelludo/cirugía , Piel/patología , Neoplasias Cutáneas/diagnóstico , Neoplasias Cutáneas/patología , Resultado del TratamientoAsunto(s)
Diseño de Equipo , Ergonomía/instrumentación , Cirugía de Mohs/instrumentación , Dolor Musculoesquelético/prevención & control , Enfermedades Profesionales/prevención & control , Humanos , Dolor Musculoesquelético/etiología , Enfermedades Profesionales/etiología , Posición de Pie , CirujanosRESUMEN
Limited data exist comparing staples and sutures for closing scalp wounds during Mohs micrographic surgery (MMS). We surveyed practicing Mohs surgeons who were members of the American College of Mohs Surgery (ACMS) on their scalp wound closure preferences as well as the clinical and economic variables that impact their decisions. Comparisons were made between current practice habits, preferences, and provider demographics. Sixty-eight ACMS fellowship-trained Mohs surgeons completed the survey. Overall, scalp wounds during MMS were most frequently closed using staples.
Asunto(s)
Cirugía de Mohs/métodos , Grapado Quirúrgico/estadística & datos numéricos , Técnicas de Sutura/instrumentación , Suturas/estadística & datos numéricos , Adulto , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Cirugía de Mohs/instrumentación , Pautas de la Práctica en Medicina/estadística & datos numéricos , Cuero Cabelludo/cirugía , Cirujanos/estadística & datos numéricos , Técnicas de Sutura/estadística & datos numéricosRESUMEN
BACKGROUND: Telemedicine is improving access to subspecialty care within the Veterans Health Administration (VHA). Mohs micrographic surgery (MMS) is a surgical modality used to treat nonmelanoma skin cancers. OBJECTIVE: This study evaluates the use of teledermatology for preoperative consultation for MMS. METHODS AND MATERIALS: A retrospective analysis of interfacility MMS referrals to the Bronx Veterans Affairs Medical Center (VAMC) was conducted. The consult failure rates (CFRs), treatment follow-through rates, time to treatment, and travel savings for "face-to-face" preoperative consults were compared with store-and-forward "teledermatology" preoperative consults. RESULTS: Although both "teledermatology" and "face-to-face" preoperative consults resulted in an equivalent percentage of treated lesions, teledermatology had a significantly decreased CFR. In addition, teledermatology decreased the time to treatment by 2 weeks, increased the percentage of lesions treated within 60 days, and resulted in average travel savings of 162.7 minutes, 144.5 miles, and $60.00 per person. CONCLUSION: This study demonstrates that teleconsultation is effective for preoperative consults for MMS within the VHA system. Teledermatology improved access measures such as time to treatment and travel burden. This program may serve as a model not only for other VAMCs that accept interfacility MMS consults, but also for VAMCs that provide other types of access-limited subspecialty care.
Asunto(s)
Dermatología/métodos , Cirugía de Mohs/métodos , Cuidados Preoperatorios/métodos , Derivación y Consulta/tendencias , Neoplasias Cutáneas/cirugía , Telemedicina/tendencias , Anciano , Biopsia , Dermatología/organización & administración , Dermatología/estadística & datos numéricos , Dermatología/tendencias , Femenino , Accesibilidad a los Servicios de Salud/organización & administración , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/tendencias , Hospitales de Veteranos/organización & administración , Hospitales de Veteranos/estadística & datos numéricos , Humanos , Masculino , Cirugía de Mohs/instrumentación , Cirugía de Mohs/estadística & datos numéricos , Cirugía de Mohs/tendencias , Fotograbar , Cuidados Preoperatorios/estadística & datos numéricos , Cuidados Preoperatorios/tendencias , Derivación y Consulta/estadística & datos numéricos , Estudios Retrospectivos , Piel/patología , Neoplasias Cutáneas/diagnóstico , Neoplasias Cutáneas/patología , Telemedicina/organización & administración , Telemedicina/estadística & datos numéricos , Tiempo de Tratamiento , Viaje/estadística & datos numéricos , Estados Unidos , United States Department of Veterans AffairsRESUMEN
BACKGROUND: Mohs micrographic surgery, excisional surgery, and electrodessication and curettage (ED&C) are common dermatologic procedures that often use electrodessication through hyfrecators to achieve hemostasis. According to in vitro studies, electrodessication is considered safe in patients with implanted cardiac devices. To the authors' knowledge, there are no in vivo data to support this claim. OBJECTIVE: In this study, the authors aim to describe the outcomes of hyfrecation during dermatologic procedures in patients with pacemakers and implantable cardiac devices. METHODS: Retrospective chart review was completed from March 2014 to April 2018 at a single center. Forty-five patients met criteria of having a cardiac device and having undergone an electrosurgery procedure using the Conmed 2000 Hyfrecator (Utica, NY). Adverse perioperative and postoperative outcomes, as well as device malfunction, were evaluated. RESULTS: No adverse perioperative effects were reported. Device reports were examined for inappropriate firing of the defibrillator, loss of capture, temporary inhibition of pacing, battery drainage, pacing at an elevated or erratic rate, failure to deliver antitachycardia, reversion to asynchronous pacing, induction of arrhythmias, or tissue damage at lead tissue, but no such issues were found. CONCLUSION: The lack of complications associated with cardiac devices with hyfrecation is reassuring. However, prospective and larger retrospective studies are warranted.
Asunto(s)
Desfibriladores Implantables , Electrocirugia/instrumentación , Hemostasis Quirúrgica/instrumentación , Cirugía de Mohs/instrumentación , Marcapaso Artificial , Enfermedades de la Piel/cirugía , Anciano , Femenino , Humanos , Masculino , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Surgical fire is a rare event, but one with potentially devastating patient outcomes. OBJECTIVE: This study was conducted to investigate the incidence, risk factors, and outcome of surgical fires experienced by members of the American College of Mohs Surgeons (ACMS). METHODS: An internet survey was developed and sent to ACMS members. Data collected included total years of experience, total number of cases, typical management of supplemental oxygen, and surgical fires experienced. RESULTS: Eighty participants contributed data on 886,200 cases of MMS. Nine surgeons (11%) reported at least 1 surgical fire, yielding an estimated incidence of 1 fire per 88,620 cases (0.001%). The most common site of involvement was the scalp (67%). Common ignition sources included monopolar electrosurgical devices (78%) and battery-powered thermal cautery (22%). Fuel sources included towels or drapes, gauze, isopropyl alcohol, aluminum chloride, hairspray, and diethyl ether. Supplemental oxygen was not involved in any of the cases. Five patients suffered singed hair while 4 patients did not suffer any injuries. None suffered any permanent functional or aesthetic deformities. CONCLUSION: The overall risk of surgical fire in MMS is minimal. However, safety measures and greater awareness of fire risks are necessary to prevent patient harm.
Asunto(s)
Incendios/estadística & datos numéricos , Cirugía de Mohs/efectos adversos , Cirugía de Mohs/instrumentación , Quemaduras/etiología , Humanos , Incidencia , Factores de Riesgo , Cuero Cabelludo/lesionesRESUMEN
BACKGROUND: Effective treatment by Mohs micrographic surgery requires preparation of high-quality slides. OBJECTIVE: To examine a novel tissue alignment device designed to address variability in tissue processing because of excessive sample trimming. MATERIALS AND METHODS: A device was designed to account for angular errors and unparalleled tissue embedding. A retrospective chart review was performed both with and without the use of the device over the course of a 4-year period (2012-2015). RESULTS: Between January 1, 2012, and June 10, 2014, before device implementation, mean number of stages per case was 1.65 (n = 3,680) and mean number of surgeries per day was 6.34 (n = 640). Between June 11, 2014, and October 02, 2015, with device implemented, the average number of stages per case between decreased to 1.58 (n = 2,562) and the number of daily surgeries increased to 7.05 (n = 358). This represents a significant decrease in number of stages per case by 0.07 stages (95% CI: -0.01 to -0.13, p = .02), as well as an increase in the number of cases per day by 0.71 cases (95% CI: 0.12-1.3, p < .01). CONCLUSION: Slide preparation using the novel alignment device may result in less tissue waste and more cases being performed daily.
Asunto(s)
Microtomía/instrumentación , Cirugía de Mohs/instrumentación , Neoplasias Cutáneas/cirugía , Adhesión del Tejido/instrumentación , Diseño de Equipo , Humanos , Estudios Retrospectivos , Neoplasias Cutáneas/patologíaRESUMEN
Confocal mosaicking microscopy (CMM) enables rapid imaging of large areas of fresh tissue ex vivo without the processing that is necessary for conventional histology. When performed in fluorescence mode using acridine orange (nuclear specific dye), it enhances nuclei-to-dermis contrast that enables detection of all types of basal cell carcinomas (BCCs), including micronodular and thin strands of infiltrative types. So far, this technique has been mostly validated in research settings for the detection of residual BCC tumor margins with high sensitivity of 89% to 96% and specificity of 99% to 89%. Recently, CMM has advanced to implementation and testing in clinical settings by "early adopter" Mohs surgeons, as an adjunct to frozen section during Mohs surgery. We summarize the development of CMM guided imaging of ex vivo skin tissues from bench to bedside. We also present its current state of application in routine clinical workflow not only for the assessment of residual BCC margins in the Mohs surgical setting but also for some melanocytic lesions and other skin conditions in clinical dermatology settings. Last, we also discuss the potential limitations of this technology as well as future developments. As this technology advances further, it may serve as an adjunct to standard histology and enable rapid surgical pathology of skin cancers at the bedside.
Asunto(s)
Carcinoma Basocelular/diagnóstico por imagen , Dermatólogos/tendencias , Dermatología/tendencias , Microscopía Confocal , Microscopía Fluorescente , Cirugía de Mohs/tendencias , Cirujanos/tendencias , Dermatología/instrumentación , Humanos , Microscopía Confocal/estadística & datos numéricos , Microscopía Fluorescente/estadística & datos numéricos , Cirugía de Mohs/instrumentaciónAsunto(s)
Aumento de la Imagen/instrumentación , Microscopía Confocal/instrumentación , Cirugía de Mohs/instrumentación , Neoplasias Cutáneas/patología , Piel/citología , Manejo de Especímenes/instrumentación , Dermoscopía/instrumentación , Diseño de Equipo , Análisis de Falla de Equipo , Humanos , Inmovilización/instrumentación , Márgenes de Escisión , Estimulación Física/instrumentación , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Neoplasias Cutáneas/diagnóstico por imagenRESUMEN
PURPOSE: To validate the innovative Dry Ice method, comparing it with two standard methods currently used for tissue processing in Mohs surgery, the Heat Sink method and the Miami Special. METHODS: Forty eight samples of pigs kin with the standard beveled Mohs technique were used, and randomly allocated into six groups. Each group was processed with one of the 3 methods and evaluated for: The freezing time, the depth required to cut into the block to obtain a complete section, and the quality of histological slides analyzed with a image software. The statistical analysis was performed with the software SAS(r) System. The inferential analysis was made by one-way ANOVA. RESULTS: The Miami Special showed a processing time significantly shorter than Dry Ice method and Heat Sink method. There was no significant difference in the depth required to cut into the blocks, and area of surgical margins visualized. CONCLUSION: The Dry Ice method was as efficient as the other two methods currently used in Mohs surgery, considering the individual advantages and disadvantages of each method.
Asunto(s)
Secciones por Congelación/métodos , Cirugía de Mohs/normas , Adhesión del Tejido/métodos , Análisis de Varianza , Animales , Modelos Animales de Enfermedad , Hielo Seco , Cirugía de Mohs/instrumentación , Neoplasias Cutáneas/cirugía , PorcinosRESUMEN
Mohs micrographic surgery (MMS) is a treatment method aiming at thorough, personalized eradication of skin cancers by mean of staged excision of tissues surrounding the tumor with complete (100%) histopathological examination of their margins. In many MMS laboratories, the excised tissue is divided, shaped, frozen in a cryostat with a heat extractor and positioned manually (with the block on the object disc) in an articulated cryostat chuck during cutting. However, these activities may be difficult, time-consuming and associated with the risk of imprecise tissue sectioning. Development of a laboratory device allowing for processing of large tissue specimens, with the function of mechanical, mathematically steered positioning of the tissue block surface directly to the microtome knife cutting place, eliminating the need for manual adjustment. The prototype device was designed and manufactured. Its functioning was tested on 513 histological slides produced during 212 operations of skin cancers using MMS. The depth of the first complete sections and the diameter of sections were measured. Complete sections were obtained at an average depth of 81.60 ïm (min. 20 ïm, max. 180 ïm, SD = 29.15), whereas the average diameter of sections was 18.11 mm (min. 4 mm, max. 42 mm, SD = 9.10). The histological processing of large specimens with mathematically based positioning of the tissue surface in relation to the cryotome knife cutting plane is precise, fast and easy. The device can be useful in those MMS centers which continue to employ manual setting of the cryostat chuck or share the cryostat with other users, which prevents fixing the chuck position (including large hospital settings). It may also be helpful in centers using a cryostat with a fixed chuck, for the correction of minimal inaccuracies of its preset position.
Asunto(s)
Secciones por Congelación/instrumentación , Cirugía de Mohs/instrumentación , Neoplasias Cutáneas/cirugía , HumanosRESUMEN
ABSTRACT PURPOSE: To validate the innovative Dry Ice method, comparing it with two standard methods currently used for tissue processing in Mohs surgery, the Heat Sink method and the Miami Special. METHODS: Forty eight samples of pigs kin with the standard beveled Mohs technique were used, and randomly allocated into six groups. Each group was processed with one of the 3 methods and evaluated for: The freezing time, the depth required to cut into the block to obtain a complete section, and the quality of histological slides analyzed with a image software. The statistical analysis was performed with the software SAS(r) System. The inferential analysis was made by one-way ANOVA. RESULTS: The Miami Special showed a processing time significantly shorter than Dry Ice method and Heat Sink method. There was no significant difference in the depth required to cut into the blocks, and area of surgical margins visualized. CONCLUSION: The Dry Ice method was as efficient as the other two methods currently used in Mohs surgery, considering the individual advantages and disadvantages of each method.
Asunto(s)
Animales , Cirugía de Mohs/normas , Adhesión del Tejido/métodos , Secciones por Congelación/métodos , Neoplasias Cutáneas/cirugía , Porcinos , Análisis de Varianza , Cirugía de Mohs/instrumentación , Modelos Animales de Enfermedad , Hielo SecoRESUMEN
A useful application of the flexible razor blade in Mohs micrographic surgery that can save time and result in a well-presented specimen is described.