Remote patient monitoring to facilitate same-day discharge after laparoscopic sleeve gastrectomy: a pilot evaluation.

BACKGROUND: Limited hospital inpatient capacity, exacerbated by SARS-CoV-2 (COVID-19) and associated staffing shortages, has driven interest in converting surgeries historically done as inpatient procedures to same-day surgeries (SDS). Remote patient monitoring (RPM) has the potential to increase safety and confidence in SDS but has had mixed success in a bariatric population. OBJECTIVES: Assess the feasibility of and adherence to a protocol offering patients same-day laparoscopic sleeve gastrectomy (SG) supported by RPM with an updated wearable device. Secondary outcomes were readmissions, costs, adherence, and clinical alarm rates. SETTING: Academic, military tertiary referral center (United States). METHODS: A single-center, retrospective case control study of patients undergoing SG, comparing SDS with RPM to patients admitted to the hospital for SG during this time. Patients for SDS were selected by set inclusion/exclusion criteria and patient/surgeon preference, and perioperative management was standardized. RESULTS: Twenty patients were enrolled in the SDS group, then compared with 53 inpatients. Inpatients were older (46 versus 39, P = .006), but with no significant differences in sex, preoperative body mass index, or co-morbidities. RPM wearable and blood pressure adherence was found to be 97% and 80%, respectively. Readmission rates were similar (10% versus 7.5%, P > .05). RPM alarm rates were .5 (0-1.3) per patient for each 24-hour home monitoring period. SDS patients also demonstrated the potential for cost savings over inpatient SG, depending on the number of patients monitored per day as well as the healthcare setting. CONCLUSIONS: SG as SDS with RPM was a feasible approach. It should be evaluated in other surgical procedures and higher-risk patient populations.

An experimental comparison of the effects of bacterial colonization on biologic and synthetic meshes.

PURPOSE: Biologic meshes are being used with increasing frequency to repair contaminated abdominal wall defects despite high long-term recurrence and infection rates associated with their use. Recent clinical reports describing the success of lightweight, macroporous synthetic meshes in contaminated ventral hernia repairs have led some surgeons to challenge the belief that synthetics are contraindicated in contaminated fields. We aimed to determine whether a frequently used biologic mesh (Strattice(TM)) is more resistant to bacterial colonization than macroporous synthetic mesh (Parietex(TM) Progrip(TM)) after inoculation with two common pathogens. METHODS: Rats (n = 48) were implanted subcutaneously with Strattice(TM) or Progrip(TM). Meshes were inoculated with sterile saline or a suspension containing 10(6) colony-forming units of Staphylococcus aureus or Escherichia coli prior to wound closure (n = 8 per subgroup). Meshes were explanted at 4 weeks and underwent microbiologic and histologic analyses. RESULTS: Progrip(TM) demonstrated superior bacterial clearance compared to Strattice(TM) (E. coli, 88 vs. 17% clearance, p = 0.03; S. aureus, 75 vs. 50%, p = 0.61; combined bacterial strains, 81 vs. 36%, p = 0.02; respectively). In the Strattice(TM) group, severely degraded meshes were observed in 100% of animals inoculated with E. coli (but 0% inoculated with S. aureus). In contrast, all Progrip(TM) meshes remained intact regardless of inoculum. Scores for neovascularization were higher in the synthetic group irrespective of contamination (p < 0.05). CONCLUSIONS: Biologic meshes may not be more resistant to bacterial colonization than reduced-weight synthetics, and their resistance may differ in response to different pathogens. The routine use of biologics in contaminated ventral hernia repair should be questioned, particularly in the presence of E. coli.

Surgical Team Assessment Training: improving surgical teams during deployment.

BACKGROUND: Simulation and team training are accepted as critical patient safety strategies to improve team performance and can help achieve better outcomes. Standardized and realistic drills conducted by skilled physicians and nurses who demonstrate consistent use of principles which enhance communication and teamwork increase the likelihood of improved clinical outcomes. METHODS: Two, 4-member surgeon/nurse teams traveled to 8 Army surgical resuscitation medical treatment facilities in Iraq during July and August 2011. At each site, a new program called Surgical Team Assessment Training was introduced and implemented to 220 military personnel. Two multi-patient scenarios were designed to test resuscitative and operating room medical decision-making, communication, and co-ordination of care. In addition, 2 hours of didactic instruction emphasized principles of TeamSTEPPS applied to emergency and operating rooms during care of patients with multiple, complex traumatic injuries. Anonymous surveys were completed by participants following the training. RESULTS: Participants were significantly more likely to rate this training as very helpful following training compared with their opinion before participation (53% vs 37%, P < .05). Seventy-seven percent felt that it would improve overall patient outcomes, 78% said it would likely contribute to saving lives in combat, and 98% felt it should be provided to military Emergency Medicine and Surgical residents. CONCLUSIONS: Surgical Team Assessment Training can be successfully implemented in an austere, hostile environment and improve trauma team function by incorporating simulation training models and TeamSTEPPs concepts. Expansion of this program for predeployment and resident training is currently under investigation based on the extremely positive responses.

Posttraumatic lingual artery pseudoaneurysm treated with ultrasound-guided percutaneous thrombin injection.

Pseudoaneurysms of the lingual artery are extremely rare and are commonly iatrogenic in nature or less frequently a result of blunt or penetrating trauma. Traditionally, these vascular abnormalities have been repaired with open or endovascular techniques. Although ultrasound-guided percutaneous thrombin injection has become a standard treatment for superficial pseudoaneurysms, there are no reports of this being used in the treatment of lingual artery pseudoaneurysms. We report the case of a 26-year-old man who suffered a penetrating head and neck injury after an improvised explosive device blast in Iraq who presented with persistent oropharyngeal swelling. Color-flow Doppler ultrasonography revealed the classic yin/yang sign of a pseudoaneurysm, and a computed tomography scan was obtained that revealed a right lingual artery pseudoaneurysm. With the lack of endovascular capabilities and the excessive risk of open surgery, thrombin was injected directly into the pseudoaneurysm under ultrasound guidance. A computed tomography scan and Doppler ultrasonography revealed complete resolution of the aneurysm. This article presents the first reported case in the English literature of a lingual artery aneurysm after penetrating trauma managed successfully with ultrasound-guided percutaneous thrombin injection.

Evaluation of Six Split-thickness Skin Graft Donor-site Dressing Materials in a Swine Model.

BACKGROUND: Numerous dressings for split-thickness skin graft donor sites are commercially available with no conclusive evidence-based consensus regarding the optimal dressing choice. This study was conducted to identify which of 5 commonly used materials promotes wound healing most effectively for use on split-thickness donor sites in comparison with our standard dressing, Xeroform (petrolatum gauze). METHODS: Twenty-four partial-thickness wounds were created on the backs of 4 pigs using a dermatome. Wounds (n = 4 per dressing type per pig) were treated with Xeroform, Opsite (polyurethane film), Kaltostat ( calcium sodium alginate), DuoDERM (hydrocolloid), Aquacel (hydrofiber), and Mepilex (silicone foam). Full-thickness skin samples were excised at 3 or 5 days and evaluated histologically for reepithelialization and inflammation. Comparisons also included incidence of infection, ease of use, and cost analyses. RESULTS: DuoDERM elicited the greatest percent reepithelialization (81%) and Mepilex the lowest (33%) after 3 days (P = 0.004). All dressings demonstrated complete reepithelialization except Mepilex (85%) at 5 days. There were no infections and inflammation was mild among all treatments. Mepilex was easiest to use, whereas Aquacel, Kaltostat, and Opsite were most difficult (P = 0.03). Xeroform was most cost-effective and Aquacel most expensive. Combined scoring revealed DuoDERM = Xeroform > Opsite = Mepilex > Kaltostat > Aquacel. CONCLUSIONS: DuoDERM and Xeroform were most effective overall. DuoDERM tended to outperform all dressings in reepithelialization at 3 days, while Xeroform was least expensive, easy to use, and demonstrated rapid reepithelialization. These findings suggest that Xeroform may be preferred for use on large donor-site areas. DuoDERM may be more appropriate for small donor sites when healing time is a priority.