Data analysis of vascular surgery instrument trays yielded large cost and efficiency savings.

BACKGROUND: Surgical procedures account for 50% of hospital revenue and ∼60% of operating costs. On average, <20% of surgical instruments will be used during a case, and the expense for resterilization and assembly of instrument trays ranges from $0.51 to $3.01 per instrument. Given the complexity of the surgical service supply chain, physician preferences, and variation of procedures, a reduction of surgical cost has been extremely difficult and often ill-defined. A data-driven approach to instrument tray optimization has implications for efficiency and cost savings in sterile processing, including reductions in tray assembly time and instrument repurchase, repair, and avoidable depreciation. METHODS: During a 3-month period, vascular surgery cases were monitored using a cloud-based technology product (OpFlow, Operative Flow Technologies, Raleigh, NC) as a part of a hospital-wide project. Given the diversity of the cases evaluated, we focused on two main vascular surgery trays: vascular and aortic. An assessment was performed to evaluate the exact instruments used by the operating surgeons across a variety of cases. The vascular tray contained 131 instruments and was used for the vast majority of vascular cases, and the aortic tray contained 152 instruments. Actual instrument usage data were collected, a review and analysis performed, and the trays optimized. RESULTS: During the 3-month period, 168 vascular surgery cases were evaluated across six surgeons. On average, the instrument usage per tray was 30 of 131 instruments (22.9%) for the vascular tray and 19 of 152 (12.5%) for the aortic tray. After review, 45.8% of the instruments were removed from the vascular tray and 62.5% from the aortic tray, for 1255 instruments removed from the versions of both trays. An audit was performed after the removal of instruments, which showed that none of the removed instruments had required reinstatement. The instrument reduction from these two trays alone yielded an estimated costs savings of $97,781 for repurchase and $97,444 in annual resterilization savings. Annually, the removal of the instruments is projected to save 316.2 hours of personnel time. The time required for operating room table setup decreased from a mean of 7:44 to 5:02 minutes for the vascular tray (P < .0001) and from 8:53 to 4:56 minutes for the aortic tray (P < .0001). CONCLUSIONS: Given increasing cost constraints in healthcare, sterile processing remains an untapped resource for surgical expense reduction. A comprehensive data analytics solution provided the ability to make informed decisions in tray management that otherwise could not be reliably performed.

Data Analysis of Plastic Surgery Instrument Trays Yields Significant Cost Savings and Efficiency Gains.

PURPOSE: Inpatient surgery costs have risen 30% over the past 5 years, and the operating room accounts for up to 60% of total hospital operational expense. On average, only 13.0% to 21.9% of instruments opened for a case are used, contributing to significant avoidable reprocessing, repurchase, and labor expense. METHODS: A comprehensive review of 40 major instrument trays at UNC Rex Hospital was conducted using a technology service (OpFlow; Operative Flow Technologies, Raleigh, NC). Among the full scope of the project, the general plastics tray and breast reconstruction tray were evaluated for the plastic surgery service line over a 3-month period. Intraoperative data collection was performed on the exact instruments used across a standard breadth of cases. Data analytics were conducted stratifying instrument usage concordance among surgeons by tray and procedure type. After a surgeon-led review of the proposed new tray configurations, the optimized versions were implemented via a methodical change management process. RESULTS: A total of 183 plastic surgery cases were evaluated across 17 primary surgeons. On average, the instrument usage per tray was 15.8% for the general plastics tray and 23.5% for the breast reconstruction tray. After stakeholder review, 32 (45.1%) of 71 instruments were removed from the general plastics tray and 40 (36.7%) of 109 were removed from the breast reconstruction tray, resulting in a total reduction of 2652 instruments. This resulted in a decrease of 81,696 instrument sterilization cycles annually. The removal of the instruments yielded an estimated cost avoidance of US $163,800 for instrument repurchase and US $69,441 in annual resterilization savings. The instrument volume reduction is projected to save 383.5 hours of sterile processing personnel time in tray assembly annually. CONCLUSIONS: An analytics-driven method applying empirical data on actual case-based instrument usage has implications for better efficiency, improved quality, and cost avoidance related to instrument repurchase and sterile processing. Given increasing cost constraints and the transition to value-based care models, leveraging a technology-based solution enables meaningful change in the sterile processing department as a source for cost reduction and quality of care improvement.

A Patient With Schimmelpenning Syndrome and Mosaic KRAS Mutation.

Schimmelpenning syndrome is a neurocutaneous disorder characterized by craniofacial nevus sebaceus that fall along embryonic cutaneous lines and tend to be associated with neurological, ocular, skeletal, and vascular abnormalities. We report a child with extensive nevus sebaceus of the scalp, face, and thorax and other unusual physical findings who was found to have a mosaic mutation of KRAS c.35G>A p.12D pathognomonic of Schimmelpenning syndrome.

Correction of Microstomia Reconstruction With the Use of Acellular Dermal Matrix for Buccal Reconstruction.

Correction of microstomia is challenging with a high rate of recurrence. We report the successful treatment of microstomia using acellular dermal matrix (ADM) as an adjunct for intraoral lining with >1 year of follow-up.A 9-year-old international patient with severe immunodeficiency presented with severe microstomia because of recurrent oral infections. She had undergone 3 previous failed attempts to re-establish an adequate oral opening and was dependent on enteral nutrition via gastrostomy tube. She underwent release of the oral commissure scar contracture and orbicularis oris and the resultant mucosal defect was lined with ADM. A postoperative splint was used for 8 weeks. One-year follow-up demonstrated maintenance of the oral aperture with complete mucosalization of the ADM; the patient was able to resume oral diet and regular dental hygiene.Mucosal reconstruction with ADM is a viable alternative to local flaps and in this case exhibited minimal soft tissue contraction.

Upper Eyelid Coloboma Repair Using Accessory Preauricular Cartilage in a Patient With Goldenhar Syndrome: Technique Revisited.

We present an unusual case of upper eyelid coloboma repair in a patient with Goldenhar syndrome. We describe the use of a modified Cutler-Beard flap with concurrent inlay graft using cartilage from a preauricular appendage. This technique provides the benefits of autologous tissue, while minimizing donor site morbidity and reducing the risk of upper eyelid retraction.

Conjoined Twin Separation: Integration of Three-Dimensional Modeling for Optimization of Surgical Planning.

Conjoined twinning is a rare anomaly, with an incidence of approximately 1 in 100,000 live births. There is a high perinatal mortality rate, but twins who survive pose reconstructive challenges that require meticulous preoperative planning. The authors describe the senior surgeon's career experience with conjoined twin separation, and the evolution of medical modeling and 3-dimensional imaging as a critical component in presurgical planning.The authors performed a retrospective review of all consecutive patients of conjoined twin separation at a single institution from January 2004 to December 2013. Data were collected related to patient demographics, comorbidities, operative technique, perioperative complications, survival, long-term outcomes, and the type of medical modeling system used for preoperative planning.Five sets of conjoined twins underwent separation during the 10-year study period. There were 3 sets of thoraco-omphalopagus twins, 1 set of pyopagus twins, and 1 set of ischiopagus tetrapus twins. The mean age at separation was 70 days, with a mean of 3.5 surgical procedures performed per patient during the first year of life. One set of twins experienced postseparation complications that warranted immediate return to the operating room. The overall survival rate after separation was 70%. The imaging methods used were computed tomography scan with 3-dimensional reconstruction, plaster molds, medical modeling with composite printing, and virtual surgical planning.The use of imaging and medical modeling in presurgical planning has proven to be an important element in optimizing the outcomes for patients with this rare anomaly.

An Unconventional Presentation of Branchio-Oculo-Facial Syndrome.

Branchio-oculo-facial syndrome (BOFS) is a rare disorder characterized by branchial or pharyngeal arch malformations, ocular findings, and craniofacial anomalies. Activating mutations in the enhancer-binding protein 2 alpha, TFAP2A, gene is responsible for the autosomal-dominant inheritance of BOFS. While documented patients of BOFS report wide variability in phenotype expressivity, patients typically demonstrate cervical or infra-auricular anomalies, diverse ocular malformations including microphthalmia and coloboma, and highly characteristic pseudo-cleft or palate defects. The authors present the case of an infant with an unconventional presentation of BOFS to highlight key distinguishing features of this disorder, and to emphasize the importance of a multidisciplinary approach in the diagnosis and management of these patients.

Craniosynostosis Following Fetal Methotrexate Exposure.

Methotrexate (MTX) is an antimetabolite, folic acid antagonist that inhibits purine nucleotide production, DNA synthesis, and cellular proliferation. Despite widespread therapeutic uses, MTX remains a potent teratogen. Methotrexate embryopathy encompasses multiorgan system dysfunction, including intrauterine growth restriction as well as cardiac, craniofacial, renal, genital, and skeletal abnormalities. Effects of MTX exposure on fetal development continue to be described. This series of 4 patients with MTX-associated craniosynostosis represents the largest published association between prenatal MTX exposure and premature cranial suture closure.

Achondroplasia and multiple-suture craniosynostosis.

Genetic mutations in the fibroblast growth factor receptor 3 gene may lead to achondroplasia or syndromic forms of craniosynostosis. Despite sharing a common genetic basis, craniosynostosis has rarely been described in cases of confirmed achondroplasia. We report an infant with achondroplasia who developed progressive multiple-suture craniosynostosis to discuss the genetic link between these clinical entities and to describe the technical challenges associated with the operative management.

Extradural Ossification Following Epidural Hematoma in Children: A Rare But Significant Entity.

There has been a profound increase in the number of patients undergoing head computed tomography after minor injuries and the identification of epidural hematomas has risen concurrently. Although emergent craniotomy and evacuation has been the conventional standard for management, some epidural hematomas can be managed nonoperatively in carefully selected patients. Because of the difficulty in clinically monitoring epidural hematoma absorption and resolution because of the attributed risks of imaging radiation exposure in pediatric patients, the exact incidence of epidural hematoma ossification is unknown. Integrating epidural hematoma calcification into management algorithms is not clearly defined in the literature. The authors report a case of a 2-year-old girl with a calcified epidural hematoma requiring surgical treatment. With the incidence of epidural hematomas rising, providers should be aware of the rare but consequential incidence of epidural hematoma ossification. After literature review and discussion of the pathophysiology, the authors present an algorithmic approach to account for this rare entity. For conservative management of asymptomatic epidural hematomas, providers should consider follow-up magnetic resonance imaging to evaluate resolution in 2 to 3 months. If the magnetic resonance imaging indicates a failure to resolve, a computed tomography scan should then be performed to evaluate ossification and possible need for surgical intervention.

Frontal Encephalocele Associated With a Bilateral Tessier Number Three Cleft and Fraser Syndrome.

Oblique craniofacial clefts and encephaloceles are each rare conditions, and only a few instances of these findings in combination have been described. Each pathologic entity presents a unique reconstructive challenge. The authors report the case of a male infant who presented with a large right frontoencephalocele and bilateral Tessier number 3 clefts. A review of the pertinent literature, including specific considerations related to perioperative management and technical aspects of the surgical approach, is discussed.

Evaluating the safety and efficacy of tranexamic acid administration in pediatric cranial vault reconstruction.

BACKGROUND: Blood loss is the leading cause of mortality after major craniofacial surgery. Autologous blood donation, short-term normovolemic hemodilution, and intraoperative blood salvage have shown low efficacy in decreasing transfusions. Tranexamic acid (TXA) is a synthetic antifibrinolytic drug that competitively decreases the conversion of plasminogen to plasmin, thereby suppressing fibrinolysis. The purpose of this study was to investigate the impact that TXA administration has on intraoperative blood loss and blood product transfusion in pediatric patients undergoing cranial vault reconstruction. METHODS: An Internal Review Board-approved retrospective study was conducted on a consecutive series of pediatric patients undergoing cranial vault reconstruction from January 2009 to June 2012. Seventeen consecutive patients who received TXA at the time of cranial vault reconstruction were compared with 20 patients who did not receive TXA. Criteria for blood product transfusion were identical for both groups. Outcomes including perioperative blood loss, volume of blood transfused, and adverse effects were analyzed. RESULTS: The TXA group had a significantly lower perioperative blood loss (9.4 versus 21.1 mL/kg, P < 0.0001) and lower volume of perioperative mean blood product transfusion (12.8 versus 31.3 mL/kg, P < 0.0001) compared with the non-TXA group. There was no significant difference in demographic data, infection rate, change in preoperative to postoperative hematocrit, duration of surgery, or complication rates between the TXA and non-TXA groups. No drug-related adverse effects were identified in patients who received TXA. CONCLUSIONS: The use of TXA in pediatric cranial vault reconstruction significantly reduces perioperative blood loss and blood product transfusion requirements. The TXA administration is safe and may improve patient outcomes by decreasing the likelihood of adverse effects related to blood product transfusion.

Carotid artery dissection and stroke complicating treatment of postmandibular distraction ankylosis: a case report.

Mandibular distraction osteogenesis is an increasingly accepted treatment option for severe upper airway obstruction in grade 3 Robin sequence. Complications are rarely reported but can include fracture, pin dislodgement, tooth bud damage, and temporomandibular joint ankylosis. Operative correction of these complications can carry inherent risks of their own. We present a patient who incurred carotid artery dissection and stroke after release of postdistraction coronoid-zygomatic ankylosis for the treatment of mandibular micrognathia.

Aesthetic outcomes of acellular dermal matrix in tissue expander/implant-based breast reconstruction.

INTRODUCTION: Tissue expander and implant-based breast reconstruction after mastectomy is the most common method of breast reconstruction. Modifications of the traditional total submuscular reconstruction (TSR) have been made using acellular dermal matrix (ADM) to create an inferolateral sling and a more natural implant pocket for superior aesthetic results. The objective of this study was to assess aesthetic outcomes when using ADM in breast reconstruction. METHODS: A retrospective chart review identified all patients who underwent implant-based breast reconstruction from 2005 to 2009 at our institution. Demographic information, complications, reoperations, and aesthetic outcome data were collected for all patients meeting inclusion criteria related to adequate follow-up and postoperative photographs. Five aesthetic outcomes were evaluated for all study patients by 18 blinded evaluators using postoperative photographs. Outcomes were scored on a scale of 1 to 5, with 5 representing the best possible aesthetic score. RESULTS: A total of 122 patients underwent 183 tissue expander-based reconstructions (ADM, n = 58; TSR, n = 125). The infection rate in patients with ADM was 16.2% compared to 5.9% in TSR patients, but this was not statistically significant (P = 0.09). Capsular contracture was more common in TSR patients (23.5%), compared to those with ADM (8.1%), P = 0.048. Aesthetic scores from the attending plastic surgeons were as follows: natural contour (ADM, 3.36; TSR, 3.02; P = 0.0001), symmetry of shape (ADM, 3.57; TSR, 3.27; P = 0.005), symmetry of size (ADM, 3.68; TSR, 3.42; P = 0.002), position on chest wall (ADM, 3.75; TSR, 3.45; P = 0.004), and overall aesthetic appearance (ADM, 3.56; TSR, 3.20; P = 0.0001). CONCLUSIONS: For all 5 aesthetic parameters evaluated, the ADM group scored significantly higher than the TSR group by 18 blinded evaluators. These consistent findings suggest that the use of ADM in breast reconstruction does confer a significant advantage in aesthetic outcomes for breast reconstruction. This is likely at the cost of a higher infection rate when using ADM; however, that may be offset by the advantage of a lower rate of capsular contracture in patients with ADM.

Outcome study of the surgical management of panniculitis.

Patients with panniculus morbidus have an abdominal panniculus that becomes a pathologic entity, associated with the development of candidal intertrigo, dermatitis, lymphedema, and ischemic panniculitis. Panniculectomy is a standard treatment for this problem. The objective of this study was to determine risk factors for complications associated with panniculectomy surgery to lower the complication rate. We performed a retrospective chart review of patients who underwent panniculectomy between 1999 and 2007 by looking at data related to surgical complications, comorbidities, age, and gender. In 563 patients, we recorded the incidence of the following complications: wound-related (infection, dehiscence, and/or necrosis), hematoma/seroma, respiratory distress, blood transfusions, deep venous thrombosis or pulmonary embolism, and death. Overall, 34.3% of patients suffered at least 1 complication. In patients with wound complications specifically, there was a significantly higher body mass index versus those with no wound complications (43.7% vs. 30.7%, P < 0.0001). Smokers also had a higher rate of wound complications (40.5% vs. 19.5%, P < 0.0001).

Outcome analysis of 541 women undergoing breast conservation therapy.

Breast conservation therapy (BCT) has evolved as a favorable approach to the management of early-stage breast cancer. Shortcomings of BCT include the potential need for re-excision in the event of positive tumor margins as well as the untoward sequelae of radiation therapy. Both of those factors have led to a substantial proportion of patients undergoing BCT who ultimately report suboptimal aesthetic outcomes. Application of plastic surgery principles to the management of this patient subset has been shown to be beneficial from both an oncologic and cosmetic perspective.The aim of this study was to identify factors that may predict which patients would benefit most from involvement of a plastic surgeon before BCT. A retrospective analysis was performed on 762 patients undergoing lumpectomy during a 10-year study period at a single institution. Younger women and patients with tumor size approaching 2 cm were noted to have a significantly higher likelihood of oncologic outcomes that ultimately required breast reconstruction. Integration of oncoplastic techniques in the surgical management of patients undergoing BCT would likely contribute to improvement in aesthetic outcomes and overall patient satisfaction.

Time-dependent perioperative anesthetic management and outcomes of the first 100 consecutive cases of spring-assisted surgery for sagittal craniosynostosis.

BACKGROUND: The anesthetic risks and outcomes of the first 100 consecutive spring-assisted surgeries (SAS) for cranial expansion from a single institution are reported. The effect of number of procedures was also tested on hematocrit postoperative day 1 (POD1), anesthesia time, and surgery time of the first procedure. METHODS: The records of 100 consecutive patients undergoing SAS were reviewed. Anesthesia management and related complications are presented. Time series linear regression analysis was performed on hematocrit POD1, anesthesia time, and surgery time of the first procedure. RESULTS: The average age of the first insertion procedure was 4.4 and 9.0 months for the second removal procedure. Two patients were inadvertently extubated during positioning. Thirty-eight children had a decrease in blood pressure >20% from baseline. No child was admitted to the intensive care unit. No patient received any blood or blood product transfusion. Anesthesia time, surgery time, and hematocrit POD1 were correlated with procedure number or experience. CONCLUSIONS: Changes in anesthetic management resulted from changing the procedure. The reduction in volume resuscitation reduces the need for invasive monitoring. Facility and comfort with the surgical procedure increase with time and number of procedures performed. This experience further reduces blood loss and risk of transfusion.

Outcomes of immediate breast reconstruction in patients undergoing single-stage sentinel lymph node biopsy and mastectomy.

The ability to more definitively plan breast reconstruction after obtaining final histologic analysis of the sentinel lymph node biopsy (SLNB) has led several groups to advocate a staged approach to SLNB and mastectomy. Certain disadvantages are inherent in that approach, including increased patient morbidity, financial expense, and inconvenience. A retrospective review was conducted 195 procedures in which mastectomy and SLNB were performed in a single stage with immediate breast reconstruction (IBR) over a 10-year period. Long-term outcomes were analyzed within the context of patient characteristics and SLNB results. Intraoperative SLNB analysis was found to be a reliable method for planning IBR, as there were no patients noted to have untoward sequelae as a result of a false-negative SLNB, and the probability of postmastectomy radiation therapy was predictable based on the intraoperative SLNB results. We advocate that SLNB be performed in a single stage with mastectomy and IBR.

Subatmospheric pressure therapy: basic science review.

Subatmospheric pressure (SAP) therapy has evolved as a mainstay in the treatment of acute and chronic wounds over the past 20 years. The significant improvement in wound healing upon application of a SAP therapy system such as the Vacuum Assisted Closure (V.A.C.; KCI, San Antonio, TX) device, historically has been related to general principles such as edema reduction, bacterial clearance, and increased perfusion to the wound bed. Recent investigations have also indicated that microdeformation and regulation of biochemical mediator expression play a role in the improved outcomes seen with SAP therapy. Future studies will pursue further the mechanisms by which SAP functions to render such impressive results in wound healing.

Impact of sentinel lymph node biopsy on immediate breast reconstruction after mastectomy.

Traditionally, sentinel lymph node biopsy (SLNB) is performed at the time of mastectomy and reconstruction. However, several groups have advocated SLNB as a separate outpatient procedure before mastectomy, when immediate reconstruction is planned, to allow for complete pathologic evaluation. The purpose of this study was to determine the impact of intraoperative analysis of SLNB on the reconstructive plan when performed at the same time as definitive surgery. A retrospective review was conducted of all mastectomy cases performed at a single institution between September 1998 and November 2007. Of the 747 mastectomy cases reviewed, SLNB was conducted in 344 cases, and there was immediate breast reconstruction in 193 of those cases. There were 27 (7.8%) false negative and three (0.9%) false positive intraoperative analysis of SLNB. Touch preparation analysis from the SLNB changed the reconstructive plan in four (2.1%) cases. In our experience, SLNB can be performed at the time of mastectomy with minimal impact on the reconstructive plan. A staged approach incurs significant additional expense, increases the delay in initiation of systemic therapy and the propensity of procedure-related morbidity; therefore, SLNB should not be performed as a separate procedure before definitive surgery with immediate breast reconstruction.