Automated Titanium Fasteners Versus Hand-Tied Knots: A Randomized Controlled Trial.

BACKGROUND: The relative benefits of automated titanium fasteners (LSI Solutions, Victor, NY) have not been examined in patients undergoing sternotomy. The aim of this study was to assess the time and cost required for suture fixation with the automated device versus conventional hand tying in sternotomy for mitral or tricuspid ring annuloplasty. METHODS: Fifty patients scheduled to undergo primary mitral or tricuspid, or both, ring annuloplasty-based valve repair operation by a single surgeon were randomly assigned to receive either conventional hand-tied knots or automated titanium fasteners, with 25 patients in each group. The primary outcome variable was the time required to affix the annuloplasty device to the valve annulus. RESULTS: The times taken to affix a mitral annuloplasty band or ring were 6.1 ± 0.9 min for manual tying versus 3.1 ± 0.4 min for automated fasteners (p < 0.0001); when calculated per annuloplasty stitch, the values were 22 ± 2 s versus 12 ± 1.1 s, respectively (p < 0.0001). The corresponding values for tricuspid annuloplasty were 4.2 ± 1.2 min (hand tying) versus 2.2 ± 0.3 min (automated fasteners) (p = 0.0005), and the times for each suture were 20 ± 2.1 s versus 13 ± 2 s, respectively (p = 0.0004). The use of the automated fastener had no significant impact on aortic cross-clamp time or cardiopulmonary bypass duration. Total cost associated with annuloplasty fixation with automated titanium fasteners (device cost in addition to operating room time cost) was significantly higher than with hand tying ($1,190 ± 374 vs $164 ± 60; p < 0.0001). CONCLUSIONS: Using the automated fastener to facilitate annuloplasty fixation through a sternotomy resulted in a small procedural time savings (average of 10 s/stitch) that had no overall impact on cardiopulmonary bypass or cross-clamp times but added an average cost of $1,026 to the operation.

Importance of surgeon-performed ultrasound in the preoperative nodal assessment of patients with potential thyroid malignancy.

INTRODUCTION: A comprehensive cervical ultrasound evaluation is essential in the operative planning of patients with thyroid disease. Reliance on radiographic reports alone may result in incomplete operative management as pathologic lymph nodes are often not palpable and evaluation of the lateral neck is not routine. This study examined the role of surgeon-performed ultrasound in the evaluation of patients who underwent lateral neck dissection for thyroid cancer. METHODS: We conducted a retrospective review of a prospectively maintained database of patients who underwent therapeutic lymph node dissection for thyroid cancer between 2001 and 2016 at our tertiary referral center. All patients had surgeon-performed ultrasound preoperatively by 1 of 7 endocrine surgeons. These findings were compared with prereferral imaging studies to determine the value of surgeon-performed ultrasound to their overall treatment. RESULTS: Of 92 patients who underwent thyroidectomy with lateral neck dissection, 97% had prereferral imaging of the neck (ultrasonography, computed tomography, positron emission tomography). Of these patients, nodal disease was suggested by computed tomography scanning in 70.8% and by ultrasonography in 54%. Of all patients, 45% had positive lateral neck nodes detected only on surgeon-performed ultrasound despite prior neck imaging. Nodal disease was identified in 50% of patients with only 1 study and 50% of patients with greater than 1 study before surgeon-performed ultrasound. Of patients with nodes detected by surgeon-performed ultrasound, only 67% had a prereferral diagnosis of thyroid cancer. CONCLUSIONS: Our data demonstrate that reliance on standard preoperative imaging alone would have led to an incorrect initial operation in 45% of our patients. Awareness of the limitations of prereferral imaging is important for surgeons treating patients with thyroid and parathyroid disease. Surgeon-performed ultrasound is a useful tool in the diagnosis and accurate staging of patients.