A Cost-Effective Delivery System for FloSeal During Endoscopic and Microscopic Brain Surgery.

OBJECTIVE: To share our experience with a new delivery system for the flowable hemostatic matrix, FloSeal, in endoscopic and microscopic skull base surgery. METHODS: We prospectively analyzed the use of FloSeal with a hemostatic delivery system in transnasal endoscopic and microscopic skull base procedures performed at the authors' institution from January 1, 2015, to June 30, 2015. In all cases the number of aliquots was noted for the entire operation, and the total number of FloSeal ampules of 5 mL was also recorded. RESULTS: Our device allowed controlled application of small amounts (0.5-1 mL) of FloSeal to the site of bleeding. This controlled application resulted not only in increased visibility during its application, but it also reduced the amount of FloSeal required during the procedure. We were able to use 5-10 applications per 5-mL ampule of FloSeal within an individual procedure. No procedure required more than one 5-mL ampule of FloSeal. Therefore, the use of our device results in a reduction of costs. Prior to the use of our device, we were often only able to use 1 vial of 5 ml of material for 1 or 2 applications, especially in transnasal endoscopic procedures when working along a deep corridor. CONCLUSIONS: Our results indicate that our delivery device of FlowSeal can effectively control hemostasis by applying small amounts of FlowSeal to the site of bleeding. This results in increased visibility during hemostasis and a reduction of cost.

Comparative analysis of Cutanplast and Spongostan nasal packing after endoscopic sinus surgery: a prospective, randomized, multicenter study.

Commercial gelatin-based packing materials are available under different names and compositions to be used after endoscopic sinus surgery (ESS). The purpose of this study was to investigate the efficacy of Spongostan and Cutanplast nasal packing on patients' subjective symptoms, hemostasis, and wound healing following ESS. One hundred adult patients with chronic sinusitis requiring the same extent of ESS were included. Following surgery, one nasal cavity was packed with Cutanplast and the other one with Spongostan. Patients' subjective symptoms while the packing was in situ, hemostatic properties, degree of remaining amount of packing materials, postoperative wound healing, and the cost of the pack were evaluated. Cutanplast and Spongostan are equally effective in the control of postoperative bleeding following ESS. However, Cutanplast packing was significantly more comfortable than Spongostan for nasal obstruction, postnasal drip, rhinorrhea, and headache. Furthermore, the Cutanplast packing was significantly less painful at all time points. The remaining amount of the pack was significantly lower in the Cutanplast than Spongostan packing. Spongostan packing appears to impair wound healing within the sinus cavities up to 3 months postoperatively. Cutanplast was less expensive than Spongostan as used in this study. Cutanplast may be more useful gelatin-based packing material than Spongostan in terms of efficacy and cost-benefit after ESS.

Transcatheter arterial chemoembolization for hepatocellular carcinoma: prospective assessment of the right inferior phrenic artery with C-arm CT.

PURPOSE: To assess the usefulness of C-arm computed tomography (CT) of the right inferior phrenic artery (RIPA) in transcatheter arterial chemoembolization of patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: From December 2007 to April 2008, C-arm CT of the RIPA was prospectively performed in 32 patients with HCC. Two interventional radiologists who performed C-arm CT assessed the additional information provided with C-arm CT as grade 1 (no additional information), grade 2 (added information without an effect on the treatment plan), or grade 3 (added information with an effect on the treatment plan). Tumor feeders and feeders of a systemic-to-pulmonary shunt were recorded. RESULTS: The information provided by C-arm CT was classified as grade 1 for nine of the 32 patients (28%), grade 2 for 20 patients (63%), and grade 3 for three patients (9%). The most common additional information from C-arm CT scans of the RIPA was the differentiation between the tumor and the systemic-to-pulmonary shunt. A systemic-to-pulmonary shunt from the RIPA was observed in 22 patients (69%), and the most common feeder of a systemic-to-pulmonary shunt was the azygoesophageal branch. CONCLUSIONS: C-arm CT of the RIPA provides additional imaging information for the differentiation of a tumor from a nontumorous condition during chemoembolization for HCC with a suspected blood supply from an RIPA.

Cost-effectiveness of hepatic arterial chemoembolization for colorectal liver metastases refractory to systemic chemotherapy.

PURPOSE: To calculate the cost-effectiveness of hepatic arterial chemoembolization (HACE) for the treatment of colorectal liver metastases (CLM) over a range of survival benefits and to determine the survival benefit that HACE must confer to meet three thresholds of cost-effectiveness. MATERIALS AND METHODS: A spreadsheet model was used to estimate the marginal direct cost of HACE compared with palliative care from a payer's perspective. Medicare reimbursement amounts represented costs, while probabilities of reembolization and complications were obtained from records of patients who underwent HACE. Marginal cost-effectiveness was calculated from marginal direct cost by varying the survival benefit of HACE compared with palliative care from 0 to 24 months. Break-even analyses were conducted to determine the survival benefit at which the cost-effectiveness of HACE would decrease below three threshold values derived from a literature review. RESULTS: The marginal cost-effectiveness of HACE compared with palliative care, given survival benefits of 3, 6, and 12 months, was $82,385, $41,193, and $21,045 per life-year (LY) gained, respectively. Cost-effectiveness thresholds of $20,000 (strict), $50,000 (moderate), and $100,000 (generous) per LY gained required survival benefits of 12.63, 4.94, and 2.47 months, respectively, more than the expected baseline. CONCLUSION: The cost-effectiveness of HACE for the treatment of CLM varies considerably according to the anticipated survival benefit. Results of future randomized controlled trials must demonstrate a survival benefit of nearly 5 months for HACE to meet the moderate cost-effectiveness standard of $50,000 per LY gained.

Power Doppler sonography of hepatocellular carcinoma treated by transcatheter arterial chemoembolization. Assessment of the therapeutic effect.

PURPOSE: To evaluate the usefulness of power Doppler sonography (PDS) in assessing the therapeutic effect of transcatheter arterial chemoembolization (TACE) in hepatocellular carcinoma (HCC). MATERIAL AND METHODS: TACE was performed in 43 patients (48 lesions) with HCC. All patients were examined with both PDS and color Doppler sonography (CDS) to assess the therapeutic results 1 week after TACE. Follow-up hepatic angiography was performed in 39 patients 3-4 months after TACE and then CT after iodized oil reinjection was also performed 3-4 weeks after a repeat TACE; in the remaining 4 patients, hepatectomy was performed within one month after chemoembolization and histologic study was undertaken to confirm the Doppler findings. RESULTS: Determination of therapeutic results with PDS and CDS were in agreement with those of follow-up findings in 37 and 29 of the 48 lesions, respectively. There was a significant difference in overall accuracy (p=0.038) between PDS and CDS results. CONCLUSION: PDS is more effective than CDS for evaluating changes in tumor vascularity after TACE. PDS may also replace angiography in assessing the therapeutic effects of TACE for HCCs, except in deep-seated areas.

Cost reduction of skin biopsy and surgical instrumentation.

Saving the physicians time is very desirable in rendering first-rate dermatological service at lower cost. The aim is to reduce surgical instrumentation during skin biopsy procedures and follow-up visits. A combined instrument is used to obtain skin biopsies from 100 patients, and gelatin sponge plugs are used in hemostasis and to assist healing of the biopsy wound site. Skin biopsy samples are obtained simply and with ease, and, as the tissue sample is handled minimally, it appears to be more intact and less distorted in comparison to the usual procedure. Skin biopsy samples can be obtained with the combined instrument in a more cost-effective manner with savings of the physician's time and less instrumentation.