Surgical outcomes and complications of bedside tracheostomy in the ICU for patients on ECMO.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) is increasingly employed in the management of patients with severe cardiac and pulmonary dysfunction. Patients commonly require tracheostomy for ventilator liberation. Though bedside percutaneous tracheostomy is commonly performed, it has the potential for increased complications, both surgical and with the ECMO circuit. We examined surgical outcomes of bedside percutaneous tracheostomy in the ECMO population. METHODS: Patients were identified from an institutional database for bedside procedures. Demographics and data on complications were recorded. Descriptive statistics were calculated. RESULTS: 37 patients on ECMO at the time of tracheostomy were identified. Median age and BMI were 43.2 and 28.0, respectively. 33 patients (89%) were on VV ECMO, and 4 (11%) were on VA ECMO. All were on anticoagulation prior to tracheostomy, which was held for 4 h before and after the procedure in all cases. There were no procedure-related deaths or airway losses. No patients experienced periprocedural clotting events of their ECMO circuit or oxygenator within 24 h. 3 patients (8%) required reintervention (re-exploration or bronchoscopy) for bleeding. Four other patients (10%) had minor bleeding controlled with packing. One patient had pneumomediastinum which resolved without intervention, and one had an occlusion of their tracheostomy which was treated with tracheostomy exchange. CONCLUSIONS: Bedside percutaneous tracheostomy is feasible for patients on ECMO. Further study is needed to determine specific risk factors for complications and means to mitigate these. Bedside percutaneous tracheostomy may be considered as part of the management of patients on ECMO to help facilitate liberation from mechanical support.

Current Perceptions of the Aesthetically Ideal Position and Size of the Male Nipple-Areola Complex.

BACKGROUND: The dimensions of the nipple-areola complex (NAC) and its location on the chest wall are important aesthetic factors in male breast surgery. OBJECTIVES: This study examines the perceptions of aesthetic surgeons and the general population for the aesthetically ideal position and size of male NAC. METHODS: An online survey was distributed to the American Society for Aesthetic Plastic Surgery (ASAPS) members and to the general population. Parameters queried included demographics for all participants and academic details for ASAPS members. Both surveys included a male model picture with 16 separate choices for the NAC position from a frontal view, 5 choices for the NAC position from a lateral view, and 6 choices for the NAC dimensions. For all 3 sets of images, the participants were asked to rank the top 3 images they considered most "aesthetically pleasing" in descending order. A weighted scoring rule was created to quantitatively evaluate image choices. Standard statistical methods were employed for analysis. RESULTS: The survey was completed by 272 ASAPS members and 4909 participants from the general population. The top 3 choices for NAC location on frontal view were the same for ASAPS members and the general population. The most popular NAC location on lateral view was the same for both groups, but the preferred locations differed between the 2 groups for the second and third choices. The most popular dimensions of the NAC were 2 cm (vertical) × 3 cm (horizontal) followed by 2 cm × 2 cm for both groups. Comparison of the 3 top image choices scores between different ethnic groups and individuals with different gender or sexual orientation demonstrated similar trends. CONCLUSIONS: This survey identified the preferred position and dimensions of the NAC on the male breast for plastic surgeons and the general population. These parameters should be considered when counseling males undergoing breast surgery.

Implementation of a Trauma Quality Improvement Program Communications Package Decreases Time-to-Operation for Facial Trauma.

INTRODUCTION: Facial trauma is common and carries significant morbidity and cost. Suboptimal interdisciplinary communication is associated with negative health outcomes. This study evaluates the clinical impact of implementation of American College of Surgeons Trauma Quality Improvement Program (TQIP) interdisciplinary communication guidelines between facial surgery and trauma teams. METHODS: Patients with facial trauma presenting to our level 1 trauma center between May and December 2017 were included (N = 812) and split into 3 groups, each anonymously representing a service that treats facial trauma. Services 1 and 2 were controls, and service 3 adopted TQIP communication guidelines. Mean and slope of time-to-operation (TTO) and mean length of stay were assessed 106 days before (n = 95) and 107 days after (n = 77) implementation. RESULTS: For service 3, mean TTO decreased significantly from 6.2 to 2.9 days (P = 0.005) after implementation of the communication intervention. There was no significant difference in mean TTO preimplementation versus postimplementation in either control cohort, including service 1 (4.6 vs 4.9 days; P = 0.59) and service 2 (4.2 vs 4.5 days; P = 0.62). Average length of stay did not differ significantly between the preintervention versus postintervention in any service (service 1: 9.0 vs 8.3 days, P = 0.43; service 2: 4.6 vs 6.6 days, P = 0.85; service 3: 6.7 vs 6.4 days, P = 0.45). CONCLUSION: Our study demonstrates that cost-free TQIP-guided improvement in interdisciplinary communication between the trauma service and a consulting surgical specialist decreases TTO for patients with operative facial trauma. Health care providers should develop strong well-defined communication channels between collaborating teams involved in patient care to optimize patient clinical outcomes.

Acute Effects of Systemic Glucocorticoids on the Vocal Folds in a Pre-Clinical Model.

OBJECTIVES/HYPOTHESIS: Systemic glucocorticoids (GC)s are employed to treat various voice disorders. However, GCs have varying pharmacodynamic properties with adverse effects ranging from changes in epithelial integrity, skeletal muscle catabolism, and altered body weight. We sought to characterize the acute temporal effects of systemic dexamethasone and methylprednisolone on vocal fold (VF) epithelial glucocorticoid receptor (GR) nuclear translocation, epithelial tight junction (ZO-1) expression, thyroarytenoid (TA) muscle fiber morphology, and body weight using an established pre-clinical model. We hypothesized dexamethasone and methylprednisolone will elicit changes in VF epithelial GR nuclear translocation, epithelial ZO-1 expression, TA muscle morphology, and body weight compared to placebo-treated controls. METHODS: Forty-five New Zealand white rabbits received intramuscular injections of methylprednisolone (4.5 mg; n = 15), dexamethasone (450 µg; n = 15), or volume matched saline (n = 15) into the iliocostalis/longissimus muscle for 6 consecutive days. Vocal folds from 5 rabbits from each treatment group were harvested at 1-, 3-, or 7 days following the final injection and subjected to immunohistochemistry for ZO-1 and GR as well as TA muscle fiber cross-sectional area (CSA) measures. RESULTS: Dexamethasone increased epithelial GR nuclear translocation and ZO-1 expression 1-day following injections compared to methylprednisolone (P = .024; P = .012). Dexamethasone and methylprednisolone increased TA CSA 1-day following injections (P = .011). Methylprednisolone decreased body weight 7 days following injections compared to controls (P = .004). CONCLUSIONS: Systemic dexamethasone may more efficiently activate GR in the VF epithelium with a lower risk of body weight loss, suggesting a role for more refined approaches to GC selection for laryngeal pathology.

Evaluating hip disarticulation outcomes in a 51-patient series.

Background: Hip disarticulations are proximal lower extremity amputations with high postoperative complication and mortality rates. The purpose of the study was to evaluate hip disarticulation outcomes at our institution. Targeted Muscle Reinnervation (TMR) is an effective surgical technique shown to reduce pain in amputees. A secondary goal of the study was to evaluate the impact of implementing TMR on this patient population. Methods: A retrospective review was performed for patients who underwent hip disarticulation with and without TMR between 2009 and 2020. Information on one-year mortality, thirty-day complication rates, operation times, surgical charges, and pain scores was collected. Results: Fifty-one patients underwent hip disarticulation, eight of which had TMR performed at the time of their hip disarticulation. The one-year mortality rate was 37% with 30-day infection, readmission, reoperation, and rates of 37%, 39%, and 27% respectively. The thirty-day major complication rate was 47% overall but not statistically significantly different between groups. There were no differences between groups with regard to 30-day readmission, reoperation, and infection rates. Conclusions: Our results represent one of the largest series of hip disarticulation outcomes. Performing TMR at the time of hip disarticulation did not negatively affect outcomes and may be a beneficial adjunct to improve pain. Further research is warranted.

The complex relationship between estrogen and migraines: a scoping review.

BACKGROUND: Migraines are a chronic disease for millions worldwide and have been hypothesized to be hormonally mediated due to their higher prevalence in females and menstrual associations. Estrogen has been commonly implicated in migraine pathogenesis, yet its exact role in the pathophysiology of migraines has yet to be fully understood. METHOD: We conducted a scoping review of the literature regarding estrogen's role in migraine pathogenesis and included 19 studies out of an initial 202 in the final review. Two independent reviewers screened and extracted data from included studies based on predetermined inclusions and exclusion criteria. RESULTS: The estrogen withdrawal hypothesis, discussed by 12 of the reviewed studies, is the most discussed theory about estrogen's role in migraine physiology and describes the association of migraine onset with natural declines in estrogen levels, particularly when estrogen levels fall below 45-50 pg/mL after an extended period of priming. Additional findings suggest that women with a history of migraine have an increased sensitivity to physiologic fluctuations in estradiol levels. Several studies suggest that migraines are associated with menstruation. CONCLUSION: It appears that estrogen is very likely to play a key role in migraine pathogenesis, but seems to affect patients in different ways depending on their past medical history, age, and use of hormonal therapy. Further research is warranted to isolate the effects of estrogen in each unique patient population, and we believe that studies comparing menstruating women to postmenopausal women could help shed light in this area.

Strategies for Mesh Fixation in Abdominal Wall Reconstruction: Concepts and Techniques.

SUMMARY: Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.

No-Touch Technique of Mesh Placement in Ventral Hernia Repair: Minimizing Postoperative Mesh Infections.

Synthetic mesh is commonly used in ventral hernia repairs to reinforce the abdominal closure and minimize hernia recurrence rates. However, the use of synthetic mesh is associated with certain risks, most notably infection requiring explantation. This study sought to evaluate the use of a "no-touch" technique with antibiotic solution during synthetic mesh placement in ventral hernia repairs and its impact on complication/infection rates. The authors retrospectively reviewed a prospectively maintained database of patients undergoing abdominal wall reconstruction with synthetic mesh from 2013 to 2018 by a single surgeon with a minimum 1-year follow-up. Data collected included demographic data, medical comorbidities, hernia history, and the type of antibiotics used in the no-touch technique. Complications were stratified into short-term (<30 days), medium-term (30 to 90 days), and long-term (91 to 365 days) complications. Results were compared to previously published rates in the literature. Eighty-eight patients met inclusion criteria. Fourteen patients (15.9 percent) experienced postoperative complications (two patients had multiple complications); six of these patients (6.8 percent) were readmitted to the hospital for management. Subsequently, three of the readmitted patients (3.4 percent) required reoperations related to abdominal infection and required removal of the synthetic mesh. A total of 16 complication events occurred in the cohort: 13 short-term complications (81.3 percent), three medium-term complications (18.7 percent), and zero long-term complications. The authors conclude that the no-touch technique for mesh placement in ventral hernia repairs appears to be efficacious in minimizing infectious complications with mesh placement, although further prospective studies are required to further define this relationship. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Improving Strength and Quality of Epitendinous Repairs.

Background: Epitendinous sutures not only join the 2 severed tendon edges but also supply strength and support to the repair. Multiple techniques have been described, but none of them include another thread of suture. This could potentially increase the strength of the repair without affecting gliding. Methods: Caprine tendons were harvested, transected, and sutured with 6-0 Prolene. Four groups were created: single thread running (SR), single thread locking (SL), double thread running (DR), and double thread locking (DL). An Instron 5542 was used to pull the repaired tendons apart, and the energy at the break was calculated (gf/mm). For gliding resistance, we harvested a human A2 pulley. A pre- and postrepair value was obtained, and a ratio was elaborated. A single-factor analysis of variance and independent sample t tests were performed. Results: The SR group had a mean energy at break of 9339.71 ± 1630.212 gf/mm; the SL group, 9629.96 ± 1476.45 gf/mm; and the DR group, 9600.221 ± 976.087 gf/mm, with no statistical significance. The DL group was significantly higher at 14 740.664 ± 2596.586 gf/mm (P < .05). When comparing SR with DL for gliding, SR had less than half of the resistance than DL (0.018 ± 0.004 and 0.049 ± 0.015 N/mm, respectively), with statistical significance (P < .05). Conclusion: Using a single suture thread for running epitendinous repair is no different than locking with a single thread or using an extra thread in a running fashion. Performing a double suture thread with a locking technique is significantly stronger than the previously mentioned repairs, with the disadvantage of more resistance at the pulley.

Advantages of a Fixation-Free Technique for Open Retromuscular Ventral Hernia Repair.

BACKGROUND: In open retromuscular ventral hernia repair, fixation-free mesh placement is increasingly prevalent and may minimize pain; the main concern with this technique is short-term technical failure and hernia recurrence. This study compared outcomes following mechanical mesh fixation (i.e., sutures, staples, tacks) versus fixation-free mesh placement. METHODS: Adults who underwent open, elective, retromuscular ventral hernia repair of 15 cm width or less with permanent synthetic mesh placement in a clean wound were identified. Propensity score matching was used to compare patients who received mechanical mesh fixation to those who received fixation-free mesh placement. Thirty-day hernia recurrence was the primary outcome, with secondary outcomes of 30-day hospital length of stay and 30-day rates of readmission, reoperation, wound events, pain, and abdominal wall function. One- and 2-year composite recurrence and 3-year cumulative composite recurrence were also evaluated. RESULTS: A 3:1 propensity score match was performed on 299 fixation-free patients identifying 897 mechanical fixation patients, with a mean body mass index of 31 kg/m and mean age of 57.5 years. There was no difference in 30-day recurrence between mechanical and fixation-free approaches (0.2 percent versus 0 percent; p = 1). Median length of stay was longer for mechanical fixation (4 versus 3 days; p = 0.002). In the mechanical fixation group, pain scores were higher (worse pain, 46 versus 44; p = 0.001), and abdominal wall function scores were lower (worse function, 47 versus 60; p = 0.003), with no differences in rates of hospital readmission, reoperation, or wound events. There were no differences in long-term outcomes of 1- and 2-year composite recurrence, or 3-year cumulative composite recurrence. CONCLUSION: For short-term technical durability, fixation-free mesh placement in open retromuscular ventral hernia repair is an acceptable alternative to mechanical fixation for hernia defects of 15 cm or less. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cost-Utility Analysis of Biologic and Biosynthetic Mesh in Ventral Hernia Repair: When Are They Worth It?

BACKGROUND: Biologic and biosynthetic meshes typically cost more than synthetic meshes for use in ventral hernia repair (VHR), with unknown comparative effectiveness. STUDY DESIGN: Cost-utility analysis was performed from a limited societal perspective assessing direct medical costs and outcomes for open, elective, retromuscular VHR. Short-term and 5-year major complications and costs were modeled using best available evidence from published studies, Healthcare Cost and Utilization Project data, and Americas Hernia Society Quality Collaborative data. Costs were analyzed in 2017 US dollars, and utilities were assessed using quality adjusted life years (QALYs). Sensitivity analyses were performed to determine threshold probabilities of long-term complications favoring particular mesh types. RESULTS: Synthetic mesh was the preferred strategy, with a cost of $15,620 and QALYs of 18.85, assuming a baseline 5.6% rate of long-term complications for all meshes. One-way sensitivity analysis demonstrated that biosynthetic and biologic mesh became the better choice as long-term complication rates for synthetic mesh increased to 15.5% and 26.2%, respectively. Two-way sensitivity analysis demonstrated that biologic and biosynthetic meshes became favorable as the cost of biologic mesh decreased and long-term synthetic mesh complication rates increased. Biologic and biosynthetic meshes also became more cost-effective when their relative long-term complication rates decreased and long-term synthetic mesh complication rates increased. CONCLUSIONS: Using modeling techniques, synthetic mesh is the best option for retromuscular VHR given currently available evidence. We established long-term complication thresholds, possibly justifying the higher up-front costs for biologic or biosynthetic meshes. This emphasizes the critical need to obtain long-term complication surveillance data to help individualize mesh choice in VHR.