A novel simulation module for segmental mandibulectomy and mandible reconstruction using 3D models.

INTRODUCTION: Mandibular resection and reconstruction are common but complex procedures in head and neck surgery. Resection with adequate margins is critical to the success of the procedure but technical training is restricted to real case experience. Here we describe our experience in the development and evaluation of a mandibular resection and reconstruction simulation module. METHODS: 3D printed (3DP) models of a mandible with a pathologic lesion were developed from imaging data from a patient with an ameloblastoma. During an educational conference, otolaryngology trainees participated in a simulation in which they reviewed a CT scan of the pathologic mandible and then planned their osteotomies before and after handling a 3DP model demonstrating the lesion. The adequacy of the osteotomy margins was assessed and components of the simulation were rated by participants with pre- and post-training surveys. RESULTS: 52 participants met criteria. After reviewing the CT scan, 34 participants (65.3 %) proposed osteotomies clear of the lesion. This proportion improved to 48 (92.3 %, p = 0.001) after handling the 3D model. Among those with initially adequate margins (n = 33), 45.5 % decreased their margins closer to the ideal, 27.2 % made no revision, 21.2 % widened their margins. 92 % of participants found the simulation beneficial for surgical planning and technical training. After the exercise, the majority of participants had increased confidence in conceptualizing the boundaries of the lesion (69.2 %) and their abilities to ablate (76.5 %). CONCLUSIONS: The structured mandibulectomy simulation using 3DP models was useful in the development of trainee experience in segmental mandible resection. LAY SUMMARY: This study presents the first mandibulectomy simulation module for trainees with the use of 3DP models. The use of a 3DP model was also shown to improve the quality of surgical training.

Effect of Smoking History on 30-Day Morbidity Following Bariatric Surgery.

INTRODUCTION: Smoking and postoperative complications are well documented across surgical specialties. Preoperative smoking cessation is frequently recommended by surgeons. In this study, we assessed to what degree documented smoking history increased a patient's risk of postoperative complications. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for the years 2015-2018 was used. Patients were included if they underwent primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (LRYGB). Patients with a documented smoking history were assigned to the "SH" cohort and patients without smoking history were assigned to the "NSH" cohort. Patients without documentation regarding smoking history, missing variables, younger than 18, with prior surgery, or lost to follow-up were excluded. 30-day morbidity and mortality data were assessed. Multiple logistic regression analysis was made based on all available patient characteristics and perioperative factors, continuous variables were analyzed using Student's t-test and categorical variables were compared using the chi-square test. RESULTS: After evaluation of 760,076 patients on the MBSAQIP database, 650,930 patients underwent non-revisional bariatric surgery, including 466,270 SG and 184,660 LRYGB. Of the total patients included in the study, 44,606 patients were assigned to the SH cohort and 479,601 were assigned to the NSH cohort. 4628 of patients did not have documented smoking status. Within 30 days SH patients had higher rates of readmission (4.2% vs 3.7%, P < .0001), reoperation (1.3% vs 1.1%, P < .0001), unplanned intubation (.2% vs .1%, P = .0212), and unplanned ICU admission (.7% vs .0.6%, P = .0022). CONCLUSION: SH patients undergoing bariatric surgery were at significantly increased risk of readmission and reoperation within 30 days of procedure. In addition, SH patients were more likely to have unplanned intubation and unplanned ICU admission. Given the higher rates of complications in smoking patients, this study would suggest that preoperative smoking cessation in patients prior to primary bariatric surgery might be beneficial. Further study is warranted to compare short-term cessation vs long-term cessation preoperatively, which was not assessed in our study.

Initial Experience Using 3-Dimensional Printed Models for Head and Neck Reconstruction in Haiti.

This report describes the first use of a novel workflow for in-house computer-aided design (CAD) for application in a resource-limited surgical outreach setting. Preoperative computed tomography imaging obtained locally in Haiti was used to produce rapid-prototyped 3-dimensional (3D) mandibular models for 2 patients with large ameloblastomas. Models were used for patient consent, surgical education, and surgical planning. Computer-aided design and 3D models have the potential to significantly aid the process of complex surgery in the outreach setting by aiding in surgical consent and education, in addition to expected surgical applications of improved anatomic reconstruction.

3D printed temporal bone as a tool for otologic surgery simulation.

PURPOSE: In this face validity study, we discuss the fabrication and utility of an affordable, computed tomography (CT)-based, anatomy-accurate, 3-dimensional (3D) printed temporal bone models for junior otolaryngology resident training. MATERIALS AND METHODS: After IRB exemption, patient CT scans were anonymized and downloaded as Digital Imaging and Communications in Medicine (DICOM) files to prepare for conversion. These files were converted to stereolithography format for 3D printing. Important soft tissue structures were identified and labeled to be printed in a separate color than bone. Models were printed using a desktop 3D printer (Ultimaker 3 Extended, Ultimaker BV, Netherlands) and polylactic acid (PLA) filament. 10 junior residents with no previous drilling experience participated in the study. Each resident was asked to drill a simple mastoidectomy on both a cadaveric and 3D printed temporal bone. Following their experience, they were asked to complete a Likert questionnaire. RESULTS: The final result was an anatomically accurate (XYZ accuracy = 12.5, 12.5, 5 µm) 3D model of a temporal bone that was deemed to be appropriate in tactile feedback using the surgical drill. The total cost of the material required to fabricate the model was approximately $1.50. Participants found the 3D models overall to be similar to cadaveric temporal bones, particularly in overall value and safety. CONCLUSIONS: 3D printed temporal bone models can be used as an affordable and inexhaustible alternative, or supplement, to traditional cadaveric surgical simulation.

Quality improvement in tracheostomy care: A multidisciplinary approach to standardizing tracheostomy care to reduce complications.

PURPOSE: Develop a model for quality improvement in tracheostomy care and decrease tracheostomy-related complications. METHODS: This study was a prospective quality improvement project at an academic tertiary care hospital. A multidisciplinary team was assembled to create institutional guidelines for clinical care during the pre-operative, intra-operative, and post-operative periods. Baseline data was compiled by retrospective chart review of 160 patients, and prospective tracking of select points over 8 months in 73 patients allowed for analysis of complications and clinical parameters. RESULTS: Implementation of a quality improvement team was successful in creating guidelines, setting baseline parameters, and tracking data with run charts. Comparison of pre- and post-guideline data showed a trend toward decreased rate of major complications from 4.38% to 2.74% (p = 0.096). Variables including time to tracheotomy for prolonged intubation, surgical technique, day of first tracheostomy tube change, and specialty performing surgery did not show increased risk of complications. There were increased tracheostomy-related complications in cold months (p = 0.04). CONCLUSIONS: An interdisciplinary quality improvement team can improve tracheostomy care by identifying system factors, standardizing care among specialties, and providing continuous monitoring of select data points.

Changes in the jugular bulb associated with sacrifice of the internal jugular vein.

OBJECTIVE: To determine whether sacrifice of the internal jugular vein (IJV) causes subsequent changes in the jugular bulb. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Patients were selected by CPT code for neck dissection and were included in the study if they had undergone unilateral neck dissection and had preoperative and postoperative computed tomographic scans through the temporal bone. INTERVENTIONS: The jugular bulb was measured in the axial plane for anteroposterior and mediolateral diameters. MAIN OUTCOME MEASURES: Cross-sectional area of the jugular bulb was calculated, and comparison was made between preoperative and postoperative studies in patients with or without ligation of the IJV. RESULTS: After unilateral neck dissection, the mean change in the size of the jugular bulb ipsilateral to surgery with sacrifice of the IJV was found to be -10.4 mm (95% confidence interval [95% CI], ± 8.54 mm); ipsilateral to surgery without sacrifice of the internal jugular, -0.2 mm (95% CI, ± 3.24 mm); contralateral to surgery with sacrifice of the IJV, +1.9 mm (95% CI, ± 11.12 mm); and contralateral to surgery without sacrifice of the IJVa, +1.0 mm (95% CI, ± 2.66 mm). Analysis of variance demonstrated a significant difference for changes in the jugular bulb area ipsilateral to surgery with sacrifice of the IJV (p = 0.03) when compared with contralateral to surgery without sacrifice of the IJV. CONCLUSION: Changes in size of the jugular bulb occur with surgical manipulation of the jugular vein. This study demonstrates a decrease in the size of the jugular bulb with ipsilateral IJV sacrifice.

Lack of effect of stimulant combination with second-generation antipsychotics on weight gain, metabolic changes, prolactin levels, and sedation in youth with clinically relevant aggression or oppositionality.

BACKGROUND: Second-generation antipsychotics (SGAs) are associated with weight gain, metabolic abnormalities, sedation/sleep disturbance, and prolactin abnormalities, especially in youths. Although stimulants have opposing dopamine receptor and adverse effects, it is unclear whether stimulant co-treatment counteracts the therapeutic or side effects of antipsychotics. METHODS: This was a naturalistic cohort study including 153 antipsychotic trials in youths aged 4-19 (mean, 11.3 +/- 3.0) years, started on an SGA for clinically significant aggression or oppositionality associated with oppositional defiant disorder, conduct disorder, disruptive behavior disorder not otherwise specified (NOS), impulse control disorder NOS, intermittent explosive disorder, Tourette's disorder, autistic disorder, and pervasive developmental disorder NOS. Patients underwent fasting assessments of body composition, lipids, glucose, insulin, prolactin, sedation, and general efficacy at baseline, weeks 4, 8, and 12, comparing patients co-prescribed stimulants (n = 71) with those not co-prescribed stimulants (n = 82). RESULTS: Patients received risperidone (33.3%), aripiprazole (29.4%), quetiapine (18.4%), olanzapine (11.8%), ziprasidone (5.9%), or clozapine (0.7%). With and without adjustment for differences in baseline variables (sex, prior stimulant use, primary Diagnostic and Statistical Manual of Mental Disorders, 4(th) edition [DSM-IV] disorders, co-morbid attention-deficit/hyperactivity disorder [ADHD], present in 46.3% of youths not receiving stimulants, and some body composition parameters), patients on versus off stimulants did not differ on any of the assessed outcomes (all p values > or = 0.1). CONCLUSIONS: In contrast to guidelines, stimulant use did not precede or accompany antipsychotic use during the current episode of aggression/oppositionality in almost half of those youths who had aggressive/oppositional behavior and a DSM-IV diagnosis of ADHD. At the clinically prescribed doses, stimulant co-treatment of SGAs did not seem to significantly reduce antipsychotic effects on body composition, metabolic parameters, prolactin, sedation, and broad efficacy.

Laparoscopic vs open gastric bypass in the management of morbid obesity: a 7-year retrospective study of 1,364 patients from a single center.

METHODS: We performed a retrospective analysis of 1,364 consecutive morbidly obese patients who underwent restrictive-malabsorptive Roux-en-Y gastric bypass (RYGBP) between January 1998 and December 2004. A selective use of open and laparoscopic approaches was employed since 2001. Patients were seen in the office at 1 week; 2, 3, 6, 9, 12, and 24 months; and yearly thereafter. During visits, each patient was weighed and dietary intake and exercise regimen were recorded. RESULTS: We report a sustained weight reduction in over 90% of patients. The anastomotic leak rate was 0.15%, the 30-day readmission rate was 1.17%, and the overall mortality rate was 0.15%. Minor surgical site infection rate was 0.5%, and revision to long limb RYGBP rate was 0.07%. CONCLUSIONS: Morbid obesity represents a significant health issue. None of the medical methods of weight reduction provide a lasting weight reduction. Surgery offers the only achievable long-term solution. Although not yet universally employed, laparoscopic RYGBP is rapidly becoming the standard operation for the surgical treatment of clinically severe obesity.

Antiperistaltic (retrograde) intussusception after Roux-en-Y gastric bypass.

Adult intussusception has been described after various types of gastrointestinal surgery. In some instances there may be intussusception of the jejunum into the stomach via a gastrointestinal stoma, a rare complication known as jejunogastric intussusception (JGI). We present a retrospective review of two cases of retrograde intussusception occurring years after open Roux-en-Y gastric bypass (RYGB) for morbid obesity. To our knowledge there have been no documented reports of JGI occurring after RYGB and only scattered reports of JGI after Roux-en-Y reconstruction in general. Two reports of intussusception following RYGB were identified in the English literature and comprised three patients, only one of whom suffered a retrograde intussusception. As the number of RYGB procedures continues to rise, we will likely see more of this entity; and it is therefore crucial that surgeons consider acute and chronic intussusception as a cause of abdominal pain in patients who have undergone RYGB.

A study of discrimination within the medical community as viewed by obese patients.

BACKGROUND: Although prejudice may not be verbal in nature, the lack of response from professional and non-professional medical personnel regarding the obese patients' needs (medical equipment, comfortable surroundings, properly fitting attire, etc.), leads one to assume that obese patients continue to be a target of unfavorable opinion. METHODS: 200 patients from four busy east coast bariatric practices received detailed surveys requesting information regarding experiences incurred during the entire peri-operative period. The responses were blinded as to patient or site of surgery. Patients were questioned about attitudes of primary care and consulting physicians and staff, all hospital and outpatient departments, and patient care areas within the hospital. The appropriateness of equipment was also questioned. RESULTS: There were 40 respondents aged 44.7 years (range 21-61 years); 34 were women. Average preoperative weight was 145 kg (range 101.8-231.8 kg). Average weight loss at time of survey was 42.8 kg; average time after surgery was 9.5 months. Responses concerning physician attitudes were similar through all patient groups. There was no difference in degree of discrimination felt by the lightest or the heaviest of the morbidly obese. 7 patients (17%) changed primary care physicians due to a perceived indifference, lack of concern, or negative attitude toward bariatric surgery. The procedure-oriented physicians (orthopedic surgeons and gastroenterologists) were most supportive, while social workers and psychologists scored lowest. Most hospital departments treated patients well, except those with equipment that may be affected by increased patient weight (e.g. treadmills and x-ray tables). CONCLUSION: Patients undergoing bariatric surgery continue to feel misunderstood and mistreated by medical and non-medical personnel involved in the treatment of their obesity. Like other forms of prejudice, this most likely is due to a lack of understanding of the disease of morbid obesity, the root causes and the medical consequences if untreated. Despite laws designed to prevent discrimination based on appearance, unfavorable attitudes and practices persist. A plan for continued education of the medical and non-medical communities is essential to breakdown the barriers in place due to ignorance and indifference. Patient support groups continue to play an important role in the ongoing battle to correct the negative effect of these attitudes on the morbidly obese patient.