Microwave Ablation as Bridging Therapy for Patients with Hepatocellular Carcinoma Awaiting Liver Transplant: A Single Center Experience.

PURPOSE: To determine the pathologic response of computed tomography-guided percutaneous microwave ablation as bridging therapy for patients with hepatocellular carcinoma awaiting liver transplant, and its subsequent effect on survival. MATERIALS AND METHODS: A single-center retrospective analysis was conducted on 62 patients (M:F = 50:12) with mean age of 59.6 years ± 7.2 months (SD). Sixty-four total MWA procedures were performed for hepatocellular carcinomas within Milan criteria as bridging therapy to subsequent orthotopic liver transplant between August 2014 and September 2018. The pathology reports of the explanted livers were reviewed to assess for residual disease. Residual disease was categorized as complete or incomplete necrosis. Patient demographics, tumor/procedural characteristics, and laboratory values were evaluated. Survival from time of ablation and time of transplantation were recorded and compared between cohorts using log rank tests. RESULTS: The mean tumor size was 2.4 cm ± 0.7 cm (SD), (range = 1-4.6 cm). 32 (50%) cases required hydrodissection. Histopathologic necrosis was seen in 66% of cases at time of liver transplantation. Median time to liver transplant post-MWA was 12.6 months. [IQR = 8.6-14.8 months]. The median survival from ablation was 60.8 months [IQR = 45.5-73.7 months], and the median survival from transplant was 49.3 months [IQR = 33.7-60.1 months]. There was no significant difference in survival for patients with complete versus incomplete necrosis from ablation or liver transplant (p = 0.49, p = 0.46, respectively). CONCLUSIONS: Computed tomography-guided percutaneous microwave ablation is an effective bridge to orthotopic liver transplantation for patients with hepatocellular carcinoma. CEBM LEVEL OF EVIDENCE: Level 3, non-randomized controlled cohort study/follow-up study.

Primary Versus Revision Discectomy for Adults With Herniated Nucleus Pulposus: A Propensity Score-Matched Multicenter Study.

STUDY DESIGN: Retrospective propensity score matched analysis. OBJECTIVE: To compare the incidence of any 30-day perioperative complication following primary and revision discectomy for lumbar disc herniation. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was used to identify patients undergoing primary or revision lumbar discectomy from 2005 to 2012. Propensity score matching was performed to create matched pairs of primary and revision discectomy cases for analysis. Univariate analysis was then performed to compare 30-day morbidity and mortality between propensity score-matched pairs. RESULTS: We identified 4730 cases of primary discectomy performed through a minimally invasive or open approach and 649 revision discectomy cases. Baseline patient characteristics and comorbidities were compared and then propensity score-matched adjustments were made to create 649 matched pairs of primary and revision cases. On univariate analysis, there were no significant differences in 30-day perioperative outcomes between the 2 groups. CONCLUSION: While there were no significant differences in 30-day perioperative complications between patients undergoing primary lumbar discectomy and those undergoing revision lumbar discectomy, this finding should be interpreted with caution since the ACS-NSQIP database lacks functional and pain outcomes, and also does not include dural tear or durotomy as a complication. Future large-scale and long-term prospective studies including these variables are needed to better understand the outcomes and complications following primary versus revision discectomy for lumbar disc herniation.

Patient Factors Contributing to Prolonged Postoperative Length of Stay and Increased Rate of Readmission After Elective Posterior Cervical Fusion.

STUDY DESIGN: This is retrospective study of prospectively collected data. OBJECTIVE: To identify patient factors that are independently associated with prolonged length of stay (LOS) and readmission after posterior cervical fusion (PCF) utilizing a large national database. SUMMARY OF BACKGROUND DATA: A number of studies have investigated the morbidity and mortality after PCF; however, little is known about the factors that are associated with prolonged LOS and readmission, both of which incur increased costs for patients and hospitals. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2014. Current Procedural Terminology code 22600 was used to identify patients who underwent PCF. All patient factors were assessed for association with LOS and readmission rate using bivariate and multivariate logistic regressions. RESULTS: A total of 2667 patients who underwent PCF met the inclusion criteria for LOS analysis. Average (±SD) LOS was 3.92 (±3.24) days, and median LOS was 3 days (interquartile range, 2-5 d). On multivariate analysis, increased LOS was found to be significantly associated with dependent functional status (P<0.001), diabetes mellitus (P=0.021), preoperative anemia (P=0.001), American Society of Anesthesiologists class 3 or 4 (P<0.001), and number of fused levels (P<0.001). A total of 2591 patients met criteria (LOS≤11 d) for analysis of readmission. Readmission rate among these patients was 7.1%. Average (±SD) LOS of the patients not readmitted within 30 days of operation was 3.89 (±3.25), whereas the average (±SD) LOS of the patients readmitted was 4.24 (±3.08). On multivariate analysis, readmission was found to be significantly associated with only dependent functional status (P=0.019) and increased number of fused levels (P=0.032). CONCLUSIONS: The current study provides valuable information on patient factors that are associated with prolonged LOS and readmission, which would be useful in enhanced informed consent before surgery, surgical planning, discharge planning, and optimizing postoperative care. LEVEL OF EVIDENCE: Level III.

Implementation of remote video auditing with feedback and compliance for manual-cleaning protocols of endoscopic retrograde cholangiopancreatography endoscopes.

A pilot initiative to assess the use of remote video auditing in monitoring compliance with manual-cleaning protocols for endoscopic retrograde cholangiopancreatography (ERCP) endoscopes was performed. Compliance with manual-cleaning steps following the initiation of feedback was measured. A video feed of the ERCP reprocessing room was provided to remote auditors who scored items of an ERCP endoscope manual-cleaning checklist. Compliance feedback was provided in the form of reports and reeducation. Outcomes were reported as checklist compliance. The use of remote video auditing to document manual processing is a feasible approach and feedback and reeducation increased manual-cleaning compliance from 53.1% (95% confidence interval, 34.7-71.6) to 98.9% (95.0% confidence interval, 98.1-99.6).

Remote video auditing with real-time feedback in an academic surgical suite improves safety and efficiency metrics: a cluster randomised study.

IMPORTANCE: Compliance with the surgical safety checklist during operative procedures has been shown to reduce inhospital mortality and complications but proper execution by the surgical team remains elusive. OBJECTIVE: We evaluated the impact of remote video auditing with real-time provider feedback on checklist compliance during sign-in, time-out and sign-out and case turnover times. DESIGN, SETTING: Prospective, cluster randomised study in a 23-operating room (OR) suite. PARTICIPANTS: Surgeons, anaesthesia providers, nurses and support staff. EXPOSURE: ORs were randomised to receive, or not receive, real-time feedback on safety checklist compliance and efficiency metrics via display boards and text messages, followed by a period during which all ORs received feedback. MAIN OUTCOMES AND MEASURES: Checklist compliance (Pass/Fail) during sign-in, time-out and sign-out demonstrated by (1) use of checklist, (2) team attentiveness, (3) required duration, (4) proper sequence and duration of case turnover times. RESULTS: Sign-in, time-out and sign-out PASS rates increased from 25%, 16% and 32% during baseline phase (n=1886) to 64%, 84% and 68% for feedback ORs versus 40%, 77% and 51% for no-feedback ORs (p<0.004) during the intervention phase (n=2693). Pass rates were 91%, 95% and 84% during the all-feedback phase (n=2001). For scheduled cases (n=1406, 71%), feedback reduced mean turnover times by 14% (41.4 min vs 48.1 min, p<0.004), and the improvement was sustained during the all-feedback period. Feedback had no effect on turnover time for unscheduled cases (n=587, 29%). CONCLUSIONS AND RELEVANCE: Our data indicate that remote video auditing with feedback improves surgical safety checklist compliance for all cases, and turnover time for scheduled cases, but not for unscheduled cases.

Our experience with two cardioplegic solutions: dextrose versus non-dextrose in adult cardiac surgery.

Intraoperative hyperglycemia has been observed to be associated with increased morbidity and mortality after cardiac surgery. Dextrose cardioplegia is used for its cardioprotective effects but may lead to intraoperative hyperglycemia and more postoperative complications. This was a retrospective observational study. Patient records (n = 2301) were accessed from a large database at a tertiary care facility. The two groups (dextrose vs. nondextrose) were then matched using preoperative variables of age, sex, body mass index, wound exposure time, preoperative HbA1c levels, renal failure, hypertension, and prior cerebrovascular disease. The following outcomes were recorded: 30-day mortality, sternal wound infection, stroke, and highest glucose level on cardiopulmonary bypass. The dextrose cardioplegia group showed statistically higher intraoperative glucose levels (272.76 +/- 55.92 vs. 182.79 +/- 45, p value = .0001). There was no difference in postoperative mortality, sternal wound infections or stroke incidence, nor in other secondary outcomes. The type of cardioplegia solution was shown to affect glucose levels; however, there was no effect on postoperative complication rates.

Multiple cervical levels: increased risk of dysphagia and dysphonia during anterior cervical discectomy.

BACKGROUND: Anterior cervical discectomy (ACD) is widely used for symptomatic cervical spine pathologies. The most common complications associated with this type of surgery are dysphagia and dysphonia; however, the risk factors associated with them have not been adequately elucidated. The purpose of this study is to assess the incidence of self-reported dysphagia and dysphonia and the associated risk factors after ACD. METHODS: This study used a retrospective chart review of 149 patients who underwent ACD at a tertiary care facility operating in the New York metropolitan area over a period of 2½ years. Charts for ACD patients were reviewed by 6 trained researchers. Incidence rates for self-reported dysphagia and dysphonia were calculated using 95% exact confidence intervals (CI). Risk factors such as age, sex, surgical hours, number of disc levels, airway class, American Society of Anesthesiologists class, fiberoptic intubation, and intubation difficulty were assessed using logistic regression. RESULTS: The incidence of self-reported dysphagia was 12.1% (95% exact CI, 7.3%-18.4%); for dysphonia the self-reported incidence was 5.4% (95% exact CI, 2.3%-10.3%). Patients who underwent surgery at ≥4 cervical levels had a significant 4-fold increased risk (odds ratio=4; 95% CI, 1.1-13.8) of developing dysphonia and/or dysphagia compared with patients who underwent surgery at a single surgical level. CONCLUSIONS: This study confirms previous findings that the risk of developing dysphagia and/or dysphonia increases with the number of surgical levels, with multiple cervical levels representing a significantly higher postoperative risk, as compared with surgery at 1 level.