Lateral geniculate artery pseudoaneurysm after arthroscopic medial meniscectomy.

Vascular complications after arthroscopy are rare and generally present as transient paresthesia most likely due to nervous injury or vasospasm. Rare cases of genicular artery injuries can occur and generally involve the medial genicular artery due to proximity to the right arthroscopic knee hook. This case, however, represents a rare lateral inferior genicular artery injury resulting in a symptomatic pseudoaneurysm. In addition, during the workup, the best visualization of the pseudoaneurysm was possible using duplex ultrasound. The diagnostic information seen on ultrasound was paramount and superseded the findings from conventional angiography and computed tomography angiography, both of which were nonspecific. In brief, this case not only highlights a rare surgical complication but also emphasizes the importance of duplex ultrasound compared with angiography and computed tomography in the workup of pseudoaneurysms.

The Cost of Being a Woman in Academic Cardiothoracic Surgery: Joint Collaboration of The Society of Thoracic Surgeons Workforces on Diversity, Equity, and Inclusion and Cardiothoracic Surgery Practice Models.

BACKGROUND: Gender disparity in the cardiothoracic surgery workforce is challenging to enumerate and quantify. The purpose of our work is to use the most current data to quantify the percentage of women in academic cardiothoracic surgery and salary disparity between women and men. METHODS: We performed a cross-sectional analysis of data collected by the Accreditation Council for Graduate Medical Education Data Resource Book 2021 and Association of American Medical Colleges Faculty Data for U.S. Medical School Faculty 2019, 2020, and 2021. We used descriptive analysis of the number of faculty and mean salaries of academic cardiothoracic surgeons according to academic rank and gender. Salary disparity in cardiothoracic surgery was compared with salary disparities seen among surgical specialties and academic clinicians. RESULTS: Over the past 3 years, women comprised 11.5% of the cardiothoracic workforce. In 2021, cardiothoracic surgeons who were women earned $0.71 to $0.86 for every $1.00 earned by cardiothoracic surgeons who were men. Ascending academic rank correlated with greater gender salary disparity; women professors earned less than men of equal and lower academic rank. From 2019 to 2021, women of the academic ranks of associate professor, professor, and chief of cardiothoracic surgery experienced a decrease in mean salaries, whereas men of equivalent academic ranks experienced an increase in mean salaries. CONCLUSIONS: Gender disparity in cardiothoracic surgery persists, with low representation of women and salary disparity at every academic rank.

Multiple Internal Hernias: A Complication of Laparoscopic Roux-en-Y Gastric Bypass.

Introduction: Internal hernias are the most common cause of small bowel obstruction following laparoscopic Roux-en-Y gastric bypass surgery (LRYGBP) with four distinct types. Herein, we report the clinical course of a patient with two independent hernias at the Petersen's space and a rarer subtype at the jejunojejunal window. A high index of suspicion for less common subtypes of internal hernias and the possibility of multiple, simultaneous internal hernias is critical. Case Description: We describe the case of a 52-year-old female with a history of LRYGBP who presented with abdominal pain and emesis due to an internal hernia at Peterson's defect, requiring subsequent laparoscopic repair. On postoperative day three, the patient presented again with recurrent abdominal pain and emesis. Repeat exploratory laparoscopy found a separate internal hernia involving the jejunojejunal window with the previously repaired Petersen's defect intact. Discussion: This case illustrates a unique scenario of a patient post-LRYGBP with multiple internal hernias at the Peterson's space and the less common jejunojejunal window, which was missed during the index surgery. Failure to identify simultaneous hernias may result in additional invasive intervention and further morbidity. Conclusion: Multiple less-common variants of internal hernias may present simultaneously following LRYGBP.

The Scan, the Needle, or the Knife? National Trends in Diagnosing Stage I Lung Cancer.

OBJECTIVE: Indeterminate lung nodules have been increasingly discovered since the expansion of lung cancer screening programs. The diagnostic approach for suspicious nodules varies based on institutional resources and preferences. The aim of this study is to analyze factors associated with diagnostic modalities used for early-stage non-small cell lung cancer (NSCLC). METHODS: The National Cancer Database was queried for all patients with stage I NSCLC from 2004 to 2015. Four diagnostic modalities were identified, including clinical radiography alone (CRA), bronchial cytology (BC), procedural biopsy (PB), and surgical biopsy (SB). A multivariable multinomial logistic regression was used to assess associations of patient demographics, cancer characteristics, and facility characteristics with these modalities. RESULTS: Of 250,614 patients, 4,233 (1.7%) had CRA, 5,226 (2.1%) had BC, 147,621 (59.9%) had PB, and 93,534 (37.3%) had SB. Older patients were more likely to receive CRA (adjusted odds ratio [ORadj] = 5.3) and less likely to receive SB (ORadj = 0.73). Black patients were less likely to receive SB (ORadj = 0.83) and more likely to receive BC (ORadj = 1.31). Private insurance was associated with SB (ORadj = 1.11), whereas Medicaid was associated with BC (ORadj = 1.21). Patients more than 50 miles from the facility were more likely to undergo SB (ORadj = 1.25 vs PB; ORadj = 1.30 vs CRA; ORadj = 1.38 vs BC). Patients receiving SB had shorter days from diagnosis to treatment (23.0 vs 53.5 to 64.7 for other modalities, P < 0.001). CONCLUSIONS: Diagnostic SB to confirm early-stage NSCLC was associated with younger age, greater travel distance, and shorter time to treatment in comparison with other modalities. Black race and non-private insurance were less likely to be associated with SB.

Challenges in the Methodology for Health Disparities Research in Thoracic Surgery.

Research on health disparities in thoracic surgery is based on large population-based studies, which is associated with certain biases. Several methodological challenges are associated with these biases and warrant review and attention. The lack of standardized definitions in health disparities research requires clarification for study design strategy. Further inconsistencies remain when considering data sources and collection methods. These inconsistencies pose challenges for accurate and standardized downstream data analysis and interpretation. These sources of bias should be considered when establishing the infrastructure of health disparities research in thoracic surgery, which is in its infancy and requires further development.

Power of the collective: A review of multimodal internet-based surgical education resources in the 21st century.

Electronic resources have changed surgical education in the 21st century. Resources spanning from digital textbooks to multiple choice question banks, online society meetings, and social media can facilitate surgical education. The COVID pandemic drastically changed the paradigm for education. The ramifications of Zoom lectures and online surgical society meetings will last into the future. Educators and learners can be empowered by the many available electronic resources to enhance surgical training and education.

Integrating Endovascular and Operative Intervention in Trauma.

BACKGROUND: Patterns of utilization of the hybrid operating room (hybrid-OR) in trauma have not been described. The aim of this study was to describe the sequencing and integration of endovascular and operative interventions in trauma using a hybrid-OR. MATERIALS AND METHODS: This is a single-center, retrospective cohort study of trauma patients who underwent both endovascular and operative intervention (2013-2019). Patients were separated into four groups based on procedure patterns: concomitant-linked (C-L), concomitant-independent, serial-linked (S-L) and serial-independent (S-I). The groups were defined as follows: C-L - related endovascular and operative interventions in the same OR; concomitant-independent - unrelated interventions in the same OR; S-L - related interventions in separate ORs; S-I - unrelated interventions in separate ORs. Patient characteristics, procedures performed and time to angiography in each group were analyzed. RESULTS: Out of 202 patients, most procedures utilizing the hybrid-OR were for hemorrhage control (84.1%) and were performed in a C-L manner (36.1%). Patients in the C-L group were most likely to undergo lower extremity revascularization and received the most transfusions. Patients in the S-L and S-I groups were more severely injured, had greater severe abdominal injury and were more likely to undergo damage control surgery and solid organ interventions, respectively. The C-L group had the highest percentage of patients to undergo angiography within 12 h (77%, P = 0.053). CONCLUSION: The hybrid-OR is an ideal space for hemorrhage control in trauma, but there is room for improvement in the triage of patients with non-compressible torso hemorrhage. Current practice patterns prioritize the hybrid-OR for management of lower extremity injury and are not optimal. Use of the hybrid-OR could be improved by concomitant management of patients with severe abdominal injury requiring damage control surgery.

Certification in endovascular hemostasis for trauma surgeons: Possible and practical?

BACKGROUND: Endovascular hemostasis is commonplace with many practitioners providing services. Accruing sufficient experience during training could allow acute care surgeons (ACSs) to expand their practice. We quantified case load and training opportunities at our center, where dedicated dual-trained ACS/vascular surgery faculty perform these cases. Our aim was to assess whether ACS fellows could obtain sufficient experience in 6 months of their fellowship in order to certify in these techniques, per the requirements of other specialties. METHODS: We performed a retrospective case series where we reviewed 6 years (2013-2018) of endovascular activity at an academic, level I trauma center quantifying arterial access, angiography, embolization, stent and stent graft placement, and IVC filter procedures. This was compared with the certification requirements for interventional radiology, vascular surgery, cardiothoracic surgery, and interventional cardiology. RESULTS: Between 2013 and 2018, 1,179 patients with a mean ± SD Injury Severity Score of 22.47 ± 13.24, underwent 4960 procedures. Annual rates per procedure, expressed as median (interquartile range), were arterial access 193.5 (181-195.5), diagnostic angiography 352 (321.5-364.5), embolization 90.5 (89.25-93.25), stent placement 24 (13.5-29.25), and IVC filter procedures 16.5 (10-23.75). Our 6-month case volume exceeded or was within 85% of the required number of cases for vascular surgery and interventional radiology training, with the exception of stent-graft deployment for both specialties, and therapeutic procedures for vascular surgery. CONCLUSION: The case volume at a large trauma center with a dedicated endovascular trauma service is sufficient to satisfy the case requirements for endovascular certification. Our trainees are already acquiring this experience informally. An endovascular trauma curriculum should now be developed to support certification within ACS fellowship training.

Outcomes following abdominal trauma in Scotland.

PURPOSE: Traumatic abdominal injury is associated with significant mortality, especially in hemodynamically unstable patients. Trauma management now supports more conservative surgical management with judicious non-operative management. The aim of this study is to use STAG data to characterize abdominal trauma outcomes, focusing on factors that may influence mortality. METHODS: A retrospective analysis of prospectively collected STAG data was queried using AIS codes for Scottish abdominal trauma patients between 2011 and 2015. Patients were divided into non-survivor and survivor groups, reflecting mortality. Following this, outcomes and injury patterns of patients undergoing operative or non-operative management were compared between groups. RESULTS: A total of 1226 were analyzed. The mean age of the cohort was 42.47 ± 19.42 years, with most patients suffering blunt injuries. Non-survivors had more severe injuries to the liver, diaphragm, pancreas, vasculature, and pelvis (p < 0.001, p = 0.005, p = 0.025, p < 0.001, and p < 0.001, respectively). Survivors more often received CT scanning (0.09 [0.03-0.27]) and underwent surgical intervention (57.4% vs 39.7%; p = 0.001). Non-survivors more often had a shorter time till operative intervention (2.6 h vs 6.3 h, p < 0.001). CONCLUSIONS: About 7% of patients in the STAG registry display abdominal injury. Mortality was found to have strong associations with older age, hemodynamic instability, poor neurological status, and head and neck injury. Outcomes may improve with the anticipated creation of the Scottish Trauma System.

Marijuana use does not affect the outcomes of bariatric surgery.

BACKGROUND: The decriminalization of marijuana and legalization of derived products requires investigation of their effect on healthcare-related outcomes. Unfortunately, little data are available on the impact of marijuana use on surgical outcomes. We aimed to determine the effect of marijuana use on 30-day complications and 1-year weight loss following laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). METHODS: At a large academic center, 1176 consecutive patients undergoing primary bariatric surgery from 2012 to 2017 were identified and separated into cohorts according to marijuana use. The only exclusions were 19 patients lost to follow-up. Propensity score matching, using logistic regression according to preoperative age, gender, BMI, and comorbid conditions, yielded 73 patient pairs for the control and study arms. All patients were followed two years postoperatively. RESULTS: Excess BMI lost did not differ between marijuana users and controls at 3 weeks (23.0% vs 18.9%, p = 0.095), 3 months (42.0% vs 38.1%, p = 0.416), 6 months (60.6% vs 63.1%, p = 0.631), 1 year (78.2% vs 77.3%, p = 0.789), or 2 years (89.1% vs 74.5%, p = 0.604). No differences in the rate of major 30-day postoperative complications, including readmission, infection, thromboembolic events, bleeding events and reoperation rates, were found between groups. Follow-up rate at two years was lower in marijuana users (12.3% vs 27.4%, p = 0.023). CONCLUSION: This study suggests marijuana use has no impact on 30-day complications or weight loss following bariatric surgery, and should not be a contraindication to bariatric surgery.

Radial versus femoral arterial access for trauma endovascular interventions: A noninferiority study.

BACKGROUND: The majority of endovascular interventions for trauma are performed using transfemoral access (TFA). Transradial access (TRA) is a recently integrated alternative at the authors' institution. This noninferiority study compares the technical success and complication rate of TRA compared with TFA. METHODS: All patients undergoing emergent endovascular interventions between March 2016 and March 2019 were identified from a prospectively maintained database. Data were collected on access type, complications, and procedural success. A noninferiority margin was established from previous randomized trials for technical success (0.475) and complications (0.015). RESULTS: Over 3 years, 96 patients underwent TRA and 335 patients received TFA. The overall technical success rate was 98.1%, without significance based on access strategy (p = 0.078). All femoral arteries and 97.9% (n = 94) of radial arteries were accessed as intended. Complications occurred in 1.0% of TRA and 9.9% of TFA groups (p = 0.002). In the TFA group, complications included access site bleeding, hematoma, pseudoaneurysm, lower limb ischemia, and femoral artery thrombosis (n = 6, 14, 3, 3, and 4, respectively). In the TRA group, complications included radial artery thrombosis (n = 1). Transradial access procedural success and complication rate fell within the lower bound confidence interval of the noninferiority margin, demonstrated the noninferiority of TRA in this data set. CONCLUSION: Transradial access in a cohort of trauma patients undergoing endovascular intervention does not appear to be inferior to TFA in relation to technical success and complications. For patients where groin access may be challenging, TRA is a useful, efficacious, and safe alternative. Longer-term study is required to fully characterize the advantages and disadvantages of TRA compared with TFA. LEVEL OF EVIDENCE: Therapeutic V.

Preoperative Opioid Prescription Patients Do Not Suffer Distinct Outcomes After Bariatric Surgery: a Matched Analysis of Outcomes.

PURPOSE: While over 200 million opioid prescriptions are written annually for chronic pain in the USA, little has been written on the impact of opioids on bariatric surgery, specifically on the effects of prescription opioid use on weight loss post laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS: We completed a matched-cohort, retrospective review in 1176 consecutive patients undergoing primary bariatric surgery at a single institution. Patients were grouped into chronic prescription opioid users (POU), defined as ongoing opioid use for > 3 months at the time of surgery, and opioid-naïve controls (CON), defined as no opioid use prior to surgery. About 130 POU and 130 CON patients were then matched according to preoperative comorbid conditions and demographics. RESULTS: Percent total weight loss was similar at 3 weeks, 3 months, 6 months, 1 year, and 2 years in POU and CON-9.6 ± 5.8 vs 8.9 ± 4.5 (p = 0.057), 18.4 ± 7.2 vs 18.5 ± 7.2% (p = 0.901), 28.0 ± 9.4 vs 27.9 ± 12.9% (p = 0.894), 30.3 ± 13.0 vs 32.8 ± 9.0% (p = 0.387), and 31.4 ± 12.7 vs 36.9 ± 21.3% (p = 0.369), respectively. The 30-day readmission, reoperation, venothrombotic event rate, bleeding rate, and infection rate were similar in POU compared to CON patients. CONCLUSIONS: Complications and weight loss outcomes are similar for prescription opioid users compared to opioid-naïve controls following bariatric surgery. Chronic prescription opioid use is not a contraindication to bariatric surgery.

Improving the safety of resuscitative endovascular balloon occlusion of the aorta - Compliant versus semi-compliant balloon systems.

OBJECTIVES: Resuscitative endovascular balloon occlusion of the aorta is an alternative to resuscitative thoracotomy in non-compressible torso haemorrhage. Low-profile, compliant balloon catheter systems have been developed, which can be deployed without the need for fluoroscopy. However, concern exists for over inflation and aortic injury, especially as compliant balloon material can stretch reducing syringe feedback and limiting the effectiveness of a safety valve. An alternative material would be a semi-compliant balloon material, but its performance is unknown. The aim of this study was to compare the inflation characteristics of compliant versus semi-compliant balloon systems and to determine whether a pressure relief safety valve can be practically applied to a semi-compliant balloon catheter as a safety device. METHODS: This was an ex vivo study using porcine segments of thoracic aorta. The study consisted of two phases. The first phase involved intermittent inflation of six compliant balloon and six semi-compliant balloon balloons until balloon or aortic rupture. In the second phase, six semi-compliant balloons with the pressure-relief valve set at 0.45 atmospheres were inflated in the aortas until the valve release, followed by injection with additional 30 mL. Data including pressure, volume, balloon working length, diameter and circumferential stretch ratio were collected. RESULTS: At failure, mean balloon volume was almost double in compliant balloon group vs semi-compliant balloon group - 49.83 mL (±23.25) and 25.16 mL (±8.93), respectively (p = 0.004), with 36% increase in working length in the compliant balloon group - 81.17 mm (±19.11) vs 59.49 (±4.86) for semi-compliant balloon (p = 0.023). When plotted, the relationship pattern between volume and pressure fit a linear model for the compliant balloon, and a quadratic model for the semi-compliant balloon. Following attempted over inflation with the pressure valve, there was no change in parameters before and after attempted over inflation. CONCLUSIONS: The inflation profile differs between balloon designs. In contrast to semi-compliant balloons, compliant balloons will accommodate more volume to mitigate increase in pressure. This does not completely eliminate the risk of over inflation. The inflation characteristics of the semi-compliant balloon permit pairing it with a safety valve, which could lead to a development of a safer balloon technology in the future.

Safety and efficacy of radial access in trauma in 65 trauma endovascular cases.

OBJECTIVE: Endovascular techniques in trauma surgery are becoming increasingly important in patient management, with procedures such as pelvic and splenic angioembolization becoming the standard of care for certain injuries. Traditionally, such interventions are performed via femoral access, although the morbidity of this approach is not insignificant (3%-10%). Transradial access (TRA) is an attractive alternative, pioneered by cardiologists, with low rates of access site complications in patients undergoing coronary intervention. Recently, this technology has extended to other interventions. The aim of this study was to present the initial experience of a radial program in a busy trauma center, with specific regard to safety and complications. METHODS: The medical records of trauma patients undergoing endovascular procedures via TRA between March 2018 and December 2018 were queried for procedural and postoperative data. Demography and injury characteristics were presented for the overall cohort, followed by a comparison of procedural data and complications between laterality. Continuous variables were compared using a two-tailed t-test and categorical variables were compared using a χ2 test. RESULTS: Over a 9-month period, 65 patients underwent 81 interventions via TRA, most commonly solid organ or pelvic angiography/embolization. Radial artery access was achieved in all patients, with procedural success achieved in all but two patients (n = 63 [96.9%]) who had hypoplastic radial artery anatomy, who underwent ulnar access. The overall technique-related complication rate was 1.5% with no difference observed between laterality (n = 1; P = .523). One patient with an admission Glasgow Coma Score of 3 and coagulopathy developed radial artery thrombosis after pelvic angiography via right TRA. Mortality was seen in seven patients (10.8%) owing to hemorrhagic shock (n = 3 [42.8%]) or multiorgan failure (n = 4 [57.1%]). There were no cases of postprocedural access site bleeding, hematoma, pseudoaneurysm, vascular injury, intraoperative arrhythmia or cerebrovascular accident, arteriovenous fistula formation, or infection. CONCLUSIONS: TRA is a feasible and low-risk alternative for endovascular intervention in the trauma patient. It yields good technical success with low morbidity. Although larger studies are needed to establish the full efficacy of TRA at the multi-institutional level, this single-institution study demonstrates the legitimacy of an alternative means for endovascular intervention in the trauma patient.

A Comparison of Transradial and Transfemoral Access for Splenic Angio-Embolisation in Trauma: A Single Centre Experience.

OBJECTIVE: The study compared transradial access (TRA) and transfemoral access (TFA) for splenic angio-embolisation (SAE), with a focus on technical success, intra-operative adjuncts, and complications. METHODS: This was a retrospective comparative study of all trauma patients undergoing SAE by TRA or TFA between February 2015 and February 2019 at a single institution. The medical records were queried for procedural and post-operative data, with comparisons made based on access site. Continuous variables were compared using a two tailed t test and categorical variables were compared using a chi square test. RESULTS: Over a four year period, there were 47 cases of SAE via TRA and 127 via TFA. Technical success was 95.7% during TRA and 98.4% during TFA (p = .30). Technical failures were a result of failed splenic artery cannulation after successful radial or femoral access. Time to splenic cannulation was shorter in the TRA group (19 min vs. 30 min; p = .008). Two or fewer catheters were used during TRA, whereas more than two catheters were needed during TFA (p < .001). There were no statistically significant differences in procedure length, fluoroscopy time, radiation dose, or contrast volume between groups. Nine patients (5.2%) developed access related complications, all in the TFA group (p = .12). Mortality rate was 2.3% (n = 4), with no statistical significance between groups (p = .71). CONCLUSION: While TFA is the conventional strategy for SAE, TRA is a safe and efficacious modality for SAE in trauma patients. Although larger studies are needed to establish the full efficacy of TRA for SAE at the multi-institutional level, this single centre study demonstrates the legitimacy of an alternative means for SAE in the trauma population.

A Surgical Endovascular Trauma Service Increases Case Volume and Decreases Time to Hemostasis.

OBJECTIVES: The aim of this study was to evaluate the effect of a recently active endovascular trauma service (ETS) on case volume and time to hemostasis, as a complement to an existing interventional radiology (IR) service. SUMMARY BACKGROUND DATA: Endovascular techniques are vital for trauma care, but timely access can be a challenge. There is a paucity of data on the effect of a multispecialty team for delivery of endovascular hemorrhage control. METHODS: The electronic medical record of trauma patients undergoing endovascular procedures between 2013 and 2018 was queried for provider type (IR or ETS). Case volume and rates were expressed per 100 monthly admissions, normalizing for seasonal variation. Interrupted time series analysis was used to model the case rate pre- and post-introduction of the ETS. Admission-to-procedure-time data were collected for pelvic angioembolization as a marker of patients requiring emergency hemostasis. RESULTS: During 6 years, 1274 admission episodes required endovascular interventions. Overall case volume increased from 2.7 to 3.6 at a rate of 0.006 (P = 0.734) after introduction of the ETS. IR case volume decreased from 3.3 to 2.6 at a rate of 0.03 (P = 0.063). ETS case volume increased at a rate of 0.048 (P < 0.001), which was significantly different from the IR trend (P < 0.001). Median (interquartile range) time-to-procedure (hours) was significantly shorter for pelvic angioembolization [3.0 (4.4) vs 4.3 (3.6); P < 0.001] when ETS was compared to IR. CONCLUSION: A surgical ETS increases case volume and decreases time to hemostasis for trauma patients requiring time sensitive interventions. Further work is required to assess patient outcome following this change.

Infection after penetrating brain injury-An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15-19, 2019, in Austin, Texas.

BACKGROUND: Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis. METHODS: Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ and Wilcoxon's rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center. RESULTS: Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = <0.001) and in patients with surgical intervention (10% vs. 3%; p < 0.001). CONCLUSION: There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use. LEVEL OF EVIDENCE: Therapeutic, level IV.

Comparison of a novel, endoscopic chest tube insertion technique versus the standard, open technique performed by novice users in a human cadaver model: a randomized, crossover, assessor-blinded study.

BACKGROUND: The technique of tube thoracostomy has been standardized for years without significant updates. Alternative procedural methods may be beneficial in certain prehospital and inpatient environments with limited resources. We sought to compare the efficacy of chest tube insertion using a novel, endoscopic device (The Reactor™) to standard, open tube thoracostomy. METHODS: Novice users were randomly assigned to pre-specified sequences of six chest tube insertions performed on a human cadaver model in a crossover design, alternating between the Reactor™ and standard technique. All subjects received standardized training in both procedures prior to randomization. Insertion site, which was randomly assigned within each cadaver's hemithorax, was marked by the investigators; study techniques began with skin incision and ended with tube insertion. Adequacy of tube placement (intrapleural, unkinked, not in fissure) and incision length were recorded by investigators blinded to procedural technique. Insertion time and user-rated difficulty were documented in an unblinded fashion. After completing the study, participants rated various aspects of use of the Reactor™ compared to the standard technique in a survey evaluation. RESULTS: Sixteen subjects were enrolled (7 medical students, 9 paramedics) and performed 92 chest tube insertions (n = 46 Reactor™, n = 46 standard). The Reactor™ was associated with less frequent appropriate tube positioning (41.3% vs. 73.9%, P = 0.0029), a faster median insertion time (47.3 s, interquartile range 38-63.1 vs. 76.9 s, interquartile range 55.3-106.9, P < 0.0001) and shorter median incision length (28 mm, interquartile range 23-30 vs. 32 mm, interquartile range 26-40, P = 0.0034) compared to the standard technique. Using a 10-point Likert scale (1-easiest, 10-hardest) participants rated the ease of use of the Reactor™ no different from the standard method (3.8 ± 1.9 vs. 4.7 ± 1.9, P = 0.024). The Reactor™ received generally favorable scores for all parameters on the post-participation survey. CONCLUSIONS: In this randomized, assessor-blinded, crossover human cadaver study, chest tube insertion using the Reactor™ device resulted in faster insertion time and shorter incision length, but less frequent appropriate tube placement compared with the standard technique. Additional studies are needed to evaluate the efficacy, safety and potential advantages of this novel device.