Postoperative management of Zenker's diverticulum: Results of the American Bronchoesophagological Association survey.

INTRODUCTION: Although treatment of Zenker's diverticulum (ZD) is commonly performed by otolaryngologists using a variety of surgical techniques, there is little published data on the postoperative management of patients. We sought to determine practice patterns among members of the American Bronchoesophagological Association (ABEA) after surgery for ZD. METHODS: An online questionnaire was designed via JotForm™ and subsequently sent to active members of the ABEA. Responses were analyzed using descriptive statistics. RESULTS: Twenty-three members (6.6 %) completed the survey. Most (73.9 %) were fellowship trained in laryngology and reported performing >5 procedures per year. Most laryngologists reported employing multiple techniques including transcervical (TC) (73.9 %), endoscopic stapling (ES) (65.2 %), endoscopic CO2 laser (EL) (56.5 %), and endoscopic harmonic scalpel (EH) (4.3 %). Postoperatively, 52.3 % of respondents placed patients in 23-hour observation after TC, 66.7 % after ES, 69.2 % after EL, and 100 % after EH. 47.1 % of respondents used standard overnight admission after TC, as compared to 13.3 % after ES, 23.1 % after EL and 0 % after EH. Postoperative esophagography was utilized by 70.6 % of respondents after TC, 20 % after ES, 38.5 % after EL, and 100 % after EH. A peroral diet was started postoperatively on the day of surgery by 26.7 % respondents after ES but not after any of the other techniques. CONCLUSION: Most laryngology trained respondents employ multiple techniques for the treatment of ZD including at least 1 endoscopic technique. Respondents were more likely to hospitalize patients after a transcervical than endoscopic approach. Postoperative esophagography was utilized in most patients after TC, but not after ES or EL. Most respondents admit patients for 23-hour observation and start a peroral diet on postoperative day 1 regardless of technique.

Comparative analysis of acute blood loss anemia in robotic assisted vs. manual instrumented total knee arthroplasty.

Introduction: Robotic assisted total knee arthroplasty has become an increasingly popular technique over the past several years. Manual total knee arthroplasty can be associated with acute blood loss anemia. Instrumentation of the femoral canal with the alignment guide may in part contribute to this blood loss. Because the femoral canal is not entered during robotic assisted total knee arthroplasty, the blood loss may be lower compared to that seen in manual total knee arthroplasty. The purpose of this study was to determine if acute blood loss is greater in manually instrumented total knee arthroplasty versus robotic assisted total knee arthroplasty. Materials and methods: This retrospective cohort study was performed in a large tertiary academic hospital network by two fellowship trained surgeons. Patients underwent either robotic assisted or manually instrumented total knee arthroplasty and were assessed for postoperative acute blood loss anemia, defined as hemoglobin <13 g/dL for males or <12 g/dL for females plus a 2 g/dL drop from preoperative levels, as well as postoperative drop in hemoglobin. Results: A total of 75 patients were included in each study arm. There was no significant difference (p > 0.05) in postoperative hemoglobin in robotic assisted (2.1 g/dL) compared to manually instrumented total knee arthroplasty (2.1 g/dL). There was no significant difference in the incidence of postoperative acute blood loss anemia between robotic assisted (45 %) and manually instrumented total knee arthroplasty (39 %). Higher BMI and increased age were protective against postoperative drop in hemoglobin. These protective effects were not significant when controlling for confounding variables. Surgical time was significantly longer for robotic assisted (99 min) versus manually instrumented total knee arthroplasty (86 min) (p < 0.001). Conclusions: There is no significant difference in acute blood loss when comparing patients undergoing robotic assisted and manually instrumented total knee arthroplasty.

Enhancing recovery and reducing readmissions: The impact of remote monitoring on acute postoperative care in outpatient total joint arthroplasty.

Introduction: Outpatient total joint arthroplasty (TJA) is gaining popularity in the United States. With a shift towards value-based healthcare and bundled payment models, the importance of safe discharge after TJA is pertinent in reducing readmissions and subsequent cost of care. However, many acute issues or complications may not occur until after discharge which can result in emergency department visits and readmission. Our study aims to characterize the effect of remote monitoring devices on acute postoperative recovery in TJA discharged within 24 h. We hypothesized there would be a decreased readmission rate in the remote home monitoring cohort. Methods: This prospective cohort compared 50 outpatient TJAs (primary total hip and total knee replacements) defined as discharged within 24 h with a remote home monitoring device to 50 outpatient TJAs who did not receive remote monitoring. Demographics, hospital length of stay, American Society of Anesthesiology scores, and Charlson Comorbidity Index were compared with no significant difference observed between cohorts (p > 0.05). Patients' vital signs were transmitted to a virtual response center for up to 48 h after discharge. An on-call medical team reviewed the transmissions and if prompted, would contact the patient to troubleshoot and triage. Primary outcome was 30-day hospital readmissions rates, while 30-day ED visits and patient satisfaction scores for the remote home monitoring were measured as secondary outcomes. Results: Within the remote monitoring cohort there was a 20 % incidence (10 patients) of abnormal vitals captured and 2 patients visited the ED, however there were no readmissions attributed to this group. Readmission rates and ED visits in the control non-monitored group were significantly higher at 12 % (p = 0.03), secondary to syncope, uncontrolled postoperative pain, cellulitis, hip dislocations, and postoperative fever. Of the patients who received remote monitoring, 14 % had trouble connecting the device to their smartphone, 44 % felt home monitoring helped in their care while recovering at home, 52 % made them feel safer, and 70 % would recommend this program. Conclusions: Remote home monitoring with a virtual response team after outpatient TJA is a feasible way to mitigate readmissions in the acute postoperative period and increase patient satisfaction. Efforts to minimize costs should not be implemented at the expense of patients' health outcomes with a goal to find an appropriate balance between both agendas. Level of evidence: Therapeutic Level III.

A Novel Adenoidectomy Training System.

OBJECTIVES/HYPOTHESIS: Young residents find mirror-guided adenoidectomy difficult. Inexperienced trainees must learn to focus a headlight beam, work upside-down and backward in a small space and thoroughly ablate adenoid tissue-all new skills. We present an adenoidectomy training system that is low-cost, easy to construct, and is focused on these basic adenoidectomy skills. STUDY DESIGN: Prospective experimental study. METHODS: This training suite includes three stations each targeting a different skill. The first employs a mannequin head with exposed nasopharynx. It trains the student to coordinate a headlight and mirror while touching a series of targets with a curved probe. At the second station participants electrodessicate (or microdebride) an anchored piece of veal thymus. The third station combines both sets of skills as participants ablate thymus in a simulated nasopharynx (30 mm rectangular aluminum tube) constrained within a Crow-Davis retractor, using a headlight, mirror, and suction electrosurgical electrode (or microdebrider). To evaluate the training system's efficacy, we assessed the performance of 10 surgically naïve medical student volunteers before and after 15 minutes of practice using a validated rating scale used for adenoidectomy. RESULTS: There was significant improvement in adenoidectomy skill scores after practicing. Overall scores were higher, time taken to touch a series of targets with a headlight and mirror was less and amount of tissue ablated at the final station was greater (P < .05). CONCLUSION: This novel adenoidectomy training system is inexpensive and easy to build. Practice with the model resulted in statistically significant improvement in adenoidectomy skill scores for inexperienced student surgeons. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2056-2062, 2022.

Collagen matrix as a replacement for Gelfilm® for post-tympanostomy tube myringoplasty.

OBJECTIVE: Gelfilm® is no longer available for use in myringoplasty. We have substituted a commercially available collagen matrix (Biodesign® Otologic Repair Graft) for Gelfilm® as on onlay patch after removal of retained tympanostomy tubes. We compare the effectiveness of these two materials for post-tympanostomy tube myringoplasty. METHODS: Surgeries were performed in the same manner by residents supervised by the same surgeon during consecutive time periods. Tympanostomy tubes were removed under general anesthesia using a pick and cup forceps. Margins of the resultant perforation were rimmed and a patch placed on the lateral surface of the drum to cover the perforation. Children were seen at 4 weeks after surgery. Tympanic membrane closure was assessed by otoscopy and tympanometry. Patient age at time of myringoplasty, laterality (right/left/bilateral), and presence or absence of a persistent perforation at one month follow-up were tabulated. Total duration of tympanic intubation, tube design and material, reason for tube removal, and additional risk factors (trisomy 21, cleft palate, midfacial anomalies) were analyzed. RESULTS: 55 children met inclusion criteria. 28 children (36 ears) were patched with Gelfilm®. 27 children (35 ears) were patched with collagen matrix. Median ages at surgery and duration of intubation were similar in the two groups. There were persistent perforations at 4 weeks in 5/28 children (5/36 ears, 14%) with Gelfilm®, and 3/27 children (3/35 ears, 9%) with collagen matrix. There was no significant difference in the rate of persistent perforation between the two materials by Fisher's exact test by patients (p = 0.7049) or by ears (p = 0.7101; OR: 1.72; 95% CI 0.38-7.82). CONCLUSION: Gelfilm® and collagen matrix patches performed similarly in the operating room. Rates of tympanic membrane closure were comparable in this pilot study. Larger patient numbers will be needed to prove equivalence or superiority of collagen matrix for this application.

The Use of Photogrammetry for Interactive, Three-Dimensional Modeling of an Open Reduction and Internal Fixation of the Elbow.

We present our step-by-step guide to acquire and combine intraoperative photographs into three-dimensional models of surgical anatomy. We then apply our technique to model six steps in an open reduction and internal fixation of the elbow. Our protocol can be done with equipment and software retailing for under $500.