Comparison of transseptal puncture using a dedicated RF wire versus a mechanical needle with and without electrification in an animal model.

INTRODUCTION: Mechanical force to achieve transseptal puncture (TSP) using a standard needle may lead to overshooting and injury, and can potentially be avoided using a radiofrequency (RF)-powered needle or wire. Applying electrocautery to needles and guidewires as an alternative to purpose-built RF systems has been associated with safety risks, such as tissue coring and thermal damage. The commercially available AcQCross needle-dilator system (Medtronic) features a sharp open-ended needle for mechanical puncture, as well as a built-in connector to enable energy delivery for RF puncture. This investigation compares the safety and efficacy of the AcQCross needle to the dedicated VersaCross RF wire system and generator (Baylis Medical/Boston Scientific). METHODS: In an ex vivo porcine model, VersaCross wire punctures were performed using 1 s, constant mode (approx. 10 W) with maximum two attempts. AcQCross punctures were performed by applying energy for 2 s using a standard electrosurgical generator at 10 W (max. five attempts), 20 W (max. two attempts), and 30 W (max. two attempts). Efficacy was assessed in terms of puncture success and a number of energy applications required for TSP. Safety was assessed quantitatively as force required for TSP, energy required to puncture, and incidence of tissue coring, as well as by qualitative assessment of puncture sites. Additional qualitative observation of tissue cores and debris were obtained from TSP performed in live swine. RESULTS: RF TSP was 100% successful using the VersaCross wire with 1.0 ± 0.0 attempts. When power was used with the AcQCross needle, it failed to puncture at low (10 and 20 W) power settings; TSP was achieved with 30 W of energy with 91% success using 1.53 ± 0.51 attempts (p < .05 vs. VC) with greater variability (F1,33 = 9223.5, p < .0001). Compared to RF puncture using the VersaCross system, mechanical puncture, alone, using the AcQcross needle required six times more force (8 mm additional forward device displacement) to perforate the septum. Qualitative assessment of puncture sites revealed larger defects and more tissue charring with the AcQCross needle at 30 W compared to punctures with VersaCross wire. Tissue coring with the open-ended AcQCross needle was observed in vivo and measured to occur in 57% of punctures using the ex vivo model; no coring was observed with the closed-tip VersaCross wire. CONCLUSIONS: The AcQCross needle frequently required higher energy of 30 W to achieve RF TSP and was associated with tissue coring and charring, which have been, previously, reported when electrifying a standard open-ended mechanical needle or guidewire. These findings may limit safety and effectiveness compared to the VersaCross system.

The Electrified Wire Technique in Complex Aortic Interventions: A Case Series.

OBJECTIVES: Electrosurgery has been long used in endovascular procedures, with only case reports in the aortic field. Our aim is to present a case series with the use of an electrified wire to perform catheter-based electrosurgery by applying external current through an electrocautery pen. METHODS: Single-center retrospective case series of all patients undergoing complex aortic surgery from October 2020 to August 2023, in whom the electrified wire technique was used: (1) Perforation of a dissection flap or left subclavian artery (LSA) in situ endograft fenestration-a 0.014" polytetrafluoroethylene (PTFE) insulated guidewire is detached from the insulation with a scalpel at the end and a cautery pen is here attached with a clamp. A curved tip catheter or sheath is positioned against the aortic flap or the endograft (through a left brachial access in this case) and the wire pushed, crossing the flap by activating the electrocautery pen and (2) slicing a dissection flap ("powered cheese-wire technique")-after same preparation as above, the middle section of the 0.014 guidewire is removed from the PTFE and bent into a V-shape. Once in the aorta, the guidewire crosses from the true lumen (TL) to the false lumen (FL) and a through-and-through access is obtained. Sheaths are positioned against the flap from both sides and moved up or down while the electricity is activated, slicing the flap and communicating both lumens. Technical success and technical-related complications were evaluated. RESULTS: Eleven cases concerning aortic dissections and 1 case of aortic atresia were treated. Four patients presented urgently, whereas the rest were planned procedures. Seven cases underwent perforation of a dissection flap, 2 cases underwent the powered cheese-wire technique, in 2 cases for an LSA in situ fenestration, and in 1 case to cross an aortic atresia at the aortic isthmus. The technique was in all cases successfully applied. No complications related to the technique occurred. CONCLUSIONS: The "electrified wire" technique is a feasible and ready-available tool that can be safely used in complex aortic interventions, especially to perforate aortic tissue like dissection flaps or to perform in situ fenestrated repairs by perforation of the endograft fabric. CLINICAL IMPACT: The electrified wire technique described herein is a straightforward technique that uses readily available tools to perform electrosurgery. We present its use in complex aortic procedures. However, it could be envisioned for any vascular procedure that requires crossing of the vessel or even prosthetic material. As we have described in this series, when used along with an adequate properative planning, it can be a safe tool of great utility, as has already been demonstarted in the field of the interventional cardiology.

From FUSE to a hands-on electrosurgery course using a cadaveric model.

INTRODUCTION: Surgical procedures in contemporary practice frequently employ energy-based devices, yet comprehensive education surrounding their safety and effectiveness remains deficient. We propose an innovative course for residents that aims to provide basic electrosurgery knowledge and promote the safe use of these devices. METHODS: We developed a simulated training course for first-year general surgery and orthopedic residents. First, a survey was conducted regarding their knowledge perception about energy devices. The course consisted of two online theoretical sessions, followed by three in-person practical sessions. First-year residents performed three video-recorded attempts using a cadaveric model and were assessed through a digital platform using the Objective Structured Assessment of Technical Skill (OSATS), a Specific Rating Scale (SRS), and a surgical energy-based devices scale (SEBS). Third-year residents were recruited as a control group. RESULTS: The study included 20 first-year residents and 5 third-year residents. First-year residents perceived a knowledge gap regarding energy devices. Regarding practical performance, both OSATS and checklist scores were statistically different between novices at their first attempt and the control group. When we analyzed the novice's performance, we found a significant increase in OSATS (13 vs 21), SRS (13 vs 17.5), and SEBS (5 vs 7) pre- and post-training scores. The amount of feedback referred to skin burns with the electro-scalpel reduced from 18 feedbacks in the first attempt to 2 in the third attempt (p-value = 0.0002). When comparing the final session of novices with the control group, no differences were found in the SRS (p = 0.22) or SEBS (p = 0.97), but differences remained in OSATS (p = 0.017). CONCLUSION: This study supports the implementation of structured education in electrosurgery among surgical trainees. By teaching first-year residents about electrosurgery, they can acquire a skill set equivalent to that of third-year residents. The integration of such courses can mitigate complications associated with energy device misuse, ultimately enhancing patient safety.

Guideline No. 453: Endometrial Ablation in the Management of Abnormal Uterine Bleeding.

OBJECTIVE: To provide an update of the current evidence-based guideline on the techniques and technologies used in endometrial ablation, a minimally invasive technique for the management of abnormal uterine bleeding of benign origin. TARGET POPULATION: Women of reproductive age with abnormal uterine bleeding and benign pathology with or without structural abnormalities. BENEFITS, HARMS, AND COSTS: Implementation of the guideline recommendations will improve the provision of endometrial ablation as an effective treatment for abnormal uterine bleeding. Following these recommendations would allow the surgical procedure to be performed safely and maximize success for patients. EVIDENCE: The guideline was updated with published literature retrieved through searches of Medline and the Cochrane Library from January 2014 to April 2023, using appropriate controlled vocabulary and keywords (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding, hysterectomy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English. Grey (unpublished) literature was retrieved from the Association of Obstetricians and Gynecologists of Quebec (AOGQ) in 2023. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Obstetricians, gynaecologists, and primary care providers. SOCIAL MEDIA ABSTRACT: This is an updated version of the 2015 SOGC Endometrial Ablation guideline. The authors discuss special considerations, update evidence, and make new fluid deficit recommendations. SUMMARY STATEMENTS: RECOMMENDATIONS.

Transcatheter Myotomy for Hypertrophic Obstructive Cardiomyopathy.

PURPOSE OF REVIEW: To describe the emerging role of transcatheter septal myotomy in the treatment of hypertrophic obstructive cardiomyopathy. RECENT FINDINGS: Transcatheter septal myotomy was developed to address risk of LVOT obstruction during TMVR, however it has been performed in patients with LVOT obstruction related to hypertrophic cardiomyopathy, in whom it improves symptoms, reduces LVOT gradients, and is associated with low incidence of procedural complications. Transcatheter myotomy is a novel approach to address LVOT obstruction related to hypertrophic cardiomyopathy in patients who are not favorable surgical candidates. The risk of conduction abnormalities with transcatheter septal myotomy appears low. Research is needed to define optimal patient selection and long-term outcomes.

Factors associated with human papillomavirus persistence after loop electrosurgical excision procedure in patients with cervical squamous intraepithelial lesion.

AIM: To seek the high-risk factors of human papillomavirus (HPV) persistence and residual lesion or recurrence after loop electrosurgical excision procedure (LEEP) focus on the predictive value of intraoperative human papilloma virus (IOP-HPV) testing. METHODS: Intraoperative endocervical sample was obtained with a cytobrush from the remained cervix of 292 patients immediately after LEEP. HPV Genotyping was performed using a polymerase chain reaction technique. All patients followed by HPV genotyping and cytology every 3-6 months. The IOP-HPV testing results and possible risk factors such as age, cytology grade, menopause status, margin involvement, preoperative HPV status, and cervical lesion grade were assessed in predicting persistence of HPV and residual lesion or recurrence after surgery. RESULTS: There were 61 (20.9%) patients presented persistent HPV infection. Multivariate analyses showed that IOP-HPV positive, post-menopause and preoperative HPV multiplex infection was strongly associated with HPV persistence after LEEP, IOP-HPV positive and post-menopause was also associated with residua or recurrent disease after LEEP. CONCLUSIONS: IOP-HPV positive, post-menopause, and preoperative HPV multiplex infection are independent predictors of HPV persistence in patients with cervical squamous intraepithelial lesion treated by LEEP. IOP-HPV test is a new approach that may potentially allow for early identification of patients at high risk of HPV persistence and residua or recurrent disease after LEEP, thereby possibly facilitate an attenuated follow-up schedule for negative patients those at low risk of persistent HPV infection.

Outcomes of conventional and advanced energy devices in laparoscopic surgery: a systematic review.

INTRODUCTION: Hemostasis is an important step in all surgical procedures. Mechanical methods of hemostasis have been gradually abandoned in favor of electrosurgery. The aim of this systematic review was to evaluate the effectiveness of electrosurgical instruments utilized in minimally invasive gynecological procedures. MATERIAL AND METHODS: We performed a systematic review, including randomized controlled trials, prospective and retrospective studies, comparing the outcomes of different energy devices (EDs) used in laparoscopic gynecologic surgeries. We extracted data about blood loss (BL), mean operative time, post-operative pain, hospital stay and complications associated with each electrosurgical device. RESULTS: We included 30 studies reporting comparative outcomes concerning conventional (bipolar and monopolar) and innovative EDs (Harmonic scalpel, LigaSure, Plasma kinetic gyrus, Thunderbeat, EnSeal, Marseal, Caiman and ALAN). New EDs were found to be more efficient in complex surgeries due to less intraoperative BL and shorter operative time. No significant decrease in hospital stay, post-operative pain or complications was found with the use of new energy instruments. CONCLUSIONS: Although new electrosurgical devices seem an appealing and safer option, there is still insufficient evidence for one vessel-sealing technology to be considered superior to another. Therefore, monopolar and conventional bipolar (CB) are still widely used in laparoscopic gynecology.

Surgeons know that they don't know about the safe use of surgical energy: an international study reveals that the knowledge gap persists.

INTRODUCTION: The rate of electrosurgery complications is 0.1-2.1%. More than 10 years ago, SAGES pioneered a well-structured educational program (FUSE) aimed to teach about the safe use of electrosurgery. This inspired the development of similar training programs around the globe. Still, the knowledge gap persists among surgeons, possibly due to the lack of judgment. AIM: To investigate factors affecting the level of expertise in electrosurgical safety and their correlation with self-assessment scores among surgeons and surgical residents. MATERIALS AND METHODS: We conducted an online survey consisting of 15 questions that could be thematically broken down into 5 blocks. We analyzed how the objective scores were correlated with the self-assessment scores, professional experience, past participation in training programs, and work at a teaching hospital. RESULTS: A total of 145 specialists took part in the survey, including 111 general surgeons and 34 s-year surgical residents from Russia, Belarus, Ukraine, and Kirgizia. Only 9 (8.1%) surgeons scored "excellent," 32 (28.8%) scored "good," and 56 (50.4%) scored "fair." Of all surgical residents participating in the study, only 1 (2.9%) scored "excellent," 9 (26.5%) scored "good," and 11 (32.4%) scored "fair." The test was failed by 14 surgeons (12.6%) and 13 (38.2%) residents. The difference between the trainees and the surgeons was statistically significant. Our multivariate logistic model identified 3 significant factors predisposing to successful performance on the test: past training in the safe use of electrosurgery, professional experience, and work at a teaching hospital. Of all study participants, those with no past training in the safe use of electrosurgery, and non-teaching surgeons were the most realistic about their competencies. CONCLUSION: We have identified alarming gaps in the knowledge of electrosurgical safety among surgeons. Faculty staff and experienced surgeons scored higher, but past training was the most influential factor in improving knowledge of electrosurgical safety.

Transvaginal vesicovaginal fistula closure: A retrospective study of 28 cases at a single facility in Japan.

OBJECTIVES: We aimed to report the background of patients with vesicovaginal fistulas (VVFs) at our center, which has treated a relatively large number of such patients in Japan, as well as the ingenuity and outcomes of vesicovaginal fistula closure (VVFC). We also investigated the causes of VVFs. METHODS: A retrospective review was performed for 28 patients with VVFs treated at our center. Age, body mass index, etiology, site of fistula, and postoperative outcomes were investigated. RESULTS: Twenty-one (75%) fistulas occurred following hysterectomy. The overall success rate of VVFC was 85.7%, and the success rate limited to the first attempt was 89.5%. In 68% of cases, no bladder injury suspected as the cause of VVF was noticed during the surgery. Energy devices were used in all 12 patients for whom information on the type of device used for hysterectomy was confirmed. CONCLUSIONS: To our knowledge, this is the first report to evaluate a relatively large number of VVFCs in Japan. Although VVF is thought to be caused by bladder injury during hysterectomy, delayed thermal damage might also result in this pathology, even if there is no apparent intraoperative bladder injury.

TREATMENT EXPERIENCE OF CHRONIC LUNG ABSCESSES USING MINI-INVASIVE ELECTROSURGICAL TECHNIQUES.

OBJECTIVE: The aim: To increase the efficiency of surgical treatment of patients with chronic lung abscesses by developing mini-invasive methods of surgical treatment using electrosurgical technologies. PATIENTS AND METHODS: Materials and methods: Conducted study of the results of surgical treatment of 78 patients with chronic lung abscesses operated from 2011 to 2021. Patients were divided into two groups: the main group (37 patients who were treated using developed technologies) and a comparison group (41 patients, treated using traditional tactics). RESULTS: Results: Transthoracic and endobronchial sanitation of the purulent cavity in the lung at the first stage of treatment contributed to the rapid elimination of inflammation and significantly accelerated the regeneration of lung tissue. Clinical effectiveness in the main group was expressed in reducing the phenomena of intoxication, decrease in Leukocyte intoxication index (LII) (early as on day 5 after surgery), on the 10th day, a significant reduction in patients bacterial excretion was noted (in the main group by 18.9%, in the comparison group - by 14.6%), the average time of reducing the abscess cavity by 1/4 of the volume 6 days less, the healing time of the cavity of the AL which is on average 13 and 16 days, respectively, less. CONCLUSION: Conclusions: The developed methods of surgical interventions made it possible to significantly positively influence the level of endogenous intoxication indicators, avoid resection surgical interventions, reduce the number of postoperative complications, avoid damage to neighboring organs, reduce the time of patients with achieving a stable positive effect.

[Safety in electrosurgery: results of the All-Russian survey]. / Bezopasnost' v elektrokhirurgii: rezul'taty obshcherossiiskogo oprosa urovnya znanii.

OBJECTIVE: To assess the level of knowledge in electrosurgical safety among specialists in the Russian Federation. MATERIAL AND METHODS: An Internet survey was devoted to the issues of electrosurgical safety. The questionnaire consisted of 15 questions in 5 items. Data were collected for 2 months. Data analysis included final assessment of respondents, correlation of results with their own assessment of knowledge and parameters of surgical experience, the fact of training and belonging to the department. Question design, survey and presentation of results were performed in accordance with the CHERRIES (Check list of Reporting Results of Internet E-Surveys) criteria for Internet surveys. RESULTS: Survey enrolled 231 specialists. Excellent rating was given to 13 (5.6%) respondents, good - 66 (28.3%), satisfactory - 105 (45.1%) respondents. Forty-nine (21.03%) respondents did not overcome the passing score (7) and showed unsatisfactory knowledge of electrosurgical safety. Mean score among all participants was 8.6±2.6 (median 8 points, interquartile range [7-11]) or 53.3% of maximum value (15). In multivariate logistic model, significant factors were the completed course in electrosurgical safety (OR 2.26, 95% CI 1.30-3.97; p=0.004), experience of work (OR 1.03, 95% CI 1.01-1.05; p=0.011) and work in the department (OR 1.74, 95% CI 1.03-2.95; p=0.038). Respondents who did not take the course (positive significant correlation r=0.1629, p=0.02674) and non-departmental employees (r=0.1655, p=0.031) assess the level of knowledge more adequately with respect to real results. Respondents with completed course (r=0.1078, p=0.4659) and departmental staff (r=0.1411, p=0.2699) are prone to overestimate self-assessment (positive insignificant correlation of their own assessment and received points). CONCLUSION: We found significant knowledge gaps in electrosurgical safety among various practitioners. The main causes are no mandatory specialized courses on electrosurgical safety and insufficient motivation of specialists for self-education due to false ideas about their own level of knowledge.

Blood-saving dissection with monopolar tungsten needle electrodes and Teflon-coated spatula electrodes in tumor orthopedics.

INTRODUCTION: Resection of musculoskeletal tumors and reconstruction with tumor endoprostheses often results in blood loss requiring transfusion of blood products. We assessed the blood-saving potential of using monopolar tungsten needle electrodes and polytetrafluoroethylene (PTFE)-coated spatula electrodes (intervention) compared with conventional dissection with sharp instruments and coagulation with uncoated steel electrodes (control). METHODS: We retrospectively analyzed data of 132 patients (79 interventions, 53 controls) undergoing surgery by one single experienced surgeon in our tertiary referral center between 2012 and 2021. RESULTS: Intraoperative blood loss in the intervention group was reduced by 29% [median (IQR): 700 (400-1200) vs 500 (200-700) ml; p = 0.0043]. Postoperative wound drainage decreased by 41% [median (IQR): 1230 (668-2041) vs 730 (450-1354) ml; p = 0.0080]. Additionally, patients in need of PRBCs during surgery declined from 43% to 15% (23/53 vs 12/79; p = 0.0005), while the transfusion rate after surgery did not change notably. The number of patients in need of revision surgery due to wound healing disorders was low in both groups (control group: 4/53 vs intervention group: 4/79). Only one patient in the control group and two patients in the intervention group underwent revision surgery due to hemorrhage. Baseline characteristics were similar between groups (sex, Charlson Comorbidity score, tumor entity). CONCLUSION: Dissection with tungsten needle electrodes and PTFE-coated spatula electrodes appears an effective surgical blood-saving measure without increased risk of wound healing disorders. LEVEL OF EVIDENCE: III, retrospective comparative study. CLINICAL TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov. Identifier: NCT05164809.

Comparing the safety and effectiveness of dedicated radiofrequency transseptal wires to electrified metal guidewires.

BACKGROUND: Application of electrocautery to a metal guidewire is used by some operators to perform transseptal puncture (TSP). Commercially available dedicated radiofrequency (RF) guidewires may represent a better alternative. This study compares the safety and effectiveness of electrified guidewires to a dedicated RF wire. METHODS: TSP was performed on freshly excised porcine hearts using an electrified 0.014″ or 0.032″ guidewire under various power settings and was compared to TSP using a dedicated RF wire with 5 W power (0.035″ VersaCross RF System, Baylis Medical). The primary endpoint was the number of attempts required to achieve TSP. Secondary endpoints included the rate of TSP failure, TSP consistency, the effect of the distance between the tip of the guidewire and the tip of the dilator, and effect of RF power output level. Qualitative secondary endpoints included tissue puncture defect appearance, thermal damage to the TSP guidewire or dilator, and tissue temperature using thermal imaging. RESULTS: The RF wire required on average 1.10 ± 0.47 attempts to cross the septum. The 0.014″ electrified guidewire required an overall mean of 2.17 ± 2.36 attempts (2.0 times as many as the RF wire; p < .01), and the 0.032″ electrified guidewire required an overall mean of 3.90 ± 2.93 attempts (3.5 times as many as the RF wire; p < .01). Electrified guidewires had a higher rate of TSP failure, and caused larger defects and more tissue charring than the RF wire. Thermal analysis showed higher temperatures and a larger area of tissue heating with electrified guidewires than the RF wire. CONCLUSION: Fewer RF applications were required to achieve TSP using a dedicated RF wire compared to an electrified guidewire. Smaller defects and lower tissue temperatures were also observed using the RF wire. Electrified guidewires required greater energy delivery and were associated with equipment damage and tissue charring, which may present a risk of thrombus, thermal injury, or scarring.

Dynamic Impedance Analysis of Intestinal Anastomosis during High-Frequency Electric Field Welding Process.

The success rate of the electrosurgical high-frequency electric field welding technique lies in reasonable control of the welding time. However, the final impedance value used to control the welding time varies due to differences in tissue size and the welding method during the welding process. This study aims to introduce a new reference indicator not limited by impedance size from dynamic impedance to achieve an adequate weld strength with minimal thermal damage, providing feedback on the tissue welding effect in medical power supplies. End-to-end anastomosis experiments were conducted with porcine small intestine tissue under seven levels of compression pressure. The dynamic impedance changes were analyzed, combined with compression pressure, temperature, moisture, and collagen during welding. The welding process was divided into three stages according to the dynamic impedance, with impedance decreasing in Period Ⅰ and impedance increasing in Period Ⅲ. Period Ⅲ was the key to high-strength connections due to water evaporation and collagen reorganization. The dynamic impedance ratio is defined as the final impedance divided by the minimum impedance, and successful welding would be predicted when detecting the dynamic impedance ratio over 4 (n = 70, p < 0.001). Dynamic impedance monitoring can be used as a macroscopic real-time prediction of the anastomosis effect.

Surgical Smoke and Biological Symptoms in Healthcare Professionals and Patients: A Systematic Review.

PURPOSE: This study aimed to identify the evidence in the scientific literature between exposure to surgical smoke and biological symptoms in healthcare professionals and patients. DESIGN: A systematic review. METHODS: Electronic databases were searched, including vivo observational and experimental studies published until August 2020 in Portuguese, English, Spanish and French. FINDINGS: We identified 13 studies, with a predominance of cross-sectional (6; 46.15%), experimental laboratory (4; 30.76%) and cohort (3; 23.07%) studies. The main manifestations identified were related to respiratory tract and headache. There was identification of histopathological changes in the nasal mucosa of healthcare professionals and the presence of toxic substances from smoke identified in the urine of patients and healthcare professionals. CONCLUSION: The scientific literature on the biological symptoms of surgical smoke is mainly composed of observational studies with a reduced sample size, thus constituting aspects which limit a broader and long-term understanding of the biological effects of surgical smoke exposure in healthcare professionals and patients.

First-in-human transcatheter pledget-assisted suture tricuspid annuloplasty for severe tricuspid insufficiency.

OBJECTIVES: We report the first pledget-assisted suture tricuspid annuloplasty (PASTA) in a patient with torrential tricuspid regurgitation (TR). BACKGROUND: Tricuspid valve regurgitation is a common malignant disease with no commercially available transcatheter therapy. PASTA is a "percutaneous surgical" procedure using pledgeted sutures to create a double-orifice tricuspid valve. METHODS: An 83-year-old man had end-stage TR caused by a defibrillator lead. He consented to undergo PASTA on a compassionate basis. A double-orifice valve was created with pledgeted sutures from percutaneous right ventricular apical access. RESULTS: TR was reduced from torrential to trace. The vena contracta reduced to from 23 to 1 mm and annular area reduced from 1817 to 782 mm2 . However, the annulus dehisced and required closure with a percutaneous nitinol plug. The patient was discharged home and was alive 6 months later but with persistent symptoms. CONCLUSIONS: The anatomy of a double-orifice valve can eliminate TR but a better solution is required to avoid excessive suture tension on annular tissue.

"Powered Cheese Wire Technique" for Septal Fenestration in Complex Endovascular Repair for Chronic Thoracoabdominal Aortic Dissection.

PURPOSE: Endovascular repair of chronic thoracoabdominal aortic dissection with aneurysmal degeneration presents a therapeutic challenge when one or more visceral branches arise from the false lumen without an adjacent reentry. The chronic dissection flap can be thick and resistant to flap fenestration with standard techniques. TECHNIQUE: The powered cheese wire technique facilitates cutting of a dissection flap using electrical current on a noninsulated through-and-through wire segment. The mid-shaft of the guidewire is denuded and kinked to form the "flying V" configuration. This solution is based on the BASILICA procedure, which uses electrosurgery to split aortic valve tissue lengthwise prior to transcatheter aortic valve replacement to prevent coronary artery obstruction. We demonstrate the technique in a case of branched endovascular aortic repair of a complex thoracoabdominal dissecting aneurysm in which a renal artery from the false lumen was catheterized by creating a powered cheese wire fenestration. CONCLUSION: The powered cheese wire technique is an effective approach to access false lumen originating branches during endovascular aortic repair of chronic aortic dissections.

Preventing and managing complications in dermatologic surgery: Procedural and postsurgical concerns.

The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.

Xanthelasma palpebrarum removed with Atmospheric Plasma technique: 11-year follow up.

Xanthelasma palpebrarum is a subcutaneous lesion of the lid and cause a cosmetical issue. The aim of the present study was to evaluate the atmospheric plasma treatment for the treatment of xanthelasma with an 11-year follow up. Seventy-two patients with bilateral xanthelasma and 26 patients with unilateral xanthelasma by atmospheric plasma technique known also as voltaic arc dermabrasion (VAD, Europe Medical s.r.l. Montesilvano (PE), Italy). Photographs were obtained at the baseline and after the procedure and analyzed by an independent observer. The evaluation of the results was made 2 months after this single treatment with 11 years of follow up. The subjects average age was 48.5 years (range 41-63 years). All subjects were elected for a single session for the lesion removal. The erosion is epithelialized from the lesion margins and the dermal basal cells. After 2 months from the treatment, the result was scored as 4 (clearing of lesions > 75%, complete resolution) in 66 patients for a total of 104 lesions treated; scored as 3 in 24 patients for a total of 48 lesions, and as 2 in nine patients for a total of 18 lesions. No subjects scored 0 or 1. A total of 8 lesions showed mild erythema in the treated areas for 1 month. Numerous approaches were proposed for xanthelasma exeresis such as a surgical treatment especially in case of excessively large lesions or lesions involving the medial canthus that could produce a more limited skin laxity rapidly induces a risk of ectropion. In conclusion, the effectiveness of the present investigation suggest that the atmospheric plasma is a useful therapeutic option for the treatment of xanthelasma palpebrarum.

Current status on the adoption of high energy devices in Italy: An Italian Society for Endoscopic Surgery and New Technologies (SICE) national survey.

BACKGROUND: In the past three decades, different High Energy Devices (HED) have been introduced in surgical practice to improve the efficiency of surgical procedures. HED allow vessel sealing, coagulation and transection as well as an efficient tissue dissection. This survey was designed to verify the current status on the adoption of HED in Italy. METHODS: A survey was conducted across Italian general surgery units. The questionnaire was composed of three sections (general information, elective surgery, emergency surgery) including 44 questions. Only one member per each surgery unit was allowed to complete the questionnaire. For elective procedures, the survey included questions on thyroid surgery, lower and upper GI surgery, proctologic surgery, adrenal gland surgery, pancreatic and hepatobiliary surgery, cholecystectomy, abdominal wall surgery and breast surgery. Appendectomy, cholecystectomy for acute cholecystitis and bowel obstruction due to adhesions were considered for emergency surgery. The list of alternatives for every single question included a percentage category as follows: " < 25%, 25-50%, 51-75% or > 75%", both for open and minimally-invasive surgery. RESULTS: A total of 113 surgical units completed the questionnaire. The reported use of HED was high both in open and minimally-invasive upper and lower GI surgery. Similarly, HED were widely used in minimally-invasive pancreatic and adrenal surgery. The use of HED was wider in minimally-invasive hepatic and biliary tree surgery compared to open surgery, whereas the majority of the respondents reported the use of any type of HED in less than 25% of elective cholecystectomies. HED were only rarely employed also in the majority of emergency open and laparoscopic procedures, including cholecystectomy, appendectomy, and adhesiolysis. Similarly, very few respondents declared to use HED in abdominal wall surgery and proctology. The distribution of the most used type of HED varied among the different surgical interventions. US HED were mostly used in thyroid, upper GI, and adrenal surgery. A relevant use of H-US/RF devices was reported in lower GI, pancreatic, hepatobiliary and breast surgery. RF HED were the preferred choice in proctology. CONCLUSION: HED are extensively used in minimally-invasive elective surgery involving the upper and lower GI tract, liver, pancreas and adrenal gland. Nowadays, reasons for choosing a specific HED in clinical practice rely on several aspects, including surgeon's preference, economic features, and specific drawbacks of the energy employed.