Robot-assisted sialolithotomy with sialoendoscopy: a review of safety, efficacy and cost.

OBJECTIVE: Review the safety, efficacy and cost of robot-assisted sialolithotomy with sialoendoscopy (RASS) for large submandibular gland hilar sialoliths. STUDY DESIGN: Retrospective case series. METHODS: Patients ≥18 years diagnosed with submandibular hilar sialolithiasis between 1/1/2015 and 7/31/2018 who underwent RASS were identified. Procedure success, post-operative complications, procedure duration, and costs associated with the procedure were reviewed. RESULTS: 33 patients fit inclusion criteria. 94% of patients had successful sialolith removal. Mean sialolith size was 8.9 mm. 15.1% had transient tongue paresthesia. 0% had permanent tongue paresthesia compared to a 2% rate of lingual nerve damage cited in the literature for combined approach sialolithotomy (CAS). The average total cost was $16,921. Insurance paid 100%, 90-99%, 70-89.9%, and 40-69.9% of the expected reimbursement in 43.8%, 18.7%, 18.7% and 12.5% of patients respectively. 6% of patients self-paid. Compared to CAS, the cost of reusable robotic arms and drapes totaled $475, though these costs were included in the standardized operative cost per minute and were not forwarded to the patient. The mean procedure time was 62 minutes. Compared to published mean procedure times for CAS, the reduced operative time may account for a savings of $3332-$6069. CONCLUSION: RASS is a safe modality for submandibular hilar sialolith removal with a high success rate, low risk for temporary tongue paresthesia, and lower rate of permeant lingual nerve damage compared to CAS. Compared with CAS, RASS may result in a net reduction of operative room costs given its shorter procedure time.

Chronic Administration of the N-Methyl-D-Aspartate Receptor Antagonist Ketamine Improves Rett Syndrome Phenotype.

BACKGROUND: Rett syndrome (RTT) is a neurological disorder caused by mutation of the X-linked MECP2 gene, which results in the progressive disruption of excitatory and inhibitory neuronal circuits. To date, there is no effective treatment available for the disorder. Studies conducted in RTT patients and murine models have shown altered expression of N-methyl-D-aspartate receptors (NMDARs). Genetic deletion of the NMDAR subunit, GluN2A, in mice lacking Mecp2 is sufficient to prevent RTT phenotypes, including regression of vision. METHODS: We performed a systematic, randomized preclinical trial of chronic administration of low-dose (8 mg/kg, intraperitoneal) ketamine, an NMDAR antagonist, starting either early in development or at the onset of RTT phenotype in Mecp2-null mice. RESULTS: Daily exposure to ketamine ameliorated RTT symptoms and extended the life span of treated Mecp2-null mice without adverse side effects. Furthermore, significant improvement was observed in cortical processing and connectivity, which were fully restored to a wild-type level, particularly when treatment was started at the onset of regression. CONCLUSIONS: Our findings provide strong evidence that targeting NMDA receptors can be a safe and effective treatment for RTT.

Pretreatment with hyperbaric oxygen and its effect on neuropsychometric dysfunction and systemic inflammatory response after cardiopulmonary bypass: a prospective randomized double-blind trial.

OBJECTIVE: Animal studies have shown that pretreatment with hyperbaric oxygen can induce central nervous system ischemic tolerance and also modulate the inflammatory response. We evaluated this therapy in patients undergoing cardiopulmonary bypass. METHODS: Sixty-four patients were prospectively randomized to group A (n = 31; atmospheric air, 1.5 atmospheres absolute) or group B (n = 33; hyperbaric oxygen, 2.4 atmospheres absolute) before on-pump coronary artery bypass grafting. Age, sex, body mass index, diabetes, hypertension, smoking, coronary disease severity, left ventricular function, Parsonnet score, Euroscore, bypass time, myocardial ischemia time, and number of grafts were comparable in both groups. Canadian Cardiovascular Society angina, New York Heart Association dyspnea, and previous myocardial infarction were significantly higher in group B. Inflammatory markers were analyzed before surgery and 2 and 24 hours after bypass. Neuropsychometric testing was performed 48 hours before surgery and 4 months after surgery and included trail making A and B, the Rey auditory verbal learning test, grooved peg board, information processing table A, and digit span forward and backward. Neuropsychometric dysfunction was defined as more than 1 SD deterioration in more than 2 neuropsychometric tests. Chi-square tests, Fisher tests, t tests, and analysis of variance were used as appropriate for statistical analysis. RESULTS: Group A had a significant postoperative increase in the inflammatory markers soluble E-selectin, CD18, and heat shock protein 70. This was not observed in group B. Neuropsychometric dysfunction was also significantly higher in group A compared with group B. There was no difference in any other early postoperative clinical outcome. CONCLUSIONS: Our results seem to indicate that pretreatment with hyperbaric oxygen can reduce neuropsychometric dysfunction and also modulate the inflammatory response after cardiopulmonary bypass. However, further multicenter randomized trials are needed to clinically evaluate this form of therapy.

Intensive care unit readmission after elective coronary artery bypass grafting.

Prospective data of 3,120 consecutive patients who had elective coronary artery bypass were analyzed to identify patient profile, cost, outcome and predictors of those readmitted to the intensive care unit. Group A (n=3,002) had a single intensive care unit admission and group B (n=118) were readmitted within 30 days after surgery. Parsonnet score, EuroSCORE, age, body mass index, chronic obstructive airway disease, peripheral vascular disease, renal dysfunction, unstable angina, congestive cardiac failure, and poor left ventricular function were higher in group B. Bypass and crossclamp times were longer, and the prevalence of inotropic and balloon pump support, arrhythmias, myocardial infarction, re-exploration, blood loss and transfusion, cerebrovascular accident, wound infection, sternal dehiscence, and multisystem failure were higher in group B. Despite a 4-fold increase in cost of care, the mortality rate (32.4%) of patients readmitted to intensive care was 23-times higher than routine patients (1.4%). Crossclamp time>80 min, Parsonnet score>10, EuroSCORE>9, sternal dehiscence, ventricular arrhythmias, and renal failure predicted readmission.

Evaluation of ventral cardiac denervation as a prophylaxis against atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: To evaluate the efficacy of ventral cardiac denervation as a prophylaxis against post-coronary artery bypass grafting (CABG) atrial fibrillation (AF). METHODS: Seventy consecutive patients who underwent CABG (group A) were compared to 70 consecutive subsequent patients who underwent CABG + ventral cardiac denervation (group B). Both groups were well-matched for age, gender, disease severity, LV function, Euro scores, Parsonnet scores, preoperative beta-blockers, Ca-channel blockers, digoxin, and angiotensin converting enzyme inhibitors. The same cardioplegia, bypass, and operation techniques were used in all cases. Denervation before initiating bypass increased operation time by approximately 5 minutes. Heart rate and rhythm were monitored by continuous telemetry until postoperative day 5 and then 4- hourly until discharge. RESULTS: The cross-clamp time (p = 0.6), bypass time (p = 0.1), number of grafts (p = 0.9), inotrope usage (p = 0.4), reexploration rate (p = 1), postoperative myocardial infarction (none in either group), blood loss (p = 0.7), and length of stay (p = 0.8) were comparable in both groups. There was no significant difference in the incidence of AF; 34% in group A versus 29% in group B (p = 0.3). CONCLUSIONS: Ventral cardiac denervation failed to significantly reduce the incidence of AF following coronary revascularization in our study.

Surgical nurse assistants in cardiac surgery: a UK trainee's perspective.

OBJECTIVE: To assess the impact of surgical nurse assistants on surgical training based on a comparative audit of case-mix and outcome of coronary revascularizations assisted by surgical nurse assistants vs. surgical trainees. METHODS: Relevant recent articles on Calman reform of specialist training and European working time directive (EWTD) on junior doctor working hours were reviewed for the discussion. For the audit prospectively entered data of elective and expedite first time coronary artery bypass grafting cases from 2000 to 2003 were analysed. Group A (n=233, Consultant+Surgical nurse assistant), group B (n=1067, Consultant+Junior surgical trainee). Chi-square test, t-test and Fisher's test were used as appropriate for statistical analysis. RESULTS: Comparative preoperative variables were gender (P=0.8), body mass index (P=0.9), smoking (P=0.3), diabetes mellitus (P=0.2), hypertension (P=1), peripheral vascular disease (P=0.5), previous cerebrovascular accident (CVA)/transient ischemic attack (TIA) (P=0.3), renal dysfunction (P=0.4), preoperative rhythm disturbances (P=0.3), previous Q-wave myocardial infarction (MI) (P=0.4), Canadian Cardiovascular Society angina class (P=0.4), New York Heart Association heart failure class (P=0.4) and left ventricular function (P=0.4). Patients in group B were of higher risk due to age (P=0.01), coronary disease severity (P=0.05), left main stem disease (P=0.001), Parsonnet score (P=0.0001) and Euroscore (P=0.005. Regarding the myocardial protection technique, intermittent cross-clamp fibrillation was used more frequently in group A while antegrade-retrograde cold blood cardioplegia and off-pump coronary artery bypass were used more in group B (P=0.0001). The cross-clamp (P=0.0001) and operation time (P=0.0001) were significantly lower in group A despite a comparable mean number of grafts (P=0.2). There was no significant difference in the immediate postoperative outcome ventilation time (P=0.2), intensive care unit stay, postoperative stay (P=0.2), re-exploration for bleeding (P=0.5), inotrope+intra-aortic balloon pump (P=0.2), postoperative MI (P=0.9), postoperative rhythm disturbances (P=0.9), CVA/TIA (P=0.8), renal dysfunction (P=0.6), wound infection (P=0.7), sternal re-wiring (P=0.2), multi-organ failure (P=0.4) or mortality (P=0.1). CONCLUSIONS: Surgical nurse assistants can be used effectively in low-risk cases without compromising postoperative results. However, initiatives to tackle the EWTD should be focused on areas that do not compromise the training needs of junior surgical trainees. An intermediate grade between the present senior house officer and registrar grades could be a way forward.

Exposing the lateral and posterior surface of the heart during coronary revascularisation--a simple technique.

We describe a technique of exposing the lateral and posterior surfaces of the heart during coronary artery bypass grafting. This method provides very good steady state target vessel exposure, eversion and stabilisation, which are very important factors in determining the quality of the anastomosis.

Comparison of the immediate postoperative outcome of using the conventional two drains versus a single drain after lobectomy.

BACKGROUND: We compared the immediate postoperative outcome and cost-effectiveness of using a single chest drain in the midposition to the conventional apical and basal drains after lobectomy. METHODS: Of the 120 consecutive patients who underwent thoracotomy and lobectomy for lung cancer at our center between January 2001 and December 2002, 60 had the conventional 28 French apical and basal drains (group A), whereas the remaining 60 had a single 28 French chest drain placed in the midposition before closure (group B). The assessed outcomes included length of stay, amount and duration of drainage, subcutaneous emphysema, postremoval hemothorax and pneumothorax, drain reinsertion, patient controlled analgesia duration, maximum pain scores, and analgesic usage. RESULTS: Both groups matched in terms of age (group A vs group B mean, 65 years old vs 66 years old, respectively; p = not significant [NS]) and gender (M:F, 4:1 for group A vs 4:1 for group B). There was no significant difference in the length of stay (mean, 7.7 days for group A vs 7.8 days for group B; p = NS), amount of drainage (mean, 667 mL for group A vs 804 mL for group B; p = NS), duration of drainage (mean, 4 days for group A vs 4.3 days for group B; p = NS), duration of patient controlled analgesia (mean, 3.7 days for group A vs 4.2 days for group B; p = NS) and analgesic combinations used (nonsteroidal antiinflammatory drugs +/- oral opioids +/- paracetamol) between the two groups. There were no clinically significant postdrain removals of hemothorax or pneumothorax in either group. Group A patients had a significantly higher maximum pain score compared with group B patients (mean, 1.4 vs 1.02, respectively; p = 0.02). Cost savings per patient in group B was more than or equal to 55 US dollars, which added up to a total cost savings of approximately more than or equal to 3,300 US dollars. CONCLUSIONS: A single chest drain in the midposition is just as effective, significantly less painful, and much more cost effective than the conventional use of two drains after lobectomy.

Comparison of the immediate post-operative outcome of two different myocardial protection strategies: antegrade-retrograde cold St Thomas blood cardioplegia versus intermittent cross-clamp fibrillation.

The objective of this study was to compare the immediate post-operative outcome of two myocardial protection strategies. Data of consecutive elective first time coronary artery bypass grafting (CABG) were analysed: Group A (n=671, antegrade-retrograde cold St Thomas blood cardioplegia) and Group B (n=783, intermittent cross-clamp fibrillation). Age, angina class, myocardial infarction (MI), pre-operative rhythm, respiratory disease, smoking, diabetes mellitus (DM), hypertension (HT), renal function, cerebrovascular disease, body mass index (BMI) and Parsonnet score were comparable. Significant differences existed in gender (P=0.02), peripheral vascular disease (PVD) (P=0.04), heart failure class (P=0.0001), left ventricular (LV) function (P=0.01), disease severity (P=0.02), left main stem (LMS) (P=0.02) and preinduction intra-aortic balloon pump(IABP) (P=0.08). Group A had more grafts (P=0.008), longer bypass (P=0.0001) and cross-clamp time (P=0.0001). Post-operative inotrope, MI, arrhythmias, neurological, renal complications, multi-organ failure, sternal re-wiring, ventilation, length of stay and mortality were comparable. There was higher IABP usage and longer intensive therapy unit (ITU) stay (P=0.01) in Group B. Chronic obstructive airway disease (COAD), renal dysfunction, cross-clamp time, bypass time, post-operative inotrope or IABP and re-exploration predicted longer ITU stay. Intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate post-operative outcome comparable to antegrade-retrograde cold St Thomas blood cardioplegia in elective first-time CABG.