Laparoscopic Adjustable Gastric Band Colonization May Indicate Re-classification of Surgical Wounds.

BACKGROUND: Surgical wounds are classified as either clean, clean-contaminated, contaminated, or dirty wounds. Historically laparoscopic adjustable gastric band (LAGB) removals have been classified as clean wounds since there is thought to be no existing infection and no transection of the gastrointestinal tract. Surgical site infection (SSI) remains a publicly reported source of morbidity after laparoscopic bariatric surgery and is considered a CMS hospital-acquired condition. We present a retrospective chart review to reveal the rate of bacterial colonization of gastric bands. METHODS: This retrospective chart review included 15 patients who underwent removal of LAGB. The entire LAGB and port were removed and then sent for aerobic and anaerobic cultures. Patients were followed up to 1 month, and the incidence of surgical site infection development was recorded. RESULTS: Of the fifteen LAGBs cultured, eight cases (53%) returned positive for bacterial growth. Five of the cultures (33%) were positive for coagulase-negative Staphylococcus. One culture was positive for micrococcus species (6.7%), one culture was positive for Bacteroides fragilis (6.7%) and another was positive for Propionibacterium (6.7%). None of the 15 patients followed in the study developed an SSI by the end of 1 month. CONCLUSIONS: Given the consideration of LAGB removals as clean wounds, the incidence of LAGB colonization is high. Classification of the surgical wounds in LAGB removals should be changed from clean to contaminated. Further studies need to be pursued to determine the correlation between colonized LAGBs and the rate of SSIs. KEY POINTS: • Gastric band removals are a common bariatric procedure. • Surgical site infection remains an outcome of interest to patient, surgeon and payor. • Fifty-three percent of recovered bands were positive for bacterial growth.

Urodynamic and urethral pressure profilometry findings in women with voiding phase dysfunction treated with surgical urethrolysis.

INTRODUCTION: Long-term urodynamic (UDS) and urethral pressure profilometry (UPP) parameters in women with voiding phase dysfunction following an anti-incontinence (AI) procedure have been poorly characterized. We report our 10-year UDS findings in women with voiding phase dysfunction after AI procedure, who underwent urethrolysis. METHODS: We identified sequential records containing urethrolysis current procedural terminology codes over a 10-year period. Records of women with preoperative UDS were reviewed for demographics, UDS tracing, and outcomes following urethrolysis. RESULTS: Twenty-five women (mean age 60 years) had voiding phase dysfunction and underwent urethrolysis at a mean of 47 months (interquartile range [IQR] 12-61) after AI procedure. Preoperatively, six (24%) women required intermittent catheterization. Free uroflowmetry revealed a mean maximum peak flow (Qmax) of 9.6 ml/s (IQR 7.0-11.0), voided volume of 137 ml (IQR 81-169), and postvoid residual of 167 ml (IQR 43-288). UDS revealed a mean UPP length of 24 mm (IQR 20-27), UPP closure pressure of 78 cmH2O (IQR 59-103), detrusor pressure at maximum flow (Pdet@Qmax) of 31 cmH2O (IQR 19-43), Qmax of 7.9 ml/s (IQR 5.0-12.0), bladder outlet obstruction index of 15 (IQR 0-34), and bladder contractility index of 71 (IQR 60-81). UPP length was significantly associated (Pearson correlation, p<0.05) with bladder outlet obstruction index (r=0.80), Pdet@Qmax (r=0.75), and time since AI procedure (r=-0.70). UPP closure pressure was significantly associated with age (r=-0.64), volume of first (r=-0.64) and strong (r=-0.78) desire, and capacity (r=-0.71). Following urethrolysis, spontaneous voiding was achieved in 23 (92%) women at followup (mean 308 days). CONCLUSIONS: UPP may help characterize outlet parameters in women with voiding phase dysfunction following an AI procedure, who ultimately undergo urethrolysis.

The effect of socioeconomic status on age at diagnosis and overall survival in patients with intracranial meningioma.

BACKGROUND: Intracranial meningiomas are the most common primary tumors of the central nervous system. How socioeconomic status (SES) impacts treatment access and outcomes for brain tumor subtypes is an emerging area of research. Few studies have examined the relationship between SES and meningioma survival and management with reference to relevant clinical factors, including age at diagnosis. We studied the independent effects of SES on receiving surgery and survival probability in patients with intracranial meningioma. METHODS: 54,282 patients diagnosed with intracranial meningioma between 2003 and 2012 from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute database were included. Patient SES was divided into tertiles. Patient age groups included 'older' (>65, the median patient age) and 'younger'. Multivariable linear regression and Cox proportional hazards model were used with SAS v9.4. Results were adjusted for race, sex, and tumor grade. Kaplan-Meier survival curves were constructed according to SES tertiles and age groups. RESULTS: Meningioma prevalence increased with higher SES tertile. Higher SES tertile was also associated with younger age at diagnosis (OR = 0.890, p < 0.05), an increased likelihood of undergoing gross total resection (GTR) (OR = 1.112, p < 0.05), and a trend toward greater 5-year survival probability (HR = 1.773, p = 0.0531). Survival probability correlated with younger age at diagnosis (HR = 2.597, p < 0.001), but not with GTR receipt. CONCLUSION: The findings from this national longitudinal study on patients with meningioma suggest that SES affects age at diagnosis and treatment access for intracranial meningiomas patients. Further studies are required to understand and address the mechanisms underlying these disparities.

Prostate Artery Embolization Used in the Management of Transfusion-Dependent Hematuria After Prostatic Urethral Lift Procedure in a Patient with Thrombocytopenia: A Case Report.

Background: The prostatic urethral lift (PUL) procedure is a novel therapeutic method to treat lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). Gross hematuria after this procedure has been reported to be mild and transient. This report highlights a case of refractory transfusion-dependent hematuria after the PUL procedure in addition to its management with selective prostatic arterial embolization (PAE). Case Presentation: A 78-year-old Caucasian man with a history of myelodysplastic syndrome, thrombocytopenia, and intermittent urinary retention secondary to BPH underwent a PUL procedure. Before the procedure he received a platelet transfusion making his platelet count 58,000/µL. The day after the procedure he was admitted to a hospital for gross hematuria with clot retention. He was started on continuous bladder irrigation and taken to the operating room for clot evacuation and fulguration of prostate. His thrombocytopenia and anemia were managed with transfusions. He was treated with desmopressin, aminocaproic acid, and intravesical 1% alum without improvement. He returned to the operating room for clot evacuation in addition to photoselective vaporization of the prostate laser ablation of the prostatic fossa. He eventually required a total of four transurethral fulgurations without improvement in transfusion-dependent hematuria. Ultimately, resolution of the hematuria was achieved through bilateral PAE with Embosphere® Microspheres performed by interventional radiology. He was discharged home 2 days after the embolization procedure without recurrence of hematuria or urinary retention at a 6-month follow-up visit. Conclusion: The PUL procedure has been shown to be an effective alternative to more invasive surgical options for LUTS caused by BPH. Despite careful consideration in an attempt to alleviate urinary retention, PUL still resulted in significant bleeding in this patient with thrombocytopenia. This is the first report to highlight the use of bilateral PAE as a method for achieving control of severe refractory hematuria after PUL.

Predictors of Cervical Vertebral and Carotid Artery Dissection During Blunt Trauma: Experience From a Level 1 Trauma Center.

BACKGROUND: The current data available to identify the factors associated with vertebral and carotid artery dissection in the trauma setting are conflicting, and further research is needed to accurately assess these predictors. METHODS: The data from 950 patients who had undergone neck computed tomography angiography (CTA) at a level 1 trauma center were analyzed. Of the 950 patients, 435 were included who had undergone neck CTA for blunt traumatic injuries. The mechanism of injury was classified as high or low impact according to the hospital criteria for trauma. Positive neurological signs included altered mental status (Glasgow coma scale score ≤15 than baseline) or focal neurological deficits. Fractures and dissections were radiologically confirmed. Multivariable logistic regression software was used to analyze the data. RESULTS: Of the 435 patients, 236 (54.25%) had experienced high-impact injuries, 124 (28.51%) had vertebral fractures (including 63 displaced fractures [50.81%]), and 180 (41.38%) had had positive neurological signs on presentation. Of the 435 patients, cervical carotid artery injury had been diagnosed in 9 (2.07%), and 18 patients (4.14%) had had a cervical vertebral artery injury (VAI). Carotid artery injuries did not have significant associations with positive neurological signs, age, sex, mechanism of injury, or vertebral fracture (P > 0.05 for all). Positive neurological signs and vertebral fractures were significant predictors for VAI (odds ratio, 3.19; P < 0.05; odds ratio, 9.81; P < 0.001, respectively). Age, sex, mechanism of injury, and displacement of the vertebral fracture were not significant predictors for VAI (P > 0.05 for all). CONCLUSIONS: Positive neurological signs and the presence of cervical vertebral fractures are significant predictors for VAI. All trauma patients with cervical spine fractures and/or positive neurological findings should be considered for surveillance imaging with neck CTA and/or magnetic resonance angiography for vascular injury screening.

Socioeconomic Predictors of Pituitary Surgery.

BACKGROUND: There exists a lack of data on the effect of socioeconomic status (SES) on outcomes for pituitary tumors, which have been associated with significant morbidity. The goal of this population-level study is to investigate the role of SES on receiving treatment and survival in patients with pituitary tumors. METHODS: The Surveillance, Epidemiology, and End Results (SEER) program database from the National Cancer Institute was used to identify patients diagnosed with pituitary tumors between 2003 and 2012. SES was determined using a validated composite index. Race was categorized as Caucasian and non-Caucasian. Treatment received included surgery, radiation, and radiation with surgery. Odds of receiving surgery and survival probability were analyzed using multivariate logistic regression and Cox proportional hazards model, respectively. RESULTS: A total of 25,802 patients with pituitary tumors were identified for analysis. High SES tertile (odds ratio (OR) = 1.095; 95% confidence interval (CI) [1.059, 1.132]) and quintile (OR = 1.052; 95% CI [1.031, 1.072]) were associated with higher odds of receiving surgery (p<0.0001). Caucasian patients had higher odds of receiving surgery when compared to non-Caucasian patients (OR = 1.064; 95% CI [1.000, 1.133]; p<0.05). Neither SES nor race were significant predictors of survival probability. CONCLUSION: Socioeconomic status and race were found to be associated with higher odds of receiving surgery for pituitary tumors, and thus serve as independent predictors of surgical management. Further studies are required to investigate possible causes for these findings.

Minimally invasive lumbar pedicle screw fixation using cortical bone trajectory - Screw accuracy, complications, and learning curve in 100 screw placements.

Cortical bone trajectory (CBT) is a novel pedicle insertion technique with comparable or superior mechanical properties and reduced invasiveness compared to traditional methods. We describe the screw accuracy, complications, and learning curve associated with CBT use. A prospective cohort study was performed involving 22 patients who underwent lumbar fusion with CBT screw placement. A total of 100 cortical screws were placed. Post-operative CT scans were reviewed to assess the adequacy of screw placement and calculate the incidence of vertebral body and pedicle breaches from cortical screw placement. Technique-related complications were examined. The entire surgical cohort was divided into two groups: early experience (first 11 patients) and late experience (last 11 patients), to study the effect of learning curve on CBT screw placement. Medial pedicle breach was observed in 6/100 cases and lateral vertebral body breach was observed in 1/100 cases. The incidence of durotomy related to the technique was 4.5% (N = 1/22). Post-surgical wound infection was seen in 9.1% of patients (N = 2/22). 66.7% (N = 4/6) of medial pedicle breaches, 100% (N = 1/1) of lateral breaches, 100% (N = 1/1) of CBT technique-related CSF leaks, and 100% (N = 2/2) of wound infections occurred in the early experience phase of our study (p = 0.0945). A shift in surgical technique and greater efficiency over time decreased the incidence of overall complications in the late cohort. The difference, however, did not reach statistical significance. A lateralized starting point for the cortical screw on the pars interarticularis and use of smaller diameter screws resulted in fewer medial pedicle out-fractures and breaches.

Socioeconomic Predictors of Surgical Resection and Survival for Patients With Osseous Spinal Neoplasms.

OF BACKGROUND DATA: Primary osseous spinal neoplasms (POSNs) include locally aggressive tumors such as osteosarcoma, chondrosarcoma, Ewing sarcoma, and chordoma. For such tumors, surgical resection is associated with improved survival for patients. Socioeconomic predictors of receiving surgery, however, have not been studied. OBJECTIVE: To examine the independent effect of race on receiving surgery and survival probability in patients with POSN. STUDY DESIGN: A total of 1904 patients from the SEER program at the National Cancer Institute database, all diagnosed with POSN of the spinal cord, vertebral column, pelvis, or sacrum from 2003 through 2012 were included in the study. Race was reported as white or nonwhite. Treatment included receiving surgery and no surgery. MATERIALS AND METHODS: Multivariable logistic regression was used to determine odds of receiving surgery based on race. Survival probability based on and race and surgery status was analyzed by Cox proportional hazards model and Kaplan-Meir curves. Results were adjusted for age at diagnosis, sex, socioeconomic status (composite index), tumor size, and tumor grade. Data were analyzed with SAS version 9.4. RESULTS: The study found that white patients were significantly more likely to receive surgery (odds ratio=3.076, P<0.01). Furthermore, nonwhite race was associated with significantly shorter survival time [hazard ratio (HR)=1.744, P<0.05]. Receiving surgery was associated with improved overall survival (HR=2.486, P<0.01). After adjusting for receiving surgery, white race remained significantly associated with higher survival probability (HR=2.061, P<0.05). CONCLUSIONS: This national study of patients with typically aggressive POSN found a significant correlation between race and the likelihood of receiving surgery. The study also found race to be a significant predictor of overall survival, regardless of receiving surgical treatment. These findings suggest an effect of race on receiving treatment and survival in patients with POSN, regardless of socioeconomic status. Further studies are required to understand reasons underlying these findings, and how they may be addressed.

Minimally Invasive Lumbar Pedicle Screw Fixation Using Cortical Bone Trajectory: Functional Outcomes.

Background Pedicle screw fixation is currently the mainstay technique for lumbar spinal fusion; however, more minimally invasive techniques are available such as cortical screw fixation. Numerous studies have proven biomechanical equivalence or superiority for cortical screws but few studies have examined clinical outcomes in patients. Our study aims to examine functional outcomes, as well as fusion rates, in patients who underwent pedicle screw fixation using a cortical trajectory. Methods We retrospectively reviewed prospectively collected functional outcomes data on 10 patients with a degenerative lumbar disease who underwent cortical screw placement by the senior author. Oswestry Disability Index (ODI) and Roland Morris (RM) scoring were calculated preoperatively, at six to 12 weeks and at six to eight months. The Kruskal-Wallis test and Dunn's multiple comparison were used to analyze differences in scores over time. Results We found that over time, cortical screw fixation resulted in a mean decrease of 27 from the baseline ODI at six to eight months (p = 0.014). Additionally, six out of seven (86%) patients who had at least 12 months of radiographic follow-up showed fusion. Conclusions Cortical screw fixation showed a decrease of 27 from the baseline ODI at six to eight months, which is comparable to changes from the baseline ODI reported in three, recent, large clinical trials examining functional outcomes following traditional pedicle screw fixation.

The effect of socioeconomic status on gross total resection, radiation therapy and overall survival in patients with gliomas.

Socioeconomic status (SES) is associated with survival in many cancers but the effect of socioeconomic status on survival and access to care for patients with gliomas has not been well studied. This study included 50,170 patients from the Surveillance, Epidemiology, and End Results Program at the National Cancer Institute database diagnosed with gliomas of the brain from 2003 to 2012. Patient SES was divided into tertiles and quintiles. Treatment options included radiation, surgery (gross total resection (GTR)/other surgery), and radiation with surgery. Multivariable logistic regression and Cox proportional hazards model were used to analyze data with SAS v9.4. The results were adjusted for age at diagnosis, race, sex, tumor type, and tumor grade. Kaplan-Meier survival curves were constructed according to SES tertiles and quintiles. Patients from a higher SES tertile were significantly more likely to receive surgery, radiation, GTR, and radiation with surgery (OR 1.092, 1.116, 1.103, 1.150 respectively, all p < 0.0001). This correlation was also true when patients were divided into quintiles (OR 1.054, 1.072, 1.062, 1.089 respectively, all p < 0.0001). Furthermore, the lowest SES tertiles (HR 1.258, 1.146) and the lowest SES quintiles (HR 1.301, 1.273, 1.194, 1.119) were associated with significantly shorter survival times (all p for trend <0.0001). Surgery, radiation therapy, surgery with radiation therapy, and GTR were also found to be associated with improved overall survival in glioma patients (HR 0.553, 0.849, 0.666, 0.491 respectively, all p < 0.0001). The findings from this national study suggest an effect of SES on access to treatment, and survival in patients with gliomas.

Minimally Invasive Robotic Laser Corpus Callosotomy: A Proof of Concept.

INTRODUCTION: We describe the feasibility of using minimally invasive robotic laser interstitial thermotherapy (LITT) for achieving an anterior two-thirds as well as a complete corpus callosotomy. METHODS: Ten probe trajectories were plotted on normal magentic resonance imaging (MRI) scans using the Brainlab Stereotactic Planning Software (Brainlab, Munich, Germany). The NeuroBlate® System (Monteris Medical, MN, USA) was used to conform the thermal burn to the corpus callosum along the trajectory of the probe. The distance of the ideal entry site from either the coronal suture and the torcula or nasion and the midline was calculated. The distance of the probe tip from the dorsal and ventral limits of the callosotomy in the sagittal plane were also calculated. RESULTS: Anterior two-thirds callosotomy was possible in all patients using a posterior parieto-occipital paramedian trajectory through the non-dominant lobe. The average entry point was 3.64 cm from the midline, 10.6 cm behind the coronal suture, and 9.2 cm above the torcula. The probe tip was an average of 1.4 cm from the anterior commissure. For a total callosotomy, an additional contralaterally placed frontal probe was used to target the posterior one-third of the corpus callosum. The average entry site was 3.3 cm from the midline and 9.1 cm above the nasion. The average distance of the probe tip from the base of the splenium was 0.94 cm. CONCLUSION: The directional thermoablation capability of the NeuroBlate® system allows for targeted lesioning of the corpus callosum, to achieve a two-thirds or complete corpus callosotomy. A laser distance of < 2 cm is sufficient to reach the entire corpus callosum through one trajectory for an anterior two-thirds callosotomy and two trajectories for a complete callosotomy.

Influence of Weight Loss Attempts on Bariatric Surgery Outcomes.

Many payors require an additional attempt at nonsurgical weight loss before approval of bariatric procedures. This study evaluates this requirement by characterizing the prior weight loss attempts (WLAs) undergone by bariatric surgery patients and correlating those attempts to postoperative weight loss outcomes. Number and duration of WLAs were obtained from a preoperative clinic assessment. Body mass index (BMI) and percentage of excess weight loss (%EWL) were used to assess weight loss. Kruskal-Wallis and Spearman Correlation tests were performed to analyze data using GraphPad Prism 6. Mean number of WLAs before surgery was 3.5 ± 0.2 attempts, with an average duration of 15.2 ± 1.1 years. There was a significant negative correlation between duration of WLAs and preoperative BMI (r = -0.2637, P = 0.0025). No significant difference was found for preoperative BMI or mean 12-month %EWL among any WLA groups. The number and duration of dietary attempts before surgery do not significantly affect long-term weight loss outcomes after bariatric surgery. Given these data, an additional preoperative WLA may not be efficacious in improving patients' chances at weight loss.

Minimally Invasive Lumbar Pedicle Screw Fixation Using Cortical Bone Trajectory - A Prospective Cohort Study on Postoperative Pain Outcomes.

OBJECTIVE: Our study aims to evaluate the clinical outcomes of cortical screws in regards to postoperative pain. BACKGROUND: Pedicle screw fixation is the current mainstay technique for posterior spinal fusion. Over the past decade, a new technique called cortical screw fixation has been developed, which allows for medialized screw placement through stronger cortical bone. There have been several studies that showed either biomechanical equivalence or superiority of cortical screws. However, there is currently only a single study in the literature looking at clinical outcomes of cortical screw fixation in patients who have had no prior spine surgery. METHODS: We prospectively looked at the senior author's patients who underwent cortical versus pedicle lumbar screw fixation surgeries between 2013 and 2015 for lumbar degenerative disease. Eighteen patients underwent cortical screw fixation, and 15 patients underwent traditional pedicle screw fixation. We looked at immediate postoperative pain, changes in short-term pain (six to 12 weeks post-surgery), and changes in long-term pain (six to eight months). All pain outcomes were measured using a visual analog scale ranging from 1 to 10. Mann-Whitney or Kruskal-Wallis tests were used to measure continuous data, and the Fisher Exact test was used to measure categorical data as appropriate. RESULTS: Our results showed that the cortical screw cohort showed a trend towards having less peak postoperative pain (p = 0.09). The average postoperative pain was similar between the two cohorts (p = 0.93). There was also no difference in pain six to 12 weeks after surgery (p = 0.8). However, at six to eight months, the cortical screw cohort had worse pain compared to the pedicle screw cohort (p = 0.02). CONCLUSIONS: The cortical screw patients showed a trend towards less peak pain in the short-term (one to three days post-surgery) and more pain in the long-term (six to eight months post-surgery) compared to pedicle screw patients. Both cohorts had a statistically significant reduction in pain levels compared to preoperative pain. More studies are needed to further evaluate postoperative pain, long-term functional outcomes, and fusion rates in patients who undergo cortical screw fixation.

Magnetic Resonance-Guided Laser-Induced Thermal Therapy for Recurrent Brain Metastases in the Motor Strip After Stereotactic Radiosurgery.

The authors report a challenging case of a brain metastasis located in the motor cortex, which was not responsive to radiosurgery. Use of a novel technique, magnetic resonance-guided laser-induced thermotherapy (MRgLITT), resulted in the complete obliteration of the lesion without adverse effects or evidence of tumor recurrence at follow-up. This case illustrates that MRgLITT may provide a viable alternative for patients with brain metastases refractory to radiosurgery or in deep locations, where both stereotactic radiosurgery (SRS) and surgical resection may be ineffective.