Implementation of a novel thoracostomy tube trainer with real-time feedback.

Objectives: Simulation-based training leads to improved clinical performance but may be influenced by quality and frequency of training. Within simulation training, chest tube insertion remains a challenge as one of the main pitfalls of insertion is a controlled pleural entry. This study evaluates the efficacy of a novel training model with real-time pressure monitoring, the average force to pleural entry in a model and the utility of audio and visual feedback. Methods: This proprietary training model comprised a modified Kelly clamp device with three force sensors at the index finger (sensor 1) and two finger loops (sensors 2 and 3), and a manikin with a replaceable chest wall pad. Standard force values (Newtons (N)) were obtained by experts; expert data revealed that 3-5 s was an acceptable time range to complete the chest tube insertion. Participant level ranged from Post-graduate Year (PGY)-1 to PGY-6 with 13 total participants. Each individual was provided an introduction to the procedure and chest tube trainer. Force (N) and time (ms) measurements were obtained from entry through dermis to pleural space puncture. A significant pressure drop suggested puncturing through the chest wall (completion of the procedure). Results: Force data were captured during each phase of the procedure-linear, plateau, and drop. Linear phase (~3000 ms) was from start of procedure to point of maximum force (<30 N). Plateau phase was from maximum force to just before a drop in pressure. Drop phase was a drop in pressure by 5+ N in a span of 150 ms signaling completion of procedure. All participants were able to complete the task successfully. Force for pleural entry ranged from 17 N to 30 N; time to pleural entry ranged from 7500 to 15 000 ms. There was variability in use of all three sensors. All participants used the index sensor, however there was variability in the use of the loop sensors depending on the handedness of the participant. Left-handed users relied more on sensors 1 and 3 while right-handed users relied more on sensors 1 and 2. Given this variability, only force measurements from sensor 1 were used for assessment. Conclusions: This novel force-sensing chest tube trainer with continuous pressuring monitoring has a wide range of applications in simulation-based training of emergency surgical tasks. Next steps include evaluating its impact on accuracy and efficiency. Applications of real-time feedback measuring force are broad, including vascular access, trocar placement and other common procedures. Level of evidence: Level IV, prospective study.

Evaluating the Efficacy of Povidone-Iodine Solution Infection Prophylaxis in Immediate Tissue Expander-Based Breast Reconstruction: A Controlled Retrospective Analysis.

Background: There is currently no consensus among plastic surgeons regarding the optimal infection prophylaxis for immediate tissue expander placement following mastectomy. The goal of this study was to determine whether irrigation with 1 L of standard triple antibiotic solution (TAS) can achieve similar infection rates compared to a regimen of 180 mL of TAS with povidone-iodine solution (Betadine) painted on the field immediately prior to the placement of the expander. Methods: The 2 regimens were compared via retrospective propensity matching of all patients of the 2 senior authors who underwent bilateral tissue expander placement immediately following mastectomy with one of 3 mastectomy surgeons from January 2013 to December 2019 (n = 281). Groups were controlled for mastectomy surgeon, mastectomy type, mastectomy weight, age, race, body mass index, diabetes, hypertension, smoking, smoking status, prepectoral/subpectoral placement, use of acellular dermal matrix, operating room time, and duration of postoperative antibiotics. Results: Compared to the Betadine cohort (n = 65), the non-Betadine cohort (n = 65) experienced a similar rate of infections (13.8% vs 12.3%, P = 1.00), including major injections requiring intravenous antibiotic treatment (10.8% vs 9.2%, P = 1.00), after propensity matching. Infections in the non-Betadine cohort did not grow different bacteria on culture, require different antibiotic coverage, or result in prolonged duration of average antibiotic therapy (12.0 days vs 19.3 days, P = .19). Rates of subsequent expander washout and exchange (P = 1.00) and overall complications that required return to the operating room (P = .826) were similar between groups. Conclusion: The addition of Betadine solution to TAS added no benefit to infection prophylaxis or reduction of surgical complications in immediate tissue expander placement procedures.

Historique: Il n'y a pas de consensus entre les plasticiens au sujet de la prophylaxie optimale de l'infection lors de l'installation immédiate d'expanseurs tissulaires après une mastectomie. La présente étude visait à déterminer si l'irrigation à l'aide d'un litre de solution antibiotique triple (SAT) standard peut susciter un taux d'infection semblable à une posologie de 180 mL de SAT au moyen d'une solution de povidone-iode (BetadineMD) appliquée sur le champ opératoire immédiatement avant l'installation de l'expanseur. Méthodologie: Les chercheurs ont comparé les deux posologies par appariement rétrospectif des coefficients de propension de tous les patients des deux auteurs principaux, qui se sont fait installer des expanseurs tissulaires bilatéraux par l'un des trois chirurgiens ayant réalisé les mastectomies entre janvier 2013 et décembre 2019 (n=281). Les groupes ont été contrôlés en fonction du chirurgien ayant réalisé la mastectomie, du type et du poids de la mastectomie, de l'âge, de la race de l'indice de masse corporelle, du diabète, de l'hypertension, du tabagisme, du statut tabagique, de l'installation prépectorale ou subpectorale, du recours à une matrice dermique acellulaire, du temps passé en salle d'opération et de la durée de l'antibiothérapie postopératoire. Résultats: La cohorte qui n'avait pas pris de BetadineMD (n=65) a présenté un taux d'infection semblable à celle qui en avait pris (n=65; 12,3% par rapport à 13,8% p=1,00), y compris des injections majeures nécessitant une antibiothérapie par voie intraveineuse (9,2% par rapport à 10,8%, p=1,00) après l'appariement des coefficients de propension. Les infections dans la cohorte qui n'avait pas pris de BetadineMD n'ont pas révélé de bactéries différentes après la mise en culture, exigé une couverture antibiotique différente, ni entraîné une prolongation de la durée moyenne de l'antibiothérapie (12,0 jours par rapport à 19,3 jours, p=0,19). Le taux d'affaissement et d'échange subséquent des expanseurs (p =1,00) ainsi que le taux de complications globales qui ont entraîné un retour en salle d'opération (p = 0,826) étaient semblables entre les groupes. Conclusion: L'ajout d'une solution de BetadineMD à la SAT n'ajoutait rien à la prophylaxie de l'infection ni à la réduction des complications chirurgicales lors de l'installation immédiate d'expanseurs tissulaires.

Delayed graft function in pediatric living donor kidney transplantation.

BACKGROUND: Pediatric recipients of living donor kidneys have a low rate of delayed graft function (DGF). We examined the incidence, risk factors and outcomes of DGF in pediatric patients who received a living donor allograft. METHODS: The STARfile was queried to examine all pediatric patients transplanted with a living donor kidney between 2000 and 2020. Donor and recipient demographic data were examined, as were survival and outcomes. Recipients were stratified into DGF and no DGF groups. DGF was defined as the need for dialysis within the first week after transplant. RESULTS: 6480 pediatric patients received a living donor (LD) kidney transplant during the study period. 269 (4.2%) developed DGF post-transplant. Donors were similar in age, creatinine, and cold ischemia time. Recipients of kidneys with DGF were similar in age, sensitization status and HLA mismatch. Focal segmental glomerulosclerosis (FSGS) was the most common diagnosis in recipients with DGF, and allograft thrombosis was the most common cause of graft loss in this group. Small recipients (weight < 15 kg) were found to have a significantly higher rate of DGF. Length of stay doubled in recipients with DGF, and rejection rates were higher post-transplant. Recipients of LD kidneys who developed DGF had significantly worse 1 year allograft survival (67% vs. 98%, p < .0001). CONCLUSIONS: Pediatric living donor kidney transplant recipients who experience DGF have significantly poorer allograft survival. Optimizing the donor and recipient matching to avoid compounding risks may allow for better outcomes.

Normothermic Machine Perfusion in pediatric liver transplantation: A survey of attitudes and barriers.

BACKGROUND: NMP provides a superior strategy for the assessment and preservation of marginal donor livers and has demonstrated increased utilization and enhances organ quality when used in adult liver transplantation. We aimed to evaluate the interest of incorporating the use of NMP in pediatric liver transplantation. METHODS: An anonymous online survey was distributed to pediatric transplant surgeons and hepatologists across the United States. Respondent demographic information, attitudes toward NMP in pediatric liver transplantation, and barriers to utilization were examined. RESULTS: Thirty-two providers (18 transplant surgeons and 14 hepatologists) completed the survey, yielding a response rate of 64%. Half (50%) of respondents indicated prior exposure to NMP. Overall, 96% of respondents believed there was benefit to using NMP in pediatric liver transplantation. DCD (68%) and post-cross-clamp (75%) grafts were the greatest opportunity for NMP use. A role in splitting livers ex vivo (71%) was also seen as a potential major opportunity. Cost was perceived as a barrier to implementation (36%), followed by institutional factors (32%). Cost tolerance was significantly greater in respondents residing in OPTN regions with greater than median wait times (63% vs. 11% in OPTN regions with greater vs. shorter wait times, p = .010). CONCLUSIONS: There is significant interest within the pediatric liver transplant community for NMP to expand the donor pool. Interest appears particularly strong in regions where wait times for suitable pediatric donors are prolonged.

Rescue of an asymptomatic arterial occlusion after kidney transplant.

Arterial injury leading to vascular occlusion is a rare complication of kidney transplantation that requires urgent intervention to salvage the kidney and prevent graft loss. Occasionally, the recipient iliac vessels may be injured, resulting in acute ischaemia of the lower extremity in addition to loss of blood flow to the kidney transplant. In the case presented here, a 58-year-old man with chronic kidney disease secondary to IgA nephropathy underwent pre-emptive deceased donor renal transplantation complicated by an external iliac artery (EIA) dissection proximal to the transplant anastomosis. However, as a result of retrograde blood flow from collateral vessels, perfusion of the kidney and right lower extremity was initially preserved and early diagnosis was made after post-transplant ultrasound. This report reviews the aetiology, clinical features and therapeutic options for arterial injuries post-transplant. This case also highlights the importance of post-transplant vigilance and the value of routine postoperative ultrasound imaging.

Translating Access to Outcomes: The Impact of Socioeconomic Status on Completion of Breast Reconstruction at a National Cancer Institute (NCI)-Designated Cancer Center: Impact of SES on Completion.

The purpose of this study was to determine the impact of socioeconomic status (SES) on the completion of breast reconstruction, as defined by the percent of patients undergoing NAC reconstruction. Patients (n=949) who underwent primary breast reconstruction following a mastectomy recorded from 2007 to 2017 were divided into groups based on the median household income of their residential zip code (>/< $67,640). A three-step protocol was designed to (1) broadly compare between patients of low and high SES who were stratified by race and reconstruction type, (2) compare a smaller subset of low SES and high SES patients via propensity matching for demographic, baseline health, and oncologic factors, and (3) elucidate the strongest predictors of non-completion and delayed completion among low SES patients. Patients of lower SES appear less likely to complete NAC reconstruction, especially following staged reconstruction. That this finding presents in staged, but not immediate reconstruction, and disappears with propensity matching for oncologic factors suggests that reduced completion in patients of low SES may be attributable to advanced cancer staging and aggressive adjuvant therapy. Furthermore, expander conversion to autologous reconstruction significantly increased the likelihood of NAC reconstruction in multivariable analysis, and adjuvant radiation therapy significantly increased the time to NAC reconstruction. Further investigation will solidify the relationship between SES, cancer staging, and completion of reconstruction in a multi-site patient population. Larger multivariable analyses may also uncover other factors that can be modified or addressed to increase completion and optimize reconstruction for patients at risk of discontinuation.

Prepectoral versus Subpectoral Tissue Expander Breast Reconstruction: A Historically Controlled, Propensity Score-Matched Comparison of Perioperative Outcomes.

BACKGROUND: The rising popularity of prepectoral tissue expander placement with acellular dermal matrices in immediate breast reconstruction has prompted many studies on the safety of this technique. However, a comprehensive propensity-matched, historically controlled trial comparing perioperative outcomes following prepectoral versus partial subpectoral (dual-plane) placement of tissue expanders is lacking. METHODS: Retrospective propensity-matched cohort analysis was performed on all patients of two senior reconstructive surgeons who underwent bilateral tissue expander placement following a mastectomy with one of three breast surgeons at a single academic institution from 2012 onward (n = 260). Two matched groups (prepectoral and partial subpectoral) each consisted of 102 patients. Univariate and multivariable analyses were also performed to contextualize the risks associated with prepectoral reconstruction relative to demographic characteristics and other clinical factors. RESULTS: Compared to dual-plane subpectoral placement, prepectoral placement resulted in similar rates of overall perioperative complications (32 percent versus 31 percent; p = 1.00) and perioperative complications that required operative treatment (21 percent versus 21 percent; p = 1.00). There were no significant differences between the groups in complication rates for hematomas, seromas, impaired wound healing, and infection. Although prepectoral placement was associated with prolonged time to drain removal, those patients completed the expansion process twice as fast, were expanded further in the operating room, and were more than twice as likely to forgo clinic-based expansion. Prepectoral reconstruction was not associated with increased risk for any complications in univariate or multivariable analysis. CONCLUSIONS: Prepectoral tissue expander placement permitted greater intraoperative filling of expanders and a reduced likelihood of clinic-based expansion, with no increase in adverse outcomes compared to partial subpectoral placement. Adoption of this technique may reduce unnecessary clinic visits; shorten the delay before adjuvant therapy; and minimize patient apprehension, pain, and discomfort related to clinic-based expansion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Crowdsourced Assessment of Aesthetic Outcomes after Breast Reconstruction.

BACKGROUND: Evaluating the aesthetic success of breast reconstruction can be difficult. Patients, surgeons, and the general population may differ in what constitutes a successful outcome. Recently, crowdsourcing has emerged to accumulate and analyze data on a massive scale. The authors propose that crowdsourcing can be a useful tool to reliably rate aesthetic outcomes of breast reconstruction. METHODS: One hundred one deidentified photographs of patients at various stages of breast reconstruction were gathered. Assessment tools included a five-point Likert scale and the transverse rectus abdominis myocutaneous (TRAM) visual assessment scale. Anonymous crowd workers and a group of expert reconstructive surgeons rated an identical set of photographs on the Likert scale. Crowd workers also rated the set of photographs on the TRAM scale. RESULTS: The authors obtained 901 anonymous, layperson evaluations on both Likert and TRAM scales. Crowdsourced assessment data collection took 28.6 hours. Expert assessment took 15 months. Expert and crowdsourced scores were equivalent on the Likert scale (overall interrater reliability, κ = 0.99; 95 percent CI, 0.98 to 0.99). Intrarater reliability among each subcomponent was highly reproducible for the crowd (r = 0.98; 95 percent CI, 0.97 to 0.99) and experts (r = 0.82; 95 percent CI, 0.77 to 0.87). Breast contour and positioning were most predictive of overall aesthetic result. Skin patch and scar were least predictive of overall aesthetic appearance. CONCLUSIONS: Aesthetic outcomes rated by crowds were reliable and correlated closely with those by expert surgeons. Crowdsourcing can be a rapid, reliable, and valid way to assess aesthetic outcomes in the breast reconstruction patient.

Use of Scaffolding Tissue Biografts To Bolster Vesicourethral Anastomosis During Salvage Robot-assisted Prostatectomy Reduces Leak Rates and Catheter Times.

BACKGROUND: One of the key factors contributing to morbidity associated with salvage radical prostatectomy is a significant vesicourethral anastomosis (VUA) disruption or postoperative tissue dehiscence in the region of the distal bladder neck that causes a large prolonged urinary leak, perineal pain, and delayed catheter removal. OBJECTIVE: To describe our surgical technique using a urinary bladder extracellular matrix (UB-ECM) scaffold incorporated into the base of the VUA and the distal bladder neck during salvage robot-assisted radical prostatectomy (sRARP) and to assess outcomes and safety. DESIGN, SETTING, AND PARTICIPANTS: From March to July 2015, 15 patients underwent sRARP performed after primary therapy failure by a single surgeon. Two other groups were identified via analysis of propensity score matching. Group 2 (n=45) underwent sRARP with standard suturing without use of the graft. Group 3 (control group; n=45) underwent primary RARP with no graft placement. These two groups were compared group 1 (n=15), in which patients underwent sRARP and received the scaffold in a 1:3:3 match. SURGICAL PROCEDURE: sRARP with use of a UB-ECM scaffold in the posterior aspect of the VUA and distal bladder neck. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Clinical data were prospectively collected in a customized database and retrospectively analyzed. Analysis of variance and Student's t-test were used to test the equality of means for continuous variables, while the χ2 test was used to test categorical variables. RESULTS AND LIMITATIONS: There were no anastomotic leaks in the control group, with an average catheter time of 6.3 d (5-7 d). However, a clinically significant VUA/bladder neck disruption was observed in 16 patients (35.5%) in group 2, with a median catheterization time of 17.4 d (9-47 d), while in group 1 only one patient (6.66%) had a significant anastomotic leak on cystography (p=0.045), with median catheterization time of 11.2 d (10-52 d) for this group (p<0.05). CONCLUSIONS: Incorporation of a UB-ECM scaffold into the base of the VUA and distal bladder neck should be considered as an option to decrease morbidity associated with sRARP since it decreased the rate of VUA disruption, enhanced healing, and reduced catheterization time. This technique could be a valuable tool for all surgeons performing sRARP. PATIENT SUMMARY: We investigated the use of a scaffolding tissue graft when connecting the urethra to the bladder during salvage robot-assisted laparoscopic prostatectomy. This technique was found to be effective and safe.