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Surgical Anatomy of Carotid and Vertebral Arteries
No full textArterial supply to the brain is from the internal carotid arteries and vertebral arteries coursing on either side of the neck. These arteries arise as branches of the brachiocephalic trunk, left common carotid, and left subclavian arteries. The latter are also called supra-aortic trunks and arise from the arch of the aorta. The brachiocephalic trunk divides into the right subclavian artery and the right common carotid artery (CCA). Each CCA divides near the angle of the jaw into the external and internal carotid arteries. The internal carotid artery divides intracranially into the anterior and middle cerebral artery, which supplies anterior two-thirds of the brain. Both vertebral arteries arise from the first portion of the subclavian artery and ascend to enter the transverse foramina of the cervical vertebrae and then enter the skull and join together to form the basilar artery. The terminal branches of the basilar artery are two posterior cerebral arteries supplying posterior one-third of the brain. The common carotid artery and internal carotid artery with the internal jugular vein are contained within the carotid sheath which also includes the vagus nerve. Other important nerves in the neck are hypoglossal, ansa cervicalis, superior laryngeal, glossopharyngeal, and spinal accessory nerve. There are many anatomic variations in the arteries and nerves of the neck. Occasionally, there are persistent embryological carotid-basilar connections. These variations have important surgical implications
Carotid Endarterectomy for High Plaque and Interposition Grafting
No full textHigh plaque in a patient undergoing carotid endarterectomy is defined as extending to the level of second cervical vertebral body. In majority of cases, high plaque can be diagnosed by CT angiography of the neck. Distal exposure of the internal carotid artery is facilitated by division of sternocleidomastoid branch of occipital or occipital artery itself and division of post belly of digastric and stylohyoid muscle. Mandibular subluxation to obtain distal exposure of ICA may be necessary. There is higher incidence of cranial nerve palsy in patients undergoing CEA for high plaque. Carotid interposition grafting (CIG) is an uncommon operation as compared to carotid endarterectomy (CEA). The exposure is similar to CEA for high plaque. In some patients, distal control of the ICA may necessitate balloon occlusion. Interposition graft material can be a tapered PTFE graft, great saphenous vein graft, or superficial femoral artery conduit in patients with head and neck malignancy invading the carotid artery. Distal anastomosis of the graft to the divided ICA is performed first followed by proximal anastomosis of the divided CCA to the graft. The external carotid artery is usually ligated
Caregiver worry about COVID-19 as a predictor of social mitigation behaviours and SARS-CoV-2 infection in a 12-city U.S. surveillance study of households with children
No full textOBJECTIVE: Understanding compliance with COVID-19 mitigation recommendations is critical for informing efforts to contain future infectious disease outbreaks. This study tested the hypothesis that higher levels of worry about COVID-19 illness among household caregivers would predict lower (a) levels of overall and discretionary social exposure activities and (b) rates of household SARS-CoV-2 infections. METHODS: Data were drawn from a surveillance study of households with children (N = 1913) recruited from 12 U.S. cities during the initial year of the pandemic and followed for 28 weeks (data collection: 1-May-2020 through 22-Feb-2021). Caregivers rated how much they worried about family members getting COVID-19 and subsequently reported household levels of outside-the-home social activities that could increase risk for SARS-CoV-2 transmission at 14 follow-ups. Caregivers collected household nasal swabs on a fortnightly basis and peripheral blood samples at study conclusion to monitor for SARS-CoV-2 infections by polymerase chain reaction and serology. Primary analyses used generalized linear and generalized mixed-effects modelling. RESULTS: Caregivers with high enrollment levels of worry about COVID-19 illness were more likely to reduce direct social contact outside the household, particularly during the U.S.\u27s most deadly pandemic wave. Households of caregivers with lower COVID-19 worry had higher odds of (a) reporting discretionary outside-the-home social interaction and (b) SARS-CoV-2 infection. CONCLUSIONS: This was, to our knowledge, the first study showing that caregiver COVID-19 illness worry was predictive of both COVID-19 mitigation compliance and laboratory-determined household infection. Findings should inform studies weighing the adaptive value of worrying about infectious disease outbreaks against established detrimental health effects
Photodynamic Therapy: Overview and Mechanism of Action
No full textPhotodynamic therapy (PDT) is a versatile treatment with diverse applications in dermatology. PDT combines photosensitizers, most commonly 5-aminolevulinic acid (ALA) or methyl aminolevulinate (MAL), and a light source, such as light-emitting diodes (LEDs), fluorescent bulbs, lasers, flash lamps, or sunlight, in the presence of molecular oxygen to induce therapeutic effects primarily through singlet oxygen and reactive oxygen species generation. Downstream cellular and physiological effects include apoptosis, necrosis, and immune modulation. PDT efficacy depends on photosensitizer parameters, including photosensitizer type, concentration, dosing, temperature, and incubation time, and light source parameters such as light source, power density, wavelength, and fluence. PDT is generally safe and well tolerated; potential adverse effects such as pain and erythema are typically mild and self-limiting. Part I of this Continuing Medical Education (CME) provides a foundational overview of PDT principles, including mechanisms of action, photosensitizers, and light sources
Carcinoid Heart Disease: A Rare Complication of Metastatic Neuroendocrine Tumor
No full textCarcinoid heart disease (CHD), also known as Hedinger syndrome, is a rare but significant cardiac complication associated with metastatic neuroendocrine tumors (NETs). These tumors secret bioactive substances such as serotonin, leading to fibrotic changes primarily affecting the right-sided heart valves. A case study involving a 69-year-old male presented with a four-month history of diarrhea and a new systolic heart murmur. Transthoracic echocardiogram (TTE) results indicated a left ventricular ejection fraction (LVEF) of 60% to 65%, with severe tricuspid regurgitation and pulmonary valve stenosis. Elevated levels of 5-hydroxyindoleacetic acid (5-HIAA) were detected in a 24-hour urine test, and imaging revealed multiple hypoechoic masses in the liver and mesenteric masses adherent to the small intestine. Furthermore, a biopsy confirmed the diagnosis of a NET. Medical therapy like long-acting somatostatin injection and a peptide receptor radionuclide therapy was ineffective in reversing established valvular pathology, and the patient continued to experience clinical decline, suffering from right-sided heart failure. The patient was able to undergo combined tricuspid and pulmonary valve replacement, which resolved his symptoms. This case exemplifies the successful treatment of a rare syndrome leading to right heart failure
Achilles Rupture Repair: Modified Gift-Box With a Proximal Myotendinous Backup Fixation Technique
No full textAchilles tendon tears are not an uncommon injury, with a predominance in explosive athletes and weekend warriors in the third to fifth decade of life. Consideration of operative intervention is commonplace in young athletes, whereas less active and older individuals may opt for nonsurgical treatment. Surgical treatment is reported to improve functional outcomes in high-demand individuals and demonstrates increased plantarflexion power, better return to sports rates, and a reduced rerupture rate. Traditionally, a primary end-to-end repair of the Achilles tendon was the surgical treatment of choice. More recently, alternative advanced techniques and minimally invasive constructs have been proposed in an effort to improve repair construct while reducing soft tissue complications. This technical note describes a technique that combines a modified gift-box primary repair with backup fixation using calcaneal anchors. This technique is performed with a small, medially based incision that reduces wound and nerve complications, while promoting end-to-end tendon healing by reducing tension across the repair site through the calcaneal backup fixation
Arthroscopic rotator cuff repair with bioinductive patch achieves equivalent patient-reported outcomes and retear rate at 1 year
No full textPURPOSE: The purpose of this study was to evaluate the safety and efficacy of a bioinductive patch augmentation following arthroscopic rotator cuff repair (RCR) in terms of patient-reported outcomes, motion, and complications stratified by tear size.
METHODS: A retrospective review of patients undergoing primary RCR with and without bioinductive bovine collagen patch augmentation for supraspinatus/infraspinatus tears from 2014 to 2022 at two centers was performed. Exclusion criteria included: age \u3c 18 years, revisions, or lack of 6-month postoperative follow-up. Patients were propensity-score matched 2:1 to patch-augmented patients based on age, sex, BMI, and tear size. Outcomes were compared between the patch and control groups after being stratified by tear size.
RESULTS: A total of 125 patients patch augmented RCRs were matched to 250 controls. No significant differences in demographics or comorbidities between groups. Following stratification by tear size, VAS for partial and small/medium tears in the patch cohorts were lower (p = 0.02) at 3 months. Functional scores were not statistically different. Patch-augmented partial and small/medium tears showed increased forward elevation (p \u3c 0.05) at 1-year follow-up. Retear rates were statistically similar.
CONCLUSIONS: Bioinductive patch augmentation demonstrates equivalent outcomes for pain and function, retear rate, but is associated with improved forward elevation up to 1-year for partial and small/medium tears.
LEVEL OF EVIDENCE: Level III, retrospective cohort study
Variation in opioid-free discharge after metabolic surgery from 2018 to 2023: a state-wide analysis from the Michigan Bariatric Surgery Collaborative
No full textBACKGROUND: Efforts have been made to reduce opioid prescribing after metabolic-bariatric surgery (MBS) given the increased risk for misuse. Variation in prevalence of opioid-free discharge following MBS and its impact on outcomes remains unclear.
OBJECTIVES: To evaluate variation in opioid prescribing practices after MBS and the impact of opioid-free discharge on outcomes.
SETTING: MBS programs participating in a state-wide quality improvement collaborative.
METHODS: Using a state-wide bariatric-specific data registry, all patients who underwent MBS between 2018 and 2023 and had opioid prescribing data were identified (n = 54,276). Patient characteristics and 30-day risk-adjusted outcomes were compared between patients who were and were not prescribed opioids at discharge. Surgeon and practice characteristics were also compared between the top and bottom quartiles of opioid-free discharge.
RESULTS: The prevalence of opioid-free discharge increased from 7.7% to 32.1% over the study period. Only .4% of patients, who were opioid-free at discharge, obtained an opioid prescription within 30 days of discharge. Opioid-free discharge was associated with lower rates of emergency department (ED) visits (7.7% vs 8.2%, P = .0008), despite similar complication rates (7.6% vs 7.3%, P = .7261). There were no significant differences in age, case volume, or practice types between surgeons in the top quartile and bottom quartile for opioid-free discharge.
CONCLUSIONS: Opioid-free discharge after MBS has increased in prevalence with extremely low failure rates without negatively impacting ED visit rates. Variation in opioid prescribing persists and may be due to patient-specific factors as well as surgeon-specific preference
Development of Patient-Specific Nomogram to Assist in Clinical Decision-Making for Single Port Versus Multi-Port Robotic Partial Nephrectomy: A Report from the Single Port Advanced Robotic Consortium
No full textObjective: To develop a patient-specific algorithm to better guide clinical decision-making when considering between single port (SP) and multi-port (MP) robotic partial nephrectomy (RPN).
Materials and Methods: A retrospective review was performed on the institutional review board-approved, prospectively maintained multi-institutional database of the Single Port Advanced Research Consortium to identify all consecutive patients who underwent SP and MP-RPN between 2019 and 2023. Baseline clinicodemographic variables were used to identify the significant predictors of SP-RPN. The significant variables were used to construct a nomogram to predict the likelihood of SP vs MP-RPN.
Results: Of the 1021 patients included in our analysis, 189 (18.5%) and 832 (81.5%) underwent SP and MP-RPN, respectively. Statistically significant predictors of SP-RPN included a lower comorbidity profile, a significant abdominal surgical history as characterized by a higher Hostile Abdomen Index, as well as tumors of lower complexity. The nomogram generated using the aforementioned variables demonstrated a reasonable performance with an area under the curve of 0.79. An optimal cutoff point was determined, with likelihood ratios above 0.12 indicating a preference for SP-RPN. Of note, all SP-RPN cases that scored above the 0.12 cutoff exhibited improved perioperative outcomes, including shorter ischemia time and less intraoperative blood loss.
Conclusions: In this study, we have devised a novel patient selection nomogram aimed at enhancing clinical decision-making within the expanding repertoire of RPN approaches. The findings highlighted in this study offer valuable guidance to facilitate appropriate patient selection and thereby ensuring favorable perioperative outcomes associated with RPN procedures
Impact of transperitoneal anterior, retzius-sparing, extraperitoneal, transvesical and perineal approaches on urinary continence recovery after robot-assisted radical prostatectomy: a systematic review and meta-analysis of comparative studies
No full textBACKGROUND: Urinary incontinence significantly impacts on health-related quality of life of patients undergoing radical prostatectomy. In the last decades, several approaches (extraperitoneal, Retzius-sparing (RS), perineal and, transvesical) for robot-assisted radical prostatectomy (RARP) have proposed with the aim to improve functional outcomes in comparison with transperitoneal, anterior ones.
METHODS: We performed a systematic review and meta-analysis of studies published in English language, in the last ten years, comparing the different approaches used to perform RARP. We included only studies reporting urinary continence rates at different follow-up time points. From each eligible study, we extracted the number of analyzed patients; the study design; the continence definition; and, when available, immediate, 1-, 3-, 6-, and 12-mo urinary continence rates. Statistical analyses were performed using RevMan version 5.4 (Cochrane Collaboration, Oxford, United Kingdom, UK). The Odds Ratio (OR) with 95% confidence intervals (CIs) was calculated using the generic inverse variance. A p value of \u3c 0.05 was set as significance level when comparing studies.
RESULTS: The meta-analyses of studies comparing anterior, transperitoneal RARP and RS-RARP in terms of immediate (OR = 3.73; 95% CI: 2.17-6.43; p \u3c 0.0001), 1-mo (OR = 4.16; 95% CI: 2.68-6.48; p \u3c 0.00001), 3-mo (OR 4.71; 95% CI: 3.70-6.00; p \u3c 0.0001), 6-mo (OR 4.12; 95% CI: 2.95-5.75; p \u3c 0.00001) and 12-mo (OR = 3.25; 95% CI: 1.76-5.99; p \u3c 0.00001) urinary continence rates showed a statistically significant advantage in favor of RS approach. However, a sub-analysis of Randomized Controlled Trials showed overlapping urinary continence rates between the two approaches at 6-mo (OR = 1.99; 95% CI: 0.90-4.42; p = 0.09) and 12-mo (OR = 1.36; 95% CI: 0.43-4.31; p = 0.60) after surgery. The meta-analysis of studies comparing extraperitoneal and transperitoneal approaches showed that 6-mo urinary continence rates were overlapping between the two approaches (OR = 1.18; 95% CI: 0.85-1.65; p = 0.32). The meta-analysis of studies comparing single-port (SP) and multi-port (MP) RARP showed comparable 6-mo urinary continence rates (OR = 0.93; 95% CI 0.65-1.33; p = 0.69).
CONCLUSIONS: Within the limitations of mainly low to moderate quality of evidence, the RS approach offers significant advantages compared to an anterior, transperitoneal, approach in terms of urinary continence recovery at different follow-up time points in patients who underwent MP-RARP. MP perineal and transvesical approaches need to be further tested and might be of interest in the setting of SP-RARP. Our meta-analysis showed comparable results between SP- and MP-RARP in terms of urinary continence rates