Research Spotlight

Bresalier, R. S. and R. F. Souza (2018). “A Goblet (Cell) Half Full: What Do We Really Know About Barrett’s Esophagus-A Tribute to Emmet Keeffe.” Dig Dis Sci 63(8): 1985-1987.

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Introduction to a special issue of Digestive Diseases and Sciences, concerning Barrett’s esophagous. (No abstract available.)

Bianchi, J., G. M. Porciuncula, L. Koerich, J. Ignacio, L. M. Wolford and J. R. Goncalves (2018). “Three-dimensional stability analysis of maxillomandibular advancement surgery with and without articular disc repositioning.” J Craniomaxillofac Surg 46(8): 1348-1354.

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This retrospective cohort study aimed to assess, three-dimensionally, mandible and maxilla changes following maxillomandibular advancement (MMA), with and without repositioning of TMJ articular discs. The sample comprised cone-beam computed tomography data from 32 subjects: group 1 (n = 12) without disc displacement and group 2 (n = 20) with bilateral disc repositioning. An automatic cranial base superimposition method was used to register the images at three time points: T1 (preoperative), T2 (postoperative), and T3 (at least 11 months follow-up). To assess surgical changes (T2-T1) and adaptive responses (T3-T2), the images were compared quantitatively and qualitatively using the shape correspondence method. The results showed that surgical displacements were similar in both groups for all the regions of interest except the condyles, which moved in opposite directions – group 1 to superior and posterior positions, and group 2 to inferior and anterior positions. For adaptive responses, we observed high individual variability, with lower variability in group 2. Sagittal relapse was similar in both groups. In conclusion, there were no significant differences in skeletal stability between the two groups. The maxillomandibular advancement surgeries, with rotation of the occlusal plane, had stable results for both groups immediately after surgery and at 1-year follow-up.

Beteck, B., W. Shutze, B. Richardson, R. Shutze, K. Tran, A. Dao, G. O. Ogola and G. Pearl (2018). “Comparison of athletes and non-athletes undergoing thoracic outlet decompression for neurogenic TOS.” Ann Vasc Surg Aug 3. [Epub ahead of print].

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BACKGROUND: Neurogenic thoracic outlet syndrome (NTOS) is the most common form of TOS and may occur from injury, occupational stress or athletic endeavors. While most patients with NTOS will improve after first rib resection and scalenectomy (FRRS), the prognostic risk factors for success remain unclear. Athletes are a very motivated and disciplined demographic and therefore should be a group more likely to respond to FRRS for NTOS than non-athletes. We hypothesized that athletes would do better after FRRS than non-athletes despite the added physical stress that sporting activity imposes. METHODS: We reviewed our office records for all patients treated for TOS from July 2009 to May 2014, and extracted demographic, historical, procedural, and follow-up data. We contacted these patients to complete a survey to assess patient-centered outcomes of FRRS, and compared athlete versus non-athlete survey responses. RESULTS: 564 patients had FRRS for NTOS, and 184 (33%) responded to the survey. Of the 184 who responded, 97 were athletes (53%) and 87 were non-athletes (47%). Survey results suggested that 87% were improved in pain medication use (athletes 93% vs. non-athletes 80%, p=0.013), 77% would undergo FRRS on the contralateral side if needed (athletes 75% vs non-athletes 79%, p= 0.49), 73% had resolution of TOS symptoms (athletes 80% vs. non-athletes 65%, p=0.02), 86% could perform activities of daily living without limitation (athletes 95% vs. non-athletes 77%, p=0.0004). Although 24% of respondents required another non-TOS procedure (athletes 27% vs. non-athletes 22%, p=0.6), 89% felt that they had made the right decision (athletes 93% vs. non-athletes 80%, p=0.09). Multivariable analysis of age, race, gender, previous surgery, pre-operative physical therapy, preoperative narcotic use, and athletic status confirmed that athletic status was a significant predictor for improvement in pain medication use, complete TOS resolution, and the ability to perform activities of daily living. CONCLUSION: Most patients undergoing FRRS for NTOS are improved and satisfied with the result and indicate they made the correct choice to have FRRS. While being an athlete was an independent variable for better outcomes in activity and pain medication use, their satisfaction following FRRS was similar to that in non-athletes. Further investigation is needed to determine if these findings are due to physical and/or psychosocial factors.

Bayer, J., C. A. Moulton, K. Monden, R. M. Goldstein, G. J. McKenna, G. Testa, R. M. Ruiz, T. L. Anthony, N. Onaca, G. B. Klintmalm and P. T. W. Kim (2018). “The role of multiorgan procurement for abdominal transplant in general surgery resident education.” Am J Surg 216(2): 331-336.

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BACKGROUND: To assess the impact of participation of multiorgan procurement (MP) by general surgery (GS) residents on surgical knowledge and skills, a prospective cohort study of GS residents during transplant surgery rotation was performed. METHODS: Before and after participation in MPs, assessment of knowledge was performed by written pre and post tests and surgical skills by modified Objective Structured Assessment of Technical Skill (OSATS) score. Thirty-nine residents performed 84 MPs. RESULTS: Significant improvement was noted in the written test scores (63.3% vs 76.7%; P < 0.001). Better surgical score was associated with female gender (15.4 vs 13.3, P = <0.01), prior MP experience (16.2 vs 13.7, P = 0.03), and senior level resident (15.1 vs 13.0, P = 0.03). Supraceliac aortic dissection (P = 0.0017) and instrument handling (P = 0.041) improved with more MP operations. CONCLUSIONS: Participation in MP improves residents' knowledge of abdominal anatomy and surgical technique.

Arsalan, M., W. K. Kim, A. Van Linden, C. Liebetrau, B. D. Pollock, G. Filardo, M. Renker, H. Mollmann, M. Doss, U. Fischer-Rasokat, A. Skwara, C. W. Hamm and T. Walther (2018). “Predictors and outcome of conversion to cardiac surgery during transcatheter aortic valve implantation.” Eur J Cardiothorac Surg 54(2): 267-272.

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OBJECTIVES: Due to increasing clinical experience with transcatheter aortic valve implantation (TAVI) procedures, sophisticated imaging and advanced device technology, TAVI complication rates are low; however, patients requiring conversion to surgery are confronted with an increased mortality risk. In this retrospective study, we evaluated the predictors for conversion and the outcomes of these patients. METHODS: We analysed the records of all patients undergoing TAVI in our centre from 2011 to 2016 and focused on cases that required conversion to sternotomy. We investigated reasons and risk factors for conversion as well as 30-day and 1-year outcomes. RESULTS: During the study period, 32 (2.1%) of 1775 patients undergoing TAVI required immediate conversion to sternotomy. Annular rupture (5 of 32; 16%), device embolization (9 of 32; 28%) and pericardial tamponade (15 of 32; 47%) were the most common reasons for conversion. Usage of a self-expandable valve showed to be the only predictor for conversion (odds ratio 0.38, 95% confidence interval 0.16-0.90; P = 0.03). Survival at 30 days and 1 year was 56% and 41%, respectively. Patients who survived 30 days after conversion showed higher preoperative ejection fraction, shorter duration of surgery and shorter perfusion time. CONCLUSIONS: In this high-volume, single-centre experience, conversion to sternotomy during TAVI occurred in about 2%, with annular rupture, device embolization and pericardial tamponade being the most common causes. Complications requiring conversion showed to be unpredictable. However, in view of these life-threatening complications, the 30-day survival rate exceeding 50% emphasizes the importance of an experienced and well-attuned heart team providing immediate access to surgical bailout procedures.