[Posted 22/Jul/2024]

AUDIENCE: General Surgery, Dermatology, Family Medicine

KEY FINDINGS: Skin graft reperfusion is a protracted process that evolves differently in the graft centre and periphery, influenced by postoperative time and anatomic location. A better knowledge of this process can potentially enhance the development of strategies to induce vessel ingrowth into tissue-engineered skin substitutes.

BACKGROUND: Under optimal conditions, afferent and efferent human skin graft microcirculation can be restored 8-12 days postgrafting. Still, the evidence about the reperfusion dynamics beyond this period in a dermato-oncologic setting is scant. Authors aimed to characterise the reperfusion of human skin grafts over 4 weeks according to the necrosis extension (less than 20%, or 20%-50%) and anatomic location using laser speckle contrast imaging (LSCI).

DETAILS: Over 16 months, all eligible adults undergoing skin grafts following skin cancer removal on the scalp, face and lower limb were enroled. Perfusion was assessed with LSCI on the wound margin (control skin) on day 0 and on the graft surface on days 7, 14, 21 and 28. Graft necrosis extension was determined on day 28. Forty-seven grafts of 47 participants were analysed. Regardless of necrosis extension, graft perfusion equalled the control skin by day 7, surpassed it by day 21, and stabilised onwards. Grafts with less than 20% necrosis on the scalp and lower limb shared this reperfusion pattern and had a consistently better-perfused centre than the periphery for the first 21 days. On the face, the graft perfusion did not differ from the control skin from day 7 onwards, and there were no differences in reperfusion within the graft during the study.

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Source: Pinho, A., Brinca, A., Xara, J., et al. (2024). Postoperative Time and Anatomic Location Influence Skin Graft Reperfusion Assessed With Laser Speckle Contrast Imaging. Lasers in Surgery and Medicine. 2024; 56(6): 564-573. Published: August, 2024. DOI: 10.1002/lsm.23815.

A Systematic Review

[Posted 20/May/2024]

AUDIENCE: Nursing

KEY FINDINGS: Despite the promising results for fascia iliaca compartment block and methylprednisolone, there is limited knowledge regarding evidence-based delirium prevention interventions. Most studies had small sample sizes indicating that the current evidence is exploratory. There is an urgent need for the funding and conduct of trials to test preventative interventions for older surgical patients at intermediate to high risk of developing delirium.

BACKGROUND: Few reviews have addressed delirium prevention among intermediate to high-risk older surgical patients. Purpose of this study is to map preoperative delirium prevention interventions for older surgical patients at intermediate to high risk of developing delirium, assess outcomes and identify gaps in knowledge.

DETAILS: A systematic search was conducted of the literature published from 1990 to October 2022 in Medline, CINAHL and Ageline and of the grey literature in Google Scholar. Randomised controlled trials were retrieved that assessed the effectiveness of preoperative delirium prevention interventions for older surgical patients at intermediate to high risk of delirium. Data were extracted using a data extraction tool, and results were tabulated. Studies were assessed for bias using the Cochrane Collaboration Risk of Bias tool. Twenty-one studies met the selection criteria including N = 5096 participants. Two studies tested cognitive training, two studies tested fascia iliaca compartment block and one study assessed femoral nerve block. Ten studies tested prophylactic medications including methylprednisolone. Five studies investigated geriatric assessment and management. One study assessed transcutaneous electrical acupoint stimulation. In the two studies testing fascia iliaca compartment block, there was a reduction in postoperative delirium for orthopaedic patients. Methylprednisolone reduced postoperative delirium in orthopaedic patients and in those undergoing gastrointestinal surgery. Results of all other interventions on the occurrence of postoperative delirium and additional outcomes including the severity and duration of delirium were inconclusive.

Copyright © John Wiley & Sons Ltd. All rights reserved.

Source: Lay, N., Foley, P., and Allen, J. (2024). The Effectiveness Of Preoperative Delirium Prevention In Intermediate To High-Risk Older Surgical Patients: A Systematic Review. J Clin Nurs. 2024; 33(5): 1666-1683. Published: May, 2024. DOI: 10.1111/jocn.17020.

A Real-World Clinical Study of 126 Patients

[Posted 19/Mar/2024]

AUDIENCE: General Surgery, Family Medicine

KEY FINDINGS: FMR is a safe and effective treatment modality for improving facial atrophic acne scars, and the number of FMR treatment sessions and pulse width are associated with clinical efficacy.

BACKGROUND: Purpose of this study is to analyze the clinical efficacy and safety of fractional microneedle radiofrequency (FMR) for facial atrophic acne scars in a real-world setting.

DETAILS: The clinical data of patients with atrophic acne scars who had received FMR therapy from February 2018 to August 2022 were retrospectively analyzed. The improvement of atrophic acne scars was assessed using the ECCA Grading Scale (échelle d'évaluation clinique des cicatrices d'acné), Global Aesthetic Improvement Scale (GAIS), and modified Manchester Scar Scale (mMSS). Adverse reactions during FMR treatment were also recorded. Univariate and multivariate logistic regression analyses were performed to evaluate the efficacy and safety of FMR for atrophic acne scars. A total of 126 patients with facial atrophic acne scars were included. A total of 590 FMR treatment sessions were accomplished, with each of 82 patients receiving 4 or more treatment sessions, and 1 receiving a maximum of 14 sessions. All patients showed improvement in symptoms after FMR treatment, with moderate to significant improvement (ECCA score reduction of 26%–100%) in 92 (73.0%) patients. As the number of treatment sessions increased, the ECCA score gradually decreased from an average of 85.6 before to 35.0 after FMR. The average scores for distortion, color, and visual analogue scale (VAS) of mMSS all showed certain reductions. The change in GAIS score indicated improvement after treatment, with minimal improvement in 16 patients (12.7%), good improvement in 57 patients (45.2%), significant improvement in 45 patients (35.7%), and optimal improvement in 8 patients (6.4%). The univariate and multivariate logistic regression analyses revealed that the long pulse width and the number of FMR treatment sessions were positively associated with clinical efficacy. Compared to the short pulse-width group (200 ms), the longer pulse-width group (300 ms) (odds ratio [OR] = 8.3, p = 0.003) and the even longer pulse-width group (400–500 ms) (OR = 52.6, p 0.001) demonstrated stronger efficacies. Patients who received more than three treatment sessions had better outcomes compared to those who received three or fewer treatment sessions (OR = 4.0, p = 0.036). All patients experienced posttreatment transient erythema, but no crusting, infection, or blister. Six cases developed grid-like erythema around 1 month posttreatment and one case experienced hyperpigmentation, both of which resolved within 1–3 months after appropriate management.

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Source: Ziwei, D., Yuan, G., Yuehong, G., et al. (2024). Efficacy and Safety of Fractional Microneedle Radiofrequency for Atrophic Acne Scars: A Real-World Clinical Study of 126 Patients. Lasers Surg. Med.. 2024; 56(2): 150-164. Published: February, 2024. DOI: 10.1002/lsm.23759.

A Comparative Study

[Posted 18/Jan/2024]

AUDIENCE: General Surgery

KEY FINDINGS: Bone-cutting mechanism and the biological influence of the laser beam and ultrasound on living tissues proved to be favorable factors for patients' pain levels and tissue swelling postoperatively independent of the longer osteotomy duration compared to conventional drilling.

BACKGROUND: There are few research works with in-depth studies and direct simultaneous comparisons of the effects on tissue reactions and patients' recovery following in vivo conventional drilling, ultrasound- and laser-assisted osteotomy in humans. The current study aims to compare bone cutting duration, pain, swelling, and trismus in patients following surgical mandible third molar extraction by bone removal using three different osteotomes-a conventional rotary device, an ultrasonic unit, and an Er:YAG laser.

DETAILS: A prospective, randomized three-group comparative clinical trial was performed. As an experimental setting for the study, an open mandible third molar surgery was chosen because osteotomy is included in its protocol. Patients were divided into three groups according to the used device for bone removal. Bone cutting time intraoperatively, facial swelling, trismus, and pain on the first, second, and third postoperative days were assessed. The statistical analyses were performed using the SPSS v. 17.0-Kolmogorov-Smirnov test, one-way ANOVA, Student's t-test, Mann-Whitney test, and x² test. Statistical results were considered significant at p < 0.05 (confidence interval of difference, 95% CI). Eighty patients (34 males and 46 females with an average age of 25.18 years) were included in the study. The average time for bone removal by the conventional low-speed device (4.95 min), by the ultrasonic unit (5.13 min), and by the Er:YAG laser (9.00 min) differed significantly (p = 0.001). The mean postoperative facial swelling showed a marked difference between the groups (p < 0.05), in favor of the laser and piezo groups. The osteotome proved to influence pain intensity not only immediately after surgery (p = 0.002), but also during the followed-up period (p = 0.001), again in favor of the two above-mentioned groups. No association was found between trismus and the osteotome used by the followed-up patients (p > 0.05).

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Source: Blagova, B., Krastev, D., and Malinova, L. (2023). Conventional Drilling Versus Ultrasound and Laser Osteotomy in Mandibular Third Molar Surgery: A Comparative Study. Lasers in Surgery and Medicine. 2023; 55(10): 862-870. Published: December, 2023. DOI: 10.1002/lsm.23730.

[Posted 24/Aug/2023]

AUDIENCE: General Surgery, Internal Medicine

KEY FINDINGS: Compared to conventional ICS, NMP can significantly reduce the incidence of EAD, RPS, and IC after DCD liver transplantation.

BACKGROUND: In this study, authors sought to assess how liver allografts preserved using portable normothermic machine perfusion (NMP) compare against those that underwent ischemic cold storage (ICS) in the setting of donation after brain death (DBD) and donation after circulatory death (DCD) liver transplantation. Compared to conventional ICS, NMP may offer a more homeostatic preservation, permit physiologic assessment of organ function, and provide opportunities for graft improvement/modification. We report a single center US experience of liver NMP.

DETAILS: A single center, retrospective analysis of collected data on 541 adult whole liver transplants from 469 DBD donors (NMP[n=58] vs ICS[n=411]) and 72 DCD donors (NMP[n=52] vs ICS[n=20]) between January 2016 and December 2022. In DBD LT, male gender (OR [95% CI]: 1.83 [1.08-3.09]) and greater than 10% macrosteatosis of the donor liver (1.85 [1.10-3.10]) were statistically significant independent risk factors of early allograft dysfunction (EAD). Donor age >40yo and cold ischemia time (CIT) >7h were independent risk factors of reperfusion syndrome (RPS). 1-year, 3-year, and 5-year incidences of ischemic cholangiopathy (IC) did not differ significantly in DBD cases between the NMP and ICS cohorts. In DCD LT, NMP was an independent protective factor against EAD (0.11 [0.03-0.46]) and RPS (0.04 [0.01-0.25]). Incidence of IC in the DCD cases at 1-year and 3-year timepoints was significantly lower in the NMP cohort (1.9% compared to 20% in the ICS group).

Copyright © Wolters Kluwer Health, Inc. All rights reserved.

Source: Yamamoto, T., Atthota, S., Agarwal, D., et al. (2023). Impact of Portable Normothermic Machine Perfusion for Liver Transplantation From Adult Deceased Donors. Annals of Surgery . Published: August, 2023. DOI: 10.1097/SLA.0000000000006032.

[Posted 28/Jul/2023]

AUDIENCE: Ob/Gyn, Oncology

KEY FINDINGS: Reflexing samples with intermediate OVA1 scores significantly decreases the false-positive rate, thereby reducing unnecessary surgical referrals.

BACKGROUND: Patients with adnexal masses suspicious for malignancy benefit from referral to oncology specialists during presurgical assessment of the mass. OVA1 is a multivariate assay using a five-biomarker panel which offers high overall and early-stage sensitivity. However, OVA1 has a high false-positive rate for benign masses. Overa, a second-generation multivariate index assay was developed to reduce the false-positive rate. The aim of the present study was to use Overa as a reflex for OVA1 and increase specificity.

DETAILS: OVA1 cut-off scores were established to place patients into three categories: low, intermediate, and high cancer risk. Samples with intermediate-risk OVA1 scores were reflexed to the Overa and defined as high or low risk. This protocol was tested with 1035 prospectively collected serum samples and validated with an independent prospectively collected sample set (N = 207). Thirty-five per cent (359) of samples had intermediate OVA1 scores. Reflexing these to Overa eliminated 58% of the false-positives and improved the overall specificity from 50% to 72%. This finding was confirmed in the independent dataset, in which the specificity increased from 56% to 73%.

Copyright © John Wiley & Sons, Inc. All rights reserved

Source: Fritsche, H. A. and Bullock, R. G. (2023). A Reflex Testing Protocol Using Two Multivariate Index Assays Improves the Risk Assessment for Ovarian Cancer in Patients With an Adnexal Mass. Intl J Gynecol Obstet.. 2023; 162(2): 485-492. Published: August, 2023. DOI: 10.1002/ijgo.14733.