Laura Drudi

Vaginal vault dehiscence after robotic hysterectomy for gynecologic cancers: search for risk factors and literature review.

Introduction Vaginal vault dehiscence following robotic-assisted hysterectomy for gynecologic cancer may be attributed to surgical techniques and postoperative therapeutic interventions. We searched for risk factors in patients with gynecologic cancers and complemented this with a literature review. Methods Evaluation of prospectively gathered information on all consecutive robotic surgeries for gynecologic cancers was performed in a tertiary academic cancer center between December 2007 and March 2012. The literature was reviewed for articles relevant to “gynecologic oncology” and “robotics” with “vaginal cuff dehiscence” in the English and French languages. Respective authors were contacted to complete relevant information. Results Seven dehiscences were identified of 441 cases with established gynecologic cancers. The closures in these 7 were performed using interrupted 1-Vicryl (Ethicon Inc) (3/167; 1.8%), combination of interrupted 1-Vicryl and 1-Biosyn (Covidien Inc) (3/156, 1.9%), and V-Loc (Covidien Inc) (1/118, 0.8%) sutures. Associated risk factors included adjuvant chemotherapy and/or brachytherapy, early resumption of sexual activity, and low body mass index (mean, 23 ± 3.23 kg/m2). Dehiscences occurred regardless of suturing by staff or trainees. Review of operative videos did not reveal a detectable etiologic factor, such as excessive cautery damage to the vaginal cuff or shallow tissue sutured. All 7 colporrhexis repairs were performed through a vaginal approach without the need of laparoscopy or laparotomy. Conclusions Postoperative chemotherapy, brachytherapy, and early resumption of sexual activities are risk factors for vaginal vault dehiscence. Surgical technique, particularly the use of delayed absorbable sutures, deserves further evaluation

Validation of the da Vinci Surgical Skill Simulator across three surgical disciplines

OBJECTIVE In this paper, we evaluate face, content and construct validity of the da Vinci Surgical Skills Simulator (dVSSS) across 3 surgical disciplines. METHODS In total, 48 participants from urology, gynecology and general surgery participated in the study as novices (0 robotic cases performed), intermediates (1-74) or experts (≥75). Each participant completed 9 tasks (Peg board level 2, match board level 2, needle targeting, ring and rail level 2, dots and needles level 1, suture sponge level 2, energy dissection level 1, ring walk level 3 and tubes). The Mimic Technologies software scored each task from 0 (worst) to 100 (best) using several predetermined metrics. Face and content validity were evaluated by a questionnaire administered after task completion. Wilcoxon test was used to perform pair wise comparisons. RESULTS The expert group comprised of 6 attending surgeons. The intermediate group included 4 attending surgeons, 3 fellows and 5 residents. The novices included 1 attending surgeon, 1 fellow, 13 residents, 13 medical students and 2 research assistants. The median number of robotic cases performed by experts and intermediates were 250 and 9, respectively. The median overall realistic score (face validity) was 8/10. Experts rated the usefulness of the simulator as a training tool for residents (content validity) as 8.5/10. For construct validity, experts outperformed novices in all 9 tasks (p < 0.05). Intermediates outperformed novices in 7 of 9 tasks (p < 0.05); there were no significant differences in the energy dissection and ring walk tasks. Finally, experts scored significantly better than intermediates in only 3 of 9 tasks (matchboard, dots and needles and energy dissection) (p < 0.05). CONCLUSIONS This study confirms the face, content and construct validities of the dVSSS across urology, gynecology and general surgery. Larger sample size and more complex tasks are needed to further differentiate intermediates from experts.

A Descriptive Study of Bicycle Helmet Use in Montreal, 2011

ObjectiveThe purpose of this study was to describe bicycle helmet use among Montreal cyclists as a step towards injury prevention programming.MethodsUsing a cross-sectional study design, cyclists were observed during 60-minute periods at 22 locations on the island of Montreal. There were 1–3 observation periods per location. Observations took place between August 16 and October 31, 2011. Standard statistical methods were used, unadjusted and adjusted odds ratios and 95% confidence interval were calculated.ResultsA total of 4,789 cyclists were observed. The helmet-wearing proportion of all cyclists observed was 46% (95% CI 44-47). Women had a higher helmet-wearing proportion than men (50%, 95% CI 47–52 vs. 44%, 95% CI 42–45, respectively). Youth had the highest helmet-wearing proportion (73%, 95% CI 64-81), while young adults had the lowest (34%, 95% CI 30-37). Visible minorities were observed wearing a helmet 29% (95% CI 25-34) of the time compared to Caucasians, 47% (95% CI 46-49). BIXI (bike sharing program) riders were observed wearing a helmet 12% (95% CI 10-15) of the time compared to riders with their own bike, 51% (95% CI 49-52).ConclusionsAlthough above the national average, bicycle helmet use in Montreal is still considerably low given that the majority of cyclists do not wear a helmet. Injury Prevention Programs could target the entire cyclist population, but special attention may be warranted in specific groups such as young men, visible minorities, BIXI riders, and those riding in tourist areas. Additionally, a collaborative enterprise with the bicycle sharing system BIXI Montreal™ could prove to be fruitful in addressing the availability of bike helmets for BIXI riders.RésuméObjectifDécrire le port du casque de cycliste chez les cyclistes montréalais en vue d’instaurer des programmes de prévention des blessures.MéthodeÀ la faveur d’une étude transversale, nous avons observé les cyclistes sur des périodes de 60 minutes à 22 endroits sur l’île de Montréal. Il y a eu de 1 à 3 périodes d’observation à chaque endroit. Les observations ont eu lieu entre le 16 août et le 31 octobre 2011. Nous avons utilisé des méthodes statistiques types et calculé les rapports de cotes ajustés et non ajustés et les intervalles de confiance de 95 %.RésultatsNous avons observé 4 789 cyclistes en tout. La proportion observée de cyclistes portant le casque était de 46 % globalement (IC de 95 %: 44-47). Cette proportion était plus élevée chez les femmes (50 %, IC de 95 %: 47–52) que chez les hommes (44 %, IC de 95 %: 42–45). Les jeunes étaient proportionnellement les plus nombreux à porter un casque (73 %, IC de 95 %: 64-81), tandis que les jeunes adultes étaient proportionnellement les moins nombreux à le faire (34 %, IC de 95 %: 30-37). Le port du casque observé chez les cyclistes membres de minorités visibles était de 29 % (IC de 95 %: 25-34), contre 47 % chez les cyclistes blancs (IC de 95 %: 46-49). Les utilisateurs du BIXI (vélo en libre-service) ont été observés en train de porter un casque 12 % du temps (IC de 95 %: 10-15), contre 51 % du temps chez les cyclistes ayant leur propre vélo (IC de 95 %: 49-52).ConclusionsBien qu’il soit supérieur à la moyenne nationale, le port du casque de cycliste à Montréal est encore très faible, car la majorité des cyclistes n’en porte pas. Les programmes de prévention des blessures pourraient cibler tous les cyclistes, mais il serait justifié d’accorder une attention particulière à certains groupes: les jeunes hommes, les minorités visibles, les utilisateurs du BIXI et les cyclistes dans les zones touristiques. Par ailleurs, une collaboration avec le système de vélos en libre-service BIXI Montréalmc en vue d’assurer la disponibilité de casques de cyclistes pour les usagers du BIXI pourrait être fructueuse.

Virtual Reality Surgical Simulators- A Prerequisite for Robotic Surgery

The field of computer assisted minimally invasive surgery is rapidly expanding worldwide, including in India. With more hospitals in India contemplating the acquisition of a robotic platform, training of robotic surgeons is becoming essential. Virtual reality simulators can be used for surgeons to become acquainted with the robotic console prior to live surgery. Our aim was to evaluate the amount of simulator training required before a surgeon first operates on the da Vinci® Surgical System. Simulations were conducted on the Intuitive Surgical’s da Vinci® Robot Skill Simulator using the software obtained from Mimic Technologies. Participants included attending staff surgeons experienced in robotic surgery and novices. A set of seven activities were chosen for each participant. Based on the mean exercise score from the first attempt, staff surgeons outperformed the novices in all exercises. However, the difference in score between the staff and the novices decreased after the participants repeated the exercises and by the sixth attempt most of the novices obtained similar scores to the staff, suggesting that this might be at present the minimum set of repetitions indicated (or required) prior to performing life robotic surgery.

Association of Depression With Mortality in Older Adults Undergoing Transcatheter or Surgical Aortic Valve Replacement.

Importance Depression is increasingly recognized as a risk factor for adverse outcomes in cardiovascular disease. However, little is known about depression in older adults undergoing transcatheter (TAVR) or surgical (SAVR) aortic valve replacement. Objective To determine the prevalence of depression and its association with all-cause mortality in older adults undergoing TAVR or SAVR. Design, Setting, and Participants This preplanned analysis of the Frailty Aortic Valve Replacement (FRAILTY-AVR) prospective cohort study included 14 centers in 3 countries from November 15, 2011, through April 7, 2016. Individuals 70 years or older who underwent TAVR or SAVR were enrolled. Depressive symptoms were evaluated using the Geriatric Depression Scale Short Form at baseline and follow-up. Main Outcomes and Measures All-cause mortality at 1 and 12 months after TAVR or SAVR. Logistic regression was used to determine the association of depression with mortality after adjusting for confounders such as frailty and cognitive impairment. Results Among 1035 older adults (427 men [41.3%] and 608 women [58.7%]) with a mean (SD) age of 81.4 (6.1) years, 326 (31.5%) had a positive result of screening for depression, whereas only 89 (8.6%) had depression documented in their clinical record. After adjusting for clinical and geriatric confounders, baseline depression was found to be associated with mortality at 1 month (odds ratio [OR], 2.20; 95% CI, 1.18-4.10) and at 12 months (OR, 1.532; 95% CI, 1.03-2.24). Persistent depression, defined as baseline depression that was still present 6 months after the procedure, was associated with a 3-fold increase in mortality at 12 months (OR, 2.98; 95% CI, 1.08-8.20). Conclusions and Relevance One in 3 older adults undergoing TAVR or SAVR had depressive symptoms at baseline and a higher risk of short-term and midterm mortality. Patients with persistent depressive symptoms at follow-up had the highest risk of mortality.

Outcome Reporting in Cardiac Surgery Trials: Systematic Review and Critical Appraisal.

Background There is currently no accepted standard for reporting outcomes following cardiac surgery. The objective of this paper was to systematically review the literature to evaluate the current use and definition of perioperative outcomes reported in cardiac surgery trials. Methods and Results We reviewed 5 prominent medical and surgical journals on Medline from January 1, 2010, to June 30, 2014, for randomized controlled trials involving coronary artery bypass grafting and/or valve surgery. We identified 34 trials meeting inclusion criteria. Sample sizes ranged from 57 to 4752 participants (median 351). Composite end points were used as a primary outcome in 56% (n=19) of the randomized controlled trials and as a secondary outcome in 12% (n=4). There were 14 different composite end points. Mortality at any time (all-cause and/or cardiovascular) was reported as an individual end point or as part of a combined end point in 82% (n=28), myocardial infarction was reported in 68% (n=23), and bleeding was reported in 24% (n=8). Patient-centered outcomes, such as quality of life and functional classification, were reported in 29% (n=10). Definition of clinical events such as myocardial infarction, stroke, renal failure, and bleeding varied considerably among trials, particularly for postoperative myocardial infarction and bleeding, for which 8 different definitions were used for each. Conclusions Outcome reporting in the cardiac surgery literature is heterogeneous, and efforts should be made to standardize the outcomes reported and the definitions used to ascertain them. The development of standardizing outcome reporting is an essential step toward strengthening the process of evidence-based care in cardiac surgery.

IF15. Frailty Assessment in Older Adults Undergoing Interventions for Peripheral Arterial Disease

represented 2.1% of this cohort, mid-volume practitioners represented 9.6%, and low-volume vascular practitioners represented 88.3%. The percentage of midand high-volume vascular practitioners increased significantly (5.8% to 9.1% and 0.8% to 2.3%, respectively; P < .0001), as did the number of patients they treated (25,849 to 31,602 and 1561 to 6207, respectively; P < .0001). Low-volume interventionalists saw a significant decrease in both the number of patients treated and the percentage of their overall cohort size (51,796 to 33,771 and 93.4% to 87.8%, respectively; P < .001). Table I displays the outcome variables by vascular volume and associated significance values. Table II shows the multivariate regression analysis for the outcome variables. High-volume vascular surgeons had a 27% decreased odds of in-hospital mortality and 11% decreased odds of complication compared with low-volume practitioners when performing vascular procedures (P < .001). The average length of stay and total hospital charges for patients treated by high-volume vascular surgeons were 1.5 days and

Differential Diagnosis of Upper Extremity Ischemia

23,016 less than that of low-volume practitioners (P < .001). Conclusions: The majority of vascular practitioners have diverse practices. High-volume vascular interventionalists have improved outcomes with regard to mortality, length of stay, cost, and complications. In training the next generation of vascular surgeons, the focus should be on vascularspecific skills, and practicing vascular surgeons should look to concentrate their operative breadth with the goal of improving patient outcomes.

NON-FEMORAL ACCESS IS ASSOCIATED WITH 30-DAY MORTALITY IN FRAIL PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT

Upper extremity ischemia occurs as a consequence of occlusive, embolic, or vasospastic events and occurs in the context of a wide range of associated atherosclerotic and non-atherosclerotic conditions. Classification of the wide range of causes for upper extremity ischemia is challenging but is best approached by assessing the etiology, anatomic location, and size of the affected arteries. The careful consideration of patient history, clinical evaluation, and physical examination with selective radiologic imaging can help the clinician pinpoint the underlying causes for ischemia as well as direct subsequent treatment. In this chapter, the authors will provide an overview of the causes of acute and chronic upper extremity arterial ischemia as well as outline the appropriate steps for clinical diagnostic evaluation. The diagnostic imaging modalities available for patient assessment are reviewed, and a brief discussion of the medical, surgical, and endovascular options for treatment of patients with upper extremity ischemia are outlined. This chapter will provide the clinician with the fundamentals allowing a systematic approach to the evaluation of patients and making an accurate diagnosis for the majority of patients with upper extremity ischemia.

Silver Stools Revisited

Background: We hypothesized that frail older adults may be less capable of tolerating the operative stress associated with non-femoral transcatheter aortic valve replacement (TAVR) and face a higher risk of 30-day mortality as compared to robust patients. Methods: This study was a post hoc analysis