Author: fidelmac

Background:

The aim of this systematic review was to identify all methods to quantify intraoperative fluorescence angiography (FA) of the gastrointestinal anastomosis, and to find potential thresholds to predict patient outcomes, including anastomotic leakage and necrosis.

Results:

Some 1317 articles were identified, of which 23 were included. Fourteen studies were done in patients and nine in animals. Eight studies applied FA during upper and 15 during lower gastrointestinal surgery. The quantitative parameters were divided into four categories: time to fluorescence (20 studies); contrast-to-background ratio (3); pixel intensity (2); and numeric classification score (2). The first category was subdivided into manually assessed time (7 studies) and software-derived fluorescence-time curves (13). Cut-off values were derived for manually assessed time (speed in gastric conduit wall) and derivatives of the fluorescence-time curves (Fmax, T1/2, TR and slope) to predict patient outcomes.

Conclusion:

Time to fluorescence seems the most promising category for quantitation of FA. Future research might focus on fluorescence-time curves, as many different parameters can be derived and the fluorescence intensity can be bypassed. However, consensus on study set-up, calibration of fluorescence imaging systems, and validation of software programs is mandatory to allow future data comparison.

https://pubmed.ncbi.nlm.nih.gov/33893811/

Aim:
This study aims to evaluate the extrinsic effects of conditional factors affecting quantitative parameters and to establish the optimization of indocyanine green (ICG) angiography using in vitro experiments and prospective observational study.

Results:
The fluorescence intensity had an inverse correlation with distance, and the transitional zone was shown at the distance of 4-5 cm by slope differential. FMAX , T1/2MAX , and Slope were affected significantly by camera distance, site of angiography, fluorescence emission source, ICG modes as conditional factors. On multivariate analysis, FMAX was independently associated with spectral ICG mode with red inversion, Laser mode, and camera distance. Conversely, TR was not related to any conditional factors.

Conclusion:
Since quantitative parameters of ICG angiography are influenced by various conditions, a standardized protocol is required. The application of ICG specific modes with a constant distance of 4-5 cm can provide optimized fluorescence images.

https://pubmed.ncbi.nlm.nih.gov/33894016/

Background: Fluorescence-guided visualization is a recently proposed technology in colorectal surgery.  This survey was conducted on April 2020 among 44 centres dealing with colorectal diseases and participating in the Italian ColoRectal Anastomotic Leakage (iCral) study group. Surgeons were approximately equally divided based on geographical criteria from multiple Italian regions, with a large proportion based in public (89.1%) and nonacademic (75.7%) centres. They were invited to answer an online survey to snapshot their current behaviours regarding the use of fluorescence-guided visualization in colorectal surgery. Questions regarding technological availability, indications and techniques, personal approaches and feelings were collected in a 23-item questionnaire.

Results: Questionnaire replies were received from 37 institutions and partially answered by 8, as this latter group of centres do not implement fluorescence technology (21.6%). Out of the remaining 29 centres (78,4%), fluorescence is utilized in all laparoscopic colorectal resections by 72.4% of surgeons and only for selected cases by the remaining 27.6%, while 62.1% of respondents do not use fluorescence in open surgery (unless the perfusion is macroscopically uncertain with the naked eye, in which case 41.4% of them do). The survey also suggests that there is no agreement on dilution, dosing and timing, as many different practices are adopted based on personal judgment. Only approximately half of the surgeons reported a reduced leak rate with fluorescence perfusion assessment, but 65.5% of them strongly believe that this technique will become a minimum requirement for colorectal surgery in the future. Conclusion: The survey confirms that fluorescence is becoming a widely used technique in colorectal surgery.

https://bmcsurg.biomedcentral.com/articles/10.1186/s12893-021-01191-6#Tab3

Since the COVID-19 pandemic began over a year ago, death rates in US hospitalized patients decreased from 19.7% in April 2020 to 9.3% in November, according to a study published last week in JAMA Network Open. While this may reflect improved treatments and standards of care, a JAMA Network Open research letter published this week highlights how COVID-19 can still complicate healthcare: 15% of COVID-positive patients died after surgery, compared with 7% of those without COVID. Also, hospital-acquired conditions such as catheter-associated urinary tract infections and safety indicators like post-operative hemorrhaging were both higher in those with COVID-19 (2.0% vs 0.8% and 3.3% vs 2.4%, respectively).

“Postponing surgery should be recommended for patients with a positive preoperative COVID-19 test result when possible unless surgical intervention is absolutely necessary for life- or limb-saving measures.

https://www.cidrap.umn.edu/news-perspective/2021/04/covid-hospital-death-rates-fall-impact-still-high

JAMA publication on number of deaths in the US for the period between March 1, 2020 and Jan. 2, 2021.  During that time frame covered by the analysis, a total of 2,801,439 deaths from all causes were reported in the US. That’s 22.9% higher (522,368 deaths) than would have been expected in a normal year.

Corresponding author Steven H. Woolf, MD, MPH, of the Center on Society and Health at Virginia Commonwealth School of Medicine, and colleagues, explained that some of those excess deaths not reflected in the CDC count might still have been related to the pandemic.

The investigators also found significant variance between regions. For instance, New York State had the largest relative increase in all-cause mortality, with a 38.1% increase. However, the other states populating the top 10 states in terms of excess deaths were mostly in the midwest (South Dakota, North Dakota and Ohio) and southeast (Alabama, Louisiana, and Mississippi).

The data also revealed racial disparities. For instance, while non-Hispanic Blacks make up just 12.5% of the US population, they made up 16.9% of the excess deaths reported in the study. That data point aligns with other reports suggesting racial minorities have been hit harder by the pandemic, compared to other groups.

https://jamanetwork.com/journals/jama/fullarticle/2778361?guestAccessKey=8445def5-44ef-401d-8e01-002d0fbbadf5&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=olf&utm_term=040221

The Royal College of Surgeons of Edinburgh recently reached out trainee membership to conduct a survey in order to gauge how they have been impacted by covid-19. The findings were stark. 

• 67% of those surveyed said their mental health has suffered as a result of working during the pandemic.
• As the majority of elective surgery has been paused for large periods of the last year, many trainee surgeons have missed out on valuable learning experiences. 
• Nine in ten trainees feel their craft skills as a surgeon have suffered as a result of the pandemic, and over half said they do not feel prepared to embark on the next stage of their career or training because of the disruption. 

“ There is a huge backlog of patients whose elective operations were cancelled as a result of the pandemic, and trainees will play a vital role in helping to address this. 

It is of the utmost importance that trainee surgeons are given the essential training and experience they need in the coming months, or we risk facing not just a serious skills shortage, but a longer term issue with a delay in surgical trainees completing training and entering the consultant workforce.  Trainees are truly the lifeblood of our profession. They are our future. We must ensure their development is not disadvantaged in the long-term as a result of the pandemic.”

Wall Street analysts are predicting recovery of elective surgery volumes after analyzing a consumer sentiment survey and hospital tracking data, but the forecasts come amid a stark warning from the head of the CDC that rising COVID-19 metrics jeopardizes progress.

Results from two surveys from Needham and Jefferies suggest people are visiting hospitals more and are increasingly comfortable with undergoing elective procedures. If, as Needham analysts predict, the trends translate into a significant increase in procedure volumes, medical device sales could bounce back.

A major caveat comes with data highlighted by CDC Director Rochelle Walensky, who warned rising COVID-19 cases, hospitalizations and deaths suggest the U.S. is on the same trajectory as European countries that are now contending with another resurgence.

https://www.medtechdive.com/news/analysts-tip-surgeries-to-rebound-rising-covid-19-cases-threaten-those-for/597530/

Pachychoroid disease of retina is a spectrum of diseases manifested by thickening and hyperperfusion of the choroid with changes in the sensory part of the retina. The aim of this study is to point out on a series of. Three case reports outline the difficulties in the differential diagnosis of retinal diseases in which we find thickening of the choroid.  The use of all modern imaging methods of the retina and choroid including ICG angiography plays a key role in determining the diagnosis.

Case report 1: 42-year-old patient treated for central serous chorioretinopathy. After optical coherence tomography (OCT), fluorescence angiography (FAG) and indocyanine green angiography (ICG) the diagnosis was changed to choroidal hemangioma and he was treated with photodynamic therapy (PDT) which led to a reduction of the hemangioma.

Case report 3: A 46-year-old patient was treated conservatively for CSC. After FAG and ICG, a solitary dilated choroidal vessel was found in the area of the papillomacular bundle with leakage under the sensory epithelium which was diagnosed as choroidal macrovessel. We performed PDT with a very good anatomical effect.

Conclusion: Precise differentiation of these mentioned diseases from pachychoroid retinal diseases was essential in choosing the appropriate therapy. The use of all modern imaging methods of the retina and choroid plays a key role in determining the diagnosis.

https://pubmed.ncbi.nlm.nih.gov/33740866/

The pandemic recovery is underway, but med-tech commercial execs fear it won’t be business as usual. A notable power struggle is playing out in hospital operating rooms across the country. As surgeons begin to perform elective procedures again, they aren’t always pleased about who’s writing the safety rules tied to expanding O.R. volume. From 2019 to 2020, the volume of surgical procedures declined by 11.3 million, or 12%.  The backlog is expected to push volume up by 28% in 2021 – that represents nearly 22.5 million more procedures. 

“COVID-19 gave institutions a reason not to let reps in,” said Marcus Girolamo, VP of marketing/business development for wound care product maker Urgo Medical. “People assume this is happening as a result of pandemic-related safety concerns. In many ways, accounts have been waiting for the opportunity to kick people out.”

The solution is for the sales model to evolve, which is very challenging for a business that’s so heavily relationship-based.  Ultimately, marketing “will settle into a mixed approach, especially for the institutions – hospitals, outpatient departments – where there’s an expectation that you’re there maybe not as often but present in a digital way because it’s more efficient.”

The expectation is that the backlog of elective surgeries will start taking place in the second quarter, and that hospitals will need more than a little time to recoup the billions of dollars in losses suffered due to the 2020 lockdowns. During that adjustment period, reps may or may not be welcomed back into the surgical suite.

Link to Article