A Comparative Study Between Different Surgical Techniques For Left Atrial Exclusion in Patients Undergoing Concomitant Cardiac Surgery

Objectives: To find out the most successful surgical technique to obliterate left atrial appendage (LAA) in atrial fibrillation (AF) patients who had undergone concomitant cardiac surgery. Background: About 10%-65% of patients develop AF following cardiac surgery [Rho 2009; Mathew 2004; Maesen 2012]. Cerebral cardio-embolic stroke remains the most serious complication in AF patients. LAA is the main anatomical source for thromboembolic events. The use of oral anticoagulants (OAG) is considered to be an effective method for reduction of thromboembolic complications [Johnson 2000]. The use of oral anticoagulants is faced by two important facts which are the therapy duration is still unknown [Kirchhof 2017] and importantly that between 30-50% of patients are not candidates for oral anticoagulants due to the high bleeding risk or other contraindications [Johnson 2000; Kirchhof 2017; Kirchhof 2014]. In such patients, LAA obliteration would be an optimal alternative technique as it will reduce the stroke risk by 50% [Go 2014]. Several surgical techniques with variable degrees of success rates have been used. It still is unclear which surgical technique is optimum to achieve a successful obliteration of the LAA and a considerable reduction of the postoperative stroke events in AF patients. Patients and methods: A total of 100 patients have been subjected to surgical LAA exclusion from April 2017 to April 2019 in two different centers. All patients had postoperative transesophageal echo (TEE) examination to confirm the success of LAA occlusion. All patients included in our study suffered from AF at the time of surgery or in past history, which was confirmed by ECG examination in their previous medical files. A variety of surgical techniques to close the LAA have been utilized, including surgical excision by means of scissors, patch exclusion by means of an endocardial patch, suture exclusion and finally stapler exclusion. TEE examination 16 months postoperatively divided our patients into four groups as follows: successful LAA occlusion, Patent LAA, excluded LAA with persistent flow into LAA, and remnant LAA with a stump connection with LAA more than 1 cm. Results: Out of 100 patients, 30 patients (30%) underwent surgical LAA excision, 24 patients (24%) underwent surgical epicardial suture ligation, eight patients (8%) underwent patch exclusion using autologous pericardial patch, 33 patients (33%) underwent LAA internal orifice purse string suture obliteration, and five patients (5%) underwent stapler exclusion. Forty-two patients out of 100 (42%) showed successful LAA closure. The successful LAA occlusion occurred mostly in LAA excision patients 87%, 24% in LAA internal orifice purse string suture obliteration patients, 21% in epicardial suture ligation patients, and 37.5% in patch exclusion patients. The stapler exclusion was very disappointing as we did not record a single case out of the five patients who showed a successful LAA occlusion. Stroke events were recorded in all surgical techniques except the LAA excision technique. The stroke rate after two years follow up was zero in the surgical excision group, 49% in the suture exclusion group, 20% in the patch exclusion group, and 40% in stapler exclusion group. Conclusion: Surgical LAA excision is the most successful technique for LAA occlusion and represents a promising technique for the reduction of thromboembolic events in AF patients who undergo a concomitant cardiac surgery.

Study of efficacy of band ligation and suture ligation in the treatment of second degree hemorrhoids

Background: Rubber band ligation (RBL) and suture ligation are treatment strategies adapted for management of second degree hemorrhoids, an anorectal condition leading to distal displacement of anal cushions. Aim of current study was to investigate efficacy of suture ligation and band ligation techniques used in management of grade two internal hemorrhoids in terms of intraoperative n post-operative complications.Methods: An observational prospective study was conducted on 108 patients presented with grade 2 internal heamorrhoids at JNM medical college, Raipur between 2018 to 2019. Patients were divided in two equal groups receiving rubber band and suture ligation as treatment approaches. Efficacy of both treatment approaches was studied in terms of post-operative complications observed at immediate, one week and one month follow-ups and on the basis of hospital stay time required.Results: Majority of patients in both the groups were males with most number of cases in age group of 31-40 years. There was no significant difference in dietary habits of patients in both group as well as efficacy of both treatment techniques. Post-operative pain, discomfort, prolapse were common complains in band ligation group with pain persisting even during one month follow-up. Pain, bleeding per rectum, discomfort and irritation per rectum were the most common post-operative complaints of suture ligation group during follow-up.Conclusions: Although efficacy of both treatment strategies were equivalent, RBL would be recommended over suture ligation treatment strategy due to requirement of regional anesthesia to reduce operative difficulty and more hospital stay time in suture ligation treatment strategy.

Bipolar cautery versus conventional suture ligation of vascular pedicles in thyroidectomy: a comparative clinical study

Background: Thyroidectomies are commonly performed surgeries worldwide. With better knowledge of anatomy and major advent of energy devices, morbidity of thyroidectomy has drastically declined. Two main globally followed procedures to deal with vascular pedicles are conventional suture ligation and electro cautery devices. The objectives of the present study are to compare classical suture ligation and bipolar cautery of vascular pedicles in thyroidectomy, in terms of duration of procedure, hospitalization and operative complications.Methods: Retrospective observational comparative study was conducted in 100 patients who underwent total thyroidectomy in our institution for a period of 3 years from 4 September 2017. Non random sampling techniques applied on all consecutive patients who are eligible according to the inclusion criteria. Patients divided into two groups used: suture ligation (n=50), bipolar cauterization (n=50). The main outcomes measured were surgical and hospitalization time; duration of wound drain and post-operative complications (hoarseness, hypocalcemia and seroma).Student t test (for quantitative) and Chi Squaretest (for qualitative) applied for analysis.Results: Post-operative complications are present more in the suture ligation group (66%) compared to bipolar cautery (24%). The procedure time in ligation is a 131.6±17.7 minutes which is, significantly higher compared to bipolar cautery (97±7.5 minutes). Duration of hospital stay is more in suture ligation (6±0.8 days) compared to bipolar cautery (4.9±1.3 days).Conclusions: As per our study, bipolar cauterization has significant reduction of surgery time, duration of hospital stay and postoperative complications viz seroma, hoarseness of voice, hypocalcemia compared to conventional suture ligation.

Parent Preferences for Ulnar Polydactyly Management

Introduction: Type B ulnar polydactyly is one of the most commonly encountered congenital hand differences and can be treated with either suture ligation or surgical excision. The purpose of this study was to determine what factors families consider in selecting treatment for their child with type B ulnar polydactyly. Methods: We developed an ad-hoc survey instrument for parents of children with type B ulnar polydactyly that assessed motivation for choosing treatment, parent-reported outcomes, and overall satisfaction. Face validity was confirmed with a think-out-loud protocol using 5 test subjects. We administered surveys via telephone after treatment was complete. We assessed for differences between the cohort who chose in-office suture ligation versus the cohort who opted for operating-room excision using Chi square and Fischer exact tests for categorical variables and Student t-test for continuous variables. Results: Seventy of the 156 parents of consecutive patients contacted agreed to participate (45% response rate), with a mean follow-up of 2.25 years. Twenty-eight chose in-office suture ligation and 42 chose surgical excision. Rapid treatment was prioritized more often in those who selected suture ligation than in those who opted for surgical excision (p=0.044). The complication rate for suture ligation was significantly higher than for surgical excision (p<0.0001), with the most common complication being a residual bump (i.e. nubbin or neuroma stump) (64%). Respondents with residual bumps reported significantly less satisfaction with the aesthetic appearance of their child’s hand (p<0.001) and with their child’s treatment outcome (p=0.028) compared to those without residual bumps. Conclusion: Factors considered by parents in choosing type of treatment for type B ulnar polydactyly vary and may be significantly influenced by the surgeon. Time to treatment plays a determinative role in parents opting for suture ligation rather than surgical excision. Regardless of treatment, the majority of parents remain extremely satisfied with the outcomes.

Operative Hemostasis in Trauma and Acute Care Surgery: The Role of Biosurgical Agents

Trauma and acute care surgery (TACS) constitutes the foundation of emergency surgical services in the United States. Blunt and penetrating traumatic injuries are a leading cause of death worldwide. Non-trauma general surgical emergencies are also a major source of morbidity and mortality. Operative interventions performed within the scope of TACS often revolve around the core principles of contamination control, hemostasis, surgical repair, and subsequent functional restoration. Hemorrhage control is an integral part of emergent operative interventions, and while most instances of surgical bleeding require direct suture ligation or some other form of direct tissue intervention, some circumstances call for the use of adjunctive means of hemostasis. This is especially applicable to situations and settings where direct applications of surgical energy, suture ligation, or direct compression are not possible. Difficult-to-control bleeding can be highly lethal and operative control can be very challenging when confounded by the lethal triad of acidosis, coagulopathy and hypothermia. Topical biosurgical materials (BSM) are of great value in such scenarios, and their use across a variety of settings, from pre-hospital trauma application to emergency general surgery operations, represents an important adjunct to improve patient outcomes. Here we present the different BSMs, discuss their various uses, and provide insight on future applications and developments in this important area.