Search

Background: Square knots can be difficult to construct in deep body cavities. The reversing half-hitch alternating post (RHAP) surgical knot has noninferior tensile strength and performance characteristics in deep body cavities. We compared the enterotomy repairs of novice learners in simulated deep body cavities using RHAP versus square knots after proficiency-based training. Methods: Undergraduate students were randomized to RHAP (n = 10) or square knot (n = 10) groups and trained to defined proficiency. They then performed hand-sewn enterotomy repairs of cadaveric porcine small bowels on flat surfaces and in simulated deep body cavities. We recorded time to knot-tying proficiency and to enterotomy repair, and burst pressures for the repair. Results: Mean time-to-proficiency in knot tying was equivalent between the RHAP and square knot groups (23 [standard deviation (SD) 3] v. 21 [SD 2] min, p = 0.33). Mean time for enterotomy repair in deep cavities was shorter for the RHAP group (16 [SD 2] min v. 21 [SD 1] min, p = 0.02). Mean burst pressures for enterotomy repair were equivalent on flat surfaces (128 [SD 41] v. 101 [SD 36] mm Hg, p = 0.31), and were significantly higher for the RHAP group in simulated deep body cavities (32 [SD 13] v. 105 [SD 37]mm Hg, p = 0.05). Conclusion: The RHAP knots appear to have superior performance versus square knots when tied in a deep body cavity by novice learners. Future work should focus on demonstrating the clinical relevance and broad utility of the RHAP knot in abdominal surgery. Both knot types should be taught to novice learners. Contexte : L'exécution de noeuds plats peut être difficile dans les cavités corporelles profondes. Les noeuds de type demi-clé inversée alternée (RHAP, pour reversing halfhitch alternating post) ont une résistance à la traction et un rendement semblables à ceux des noeuds plats dans ces cavités. Nous avons comparé l'efficacité des noeuds plats et des noeuds de type RHAP réalisés par de nouveaux apprenants dans des cavités profondes simulées, après leur avoir enseigné les compétences nécessaires. Méthodes : Les étudiants de premier cycle ont été aléatoirement répartis en 2 groupes, soit le groupe RHAP (n = 10) et le groupe noeud plat (n = 10), et ont reçu une formation pour développer des compétences prédéfinies. Ils ont ensuite suturé à la main un intestin grêle provenant d'un cadavre de porc, sur une surface plane et à l'intérieur d'une cavité profonde simulée. Nous avons mesuré le temps nécessaire à l'exécution du noeud et à la suture complète de l'incision, de même que la pression que pouvait subir cette suture sans se rompre. Résultats : Le temps moyen d'exécution du noeud était semblable entre les groupes RHAP et noeud plat (23 min [écart type (E.T.) 3 min] c. 21 min [E.T. 2 min]; p = 0,33). Le temps moyen nécessaire à la suture de l'incision dans la cavité profonde était plus court dans le groupe RHAP (16 min [E.T. 2 min] c. 21 min [E.T. 1 min]; p = 0,02). La pression moyenne que pouvait subir la suture sans se rompre était comparable pour les sutures effectuées sur une surface plane (128 mm Hg [E.T. 41 mm Hg] c. 101 mm Hg [E.T. 36 mm Hg]; p = 0,31), mais était significativement plus élevée dans le groupe RHAP pour les sutures faites dans la cavité profonde (32 mm Hg [E.T. 13 mm Hg] c. 105 mm Hg [E.T. 37 mm Hg], p = 0,05). Conclusion : Les noeuds de type RHAP semblent avoir un rendement supérieur à celui des noeuds plats lorsqu'ils sont réalisés dans une cavité profonde par de nouveaux apprenants. Des études ultérieures devraient se pencher sur la pertinence clinique et l'utilité générale de ces noeuds en chirurgie abdominale. Les 2 types de noeuds devraient être enseignés aux nouveaux apprenants., Suturing and hand-tying surgical knots are essential skills for a variety of medical specialties. Various surgical knot configurations with different tensile strengths and mechanisms of failure have been developed for [...]

Introduction: Tuberous sclerosis complex (TSC) is a rare, multisystem, genetic disease. A significant cause of TSC-related morbidity is potential bleeding from renal angiomyolipoma (AML). To pre-emptively decrease AML bleeding, mTOR inhibitors can be used; however, thresholds for initiating and maintaining everolimus therapy remain uncertain. Recent literature suggests not triggering active treatment of AMLs based on size thresholds alone. We evaluated the appropriateness of initiating everolimus therapy in asymptomatic patients after considering AML size, rate of growth, and other factors. Methods: Diagnostic criteria developed by the 2012 International TSC Consensus Group and presence of AML were used as inclusion criteria. Medical and imaging reports of 11/20 TSC patients from a single center were reviewed. Results: Mean age was 40.55 (±16.27) and 11 patients were female. Eight asymptomatic patients at high risk for complications underwent everolimus therapy, of which seven (88%) demonstrated decreased AML size, but multiple side effects were reported. Four high-risk asymptomatic patients did not undergo therapy due to side effect concerns, while four low-risk asymptomatic patients had stable AMLs under active surveillance. Four patients had reduced AMLs through local therapy. Conclusions: Everolimus treatment was effective for managing AML size in most high-risk, asymptomatic patients with tolerable side effects. AML size can remain relatively stable for asymptomatic, low-risk patients despite not receiving intervention(s). Patients with TSC-related AML can be safely managed with mTOR inhibitors like everolimus with shared decision-making, including factors such as bleeding risk, AML growth rate, and number and absolute size of AMLs. [ABSTRACT FROM AUTHOR]