Some bariatric surgery patients don't sense heightened blood alcohol levels

Some women's sensitivity to alcohol increased so much after bariatric surgery that the amount they could consume before feeling the effects was reduced by half compared with their pre-surgery drinking habits, while others had reduced sensitivity, researchers at the University of Illinois at Urbana-Champaign found.

After consuming an alcoholic beverage that was equivalent to having two standard drinks, women who had gastric bypass or sleeve gastrectomy surgery experienced blood alcohol-concentration peaks sooner and about twice as high—50% above the .08% blood alcohol content that's the legal threshold for drunk driving in many states—compared with gastric band patients.

The findings were in line with previous studies that showed Roux-en-Y gastric bypass and sleeve gastrectomy cause a twofold increase in peak blood alcohol levels.

Robot assisted microsurgery passes human clinical trial

Some types of surgery are much more difficult than others, and one of the primary reasons for the differences is the size of the tissue involved. Sewing tiny nerves together is much more difficult than reconnecting large parts of an intestine, for example. One of the reasons that operating on very small tissues is difficult is because of the tendency of the human hand to move slightly in undesired ways, jerking and shaking nearly imperceptibly. When operating on large body parts, this is generally not an issue, but with small tissues, the effects of hand movements are greatly magnified. Because of that, scientists have been developing robots that assist with surgery by mimicking the actions of a surgeon's hands, minus the shaking. In this new effort, the researchers tested such a robot called MUSA.

The clinical trial involved a single surgeon performing a procedure called lymphatico-venous anastomosis (LAS) on eight women. Four of the procedures were conducted without the robot, four with the robot assisting. LAS is performed to reconnect lymphatic tissue with blood vessels after patients undergo surgery to remove breast tumors. The vessels are extremely small, just 0.3 millimeters, and the surgery very difficult.

Using MUSA, the surgeon manipulated controllers that resemble surgical tools. The actions of the surgeon are mimicked by the robot using tools in its own hands. Such actions are mimicked precisely except for shaking or other undesired hand movements. The surgeon also manipulates a foot pedal for other actions such as operating the microscope through which the surgery is observed.

The results of all eight surgeries were assessed during the surgery and again three months later. The outcome of the surgery was nearly identical in all cases—full restoration of lymph node drainage. But the surgeon took nearly twice as long to perform the first surgery—his speed improved with each procedure as he became more accustomed to working with the robot. The clinical trial was deemed a success because of the surgical outcomes, and because it showed that robot-assisted microsurgery in such cases is possible—a finding that suggests less skilled surgeons, or those with shakier hands could perform such surgeries in the future.

One in five operations may lead to surprise bills, even when surgeon and hospital are in-network

On average, that potential surprise bill added up to $2,011, a team from the University of Michigan reports in the new issue of JAMA. That's on top of the nearly $1,800 the average privately insured patient would already owe after their insurance company paid for most of the costs of their operation.

All the patients in the study chose a surgeon who accepts their insurance, and had one of seven common, non-emergency operations at an in-network hospital or at an outpatient surgery center.

But they still ended up potentially owing large sums to pay other people involved in their operation or their follow-up care. The average potential surprise bill ranged from $86 for medical imaging specialists involved in a hysterectomy, to more than $8,000 for surgical assistants involved in a breast lumpectomy. These out-of-network bills were significantly more common for patients who had complications after surgery.

If the patient had an outpatient procedure with an in-network surgeon, but it took place at an ambulatory surgery center that was out-of-network, the potential surprise bill could add up to more than $19,000.

"These are eye-popping numbers, which most clinicians are likely unaware of, and which patients can't prepare for," says Karan Chhabra, M.D., M.Sc., the study's first author and a National Clinician Scholar at the U-M Institute for Healthcare Policy and Innovation, which funded the study.

The study looked at the claims that a large insurance company received from in-network and out-of-network medical providers for more than 347,000 patients under age 65 who had one of the seven operations between 2012 and 2017. Even though all the lead surgeons and the surgery locations were in-network, 20.5% of the operations led to an out-of-network bill.

Creating the ideal nasal tip contour

In the Special Communication titled "Nasal Tip Contouring: Anatomic Basis for Management," Dr. Toriumi addresses the complexity of nasal tip contouring and helps rhinoplasty surgeons navigate the many techniques available to them. He discusses the ideal nasal tip contour, options for stabilizing the base of the nose, techniques for reorienting existing tip structures, and shield tip grafting. He also recommends learning as much as possible from each case by following previous patients.

In an interview with Dr. Toriumi, led by journal Editor-in-Chief, Dr. John Rhee and titled "Evolution of a Rhinoplasty Master," Dr. Toriumi highlights a key theme over the past 30 years: the use of structural grafting to make the nose stronger and provide a better long-term aesthetic and functional outcome. Dr. Toriumi points out that structure rhinoplasty is neither preservation rhinoplasty nor is it destructive. Instead, the existing structures are supported by adding cartilage grafts. In describing the evolution in tip grafting, he says that shield tip graft can be very useful if used properly. Dr. Toriumi also discusses complex techniques at high execution risk that should be performed by more experienced surgeons. The interview also focuses on future trends in the field.

Prenatal surgery yields lasting benefits for myelomeningocele

For myelomeningocele, prenatal surgery does not improve adaptive behavior but is associated with improved mobility and independent functioning in school-aged children, according to a study published online Jan. 24 in Pediatrics.

Amy J. Houtrow, M.D., Ph.D., M.P.H., from the University of Pittsburgh, and colleagues compared adaptive behavior and other outcomes at school age (6 to 10 years) among 161 children who underwent prenatal versus postnatal surgery in the Management of Myelomeningocele Study.

The researchers observed no difference in the Vineland composite score between the prenatal and postnatal surgery groups (89.0 versus 87.5). Compared with those in the postnatal group, children in the prenatal repair group more often walked independently (93 versus 80 percent), had higher mean percentage scores on the Functional Rehabilitation Evaluation of Sensori-Neurologic Outcomes (92 versus 85), and had lower rates of hindbrain herniation (60 versus 87 percent), fewer shunts placed for hydrocephalus (49 versus 85 percent), and fewer shunt revisions (47 versus 70 percent). Significantly higher mean quality of life z scores and lower mean family impact scores were reported by parents of children who were repaired prenatally.

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Study finds that disruptive behavior in operating rooms often goes unreported

University of Manitoba researchers have found that disruptive behaviors are happening all too often in the operating room (OR) – and many clinicians who see the behavior are not reporting it to management.

A new study, published in the Canadian Journal of Anesthesia, found that almost all clinicians (97 percent) did not report all of the disruptive behavior they observed, and three out of every 10 clinicians never reported the behavior at all. Clinicians who were young, female or not in management were more likely to never report the behavior.

Additionally, only one in five clinicians said that they were satisfied with management's response to the issue.

"Disruptive behaviors range from incivility to egregious abuse, and are important because they not only affect the well-being of those working in the operating room, but can also undermine patient care," said anesthesiologist Dr. Eric Jacobsohn, senior author and associate dean of professionalism, Max Rady College of Medicine, Rady Faculty of Health Sciences.

The authors surveyed clinicians from seven countries who worked in the OR, asking about the proportion of disruptive behavior the clinicians reported to management, and the clinicians' satisfaction with management's response to the issue. The survey was completed by 4775 operating room clinicians.

"Management can only respond to incidents that they are aware of. Because of this, it is essential that clinicians who witness disruptive behaviors report them promptly to management," said Dr. Alexander Villafranca, co-lead author and research associate in the department of anesthesiology, perioperative and pain medicine, Max Rady College of Medicine.

The study was complemented by an accompanying editorial by researchers at Queens University, which congratulated the authors for "developing and validating a robust survey tool for research in this area" and stressed that more needs to be done in order to increase reporting and "conquer the silence."

"We need to design reporting systems that clinicians will use, and ensure that managers respond to reports in ways that clinicians think are fair and just," said co-lead author Ian Fast, first-year student at the Max Rady College of Medicine and research technician, department of department of anesthesiology, perioperative and pain medicine, Max Rady College of Medicine.