The application of robotics in plastic and reconstructive surgery: A systematic review

Background: Robotic assisted surgery (RAS) has seen significant advancement in many surgical specialties, although the application of robotics in plastic and reconstructive surgery remains to be widely established. This systematic review aims to assess the role of RAS in plastic and reconstructive surgery. Methods: The review protocol was published and registered a priori as CRD42024507420. A comprehensive electronic search for relevant studies was performed in MEDLINE, Embase and Google scholar databases. Results: Overall, 132 studies were initially identified, of which, 44 studies satisfied the eligibility criteria with a cumulative total of 239 patients. RAS demonstrated a high degree of procedural success and anastomotic patency in microvascular procedures. There was no significant difference in periprocedural adverse events between robotic and manual procedures. Conclusion: RAS can be feasibly implemented in plastic and reconstructive surgery with a good efficacy and safety profile, particularly for microsurgical anastomosis and trans‐oral surgery

Conservatively managed non-functioning pituitary macroadenomas—cohort study from the UK Non-functioning Pituitary Adenoma Consortium

Objective: Surveillance is often adopted for asymptomatic non-functioning pituitary macroadenomas (macroNFPAs). Due to low-quality evidence, uncertainty remains on optimal frequency of imaging/biochemical monitoring and indications for surgery. We assessed the natural history and outcomes of patients with macroNFPA who had monitoring as initial management choice from the UK NFPA Consortium. Design: This was a multicentre, retrospective, cohort study involving 21 UK endocrine departments. Methods: Clinical, imaging, and hormonal data of 949 patients followed up between January, 1, 2005 and March, 1, 2022 were analysed. Results: Incidence rate for tumour enlargement was 9.8 per 100 patient-years (95% CI, 8.8-10.8), with cumulative probabilities 1.6%, 8.1%, 18.4%, 29.2%, and 43.6% at 6-month, 1-year, 2-year, 3-year, and 5-year follow-up, respectively; rates were higher in tumours abutting/displacing optic chiasm than those not in contact with it. Amongst macroNFPAs not in contact with optic chiasm showing enlargement within 6 months, none impacted visual fields. In tumours with enlargement and continued monitoring (median 2.6 years), further growth occurred in 60.5% (33.8% probability at 2 years), stability in 35.5%, and shrinkage in 4.0%. Rates of new pituitary hormone deficits were 4.0%-4.9%, mainly driven by tumour enlargement. After transsphenoidal surgery, rates of hypopituitarism reversal were 12%-17% and those of additional anterior pituitary hormone deficits were 12%-15% (permanent vasopressin deficiency 3.5%). Conclusions: Our data provide evidence for monitoring protocols. MacroNFPAs not in contact with optic chiasm require less frequent imaging, and first follow-up scan can be delayed to 1 year. After first enlargement, variable tumour behaviour can occur. New hypopituitarism in stable tumours is rare, challenging necessity of regular pituitary function assessment

Comparing the efficacy and safety of combination triamcinolone acetonide and 5-fluorouracil versus monotherapy triamcinolone acetonide or 5-fluorouracil in the treatment of hypertrophic scars and keloids: A systematic review and meta-analysis

Background: Keloids and hypertrophic scars cause physical and psychosocial problems. Combination 5-fluorouracil (5-FU) with triamcinolone acetonide (TAC) may enhance the treatment of pathological scars, although the evidence base is limited. Objectives: We aimed to evaluate the efficacy and complication rates of combination intralesional TAC and 5-FU in comparison to monotherapy intralesional TAC or 5-FU for the treatment of keloids and hypertrophic scars. Methods: EMBASE, MEDLINE and CENTRAL were searched by two independent reviewers. The primary outcome was treatment efficacy (51% to 100% improvement). Study quality and risk of bias were assessed using Cochrane's risk of bias tool, respectively. Results: Of 277 articles screened, 13 studies were included comprising 12 randomised control trials (RCT) and 1 non-randomised study. There were six and nine studies comparing combination intralesional therapy versus monotherapy 5-FU and monotherapy TAC, respectively. The combined group demonstrated superior objective treatment efficacy compared to the monotherapy TAC group (OR 3.45, 95% C.I: [2.22-5.35], I 2=0%, P<0.00001) and monotherapy 5-FU group (OR 4.17, 95% C.I: [2.21-7.87], I 2=0%, P<0.0001). Telangiectasia was less frequent in combination therapy (OR 0.24, 95% CI: [0.11-0.52], I 2=0%, P=0.0003) compared to monotherapy TAC. Conclusions: Combined intralesional TAC and 5-FU administration demonstrated superior treatment efficacy outcomes compared to monotherapy TAC or 5-FU. Patient-reported outcome measures, lacking here, should be incorporated in the design of future research to justify clinical recommendations.https://journals.lww.com/plasreconsurg/Abstract/9900/Comparing_the_Efficacy_and_Safety_of_Combination.2010.asp

The application of robotics in plastic and reconstructive surgery: A systematic review

Background: Robotic assisted surgery (RAS) has seen significant advancement in many surgical specialties, although the application of robotics in plastic and reconstructive surgery remains to be widely established. This systematic review aims to assess the role of RAS in plastic and reconstructive surgery. Methods: The review protocol was published and registered a priori as CRD42024507420. A comprehensive electronic search for relevant studies was performed in MEDLINE, Embase and Google scholar databases. Results: Overall, 132 studies were initially identified, of which, 44 studies satisfied the eligibility criteria with a cumulative total of 239 patients. RAS demonstrated a high degree of procedural success and anastomotic patency in microvascular procedures. There was no significant difference in periprocedural adverse events between robotic and manual procedures. Conclusion: RAS can be feasibly implemented in plastic and reconstructive surgery with a good efficacy and safety profile, particularly for microsurgical anastomosis and trans-oral surgery.https://onlinelibrary.wiley.com/doi/10.1002/rcs.266

Mutation of the MYL3 gene in a patient with mid-ventricular obstructive hypertrophic cardiomyopathy

In this study, we discuss a female patient referred to cardiology with left ventricular hypertrophy at mid-ventricular segments resulting in a mid-cavitary obstruction and a left ventricular apical aneurysm. The patient had normal epicardial coronary arteries, but presented with recurrent cerebrovascular events. The patient had a positive family history for sudden cardiac death. Cardiac MRI detected positive features of left ventricular mid-cavity obstruction, left ventricular apical aneurysm and delayed gadolinium enhancement, with Holter monitoring assessment displaying segments of non-sustained ventricular tachycardia. Genetic analysis detected an myosin light chain 3 (MYL3) gene mutation. The patient will be referred to receive an implantable cardioverter defibrillator.The MYL3 gene mutation is a rare variant in patients with familial hypertrophic cardiomyopathy. To our knowledge, the presence of a left ventricular apical aneurysm has not been previously reported in literature concerning the MYL3 gene mutation. The presence of this abnormality further increases the risk of sudden cardiac death.https://casereports.bmj.com/content/15/3/e24457

Mutation of the<i>MYL3</i>gene in a patient with mid-ventricular obstructive hypertrophic cardiomyopathy

In this study, we discuss a female patient referred to cardiology with left ventricular hypertrophy at mid-ventricular segments resulting in a mid-cavitary obstruction and a left ventricular apical aneurysm. The patient had normal epicardial coronary arteries, but presented with recurrent cerebrovascular events. The patient had a positive family history for sudden cardiac death. Cardiac MRI detected positive features of left ventricular mid-cavity obstruction, left ventricular apical aneurysm and delayed gadolinium enhancement, with Holter monitoring assessment displaying segments of non-sustained ventricular tachycardia. Genetic analysis detected an myosin light chain 3 (MYL3) gene mutation. The patient will be referred to receive an implantable cardioverter defibrillator.TheMYL3gene mutation is a rare variant in patients with familial hypertrophic cardiomyopathy. To our knowledge, the presence of a left ventricular apical aneurysm has not been previously reported in literature concerning theMYL3gene mutation. The presence of this abnormality further increases the risk of sudden cardiac death.</jats:p

Risk of second brain tumour after radiotherapy for pituitary adenoma or craniopharyngioma: a retrospective, multicentre, cohort study of 3679 patients with long-term imaging surveillance

Background: Radiotherapy is a valuable treatment in the management algorithm of pituitary adenomas and craniopharyngiomas. However, the risk of second brain tumour following radiotherapy is a major concern. We assessed this risk using non-irradiated patients with the same primary pathology and imaging surveillance as controls. Methods: In this multicentre, retrospective cohort study, 4292 patients with pituitary adenoma or craniopharyngioma were identified from departmental registries at six adult endocrine centres (Birmingham, Oxford, Leeds, Leicester, and Bristol, UK and Ferrara, Italy). Patients with insufficient clinical data, known genetic predisposition to or history of brain tumour before study entry (n=532), and recipients of proton beam or stereotactic radiotherapy (n=81) were excluded. Data were analysed for 996 patients exposed to 2-dimensional radiotherapy, 3-dimensional conformal radiotherapy, or intensity-modulated radiotherapy, and compared with 2683 controls. Findings: Over 45 246 patient-years, second brain tumours were reported in 61 patients (seven malignant [five radiotherapy, two controls], 54 benign [25 radiotherapy, 29 controls]). Radiotherapy exposure and older age at pituitary tumour detection were associated with increased risk of second brain tumour. Rate ratio for irradiated patients was 2·18 (95% CI 1·31-3·62, p<0·0001). Cumulative probability of second brain tumour was 4% for the irradiated and 2·1% for the controls at 20 years. Interpretation: Irradiated adults with pituitary adenoma or craniopharyngioma are at increased risk of second brain tumours, although this risk is considerably lower than previously reported in studies using general population controls with no imaging surveillance. Our data clarify an important clinical question and guide clinicians when counselling patients with pituitary adenoma or craniopharyngioma on the risks and benefits of radiotherapy. Funding: Pfizer.https://www.thelancet.com/journals/landia/article/PIIS2213-8587(22)00160-7/fulltex

Natural history of non-functioning pituitary microadenomas: results from the UK non-functioning pituitary adenoma consortium

Objective: The optimal approach to the surveillance of non-functioning pituitary microadenomas (micro-NFPAs) is not clearly established. Our aim was to generate evidence on the natural history of micro-NFPAs to support patient care. Design: Multi-centre, retrospective, cohort study involving 23 endocrine departments (UK NFPA consortium). Methods: Clinical, imaging, and hormonal data of micro-NFPA cases between January, 1, 2008 and December, 21, 2021 were analysed. Results: Data for 459 patients were retrieved [median age at detection 44 years (IQR 31-57)-152 males/307 females]. Four hundred and nineteen patients had more than two magnetic resonance imagings (MRIs) [median imaging monitoring 3.5 years (IQR 1.71-6.1)]. One case developed apoplexy. Cumulative probability of micro-NFPA growth was 7.8% (95% CI, 4.9%-8.1%) and 14.5% (95% CI, 10.2%-18.8%) at 3 and 5 years, respectively, and of reduction 14.1% (95% CI, 10.4%-17.8%) and 21.3% (95% CI, 16.4%-26.2%) at 3 and 5 years, respectively. Median tumour enlargement was 2 mm (IQR 1-3) and 49% of micro-NFPAs that grew became macroadenomas (nearly all >5 mm at detection). Eight (1.9%) patients received surgery (only one had visual compromise with surgery required >3 years after micro-NFPA detection). Sex, age, and size at baseline were not predictors of enlargement/reduction. At the time of detection, 7.2%, 1.7%, and 1.5% patients had secondary hypogonadism, hypothyroidism, and hypoadrenalism, respectively. Two (0.6%) developed hypopituitarism during follow-up (after progression to macroadenoma). Conclusions: Probability of micro-NFPA growth is low, and the development of new hypopituitarism is rare. Delaying the first follow-up MRI to 3 years and avoiding hormonal re-evaluation in the absence of tumour growth or clinical manifestations is a safe approach for micro-NFPA surveillance.https://academic.oup.com/ejendo/article/189/1/87/720486

Patient experience of very high power short duration radiofrequency ablation for atrial fibrillation under mild conscious sedation

Background: Very high power short duration (vHPSD) radiofrequency ablation (RFA) may reduce ablation times and improve patient tolerability, permitting pulmonary vein isolation (PVI) under mild conscious sedation (mCS) and promoting same day discharge (SDD). Methods: First, a retrospective feasibility study was performed at 2 tertiary cardiac centres in the UK. Consecutive cases of first-time PVI using vHPSD ablation with 90 W lesions for up to 4 s were compared against cases performed using standard RF (sRF) and cryoballoon (Cryo) therapy. Subsequently, a prospective study of patients who had vHPSD or Cryo exclusively under mCS was undertaken. Questionnaires based on Likert and visual analogue scales (VAS) were used to measure anxiety, discomfort and pain. Results: In total, 182 patients (59 vHPSD, 62 sRF and 61 Cryo) were included in the retrospective study, with 53 (90%) of vHPSD cases successfully performed under mCS. PVI ablation time in the vHPSD group (5.8 ± 1.7 min) was shorter than for sRF (16.5 ± 6.3 min, p < 0.001) and Cryo (17.5 ± 5.9 min, p < 0.001). Fifty-one vHPSD and 52 Cryo patients were included in the prospective study. PVI ablation time in the vHPSD group was shorter than for the Cryo group (6.4 ± 2.9 min vs 17.9 ± 5.7 min, p < 0.001), but overall procedure duration was longer (121 ± 39 min vs 95 ± 20 min, p < 0.001). There were no differences in the patient experience of anxiety, discomfort or pain. SDD rates were the same in both groups (61% vs 67%, p = 0.49). Conclusions: vHPSD RFA for PVI can be performed under mCS to achieve SDD rates comparable to cryoablation, without compromising patient experience.https://link.springer.com/article/10.1007/s10840-022-01351-