Hair-sparing technique using absorbable intradermal barbed suture versus traditional closure methods in supratentorial craniotomies for tumor

Expanded applications of knotless tissue control devices in neurosurgical cranial and spinal applications

OBJECTIVES

Effective wound closure is essential to neurosurgical procedures. Historical rates of neurosurgical wound complications range from 7 to 14 %. Knotless suturing with barbed sutures may offer effective closure rates but has had limited evaluation of safety in neurosurgical applications.

METHODS

Consecutive patients undergoing cranial, spinal, and peripheral nerve neurosurgical procedures from 12/2022 until 7/2024 were included in a quality improvement initiative. A retrospective review of demographics, past medical history, and operative and postoperative variables was undertaken. The primary outcome of interest was wound complications, including surgical site infection (SSI), dehiscence, or CSF leak. A cost analysis of suture treatment was also compared. A comparison to historical control rates (7%) was performed (one-sample proportional z-test).

RESULTS

A total of 195 consecutive patients were identified, with 10 wound-related complications including 3 superficial dehiscence treated with washout, 2 pseudomeningoceles, 2 cerebrospinal fluid leaks with meningitis, and 1 each of deep dehiscence with washout, superficial dehiscence with antibiotics, and epidural hematoma. A total of 53 (27.2 %) underwent cranial, 140 (71.8 %) spine, and 3 (1.0 %) peripheral nerve procedures. Ten patients (5.1 %) had incision complications with no difference to historical controls (p = 0.3). Cost analysis showed a range 0.35-3.03X cost differences using the knotless suture technique for different neurosurgical applications.

CONCLUSION

Knotless suture techniques can be an effective closure method for a variety of neurosurgical techniques comparable to expected wound complication rates. We expand on the potential applications of this technology compared with prior studies. Further studies will be necessary to confirm these findings.

Barbed versus conventional suture in elective posterior spine surgery

PURPOSE

Barbed sutures are tissue control devices that can reduce operating room time and costs. We analyzed the utility of barbed sutures in posterior spinal surgery in order to prove non-inferiority to conventional methods for wound closure.

METHODS

A cohort of patients undergoing elective posterior spinal surgery in which barbed (prospective) versus conventional sutures (retrospective) were used was analyzed. The primary endpoint was the occurrence of wound healing complications or the need for surgical revision. Secondary endpoints included postoperative stay, readmission rate, and duration and cost of wound closure.

RESULT

A total of 483 patients participated in the study, 183 in the Barbed group and 300 in the Conventional group. Wound dehiscence or seroma occurred in 3.8% and 2.7% of the Barbed and Conventional groups, respectively (p = 0.6588). Both superficial (1.6% versus 4.0%, P = 0.2378) and deep infections (2.7% versus 4.7%, p = 0.4124) occurred similarly in both groups. Overall, the rate of re-intervention due to wound healing problems was also similar (4.9% versus 5.3%, p = 0.9906), as well as, total median hospital stay, postoperative stay and 30-day re-admission rates. The average duration of wound closure (1.66 versus 4.16 min per level operated, p < 0.0001) strongly favored the Barbed group. The mean cost of wound closure per patient was higher in the Barbed group (43.23 € versus 22.67 €, p < 0.0001).

CONCLUSIONS

In elective posterior spinal procedures, the use of barbed sutures significantly reduced the duration of wound closure. The wound healing process was not hindered and the added cost related to the suture material was small.

Incidence and Risk Factors of Surgical Site Infection After Cranial Surgery for Patients with Brain Tumors: A Systematic Review and Meta-analysis

BACKGROUND

Surgical site infections after craniotomy (SSI-CRANs) are a serious adverse event given the proximity of the wound to the central nervous system. SSI-CRANs are associated with substantial patient morbidity and mortality. Despite the importance and recognition of this event in other surgical fields, there is a paucity of evidence in the neurosurgical literature devoted to SSI-CRAN specifically in patients after brain tumor surgery.

METHODS

Systematic searches of Medline, Embase, and Cochrane Central were undertaken. The primary outcome was the incidence of SSI-CRAN at 30 and 90 days. Secondary outcomes were risk factors for SSI-CRAN.

RESULTS

Thirty-seven studies reporting 91,907 patients with brain tumors who underwent cranial surgery were included in the meta-analysis. Pooled incidence of SSI-CRAN at 30 and 90 days was 4.03% (95% CI: 2.94%-5.28%, I2 = 97.3) and 6.17% (95% CI: 3.16%-10.07%, I2 = 97.3), respectively. Specifically, incidence of SSI-CRAN following surgery for posterior fossa tumors was the highest at 9.67% (95% CI: 5.98%-14.09%, I2 = 75.5). Overall pooled incidence of readmission within 30 days and reoperation due to SSI-CRAN were 13.9% (95% CI: 12.5%-15.5%, I2 = 0.0) and 16.3% (95% CI: 5.4%-31.3%, I2 = 72.9), respectively. Risk factors for SSI-CRAN included reintervention (risk ratio [RR] 1.58, 95% CI: 1.22-2.04, I2 = 0.0), previous radiotherapy (RR 1.69, 95% CI: 1.20-2.38, I2 = 0.0), longer duration of operation (mean difference 64.18, 95% CI: 3.96-124.40 minutes, I2 = 90.3) and cerebrospinal fluid (CSF) leaks (RR 14.26, 95% CI: 2.14-94.90, I2 = 73.2).

CONCLUSIONS

SSI-CRAN affects up to 1 in 14 patients with brain tumors. High-risk groups include those with reintervention, previous radiotherapy, longer duration of operation, and CSF leaks. Further prospective studies should focus on bundles of care that will reduce SSI-CRAN.

Widening the Operative Corridor-Evaluating the Transcortical Approach to Giant Falcine Meningiomas

BACKGROUND

Giant falcine meningiomas are surgically complex as they are deep in location, concealed by normal brain parenchyma, in close proximity to various neurovascular structures, and frequently involve the falx bilaterally. Although classically accessed using a bifrontal craniotomy and interhemispheric approach, little data exist on alternative operative corridors for these challenging tumors. We evaluated perioperative and long-term outcomes in patients undergoing transcortical resection of giant bilateral falcine meningiomas.

METHODS

From 2013 to 2022, fourteen patients with giant bilateral falcine meningiomas treated via a transcortical approach at our institution were identified. Perioperative and long-term outcomes were evaluated to determine predictors of adverse events. Corticectomy depth was also analyzed to determine if it correlated with increased postoperative seizure rates.

RESULTS

57.1% of cases were WHO grade 2 meningiomas. Average tumor volume was 77.8 ± 46.5 cm3 and near/gross total resection was achieved in 78.6% of patients. No patient developed a venous infarct or had seizures in the 6 months after surgery. Average corticectomy depth was 0.83 ± 0.71 cm and increasing corticectomy depth did not correlate with higher risk of postoperative seizures (P = 0.44). Increasing extent of tumor resection correlated with lower tumor grade (P = 0.011) and only 1 patient required repeat resection during a median follow-period of 24.9 months.

CONCLUSIONS

The transcortical approach is a safe alternative corridor for accessing giant, falcine meningiomas, and postoperative seizures were not found to correlate with increasing corticectomy depth. Further prospective studies are necessary to determine the best approach to these surgically complex lesions.

Linear Scalp Incision in Brain Tumor Surgery: Intraoperative and Postoperative Considerations

BACKGROUND

Although the linear scalp incision is commonly used in neurosurgical practice, a systematic study elucidating its pros and cons in a specific surgical setting is lacking. Herein, we analyzed our experience with linear scalp incision in brain tumor surgery and the impact on intraoperative variables and postoperative complications.

METHODS

Patients undergoing brain tumor surgery (January 2014-December 2021) at 2 neurosurgical departments were included and divided into 2 groups: linear or flap scalp incision. Patients' demographics characteristics, surgical variables, and wound-related complications were analyzed.

RESULTS

More than a total of 1036 craniotomies, linear incision (mean length 6cm) was adopted in 282 procedures (27.2%). Mean maximum diameter of the craniotomy was 5.25 cm, with no statistical difference between the 2 groups. In emergency surgery (36 cases), the linear and flap incisions were used indifferently. Linear incision was predominant in supratentorial and suboccipital lesions. Flap incision was significantly more frequent among meningiomas (P < 0.01). Neuronavigation, operative microscope, and subgaleal drain were more frequently used in the flap scalp incision group (P = 0.01). Overall complication rate was comparable to flap scalp opening (P = 0.40).

CONCLUSIONS

The use of the linear incision was broadly applied for the removal of supratentorial and suboccipital tumors granting adequate surgical exposure with a low rate of postoperative complications. Tumors skull base localization resulted the only factor hindering the use of the linear incision. The choice of 1 incision over another didn't show to have any impact on intraoperative and postoperative variables, and it remains mainly based on surgeon expertise/preference.

Rare post-operative intracranial abscess due to Serratia marcescens: what we can learn from it?

BACKGROUND

Nosocomial infections caused by Serratia marcescens mostly occurred in pediatrics and it was very rarely reported after adult surgery. Here, an intracranial abscess caused by Serratia marcescens was reported. We report a rare case of a postoperative intracranial abscess caused by Serratia marcescens in a 63-year-old male patient with a left parietal mass. The patient underwent resection of the mass on June 1, 2022, and the postoperative pathology revealed an angiomatous meningioma, WHO I. He then experienced recurrent worsening of right limb movements, and repeated cranial CT scans showed oozing blood and obvious low-density shadows around the operation area. Delayed wound healing was considered. Subsequently, a large amount of pus was extracted from the wound. The etiological test showed that Serratia marcescens infection occurred before the removal of the artificial titanium mesh. Antibiotics were initiated based on the results of drug susceptibility tests. At present, the patient is recovering well and is still closely monitored during follow-up.

CONCLUSION

It is rare for Serratia marcescens to cause brain abscesses without any obvious signs of infection. This report provided in detail our experience of a warning postoperative asymptomatic brain abscess caused by an uncommon pathogen.

Evaluating Predictors of Successful Postoperative Day 1 Discharge Following Posterior Fossa Tumor Resection

BACKGROUND

Current trends in surgical neuro-oncology show that early discharges are safe and feasible with shorter lengths of stay (LOS) and fewer thromboembolic complications, fewer hospital-acquired infections, reduced costs, and greater patient satisfaction. Traditionally, infratentorial tumor resections have been associated with longer LOS and limited data exist evaluating predictors of early discharge in these patients. The objective was to assess patients undergoing posterior fossa craniotomies for tumor resection and identify variables associated with postoperative day 1 (POD1) discharge.

METHODS

A retrospective review of posterior fossa craniotomies for tumor resection at our institution was performed from 2011 to 2020. Laser ablations, nontumoral pathologies, and biopsies were excluded. Demographic, clinical, surgical, and postoperative data were collected.

RESULTS

One hundred and seventy-three patients were identified and 25 (14.5%) were discharged on POD1. Median length of stay (LOS) was 6 days. The POD1 discharges had significantly better preoperative Karnofsky performance scores (P < 0.001) and modified Rankin scores (P = 0.002) and more frequently presented electively (P = 0.006) and without preoperative neurologic deficits (P = 0.021). No statistically significant difference in 30-day readmissions and rates of PE, UTI, and DVT was found. Univariate logistic regression identified better preoperative functional status, elective admission, and lack of preoperative hydrocephalus as predictors of POD1 discharge, however only the latter remained significant in the multivariable model (P = 0.001).

CONCLUSIONS

Discharging patients on POD1 is feasible following posterior fossa tumor resection in a select group of patients. Although we found that the only independent predictor for a longer LOS was preoperative hydrocephalus, larger, prospective studies are needed to confirm these findings.

"Unshaved Intradermal Running Suture for Elective Cranial Neurovascular Surgeries"

OBJECTIVE

In this paper, we analyze the experience and propose a method of incision and stitching of the postoperative scalp wound without shaving hair in elective neurosurgical interventions.

METHODS

Between January 2021 and May 2022, 44 patients with various neurovascular pathologies were included in the study. The age of the patients varied from 28 to 58 years. All patients underwent elective surgical interventions with intradermal cosmetic sutures without shaving hair. The results of published observational series of neurosurgical patients with unshaved hair were also analyzed.

RESULTS

Treatment of the surgical field, scalp, and incision were performed without shaving hair in 44 cases. The technique of intradermal suture without shaving hair was used in 31 cases of the classical pterional approach, in 11 cases of minipteronal, in 1 case of parasagittal, and in 1 case of retrosigmoid suboccipittal approaches. The mean age of the patients was 47.5 years (±8.82). The average length of stay in the clinic was 8.02 days (±2.04). The sutures were removed on the fifth-eighth day. All cases were operated on for elective neurovascular interventions: aneurysms without rupture (95.4%), arteriovenous malformations (2.3%), and cavernous angiomas (2.3%). All but one patient (2.3%) had no wound complications-the suture ruptured at the stage of its removal from the skin.

CONCLUSIONS

Our results also show that the use of a nonresorbable intradermal suture combined with hair preservation does not affect the risk of infection.

Enhanced Recovery After Surgery (ERAS) for Cranial Tumor Resection: A Review

Enhanced Recovery After Surgery (ERAS) protocols describe a standardized method of preoperative, perioperative, and postoperative care to enhance outcomes and minimize complication risks surrounding elective surgical intervention. A growing body of evidence is being generated as we learn to apply principles of ERAS standardization to neurosurgical patients. First applied in spinal surgery, ERAS protocols have been extended to cranial neuro-oncological procedures. This review synthesizes recent findings to generate evidence-based guidelines to manage neurosurgical oncology patients with standardized systems and assess ability of these systems to coordinate multidisciplinary, patient-centric care efforts. Furthermore, we highlight the potential utility of multimedia, app-based communication platforms to facilitate patient education, autonomy, and team communication within each of the three settings.

Neuro-oncology practice guidelines from a high-volume surgeon at the COVID-19 epicenter

BACKGROUND

During the coronavirus 19 (COVID-19) pandemic, physicians have begun adapting their daily practices to prevent transmissions. In this study we aimed to provide surgical neuro-oncologists with practice guidelines during the COVID-19 pandemic based on objective data from a high-volume brain tumor surgeon at the current COVID-19 epicenter.

METHODS

All outpatient visits and surgeries performed by the senior author during the COVID-19 pandemic were compared between the initial quarantine (3/23/20-5/4/20), the plateau period following quarantine (5/5/20-6/27/20), and the second peak (6/28/20-7/20/20). In-person and telemedicine visits were evaluated for crossovers. Surgeries were subdivided based on lesion type and evaluated across the same time period.

RESULTS

From 3/23/20-7/20/20, 469 clinic visits and 196 surgeries were identified. After quarantine was lifted, face-to-face visits increased (P < 0.01) yet no change in telehealth visits occurred. Of 327 telehealth visits, only 5.8% converted to in-person during the 4-month period with the most cited reason being patient preference (68.4%). Of the 196 surgeries performed during the pandemic, 29.1% occurred during quarantine, 49.0% during the plateau, and 21.9% occurred in the second peak. No COVID negative patients developed symptoms at follow-up. 55.6% were performed on malignant tumors and 31.6% were benign with no difference in case volumes throughout the pandemic.

CONCLUSIONS

Despite exceptional challenges, we have maintained a high-volume surgical neuro-oncology practice at the epicenter of the COVID-19 pandemic. We provide the protocols implemented at our institution in order to maximize neuro-oncology care while mitigating risk of COVID-19 exposure to both patients and providers.