Use of MPH hemostatic powder for electrophysiology device implantation reduces postoperative rates of pocket hematoma and infection

A randomized controlled trial of the outcomes of Arista™ hemostatic agent in robotic ventral hernia repair

Ventral hernia repairs (VHR) are commonly performed surgical procedures in the United States, with over 300,000 cases treated annually. Robotic surgery has gained traction for its safety and efficacy in VHR, particularly with techniques such as myofascial release. However, the extensive dissection involved in these procedures may lead to postoperative complications like seromas and hematomas. This study aims to assess the effectiveness of Arista™, an FDA-approved hemostatic agent, in reducing these complications during robotic-assisted laparoscopic VHR involving mesh placement in the retrorectus space. This single-institution single-blind prospective randomized controlled trial involved 100 patients undergoing elective robotic-assisted laparoscopic VHR at a tertiary referral hernia center. Participants were randomized to receive either 5 g of Arista™ or standard of care intraoperatively, with no hemostat applied in the control group. All patients had drains placed in the retrorectus space. Primary outcomes included drain output on the first postoperative day (POD), total drain output, and duration of drain placement. Secondary outcomes included estimated blood loss (EBL), number of drains used, operative time, and length of stay (LOS). This study was funded by Becton, Dickinson and Company (BD). The mean total drain output was significantly higher in the Arista™ group (592.8 ml) compared to the control group (407.9 ml; p = 0.01), with a 39.6% increase noted. However, no significant difference in drain output on the first postoperative day or drain duration was observed. Secondary outcomes revealed no statistically significant differences in EBL, number of drains, operative time, or LOS between the groups. While the application of Arista™ during robotic-assisted laparoscopic VHR resulted in increased total drain output, it did not significantly affect other postoperative metrics, including LOS and complications. Further research is warranted to explore the potential benefits of Arista™ in specific patient populations and surgical contexts.

Microporous polysaccharide hemospheres for reducing pocket hematomas after cardiac device implantation in patients on antithrombotic therapy

Background

Various surgical procedures have employed microporous polysaccharide hemosphere (MPH) hemostatic agents. However, data regarding their effectiveness in preventing pocket hematomas (PHs) during the implantation of cardiac implantable electronic devices (CIED) among the Asian population are limited. Therefore, this study aimed to investigate the potential benefits of using MPH hemostatic agents during CIED implantations as a preventive measure against post-procedural PHs.

Methods

We conducted a retrospective, single-center, observational study involving 255 consecutive Japanese patients who underwent CIED implantation between November 2017 and April 2021. We compared PH occurrences within 28 days after CIED implantation between patients who received MPH hemostatic agents (n = 145) and those who did not (n = 110).

Results

PH development was observed in nine (6.2%) patients who received MPH hemostatic agents and in 13 (11.8%) patients without MPH hemostatic (p = .111). Kaplan-Meier analysis of PH development revealed no significant difference between the two groups (log-rank p = .102). However, utilizing MPH hemostatic agents among patients taking antithrombotic drugs, including antiplatelet medications, direct oral anticoagulants, and warfarin, significantly reduced PH incidence (log-rank p = .03). The multivariate Cox proportional hazards model demonstrated that MPH hemostatic agent utilization independently correlated with a decreased PH risk (hazard ratio 0.22, 95% confidence interval 0.08-0.63, p = .004).

Conclusions

The findings of this study suggest that the incorporation of MPH hemostatic agents into standard practice may benefit to mitigate PH risk during CIED implantations in patients on antithrombotic therapy. This simple and practical measure may be valuable, especially in high-risk patients, such as those taking antithrombotic medications.

Prevention of component separation in complex abdominal wall surgery by Botox prehabilitation: a propensity-matched study

AIM

To facilitate midline fascial closure in complex abdominal wall surgery, component separation techniques (CST) are usually required. However, CST is associated with an enlarged morbidity. Prehabilitation could increase the compliance of the abdominal wall and thereby decrease the necessity of myofascial release. This can be accomplished by administration of botulinum toxin type A (BTA) in the lateral abdominal wall musculature. The aim of this study was to determine the effect of BTA on the subsequent necessity to perform CST in patients with complex abdominal wall hernias.

METHODS

Patients with a complex abdominal wall hernia, planned to undergo CST between July 2020 and November 2022 were included. Outcome of procedures with 300U of BTA 4 (2-6) weeks prior to surgery, were retrospectively analyzed by comparison with propensity matched subjects of an historical group. Hernia width difference was assessed by CT and operative details were included.

RESULTS

A total of 13 patients with a median hernia width of 12 cm (IQR 9-14, range 24) were prehabilitated with BTA between July 2020 and November 2022. A CST was planned for all, however not required in 6/13 patients (46%) to accomplish midline fascial closure. A mean elongation of lateral abdominal wall musculature of 4.01 cm was seen in patients not requiring CST. Compared to the propensity score matched control group, a 27% reduction (p = 0.08) in the need for CST was observed.

CONCLUSION

There is a tendency for decrease of necessity for CST by preoperatively administered BTA in patients with complex abdominal wall defects. Although small, as this study used propensity matched comparison, further exploration of BTA should be encouraged.

Review of Evidence Supporting the Arista™ Absorbable Powder Hemostat

Background

Uncontrolled and diffuse bleeding is a dreaded event during open and laparoscopic surgery that may lead to postoperative complications, obstruction of the surgical field that reduces visualization, and prolonged operating times. Powder hemostats can be used to control bleeding and are easy to use, have a safe profile, and can achieve broad coverage area at a low cost.

Methods

A strategic literature search of peer-reviewed, English language studies was conducted to capture evidence on the clinical efficacy and safety of a Microporous Polysaccharide Hemosphere (MPH) based Hemostat (Arista™ Absorbable Hemostat (Arista™ AH)).

Results

Six preclinical studies were found which supported the use of MPH in various animal models of laparoscopic and open surgery, all of which demonstrated its safety and efficacy. Five single-arm and 11 comparative clinical studies similarly supported the efficacy and safety of MPH in various surgery types, including cardiac, renal, and dermatologic surgery.

Conclusion

Published evidence supports the safe and effective use of MPH across a variety of surgical settings.

Prevention and Management of Cardiac Implantable Electronic Device Infections: State-of-the-Art and Future Directions

Cardiac implantable electronic device (CIED) infection is an increasingly common complication of device therapy. CIED infection confers significant patient morbidity and health care expenditure, hence it is essential that clinicians recognise the contemporary strategies for predicting, reducing and treating these events. Recent technological advances-in particular, the development of antimicrobial envelopes, leadless devices and validated risk scores-present decision-makers with novel strategies for managing this expanding patient population. This review summarises the key issues facing CIED patients and their physicians, and explores the supporting evidence for the latest therapeutic developments in this field.

EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS)

With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

Strategies to Prevent Cardiac Implantable Electronic Device Infection

The association between the risk of mortality and cardiovascular implantable electronic device (CIED) infections has been well-established in the literature. As CIED implantations have increased in frequency in the past few decades, the incidence of CIED-related infections has also risen. Given the morbidity, mortality, and health-care costs associated with CIED infections, the prevention of device-related infection is a critical goal. Risk factors for developing CIED infections can be categorized as patient-, procedure-, or device-related. Numerous studies have highlighted different strategies for preventing CIED-related infections, which include patient optimization, device selection, and periprocedural preparation and treatment. Nonetheless, as the comorbidity burden of patients undergoing CIED implantation continues to increase, significant challenges in the successful elimination of CIED-related infections remain. This review provides a comprehensive overview of available evidence-based approaches and strategies to reduce the risk of CIED infections.