Academician Evgeniy Nikolaevich Meshalkin (1916–1997) (on the 105th anniversary of his birth)

The outstanding cardiologist and cardiac surgeon Evgeny Nikolaevich Meshalkin was born on February 25, 1916 in the city of Yekaterinoslav, now Dnepropetrovsk. In 1918, the Meshalkin family moved to Rostov-on-Don, and in 1928 to Moscow, where Evgeny graduated from school in 1930, and then studied at the factory school at the Sickle and Hammer factory. In 1941, Evgeny Nikolaevich graduated from the 2nd Moscow Medical Institute and from August 1941 to May 1945 was a participant of the Great Patriotic War permanently in the field army. After demobilization from the army, E. N. Meshalkin worked from 1946 to 1956 at the department and at the clinic of Faculty Surgery of the 2nd Moscow State Medical Institute, headed by Academician of the USSR Academy of Medical Sciences A. N. Bakulev. In 1950, he defended his PhD thesis «Intubation anesthesia», and in 1953, his first monograph «Intubation anesthesia Technique» was published. Evgeny Nikolaevich is rightfully considered one of the founders of the Russian anesthesiology. In 1953, E. N. Meshalkin defended his doctoral dissertation «Probing and contrast study of the heart and major vessels». In conditions of moderate nonperfusion hypothermia, Yevgeny Nikolaevich successfully operated on complex heart defects, performed the insertion of mechanical prostheses for mitral and aortic insufficiency. From January 1956 to 1960, he was the head of the Department of Thoracic Surgery and Anesthesiology of the Central Institute of Advanced Medical Training (now the Russian Medical Academy of Postgraduate Education). E.N.Meshalkin owns 47 copyright certificates and patents, which are implemented not only in the Research Institute of Circulatory Pathology, but also in other cardiac surgery centers in Russia. Honorary citizen of Novosibirsk Evgeny Nikolaevich Meshalkin passed away on March 8, 1997 and was buried in Novosibirsk at the Southern Cemetery. In memory of the outstanding scientist, the Novosibirsk Research Institute of Circulatory Pathology was named after Academician E. N. Meshalkin.

P-EGS25 Boerhaave’s Syndrome Secondary to Symptomatic COVID-19 Infection

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has infected over 140 million people worldwide (1). COVID-19 symptoms primarily involve the respiratory system. However, recent data suggests that gastrointestinal symptoms occur in 11-61% of cases (2, 3).Boerhaave’s syndrome is a rare and dangerous disorder of the gastrointestinal tract, associated with a mortality rate of up to 50% (4). It most commonly occurs due to a lack of coordination between upper and lower oesophageal sphincters during forceful emesis, leading to an abrupt rise in intra-oesophageal pressures which leads to a transmural tear (5). Less commonly, a tear can be secondary to prolonged coughing (6). The majority of tears occur in the distal posterolateral third of the oesophagus and have an average length of 2.2 cm (7). Risk factors include males, excess alcohol or food consumption (6). We present a case of Boerhaave’s syndrome secondary to prolonged coughing, from COVID-19 infection. The tear was 8 cm in length in the mid anterior oesophagus. The patient survived a major operation and prolonged intensive care stay. Meloy et al. (8) published one case of oesophageal rupture in symptomatic COVID-19 – unfortunately the patient passed away before intervention. Methods A 75-year-old Caucasian female was day seven of COVID-19 infection and had been coping in the community with a continuous dry cough and mild shortness of breath. She presented to Accident and Emergency in the late afternoon when her cough developed into unremitting retching, vomiting, a global headache and epigastric pain disproportionate to presentation. No associated haematemesis or change in bowel habit. Past medical history was significant for hypertension, hypothyroidism, depression and anxiety. Previous surgical history included an open appendicectomy, cholecystectomy and resection of a melanoma. She was previously independent, consumed alcohol socially, a non-smoker and compliant with her regular medications.A CT chest with contrast demonstrated distal oesophageal rupture transversely with pneumomediastinum and extensive surgical emphysema in the neck and secondary bilateral pleural effusions, consistent with Boerhaave’s syndrome. The patient was taken to theatre the next morning for an oesophago-gastro-duodenoscopy (OGD), right posterolateral thoracotomy and primary repair of the oesophageal perforation.On endoscopy, an 8cm defect in the anterior oesophagus starting at the T4 vertebral level was identified and was repaired using tunnelled permanent mesh. During the surgery, mediastinitis was noted and washed out. The antimicrobial therapy was altered post-operatively to intravenous tazocin and fluconazole. Results The management of this patient was a huge multidisciplinary team achievement. She spent forty-six days recovering in ICU, intubated, ventilated and sedated with noradrenaline vasopressor support. The patient developed a severe acute kidney injury, requiring haemofiltration. The mediastinal fluid culture grew Enterococcus faecalis, sensitive to vancomycin and antibiotic therapy was adjusted accordingly. The patient’s recovery was burdened by seizures, whilst being weaned off sedation, and episodes of bradycardia and asystole, most of which were self-resolving except one requiring thirty seconds of cardio-pulmonary resuscitation. After chest drain removal, the patient redeveloped a right sided loculated pleural effusion so a further drain was inserted.A gastrografin contrast swallow study performed thirty-five days post-operatively demonstrated no evidence of contrast leak although some tracheobronchial aspiration. She was later stepped down to the ward and recovered very well. However, a component of post-ICU delirium and low mood was persistent. The patient had a repeat water-soluble contrast study on day 77 which demonstrated a contained anastomotic leak, managed conservatively. She was deemed medically ready for discharge at day 110. She was readmitted due to dysphagia secondary to a stricture at the site of mesh repair. OGD was performed and a stent was inserted. Conclusions COVID-19 infection may lead to an abnormal presentation of Boerhaave’s syndrome, with oesophageal tears being secondary to coughing, longer and more proximal.Peri-operative morbidity in COVID patients is elevated and clinicians should consider the short and long term implications of this to provide a holistic approach to care. Clinicians should maintain an awareness of the diversity of COVID-associated complications whilst ensuring that they do not succumb to the diagnostic overshadowing that becomes commonplace during a pandemic.

Successful management of a high-output urinary fistula following radical cystectomy and ileal conduit: a conservative approach

Urinary leak following ileal conduit after a radical cystectomy is a rare yet serious complication which presents early in the postoperative period. We herein present a case of a 38-year-old man diagnosed with recurrent high-grade non-muscle invasive bladder carcinoma. He underwent robot-assisted radical cystectomy and bilateral pelvic lymph node dissection. Postoperatively, the patient developed a high output urinary fistula (800–1000 mL/day) which was confirmed by fluid creatinine levels and a contrast study. He was managed successfully with a conservative approach. The leak subsided in 6 weeks and on follow-up patient is doing well. Most of the literature favours a surgical approach in such cases, however with optimal nutritional support (enteral/parenteral), adequate diversion of urine, percutaneous drainage of undrained collections, adequate intravenous antibiotics and good nursing care, resurgery with its associated morbidity can be avoided resulting in successful outcomes.

Case Report on Hydatid Cysts with Hydropnemonothorax

Introduction: Hydatid disease is caused by a parasite infection induced by an echinococcus tapeworm. The hydatid cyst is one recognized cause of liver mass. It is a significant pathogenic, zoonotic, and parasitic illness (acquired from animals) of humans after consumption of tapeworm eggs produced in the faeces of infected dogs. Hydatid disease is a serious endemic health concern in various regions of the world. Cystic hydatid disease is most often associated with the liver (50–70%), although it can also affect the lung, spleen, kidney, bones, and brain. A hydropneumothorax occurs gradually. Case Presentation: A 35-year-old Man was taken to the Acharya Vinoba Bhave Rural Hospital with the chief complaint of abdominal discomfort, breathlessness (dyspnea) right side pain for 2 days. Approximately to the peritoneal cavity of the right chest by a hydatid cyst in the subscapular posterior part of the right lobe of the liver. For minimal ascites, a contrast study was conducted, revealing a multi-located hypodense cystic lesion spread across the abdomen was recognized as sign of hydatid disease. Conclusion: In a patient with a hydatid disease, physical and psychological therapy should be put together. In this study, we primarily focus on professional management and outstanding nursing care, which may give the comprehensive care that hydatid cyst requires. The complete health care team works together to assist the patient to restore his or her prior level of independence and happiness after a full recovery.

Diagnosis of Anastomotic Leak

Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.

SP9.1.4 Management of Small Bowel Obstruction: A Comparison to NASBO

Aim Prompt diagnosis and proactive decisions in management of small bowel obstruction (SBO) can reduce the associated morbidity, in-hospital stay and mortality. Following recommendations of National Audit of Small Bowel Obstruction (NASBO) and Bologna (2017), the “agreed pathway” of The Association of Surgeons of Great Britain and Ireland (ASGBI, 2018) sets clear guidelines to aid timely management of SBO. We aimed to audit our practice to these guidelines and compared outcomes to NASBO. Methods Data was collected retrospectively on patients admitted with SBO from July 2019 - December 2019 and presented as percentage, median or interquartile range (IQR). Results Median age of 76 included patients was 62.0 years, 53.9% were female. Aetiologies were; adhesions (59.2%), hernia (27.6%), malignancy (10.5%) and others (2.6%). Admission CTs were performed in 92.1% vs. 80.0% (NASBO), with a median time of 3.3 hours vs. 2.2 days (NASBO). Median time to surgery in those managed operatively (n = 35) was 10 hours vs. 1 day (NASBO), while in 72.0% vs. 21.0% (NASBO) of non-settling SBO, water soluble contrast study (WSCS) was performed in a median (IQR) time of 39.0 (20.0-45.4) hours. Adhesional SBO resolved in 85.7% of cases suitable for non-operative approach. Objective nutritional assessment was performed in 94.7% vs. 90.0% (NASBO). In-hospital stay, 30-day morbidity and mortality compared to NASBO were 5.0 vs. 10.7 days, 31.6% vs. 23.0% and 5.3% vs. 8.0% respectively. Conclusion ASGBI guidelines provide multi-faceted proactive approach in managing SBO; including early cross-sectional imaging, prompt WSCS use and timely nutritional interventions, promoting improved outcomes.

Pyloric stricture after corrosive ingestion in children: an attempt to address the optimum management of this rarity

Corrosive ingestion in pediatric population can have devastating consequences. Pyloric stricture which is a rarer complication has not been discussed in details in existing literature. Whereas the presentation is more or less similar, a “case specific” approach may be required for the best outcome. We analyzed our series of eight patients to formulate a suitable approach to its management. This was a prospective observational study in the department of Pediatric Surgery in a tertiary health care centre in central India. Eight (n=8) patients with corrosive injuries exclusive to the pyloric antrum were analyzed with respect to the corrosive ingested, symptomatology, nutritional status, investigation findings, surgery undertaken and follow up. Total number of patients in our study were eight. Male -7 and female-1, mean age of 6.8 years, ranging from 4 and 10 years, most common agent was acid, ingested accidentally. Period of development of gastric outlet obstruction was 23 days, range between 11 days and 33 days. Initially presented with odynophagia but later developed features of gastric outlet obstruction. Procedure performed were Heineke Mickulicz pyloroplasty and Billroth I gastroduodenostomy with FJ depending on the intra operative findings. No significant post operative complications were encountered on follow up, all the patients had improved general condition and gained adequate weight. No re do surgeries were performed. Corrosive injury of the UGI tract is not uncommon in children. Pyloric stricture as a complication is relatively rare. Parents may seek consultation late only after the child has lost reasonable amount of weight. UGI Endoscopy and UGI contrast study are indispensable to evaluate the severity of damage and formulate the optimum plan of surgery. Early surgical intervention gives excellent result. Both Pyloroplasty and Billroth I anastomosis are safe with low morbidity and excellent long term outcome.