Comparison of three purse-string suture techniques for prevention of anal leakage during surgery

OBJECTIVE To compare 3 anal purse-string suture techniques for resistance to leakage and to identify the suture technique requiring the fewest tissue bites to create a consistent leak-proof orifice closure. ANIMALS 18 large-breed canine cadavers. PROCEDURES 3 purse-string suture techniques (3 bites with 0.5 cm between bites [technique A], 5 bites with 0.5 cm between bites [technique B], and 3 bites with 1.0 cm between bites [technique C]) were evaluated. Each technique involved 2-0 monofilament nylon suture that was placed in the cutaneous tissue around the anus and knotted with 6 square throws. Standardized 2.0-cm-diameter circular templates with the designated bite number and spacing indicated were used for suture placement. Leak-pressure testing was performed, and the pressure at which saline was first observed leaking from the anus was recorded. The median and interquartile (25th to 75th percentile) range (IQR) were compared among 3 techniques. RESULTS Median leak pressure for technique A (101 mm Hg; IQR, 35 to 131.3 mm Hg) was significantly greater than that for technique C (19 mm Hg; IQR, 14.3 to 25.3 mm Hg). Median pressure did not differ between techniques A and B (50 mm Hg; IQR, 32.5 to 65 mm Hg) or between techniques B and C. CLINICAL RELEVANCE Placement of an anal purse-string suture prevented leakage at physiologic colonic and rectal pressures, regardless of technique. Placement of 3 bites 0.5 cm apart (technique A) is recommended because it used the fewest number of bites and had the highest resistance to leakage.

LMA® protector™ in patients undergoing laparoscopic surgeries: a multicenter prospective observational study

Background Laryngeal masks airway (LMA) has been increasingly used in surgical patients. However, the use of LMA in laparoscopic surgeries remains controversial. The major concerns include the potential risk of esophageal regurgitation, aspiration, and difficulties to achieve effective ventilation. The aim of this study was to evaluate the safety and effectiveness of the LMA® Protector™ in patients undergoing laparoscopic surgery. Methods Patients aged 18 to 70 years, scheduled for laparoscopic surgeries were included. The insertion time, successful insertion rate, and oropharyngeal leak pressure were measured. Airway complications and airway manipulations during the procedure were documented. Effective ventilation rate was calculated. Visible bloodstains and reflux content in the drainage channel were documented after the removal of LMA® Protector™. Results Three hundred patients were enrolled. The insertion of LMA® Protector™ failed in seven patients resulting with a successful insertion rate of 97.7%. During the maintenance of anesthesia, airway manipulation was required in 19 patients (19/293, 6.48%), in three of whom the LMA was replaced with endotracheal intubation resulting with an effective ventilation rate of 96.7% (290/300). The oropharyngeal leak pressure was 30.18 ± 5.88 cmH2O. Seventy-five patients (25.86%) reported mild sore throat on the first day after surgery. Bloodstains on study devices were noticed in 58 patients (20%). Seventy-five patients (25.86%) reported mild sore throat on the first day after surgery. Gastric reflux was noticed in the drainage tube in 5 patients (1.72%) with no signs of aspiration in any of those patients. Conclusions The LMA® Protector™ was shown to be safe and effective in patients undergoing laparoscopic surgeries. Although minor complications that require no further treatment, no clinically diagnosed aspiration was noticed in our study. Gastric reflux was noticed in the drainage tube in five patients undergoing laparoscopic gynecology surgery. Further research is needed to verify whether LMA® Protector™ is suitable for procedures in Trendelenburg position or other situations that a high risk of gastroesophageal reflux exists. Trial registration The trial was registered at the Chinese Clinical Trial Registry (ChiCTR1800018300, date of registration: September 2018).

Robust Data-Driven Leak Localization in Water Distribution Networks Using Pressure Measurements and Topological Information

This article presents a new data-driven method for locating leaks in water distribution networks (WDNs). It is triggered after a leak has been detected in the WDN. The proposed approach is based on the use of inlet pressure and flow measurements, other pressure measurements available at some selected inner nodes of the WDN, and the topological information of the network. A reduced-order model structure is used to calculate non-leak pressure estimations at sensed inner nodes. Residuals are generated using the comparison between these estimations and leak pressure measurements. In a leak scenario, it is possible to determine the relative incidence of a leak in a node by using the network topology and what it means to correlate the probable leaking nodes with the available residual information. Topological information and residual information can be integrated into a likelihood index used to determine the most probable leak node in the WDN at a given instant k or, through applying the Bayes’ rule, in a time horizon. The likelihood index is based on a new incidence factor that considers the most probable path of water from reservoirs to pressure sensors and potential leak nodes. In addition, a pressure sensor validation method based on pressure residuals that allows the detection of sensor faults is proposed.

A comparative study on the perfomance between I-gel® and Classic laryngeal mask airway in anaesthetized spontaneously breathing patients

The classic Laryngeal Mask Airway (c-LMA) is a first generation supraglottic airway device with an inflatable cuff forming a low pressure seal around the laryngeal inlet and permitting ventilation. I-gel is a supraglottic airway device made of thermoplastic elastomer which is soft gel-like and transparent. Unlike the classic LMA(c-LMA), I-gel does not have an inflatable cuff. In view of this, the present study was undertaken to compare the performance of the two supraglottic airway devices in spontaneously breathing adult patients posted for elective surgeries under general anesthesia.To compare the ease of insertion, number of insertion attempts, time for insertion, airway leak pressure, hemodynamic changes as well as perioperative complications such as cough sore throat between patients using the two devices.Sixty patients admitted in SRM medical college and research center scheduled for various elective surgical procedures under general anesthesia belonging to ASA class I and II were included in the study. They were randomly divided into two groups of 30 each using a random number generator. In group I, I-gel supraglottic airway device was used and in Group 2 classic laryngeal mask airway was used. Data was collected using a questionair containing socio-demographic details, details regarding performance of the device as well as hemodynamic changes and perioperative complications.The insertion was easy in 25 patients (83.3%) in group I, while in group II 15 patients (50%) had easy insertion. P=0.0 1781. The mean time of insertion for I-gel was (20. 17± 3 .91 seconds) which was significantly shorter compared to c-LMA (26.80 ±7.24 seconds) (P<0.001).There was no statistically significant difference between the devices with respect to number of attempts of insertion. Even though the airway leak pressure is not statically significant, the mean oropharyngeal leak pressure for I-gel was 20.40±5.68 (mm Hg), which was higher than c-LMA 18.73±5.06 (mm Hg), which is well within the normal limits to prevent aspiration. There were no statistically significant differences in hemodynamic changes. No Blood staining was seen after removal of device in I-gel group where it was observed in 2 (7%) patients in c- LMA group. Post removal cough was more in c -LMA (13 .3%) than l-gel (P= 0.04 SS*). Pharyngo-Laryngeal morbidity was more with classic LMA. Sore throat was more with the classic LMA (13 .3%) when compared to I-gel group (3%).We conclude that I-gel is a better airway when compared to c-LMA with respect to ease of insertion, shorter duration for insertion, adequate oropharyngeal seal with lesser pharyngo-laryngeal morbidity and less incidence of airway trauma.

Percutaneous Transgastric Duodenal Stenting and Gastrostomy Repair Using a Vascular Closure Device: Proof of Concept in a Porcine Model

Introduction. Gastroduodenal stenting is efficacious and safe in both benign and malignant foregut diseases. Transgastric duodenal stenting has been described and however requires a gastrostomy tube to remain in situ for 4 to 6 weeks post-procedure which can lead to complications. We present a technique for immediate gastric repair using a suture-mediated vascular closure device, without the need for a gastrostomy tube in porcine models. Methods. Percutaneous access into the stomach was achieved using fluoroscopy. Two or 3 Perclose Proglide devices were pre-deployed. The tract was dilated and a wire advanced into the distal duodenum. A 15.5 cm covered enteric stent was delivered through the gastrostomy, deployed and position confirmed. The gastrostomy was closed using Perclose Proglide sutures. Necropsy leak pressure measurement was performed to assess integrity of gastrostomy closure in the porcine models. Results. Two (n = 8) or 3 (n = 2) Perclose Proglide devices were deployed in ten porcine models, with 1 misfire (4.5%). Percutaneous transgastric access and stent delivery was successful in all porcine models. Mean leak pressure in the animals with adequately deployed devices was 219 mmHg (range 172 mmHg–270 mmHg). Conclusion. This study demonstrates percutaneous transgastric duodenal stenting with immediate gastric repair using suture-mediated vascular closure devices is a feasible procedure.

LMA ® Protector™ In Patients Undergoing Laparoscopic Surgeries: A Multicenter Prospective Observational Study

Backgroundː Laryngeal masks airway (LMA) has been increasingly used in surgical patients. However, the use of LMA in laparoscopic surgeries remains controversial. The major concerns include the potential risk of esophageal regurgitation, aspiration, and difficulties to achieve effective ventilation. The aim of this study was to evaluate the safety and effectiveness of the LMA® Protector™ in patients undergoing laparoscopic surgery. Methodsː Patients aged 18 to 70 years, scheduled for laparoscopic surgeries were included. The insertion time, successful insertion rate, and oropharyngeal leak pressure were measured. Airway complications and airway manipulations during the procedure were documented. Effective ventilation rate was calculated. Visible bloodstains and reflux content in the drainage channel were documented after the removal of LMA® Protector™. Resultsː A total of 300 patients were enrolled. The insertion of LMA® Protector™ failed in seven patients resulting with a successful insertion rate of 97.7%. During the maintenance of anesthesia, airway manipulation was required in 19 patients (19/293, 6.48%), in three of whom the LMA was replaced with endotracheal intubation resulting with an effective ventilation rate of 96.7% (290/300). The oropharyngeal leak pressure was 30.18±5.88 cmH2O. 75 patients (25.86%) reported mild sore throat on the first day after surgery. No signs of aspiration were noticed in any of those patients. Conclusionsː The LMA® Protector™ was shown to be safe and effective in patients undergoing laparoscopic surgeries. Although minor complications that requiring no further treatment, no clinically diagnosed aspiration was noticed in our study. Trial registration: The trail was registered at the Chinese Clinical Trial Registry (ChiCTR1800018300, data of registration, September 2018).

A Randomised Control Trial Comparing the Efficacy of LMA-Supreme and I-Gel as Rescue Ventilatory Device in Patients with Simulated Difficult Airway Undergoing Anaesthesia with Controlled Ventilation

Introduction: In an unanticipated difficult airway or in an emergency situation of cannot-intubate-cannot-ventilate scenario, Supraglottic Airway Devices (SGD) are recommended as rescue devices for establishing airway quickly to prevent hypoxia. Aim: To compare efficacy of i-gel airway and Laryngeal Mask Airway supreme (LMA supreme) as ventilatory devices and the time taken for their insertion in anaesthetised and paralysed patients with simulated difficult airway. Materials and Methods: One hundred and eighty adult patients with simulated difficult airway were randomly allocated to two groups of 90 patients each. In group I: i-gel and in group S: LMA supreme was inserted. Primary outcome studied was time taken for insertion of SGD. Secondary outcomes were the number of attempts taken for insertion of device, oropharyngeal leak pressure, ease of gastric catheter insertion, fibreoptic bronchoscopic view of anatomical alignment of device with glottic opening. Quantitative variables were compared using unpaired t-test/Mann-Whitney Test, between the two groups. Qualitative variable were compared using Chi-Square test/Fisher’s-exact test. Results: Total time taken for successful insertion was significantly shorter with group i-gel as compared to group LMA supreme {median (IQR) {19 (18.25-21)} versus {24 (23-24)} with p-value ≤0.0001. Overall success rate of insertion (96.67% vs 97.78%, p=1.000) and oropharyngeal leak pressure (p-value=0.555) of i-gel and LMA-S were comparable. i-gel has better anatomic alignment with glottic opening as compared to LMA-S (p-value ≤0.0001). Gastric tube insertion was easy in all patients in both the groups. Conclusion: Shorter time for the insertion of i-gel was observed due to absence of inflatable cuff, although both LMA-S and i-gel are equally efficacious as ventilatory devices in patients with simulated difficult airway under general anaesthesia with controlled ventilation.