Recommendations From the Society for the Advancement of Transplant Anesthesiology Fellowship Committee: Core Competencies and Milestones for the Kidney/Pancreas Component of Abdominal Organ Transplant Anesthesia Fellowship

The Society for the Advancement of Transplant Anesthesia (SATA) is dedicated to improving patient care in all facets of transplant anesthesia. The anesthesia fellowship training recommendations for thoracic transplantation (heart and lungs) and part of the abdominal organ transplantation (liver) have been presented in previous publications. The SATA Fellowship Committee has completed the remaining component of abdominal transplant anesthesia (kidney/pancreas) and has assembled core competencies and milestones derived from expert consensus to guide the education and overall preparation of trainees providing care for kidney/pancreas transplant recipients. These recommendations provide a comprehensive approach to pre-operative evaluation, vascular access procedures, advanced hemodynamic monitoring, assessment of coagulation and metabolic abnormalities, operative techniques, and post-operative pain control. As such, this document supplements the current liver/hepatic transplant anesthesia fellowship training programs to include all aspects of “Abdominal Organ Transplant Anesthesia” recommended knowledge.

Complete intracranial migration of ventriculoperitoneal shunt: a common procedure with a rare complication

Background Ventriculoperitoneal shunt insertion is widely used in the treatment of different kinds of hydrocephalus. Shunt failure is one of the most common complications; however complete intracranial shunt migration is rarely reported. Case presentation We report a case of an eleven-month-old girl with complete intracranial migration of Ventriculoperitoneal Shunt (Chhabra Shunt). We removed this intracranially migrated shunt with the help of an endoscope (GAAB) and inserted a new Ventriculoperitoneal Shunt (Medtronic Shunt) on the opposite side. She had a good clinical outcome. Conclusion Complete intracranial shunt migration is an extremely rare complication. It is likely due to raised intra-peritoneal pressure, strong head movements, and inadequate shunt fixation. The best possible approach to prevent shunt migration would be better patient handling along with appropriate operative techniques.

Facial Feminization Surgery: Guidelines for Patient Evaluation and Operative Techniques

Facial feminization surgery (FFS) is one of many gender affirming surgeries that can reduce gender dysphoria and rate of mis-gendering. A multidisciplinary team with experience caring for transgender patients is valuable for generating high quality outcomes and patient satisfaction. In particular, specific technical pearls can assist in improving outcomes of this procedure. This article provides a review of patient and procedure selection for a range of FFS procedures including chondrolaryngoplasty, hairline advancement, forehead reduction and recontouring, orbital opening and brow lift, rhinoplasty, lip lift or augmentation, malar augmentation, and mandibular recontouring and genioplasty. The authors share technical insights and pre- and postoperative management recommendations gained from experiences at 2 institutions performing high volume FFS.

Evaluation of functional outcome of metacarpal fractures managed by operative techniques: a hospital based study

Background: Metacarpal fractures comprise approximately 35.5% of cases in daily emergencies, mostly due to road traffic accidents, fall, and assault. The main goal of treatment is to achieve the strong bony union without any functional disability. Aim of the study was evaluation of functional outcome of metacarpal fractures managed by operative techniques and to compare the efficacy of different operative techniques.Methods: A total of 50 patients managed by various operative techniques by using k-wires, screws and plates. Functional outcome was assessed by using total active movement (TAM) and disabilities of the arm, shoulder and hand (DASH) scoring system at 6th week, 3rd month and at 6th month.Results: A total 47 fractures united and three fractures mal-united at the time of final assessment. Overall excellent and good results were achieved in 94% cases.Conclusions: Our finding suggests that open reduction and internal fixation with k-wire is most preferable method among all other operative techniques.

Clinical outcomes of Tightrope system in the treatment of purely ligamentous Lisfranc injuries

Background Purely ligamentous Lisfranc injuries are mainly caused by low energy damage and often require surgical treatment. There are several operative techniques for rigid fixation to solve this problem clinically. This study evaluated the effect of using the Tightrope system to reconstruct the Lisfranc ligament for elastic fixation. Methods We retrospectively analyzed 11 cases with purely ligamentous Lisfranc injuries treated with the Tightrope system from 2016 to 2019, including 8 male and 3 female. X-ray was performed regularly after operation to measure the distance between the first and second metatarsal joint and the visual analogue scale (VAS) score was used to evaluate pain relief. American orthopedic foot & ankle society (AOFAS) and Maryland foot score were recorded at the last follow-up. Results The average follow-up time was 20.5 months (range, 17–24). There was statistically significant difference in the distance between the first and second metatarsal joint and VAS score at 3 months, 6 months, and the last follow-up when compared with preoperative values (P < 0.05).Mean of postoperative AOFAS mid-foot scale and Maryland foot score were 92.4 ± 4.3, 94.1 ± 3.5, respectively. The Tightrope system was not removed and the foot obtained better biomechanical stability. No complications occurred during the operation. Conclusion Tightrope system in the treatment of purely ligamentous Lisfranc injuries can stabilize the tarsometatarsal joint and achieve satisfactory effect.

Complications of neuroendoscopic septostomy

OBJECTIVE The advent of neuroendoscopy revolutionized the management of complex hydrocephalus. Fenestration of the septum pellucidum (septostomy) is often a therapeutic and/or necessary intervention in neuroendoscopy. However, these procedures are not without risk. The authors sought to record the incidence and types of complications. They attempted to discern if there was decreased likelihood of septostomy complications in patients who underwent endoscopic third ventriculostomy (ETV)/choroid plexus cauterization (CPC) as compared with those who underwent other procedures and those with larger ventricles preoperatively. The authors investigated different operative techniques and their possible relationships to septostomy complications. METHODS The authors retrospectively reviewed all neuroendoscopic procedures with Current Procedural Terminology code 62161 performed from January 2003 until June 2019 at their institution. Septostomy, either alone or in conjunction with other procedures, was performed in 118 cases. Basic demographic characteristics, clinical histories, operative details/findings, and adverse events (intraoperative and postoperative) were collected. Pearson chi-square and univariate logistic regression analyses were performed. Patients with incomplete records were excluded. RESULTS Of 118 procedures, 29 (24.5%) septostomies had either intraoperative or postoperative complications. The most common intraoperative complication was bleeding, as noted in 12 (10.2%) septostomies. Neuroendocrine dysfunction, including apnea, bradycardia, neurological deficit, seizure, etc., was the most common postoperative complication and seen after 15 (12.7%) procedures. No significant differences in complications were noted between ventricular size or morphology or between different operative techniques or ventricular approaches. There was no significant difference between the complication rate of patients who underwent ETV/CPC and that of patients who underwent septostomy as a part of other procedures. Greater length of surgery (OR 1.013) was associated with septostomy complications. CONCLUSIONS Neuroendoscopy for hydrocephalus due to varying etiologies provides significant utility but is not without risk. The authors did not find associations between larger ventricular size or posterior endoscope approach and lower complication rates, as hypothesized. No significant difference in complication rates was noted between septostomy performed during ETV/CPC and other endoscopic procedures requiring septostomy.

SPIGELIAN HERNIA VARIOUS PRESENTATION AND MANAGEMENT- A CASE SERIES

BACKGROUND: Spigelian hernia is rare and requires high index of suspicion. Given the case of inconsistent ndings and signs the diagnosis of spigelian hernia presents with great difculties than its treatment. Incidence of spigelian hernia ranges from 0.1% to 2% of all abdominal hernias AIM: Aim of this case series is to analyze epidemiological aspects, clinical presentation, challenges in diagnosis, surgical technique characteristics, morbidities and hospital stay MATERIALS AND METHODS: A total number of 4 patients who had undergone surgery for spigelian hernia for a period of 6 months from the month of Jan to June 2021 in the dept of general surgery in KMCH were studied. All 4 cases have been analyzed in this study period and followed up until discharge from the hospital. RESULTS: This case series consisted of 4 cases. All cases presented with pain. Only 2 among 4 cases presented with swelling. Denitive diagnosis of all cases could be done only by CT. Out of these 1 was taken up as emergency.Intraoperatively 3 cases were interstitial and 1 was subcutaneous type. All 4 cases were treated by open surgical technique and by placing mesh at different planes CONCLUSION: Diagnosis of spigelian hernia presents with great difculties and hence one must be aware of the clinical presentation. Pain is the consistent feature of all hernias and only occasionally swelling is present which may mislead easily. Computed tomography of abdomen and pelvis still prevails as the denitive radiological investigation in the diagnosis of spigelian hernia. There are many planes at which mesh can be placed for repair where the operative techniques vary. Though the outcome was good in all four cases discussed here, the post operative complication and duration of stay was considerably less when the mesh was placed in the intermuscular plane.

Surgery for chronic pancreatitis: the comparison of two high-volume centers reveals lack of a uniform operative management

Purpose Many aspects of surgical therapy for chronic pancreatitis (CP), including the correct indication and timing, as well as the most appropriate operative techniques, are still a matter of debate in the surgical community and vary widely across different centers. The aim of the present study was to uncover and analyze these differences by comparing the experiences of two specialized surgical units in Italy and Austria. Methods All patients operated for CP between 2000 and 2018 at the two centers involved were included in this retrospective analysis. Data regarding the clinical history and the pre- and perioperative surgical course were analyzed and compared between the two institutions. Results Our analysis showed a progressive decrease in the annual rate of pancreatic surgical procedures performed for CP in Verona (no. = 91) over the last two decades (from 3% to less than 1%); by contrast, this percentage increased from 3 to 9% in Vienna (no. = 77) during the same time frame. Considerable differences were also detected with regard to the timing of surgery from the first diagnosis of CP — 4 years (IQR 5.5) in the Austrian series vs two (IQR 4.0) in the Italian series -, and of indications for surgery, with a 12% higher prevalence of groove pancreatitis among patients in the Verona cohort. Conclusion The comparison of the surgical attitude towards CP between two surgical centers proved that a consistent approach to this pathology still is lacking. The identification of common guidelines and labels of surgical eligibility is advisable in order to avoid interinstitutional treatment disparities.