Comparative Study of Low Pressure versus Standard Pressure Carbon Dioxide Pneumoperitoneum in Reducing Shoulder Tip Pain Post Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy is the gold standard treatment for cholelithiasis. Postoperative shoulder tip pain is common complaint. Evidences suggest that using low pressure pneumoperitoneum (8-10 mmHg) during the procedure rather than standard pressure (12-14 mmHg) decreases the incidence and severity of shoulder tip pain without compromising working space. Aims: The aim of this study was to evaluate the impact of low pressure and standard pressure pneumoperitoneum on shoulder tip pain post laparoscopic cholecystectomy. Methods: A prospective hospital based study conducted at Nepalgunj Medical College, Kohalpur from January 2019 to December 2020. Hundred patients were enrolled, fifty each in “low pressure carbondioxide pneumoperitoneum” and “standard pressure carbondioxide pneumoperitoneum” groups, who underwent laparoscopic cholecystectomy. The two groups were compared in terms of incidence and severity of shoulder tip pain, surgeon’s satisfaction score, top-up analgesia requirement, procedural time, conversion to standard pressure, intraoperative complications and length of hospital stay. Results: There were 45 (90%) females and five (10%) males in low pressure group and 44 (88%) females and six (12%) males in standard pressure group. Fourteen (28%) patients in low pressure and 32 (64%) patients in standard pressure group had shoulder tip pain (p=0.001). The severity of shoulder tip pain was less in low pressure group and was significant at eight hours (p=0.006) and 12 hours (p=0.008). Top-up analgesia was required more in standard pressure group. There were no intraoperative complications but only one conversion to standard pressure. Surgeon’s satisfaction score, conversion to open cholecystectomy and procedural time were comparable in both groups with shorter hospital stay in low pressure group. Conclusion: Low pressure carbondioxide pneumoperitoneum is safe and effective strategy in reducing incidence and severity of shoulder tip pain after laparoscopic cholecystectomy.

A comparative study of clinical outcome following topical versus peribulbar anesthesia in phacoemulsification surgery

The objective of our study was to evaluate and compare clinical outcomes, patients and surgeon’s satisfaction following topical versus peribulbar anesthesia in phacoemulsification surgery. A hospital based Randomized Prospective interventional Comparative Study done between November 2017 to May 2019. A total of 200 patients included in the study, ocular examination, biometry were done. Patients were randomly distributed into group1 TA (topical anesthesia) and group 2 PA (Peribulbar anesthesia), they underwent phacoemulsification with intraocular lens implantation, postoperative visual outcome and inflammation on day1 and after 1 week, VAS (Visual Analogue scale) pain scale used to analyse patients comfort and pain postoperatively. The Statistical analysis was performed by STATA 11.2 (College Station TX USA). In our study 200 participated, it was found in PA group, 60.47 ± 11.86 yrs and in TA group 59.01 ± 11.29yrs as mean age, majority were male. PA group had few complications during anesthesia and in both groups majority had no intraoperative complications. Log Mar visual acuity postoperative day 1, PA group was 0.65±0.40 and in TA was 0.49±0.32, post operative visual recovery was better in TA group patients and had less pain and more comfortable than PA. Surgeon had difficulty more with TA group patients. It was found, postoperative visual recovery was faster and better in patients with topical group with less postoperative inflammation and complications. Topical anesthesia being a non invasive procedure can be considered better than peribulbar when compared in terms of patients comfort and postoperative recovery.

Visual outcomes and intraoperative complications of small incision cataract surgery performed by junior residents in GMC

To evaluate in intraoperative complications of MSICS performed by Junior Residents and to compare the incidences of major complications in the first six months of training versus last six months of training.It is a retrospective type of study. From March 2018 to February 2019 a total of 293 manual SICS were conducted by the Junior Residents in Department of Ophthalmology. Each of the patients underwent a detailed ophthalmological examination preoperatively and underwent MSICS under peribulbar anesthesia. Consents for surgeries were obtained from each patient.Following intraoperative complications were noted: tunnel related complications, capsulorrhexis related complications, Iridodialysis, posterior capsular rent, zonular dialysis, vitreous leak, surgical aphakia, Descemet membrane detachment, placement of ACIOL, Nucleus drop and IOL drop. The patient’s immediate postoperative vision was also noted. SPSS version 15.0.Tunnel related complications were found in 13.98% patients either as scleral button holing or premature entry. Posterior capsular rents and bag disinsertion were found in total of 11.94% patients owing to which 3.07% were left aphakic. 63.13% patients had visual acuity better than 6/12 by snellens chart on first postoperative day. Performance of adequate anterior capsulotomy, minimal handling of the cornea and avoidance of posterior capsular rent are some of the challenges faced by the residents while learning MSICS. Stepwise supervised training can help a resident doctor master these steps while keeping the complications at acceptably low levels. Stepwise supervised training of residents performing MSICS can minimize complications

Endovascular treatment of medium and large intracranial aneurysms with large volume coils: A single-center experience

Background: Large volume coils are an alternative to conventional coils for the treatment of intracranial aneurysms. However, there are no published reports documenting occlusion and complication rates in medium and large intracranial aneurysms. Therefore, we present our results in this subgroup of aneurysms. Methods: A single-center, retrospective analysis of consecutive patients treated with Penumbra coils 400 in aneurysms ≥7 mm was performed. Demographics, aneurysm features, procedural details, intraoperative complications, clinical outcomes, and occlusion rates were analyzed. Results: Thirty-three patients were included for analysis, and a total of 33 intracranial aneurysms were analyzed. Mean age was 57.6 years (SD ± 12.4) and 85% of the patients were women. Large aneurysms represented 46% of cases. Paraclinoid (55%) followed by posterior communicating (30.3%) aneurysms was the most frequently treated. Ruptured and saccular aneurysms were found in 49% and 63% of the cases, respectively. The mean aneurysmal dimensions were 14.2 mm width, 11.9 mm length, 5.4 mm neck, and 2.4 dome-to-neck ratio. A dome-neck ratio <2 was identified in 39% of cases. The mean number of coils per aneurysm was 4.8. Immediate modified Raymond–Roy Grades 1, 2, and 3A were achieved in 15%, 21%, and 64%, respectively. Twenty-six patients were evaluated at a mean follow-up period of 11 months, with an adequate occlusion of 92% and a good clinical outcome (modified Rankin score ≤2) in 96% of patients. Conclusion: Endovascular treatment with PC400 coils is an effective and safe option for medium and large intracranial aneurysms with high occlusion rates, few complications, and good clinical outcomes at follow-up.

COMPARISON OF ILEAL CONDUIT AND TUUC: A 4 YEARS STUDY

Objective: This study aims to compare 4 years of experience of IC and TUUC in the same period and among similar experienced surgeons. Material & Methods: Between January 2016 and August 2019, 44 radical cystectomies were performed, but 4 patients were excluded due to incomplete data or who underwent neo-bladder procedures. The primary endpoint was 30 days of complication rate and intraoperative complications. Bowel movement, ambulation, and length of stay (LOS) postoperatively were followed-up over a period of 30-day postoperatively. Results: 12 male patients underwent TUUC and 24 male patients IC, while only 4 female patients underwent IC. The mean of LOS of IC was 12.72 8.6 and 10.08 3.5 for TUUC; there were no significant differences between arms. However, TUUC had lower intra-operatively bleeding (779.17 441.15 ml) compared to IC (1328.57 810.40 ml). There was no difference in early complications between arms. Conclusion: Our results suggest that TUU with UC diversion may be used as a viable option of urinary diversion in radical cystectomy. This technique provides similar safety both surgically and oncologically.

Geo–economic variations in epidemiology, ventilation management and outcome of patients receiving intraoperative ventilation during general anesthesia– posthoc analysis of an observational study in 29 countries

Background The aim of this analysis is to determine geo–economic variations in epidemiology, ventilator settings and outcome in patients receiving general anesthesia for surgery. Methods Posthoc analysis of a worldwide study in 29 countries. Lower and upper middle–income countries (LMIC and UMIC), and high–income countries (HIC) were compared. The coprimary endpoint was the risk for and incidence of postoperative pulmonary complications (PPC); secondary endpoints were intraoperative ventilator settings, intraoperative complications, hospital stay and mortality. Results Of 9864 patients, 4% originated from LMIC, 11% from UMIC and 85% from HIC. The ARISCAT score was 17.5 [15.0–26.0] in LMIC, 16.0 [3.0–27.0] in UMIC and 15.0 [3.0–26.0] in HIC (P = .003). The incidence of PPC was 9.0% in LMIC, 3.2% in UMIC and 2.5% in HIC (P < .001). Median tidal volume in ml kg− 1 predicted bodyweight (PBW) was 8.6 [7.7–9.7] in LMIC, 8.4 [7.6–9.5] in UMIC and 8.1 [7.2–9.1] in HIC (P < .001). Median positive end–expiratory pressure in cmH2O was 3.3 [2.0–5.0]) in LMIC, 4.0 [3.0–5.0] in UMIC and 5.0 [3.0–5.0] in HIC (P < .001). Median driving pressure in cmH2O was 14.0 [11.5–18.0] in LMIC, 13.5 [11.0–16.0] in UMIC and 12.0 [10.0–15.0] in HIC (P < .001). Median fraction of inspired oxygen in % was 75 [50–80] in LMIC, 50 [50–63] in UMIC and 53 [45–70] in HIC (P < .001). Intraoperative complications occurred in 25.9% in LMIC, in 18.7% in UMIC and in 37.1% in HIC (P < .001). Hospital mortality was 0.0% in LMIC, 1.3% in UMIC and 0.6% in HIC (P = .009). Conclusion The risk for and incidence of PPC is higher in LMIC than in UMIC and HIC. Ventilation management could be improved in LMIC and UMIC. Trial registration Clinicaltrials.gov, identifier: NCT01601223.

Video-Assisted Thoracoscopy for Vertebral Body Tethering of Juvenile and Adolescent Idiopathic Scoliosis: Tips and Tricks of Surgical Multidisciplinary Management

VATS (video assisted thoracoscopic surgery) is routinely and successfully performed in minor and major complex thoracic procedures. This technique has been recently introduced for the treatment of severe forms of idiopathic scoliosis (IS) with the aim to repair the deformity, reduce morbidity and to prevent its progression in patients with skeletal immaturity. This study aims to present VATS in anterior vertebral body tethering (AVBT) approach to support the pediatric orthopedic surgeons during vertebral body fixation. Surgical and anesthesiologic tips and tricks are reported to assure a safe procedure. The study includes preadolescents with IS and a grade of scoliosis >40° that had a high probability of deterioration due to remaining growth (December 2018 to April 2021). Skeletal immaturity of enrolled patients was assessed by Sanders classification and Risser sign. Patients had a Risser score between 0 and 1 and a Sanders score >2 and <5. AVBT technique using VATS was performed by a senior pediatric surgeon assisting the pediatric orthopedic surgeon. Twenty-three patients have been submitted to VATS AVBT in the period of study (age range 9–14 years). The patients had a classified deformity Lenke 1A or B convex right and all types of curves were treated. In all patients, the vertebrae submitted to tethering surgery ranged from D5 to D12; mean curve correction was 43%. Three postoperative complications occurred: one late postoperative bleeding requiring a chest tube positioning on 12th postoperative day; one screw dislodged and needed to be removed; one child showed worsening of the scoliosis and needed a posterior arthrodesis. Initial results of VATS AVBT in growing patients with spinal deformities are encouraging. An appropriate selection of patients and a pediatric dedicated multidisciplinary surgical approach decrease intraoperative complications, time of operation and postoperative sequelae and guarantee an optimal outcome.

Surgical and Anatomic Consideration in Endoscopic Dacryocystorhinostomy of a Patient with Damaged Sinonasal Anatomy Post–Caldwell-Luc Surgery: A Case Report

Background: The Caldwell-Luc (CL) procedure, an outdated operative procedure that is used to treat inflammatory sinus diseases, is rarely performed presently. However, physicians may encounter patients with a history of CL surgery who develop considerable postoperative changes that may lead to diagnostic confusion in imaging evaluation; increase the difficulty of future surgery, such as sinonasal surgery; and increase the incidence of future intraoperative complications. Case summary: A 67-year-old man with a surgical history of chronic sinusitis reported epiphora of the left eye for five years. Balloon dacryocystoplasty was attempted but failed. Endo-DCR (Endoscopic dacryocystorhinostomy) was indicated; however, preoperative CT (computed tomography) imaging and nasal endoscopic examination showed sinonasal anomalies and the loss of internal landmarks for localizing the lacrimal sac. Preoperative CT results indicated previous CL surgery. Endo-DCR was performed with the aid of nasal forceps and a 20-gauge vitreoretinal fiberoptic endoilluminator. A six-month follow-up revealed the complete resolution of symptoms and no signs of recurrence. Conclusions: Epiphora might be a delayed complication of the CL procedure. Before performing endo-DCR, ophthalmologists should be familiar with the sinonasal anatomy and carefully assess preoperative imaging to identify anatomical variations. Nasal forceps and transcanalicular illumination can assist in determining the precise location of the lacrimal sac during endo-DCR.

Using the Casper Stent in Carotid Angioplasty: A Single Center Experience

Objectives To establish the success rate in endovascular internal carotid artery (ICA) stenosis recanalization using the double-layer stent Casper-RX (Microvention, Inc 35 Enterprise, Aliso Viejo, California, United States of America) and to identify the main comorbidities in individuals with ICA stenosis, morphological characteristics of the stenosis, diagnostic methods, intraoperative complications, as well as morbidity and mortality within 30 days of the surgical procedure. Materials and Methods Retrospective analysis of 116 patients undergoing ICA angioplasty with a degree of stenosis ≥ 70% using Casper-RX stenting who underwent this procedure from April 2015 to December 2019. Results Technical success was achieved in 99.1% of the patients. Three of them had postprocedural complications: one transient ischemic attack (TIA) and two puncture site hematomas. A cerebral protection filter was not used in only two procedures, as these consisted of dissection of the carotid. There was satisfactory recanalization and adequate accommodation of the stents in the previously stenosed arteries, with no restenosis in 99.4% of the cases. Conclusion The endovascular treatment of extracranial carotid stenoses using the Casper-RX stent showed good applicability and efficacy. Although only two cases of thromboembolic complications occurred during the procedure, further investigation and studies on the effectiveness of this new device are needed.

Complications associated with and outcome of surgical intervention for treatment of esophageal foreign bodies in dogs

OBJECTIVE To identify complications associated with and short- and long-term outcomes of surgical intervention for treatment of esophageal foreign bodies (EFBs) in dogs. ANIMALS 63 client-owned dogs. PROCEDURES Patient records from 9 veterinary hospitals were reviewed to identify dogs that underwent surgery for removal of an EFB or treatment or an associated esophageal perforation between 2007 and 2019. Long-term follow-up data were obtained via a client questionnaire. RESULTS 54 of the 63 (85.7%) dogs underwent surgery after an unsuccessful minimally invasive procedure or subsequent evidence of esophageal perforation was identified. Esophageal perforation was present at the time of surgery in 42 (66.7%) dogs. Most dogs underwent a left intercostal thoracotomy (37/63 [58.7%]). Intraoperative complications occurred in 18 (28.6%) dogs, and 28 (50%) dogs had a postoperative complication. Postoperative complications were minor in 14 of the 28 (50%) dogs. Dehiscence of the esophagotomy occurred in 3 dogs. Forty-seven (74.6%) dogs survived to discharge. Presence of esophageal perforation preoperatively, undergoing a thoracotomy, and whether a gastrostomy tube was placed were significantly associated with not surviving to discharge. Follow-up information was available for 38 of 47 dogs (80.9%; mean follow-up time, 46.5 months). Infrequent vomiting or regurgitation was reported by 5 of 20 (25%) owners, with 1 dog receiving medication. CLINICAL RELEVANCE Results suggested that surgical management of EFBs can be associated with a high success rate. Surgery should be considered when an EFB cannot be removed safely with minimally invasive methods or esophageal perforation is present.