Assisted Vaginal Delivery - Preference of Vacuum or Forceps among Obstetricians

Objective: To determine the instrument preference among obstetricians practicing operative vaginal deliveries and to determine the prevalence and risks of vacuum or forceps Assisted Vaginal Delivery (AVD). Methods: This cross-sectional study was carried out in ACS Medical and Hospital, Chennai. A total of 520 obstetricians were included in the study. An online questionnaire was sent to all obstetricians in Chennai. The choice of procedure for specific circumstances, instrument preference [use of vacuum or forceps] and views on the complications encountered in both vacuum and forceps use at vaginal delivery were explored. For the replies, we computed means and percentages for the entire group and distinct subgroups. Risk assessment of outcome with exposure as suitable p-value was included in the statistical analysis. Results: Response rate for the questionnaire was 97% (504/520). The findings suggest that obstetricians preference was more towards vacuum due to their ease of usage. Baseline characteristics were similar between the two groups. Failed vacuum due to slipping of the cup was the most common complication faced - 62%, followed by caput succedaneum 25%, both were statistically significant. The most significant finding was that maternal injuries in the vacuum group were only 2% which was way less than those who had forceps delivery (68%) with a p-value of < 0.001. Conclusion: In this research, physician instrument choice is a significant predictor of results that should be taken into account. Use of vacuum for delivery seemed to be the choice of majority of obstetricians [334 (66%)]. Vacuum extractor rather than forceps for assisted delivery appears to reduce maternal morbidity, whereas neonatal injuries were more common in newborns delivered by vacuum. The choice of instrument should be personalized based on the patient's condition and the obstetrician's experience and expertise.

Investigation of the Indications for Endoscopic Papillectomy and Transduodenal Ampullectomy for Ampullary Tumors

Objective: The standard treatment for ampullary tumors is pancreaticoduodenectomy. However, minimally invasive procedures such as endoscopic papillectomy (EP) and transduodenal ampullectomy (TDA) have recently gained popularity. Therefore, we aimed to evaluate the effectiveness of these minimally invasive procedures for ampullary tumors. Methods: We conducted a retrospective study of 42 patients who underwent either EP or TDA for ampullary tumors between June 2011 and November 2020. Results: We found that in patients with significantly larger tumors, TDA was often selected. Patients who underwent EP had significantly shorter hospital stays. No significant differences were observed regarding procedural accidents, tumor size, and recurrence. Conclusion: No differences were observed regarding the treatment outcomes of EP and TDA except hospital stay. EP is less invasive and can be the initial choice of procedure. TDA is performed when EP is not technically feasible. No significant relationship was noted between tumor size and recurrence, and careful observation of the patient’s postoperative course is required.

Three-Dimensional Imaging of Displaced Intra-articular Calcaneal Fractures Correlates With the Perioperative Diagnosis

Background: Intra-articular calcaneal fractures are complex injuries, and CT imaging has become the standard imaging in the preoperative assessment. Most classifications of these fractures are CT-based but have been associated with limited interobserver agreement. Three-dimensional imaging has become widely available and may give a better perspective but often with 1 image only. There is not much evidence of the added value of this imaging, compared with the CT imaging. Methods: Eight experienced trauma surgeons assessed 28 different intra-articular calcaneal fractures, on conventional radiology (CR), CT, and 3-D imaging. All had extensive experience in the diagnosis and treatment of this difficult injury. The main questions concerned Sanders classification, the severity of the injury and the difficulty of the operative procedure, choice of approach, and choice of procedure. Results: The classical 2-D CT imaging of the fractures were associated with a higher Sanders classification ranking, compared with the 3-D imaging scores. However, the interobserver agreement, as measured by the Fleiss kappa, was low for all 3 imaging modalities. We found more frequent Sanders III and IV classifications with CT scan imaging compared with 3-D imaging or CR. The scores obtained after assessing 3-D imaging were also not statistically significantly different from the scores of a consensus achieved by 2 authors and based on the 3 imaging modalities and the perioperative diagnosis. Conclusion: The 3-D imaging may result in a more realistic view, reducing the frequency of classifying Sanders III fractures than with the 2-D CT imaging series. 3-D imaging may be more reliable than CT in the planning of operative treatment of displaced intra-articular calcaneal fractures. Level of Evidence: Level III.

From conservative treatment to surgery with repeated imaging modalities in post-TAVI infective endocarditis patient

Transcatheter aortic valve implantation (TAVI) is the more common choice of procedure for the severe aortic stenosis patients with high surgical risk. While the popularity of TAVI increases, TAVI related complications, such as infective endocarditis (IE) increase in number. There are no specific guidelines for TAVI-IE, so shaping a path according to patient’s clinical status is more reasonable. With different advantages for each, multiple imaging modalities should be used for follow-up. In our case, repeated multiple imaging modalities were used to decide early surgery versus conservative approach by detecting periaortic pseudoaneurysm after TAVI.

16. Locus Standi

This chapter focuses on the concept of locus standi, perhaps the most important way in which administrative law deals with the question of how to balance the protection of individual citizens’ rights and interests with the desire to ensure that government decision-making remains within legal limits and that government bodies (including the courts) are protected from vexatious litigants. It is organised as follows. The first section addresses the law that existed prior to the introduction of the Order 53 reforms in 1977 whilst the second covers the short period between the introduction of those reforms and the House of Lords’ decision in IRC v National Federation of Self-Employed and Small Businesses. The third section runs from the mid-1980s to the present day. The pervasive analytical concerns are to explore the way the law of locus standi interacts with the question of the choice of procedure issues which were addressed in chapter fifteen, and—more broadly—to assess how those two matters both singly and in combination structure in a practical sense the way our constitution gives effect to the various values inherent in theories relating to the rule of law and sovereignty of Parliament.

DOP30 Segmental vs extended colectomy for colorectal cancer in Crohn’s Disease: Results from a multi-centre retrospective comparative study

Background There is a recognized increased risk for colorectal cancer (CRC) in patients with Crohn’s disease (CD). CD patients with CRC might also show a higher prevalence of synchronous and metachronous cancers. On this basis, current guidelines recommend pan-proctocolectomy (PPC) as a treatment. Aim of this study was to evaluate oncologic outcomes and the actual risk of developing metachronous cancers in CD patients undergoing segmental colectomy (SC) for CRC. Methods All CRC CD patients undergoing surgery in select European and U.S. tertiary referral centres were enrolled. Short and long-term results of SC were compared with those of patients undergoing extended colectomies: total colectomy (TC) and panproctocolectomy (PPC). Primary outcomes were progression-free survival (PFS) and overall survival (OS). Secondary outcomes were postoperative complications, 30 days mortality, re-admission, length of stay, incidence of synchronous and metachronous lesions. Results 91 patients were included: 50 (54%) did not have Crohn’s colitis or had cancer developed in a non-involved segment; cancer developed in inflamed colic segment in 41 (46%). Patients without colitis were more often treated with SC (84%). 62 patients underwent segmental colectomies and 29 extended colectomies (EC): 19 PPC and 10 TC. Patients in the SC group were older (p 0.0429), harboured more metastases at diagnosis (p 0.0219) and were less likely to suffer from CD pancolitis (p 0.0022). Incidence of major complications was comparable in SC (8.6%) vs EC (3.45%) (p 0.06602). There was no perioperative mortality and no difference in specific complications, re-admission or length of stay. 28 patients (30%) suffered disease progression: 22 (35%) after SC and 6 (21%) after EC. Of the 19 cancer related deaths (20%), 16 (25%) were in SC and 3 (10%) in EC groups. There was no difference in unadjusted PFS between SC and EC (0.64 vs 0.79 respectively, Wilcoxon p 0.1029) nor in OS (0.74 vs 0.89, Wilcoxon p 0.1591), after a median follow up of 42 months (55.76 vs 31.13 months respectively). Multivariate analysis confirmed no difference in PFS (HR 1.582, p 0.4964) or OS (HR1 428, p 0.4758). 6 synchronous lesions were found in the 29 patients undergoing EC: 3 low grade dysplasia (10%), 1 high grade dysplasia (3.4%) and 2 preoperatively diagnosed cancers (6.8%). 1 patient (1,61%) developed a metachronous colon cancer of the 62 who had SC and none of the 10 TC. Conclusion CRC in CD is a complex situation and choice of procedure is multifaceted. Incidence of synchronous and metachronous cancers appears much lower than previously described. SC offers similar long-term outcomes to more extensive surgery. Current guidelines for the treatment of CRC in CD patients may need to be reconsidered.

Recent Advances of Interventional Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound for Patients with Surgically Altered Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be the gold standard for diagnosis and interventions in biliopancreatic diseases. However, ERCP in patients with surgically altered anatomy (SAA) appears to be more difficult compared to cases with normal anatomy. Since the production of a balloon enteroscope (BE) for small intestine disorders, BE had also been used for biliopancreatic diseases in patients with SAA. Since the development of BE-assisted ERCP, the outcomes of procedures, such as stone extraction or drainage, have been reported as favorable. Recently, an interventional endoscopic ultrasound (EUS), such as EUS-guided biliary drainage (EUS-BD), has been developed and is available mainly for patients with difficult cases of ERCP. It is a good option for patients with SAA. The effectiveness of interventional EUS for patients with SAA has been reported. Both BE-assisted ERCP and interventional EUS have advantages and disadvantages. The choice of procedure should be individualized to the patient’s condition or the expertise of the endoscopists. The aim of this review article is to discuss recent advances in interventional ERCP and EUS for patients with SAA.

O5 Outcomes of vascular and endovascular interventions performed during the COVID-19 pandemic: The Vascular and Endovascular Research Network (VERN) COvid-19 Vascular sERvice (COVER) Tier 2 study

Introduction The COVID-19 pandemic forced rapid adaptations to healthcare provision. The COvid-19 Vascular sERvice (COVER) Study aimed to contemporaneously report outcomes for patients undergoing vascular interventions worldwide during the pandemic. Methods COVER is an international multi-centre observational cohort study of outcomes following vascular interventions during the pandemic. The primary outcome was to capture procedural information on all open and endovascular interventions undertaken. Secondary outcomes included in-hospital mortality and changes in management resulting from the pandemic. Results 1103 patients from 57 institutions in 19 countries were enrolled. Mean age was 66.9±13.9 (75·6% male). The rate of suspected/confirmed COVID-19 infection was 4·0%. Overall, in-hospital mortality was 11.0%. Aortic interventions had a mortality of 15·2% (23/151), amputations 12·1% (28/232), carotid interventions 10·7% (11/103) and lower limb revascularisation 9·8% (51/521). Increased risk of in-hospital mortality was noted for patients with chronic obstructive pulmonary disease, lower respiratory tract infection, Caucasian ethnicity and those undergoing urgent/immediate surgery. Choice of procedure deviated from standard management in 7·1% cases. Adjusting for confounders, antiplatelet (OR 0·503 (0·273-0·928) and oral anticoagulant (OR 0·411 (0·205-0·824) reduced risk of in-hospital mortality. Conclusions Patients undergoing vascular intervention during the pandemic had substantially higher overall and condition-specific mortality compared to pre-pandemic cohort reports, despite low COVID-19 infection rates.

Incidence of Dumping Syndrome after Sleeve Gastrectomy, Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass

Background: Dumping syndrome (DS) is an important but often missed problem occurring after bariatric surgery. It is believed that gastric bypass procedures like Roux-en-Y Gastric Bypass (RYGB) and One-Anastomosis Gastric Bypass (OAGB) are more likely to cause DS than the pylorus-preserving Sleeve Gastrectomy (SG). The aim of this study was to evaluate the incidence of DS in patients undergoing SG, RYGB and OAGB. Methods: A retrospective clinical study with additional phone interviews of 180 morbidly obese patients (130 females; 72.2%) undergoing SG (n=50), RYGB (n=53) and OAGB (n=77) in our clinic during 2016 - 2018 was performed. Clinical and demographic data were assessed. The incidence of dumping syndrome was evaluated using validated Sigstad Score. Results: Information about the occurrence of dumping symptoms and patient satisfaction was obtained from 127 patients; 53 could not be reached by phone. Median follow-up was 20.0 ± 11.4 months. Significant differences between the surgical procedures were found for the duration of surgery, complications, incidence of DS and satisfaction postoperatively. DS occurred in 15.6% after SG, in 56.4% after RYGB and in 42.9% after OAGB. While SG showed the shortest operative time with 66.5 ± 25.3 minutes and highest patient satisfaction, the lowest complication rate was observed after OAGB with 5.2%. The RYGB group reported the longest duration of surgery with 121.0 ± 28.9 minutes, most complications (17.0%), and lowest patient satisfaction. Conclusion: The present results showed a clear superiority of SG regarding both perioperative results and incidence of DS compared to RYGB and OAGB and may impact clinicians and patients in their choice of procedure.

Post-Operative Nasal Obstruction: Comparison between External and Endoscopic Dacryocystorhinostomy

Objectives: The objectives of this study is to compare between endoscopic and external dacryocystorhinostomy (DCR) procedures with regards to both objective and subjective parameters, i.e., incidence of long term post-operative nasal obstruction and patientreported quality of life. Study Design: Prospective study Setting: Tertiary Care University Hospital Participants: Study population included 24 patients undergoing either endoscopic or external DCR with bicanalicular silicone, at the Department of Otorhinolaryngology and Head and Neck Surgery in (removed for blind peer review 1). Main outcome and measure: Changes in nasal resistance was determined by anterior rhinomanometry, and quality of life was assessed by mini rhinoconjuctivitis quality of life questionnaire (MRLQ). Results: Post-operative nasal resistance was significantly increased upon both endoscopic and external DCR (p=0.04); this outcome was temporary and returned to normal after stent removal. Quality of life (QOL) exhibited a significant bimodal improvement in both groups 3 months after the operation (p=0.03), as well as after stent removal (p=0.01). Conclusions: While endoscopic and external DCR with silicone tube stenting both lead to an improvement in quality of life, a significant temporary objective nasal obstruction occurs, more prominently after the endoscopic procedure. Pending future studies, this observed discrepancy may be an appropriate matter to convey to prospective patients prior to choice of procedure.