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.

Prevalence, Predictors, and Clinical Presentation of Acute Pericardial Effusion Following Percutaneous Coronary Intervention

Background: Iatrogenic pericardial effusion (PE) has been demonstrated to lead to cardiac injury as a sign of systemic inflammatory response.Objectives: This study sought to determine the anatomical characteristics and clinical presentation associated with PE after percutaneous coronary intervention (PCI) by using echocardiography.Methods: The clinical outcomes of all patients with coronary artery disease who underwent PCI from July 2014 to December 2018 were evaluated. The quantitative and qualitative analyses of PE were performed. The associations between the presence of PE and procedural factors were also evaluated.Results: A total of 882 patients were enrolled. PE was found in 144 patients (16.3%) and was mostly located in the anterior pericardium at low amounts. The serum levels of high-sensitive C-reaction protein before PCI and troponin T in the group with PE after PCI were significantly higher than those in the group without PE (p < 0.0001). The presence of PE was associated with the procedural time (OR = 1.02, p = 0.035) and the degree of interventional complexity (multiple vessels OR = 1.89, p = 0.014; chronic total occlusion OR = 2.04, p = 0.005; and PCI with rotational atherectomy OR = 1.15, p = 0.011) independent of the number of culprit vessels and stents. During 1-year follow-up, a significantly higher number of cardiac deaths (3) and myocardial infarctions (8) occurred in patients with PE than in patients without PE (P < 0.05).Conclusion: Post-PCI acute PE was frequent, generally mild, mainly asymptomatic, and independently associated with procedural time and complexity. This effusion, which is considered as a cardiac damage marker, could be a predominant clinical sign for long-term prognosis.

Comparison of Using Second-Generation Cryoballoon and Radiofrequency Catheter for Atrial Fibrillation Ablation in Patients With the Common Ostium of Inferior Pulmonary Veins

Aims: To compare the procedural outcomes of cryoballoon ablation (CBA) and radiofrequency ablation (RFA) in atrial fibrillation (AF) patients with the common ostium of inferior pulmonary veins (COIPV) and to explore the effect of COIPV on CBA performance through the assessment of anatomical factors.Methods: A total of 18 AF patients with COIPV were included. Pulmonary vein isolation (PVI) was performed with second-generation CBA or RFA. The anatomical characteristics of COIPV and procedural outcomes were collected.Results: The prevalence of COIPV was 0.82% in the enrolled population. PVI was achieved in all pulmonary veins (PVs) without any complications. The “tricircle” strategy was applied for RFA, and the segmental freeze strategy was performed for CBA. Compared with RFA, CBA had shorter procedural time (median: 53.0 vs. 78.0 min, p < 0.001) and longer fluoroscopy time (median: 13.5 vs. 6.0 min, p < 0.001). Higher ovality index of the ostium was seen in patients with ≥4 freezes in inferior PVs [IPVs; 0.95 (0.78–1.05) vs. 0.49 (0.21–0.83), p = 0.047]. During a median of 23.5 months of follow-up, the atrial arrhythmias-free survival after the procedure was comparable between CBA and RFA (p = 0.729).Conclusion: The second-generation CBA is an efficient and safe alternative for RFA in AF patients with COIPV. Anatomical characteristics of COIPV bring the challenge to the procedure performance of RFA and CBA.

Efficacy and Safety of Preoperative vs. Intraoperative Computed Tomography-Guided Lung Tumor Localization: A Randomized Controlled Trial

Background: Thoracoscopic removal of small pulmonary nodules is traditionally accomplished through a two-step approach—with lesion localization in a CT suite as the first step followed by lesion removal in an operating room as the second step. While the advent of hybrid operating rooms (HORs) has fostered our ability to offer a more patient-tailored approach that allows simultaneous localization and removal of small pulmonary nodules within a single-step, randomized controlled trials (RCTs) that compared the two techniques (two- vs. single-step) are still lacking.Methods: This is a RCT conducted in an academic hospital in Taiwan between October 2018 and December 2019. To compare the outcomes of traditional two-step preoperative CT-guided small pulmonary nodule localization followed by lesion removal vs. single-step intraoperative CT-guided lesion localization with simultaneous removal performed by a dedicated team of thoracic surgeons. The analysis was conducted in an intention-to-treat fashion. The primary study endpoint was the time required for lesion localization. Secondary endpoints included radiation doses, other procedural time indices, and complication rates.Results: A total of 24 and 25 patients who received the single- and two-step approach, respectively, were included in the final analysis. The time required for lesion localization was significantly shorter for patients who underwent the single-step procedure (median: 13 min) compared with the two step-procedure (median: 32 min, p < 0.001). Similarly, the radiation dose was significantly lower for the former than the latter (median: 5.64 vs. 10.65 mSv, respectively, p = 0.001).Conclusions: The single-step procedure performed in a hybrid operating room resulted in a simultaneous reduction of both localization procedural time and radiation exposure.

Safe preoperative regional nerve blocks

BackgroundProcedural time-outs and checklists are proven to be an effective means of improving teamwork and preventing wrong-sided procedures. The main objective of this study was to ensure that all regional nerve blocks being performed in the preoperative area at our hospital were executed with a proper time-out. The goal of this project was to increase integration of a safe preoperative block process including a time-out checklist to ensure; complete consents, correct patient and laterality were marked prior to each procedure. We focused on recognising events that took place before, during and after the nerve block including non-compliance with the checklist and deviations from protocol.MethodsA safe preoperative block process current and future state flowchart, revised time-out checklist and action/implementation plan as part of our Plan–Do–Study–Act model was constructed using a multidisciplinary approach. Pre-implementation and post- implementation data were collected by medical students acting anonymously via direct observation noting the presence of an anaesthesiologist, resident, nurse, time-out for procedure, checklist completed and procedure start and sedation time representing a complete time-out.ResultsThe direct observations in the pre-implementation group showed a 20% (3/15) compliance with a correct time-out. The direct observations in the post implementation group showed 85% (12/14) compliance. This revealed a 65% increase in all portions of the time-out checklist completed. Comparative analysis confirmed decrease in non-compliance and deviations from protocol as displayed by 65% increase in all portions of time-out checklist completed.ConclusionWe aimed to improve safety, communication and compliance for preoperative nerve blocks through development and implementation of a safe preoperative block process using a multidisciplinary model. We conclude that creation of a safe nerve block was achieved by integration of a preoperative nerve block process which included increased compliance to the time-out checklist, verifying patients and laterality with marking of patient prior to each procedure, identifying proper consents were completed and ensuring each regional nerve block was executed with a proper time-out.

Endoscopic submucosal dissection for colorectal neoplasia: outcomes and predictors of recurrence

Background and study aims The role of endoscopic submucosal dissection (ESD) for colorectal lesions in Western communities is unclear and its adoption is still limited. The aim of this study is to assess the long-term outcomes of a large cohort of patients treated with colorectal ESD in a tertiary Western center. Patients and methods A retrospective analysis was conducted on patients treated by ESD for superficial colorectal lesions between February 2011 and November 2019. The primary outcome was the recurrence rate. Secondary outcomes were en-bloc and R0 resection rates, procedural time, adverse events (AEs), and need for surgery. The curative resection rate was assessed for submucosal invasive lesions. Results A total of 327 consecutive patients, median age 69 years (IQR 60–76); 201 men (61.5 %) were included in the analysis. Of the lesions, 90.8 % were resected in an en-bloc fashion. The rate of R0 resection was 83.1 % (217/261) and 44.0 % (29/66) for standard and hybrid ESD techniques, respectively. Submucosal invasion and piecemeal resection independently predicted R1 resections. A total of 18(5.5 %) intra-procedural AEs (perforation:11, bleeding:7) and 12(3.7 %) post-procedural AEs occurred (perforation:2, bleeding: 10). Eighteen adenoma recurrences per 1,000 person-years (15cases, 5.6 %) were detected after a median follow-up time of 36 months. All recurrences were detected within 12 months. No carcinoma recurrences were observed. R1 resection status and intra-procedural AEs independently predicted recurrences with seven vs 150 recurrences per 1,000 person-years in the R0 vs R1 group, respectively. Conclusions Colorectal ESD is a safe and effective option for managing superficial colorectal neoplasia in a Western setting, with short and long-terms outcomes comparable to Eastern studies. En-bloc R0 resection and absence of intra-procedural AEs are associated with reduced risk of recurrence.

Initial Clinical Experience of Repeat Thrombectomy with a Retrieval Stent (RTRS) with Continuous Proximal Flow Arrest by Balloon Guide Catheter for Acute Intracranial Carotid Occlusion

Background. Balloon guide catheters (BGCs) have good performance in terms of radiological outcomes in acute ischemic thrombectomy. It is not uncommon for BGCs to be blocked by thrombi, especially in cases with acute intracranial internal carotid artery (ICA) occlusion. Our initial experience using repeat thrombectomy with a retrieval stent (RTRS) with continuous proximal flow arrest by BGC for acute intracranial ICA occlusion is presented. Methods. In patients with acute intracranial ICA occlusion treated with RTRS, clinical data, including the National Institutes of Health Stroke Scale (NIHSS) score at admission and modified Rankin Scale (mRS) score at 90 days, and procedural data, including the Extended treatment in Cerebral Infarction (eTICI) score, procedural time, and complications, were analyzed. Results. Thirty-two consecutive patients (12 men (37.5%); mean age: 73 years) were treated with RTRS using a BGC. The median NIHSS score was 19. The median puncture-to-reperfusion time was 46 minutes (range: 22-142 minutes). All patients were successfully revascularized; eTICI 2c or better recanalization was achieved in 30 (93.8%) patients. No procedure-related complications or symptomatic intracranial hemorrhage occurred. Two cases (6.3%) had distal emboli, but none had emboli to the anterior cerebral artery. Fourteen patients (43.8%) achieved a good outcome with an mRS score of 0–2 at 90 days, and 8 patients (25.0%) died. Conclusions. In patients with intracranial ICA occlusion, RTRS with proximal flow arrest by BGC is effective and safe, achieving good clinical and angiographic outcomes. This method may reduce the incidence of distal emboli in thrombectomy with stent retrievers.

Category of time limit in administrative procedural law

Administrative procedural law is full of numerous and varied procedural time limits which, as time-related categories, define the temporal boundaries of the administrative process and can act as an effective regulator of administrative procedural legal relations. The article examines the concept of time limit in administrative procedural law from the standpoint of integrativeness. It notes that the studied issue was not thoroughly elaborated in science, which appears to result from the young age of administrative procedural law as a separate branch. The research identifies substantial characteristics of the administrative procedural time limit. It reveals the temporal content of time limit in administrative procedural law. A conclusion is reached that the administrative procedural time limit results from the impact of temporal categories on the administrative procedural legal regulation when administrative cases are settled by a public administrative authority and a court. The administrative procedural time limit is recognised as a tool used for temporalizing the administrative process and aimed at ensuring the dynamism of administrative procedural activities through duration, speed, rhythm and cyclicity. The article identified the trend towards the legislative refinement of the administrative procedural time limits. In an integrative sense, the attributes inherent to the administrative procedural time limit reveal the versatility and rich inner content of the concept of time limit in administrative procedural law, which results from the legal synthesis of temporality and authoritative procedural activities of public administrative authorities and courts in settling administrative cases. The article proposed the definitions for the category of time limit in administrative procedural law both in a narrow and broad sense, as well as with an emphasis on the temporal side of the examined category.

The Q and A—The MIVI Q Catheters for Aspiration Thrombectomy—Initial Experience from London

Background: Aspiration thrombectomy is a widely accepted treatment option for large vessel occlusion (LVO). The MIVI aspiration system has a novel design to maximize the lumen size. We present the results of our initial experience with this innovative aspiration thrombectomy system. Materials and Methods: Retrospectively, we reviewed our database to find all cases of LVO treated with the MIVI Q system (February 2019 and July 2020). In addition, we recorded the baseline demographics, NIHSS, ASPECT, mTICI scores, procedural time, complications, and 90 day mRS. Results: Herein, we identified 25 patients with an average age of 65.3 ± 19.3 years (range 19–89), majority of whom were female (n = 14, 56%). The average NIHSS was 16.9 ± 6.7 (range 6–30), and the average CT ASPECT was 7.9 ± 1.4 (range 5–10). The most common clot location was the M1 segment of the MCA (n = 16, 64%). Four of the patients had tandem lesions (16%). The average clot length was 21.7 ± 31 mm (range 2–130 mm). Of the 23 cases where the Q catheter reached the proximal clot face, mTICI ≥ 2b was achieved on the first pass in 11 cases (44%), and at the end of the ‘Q aspiration’ only the procedures with 16 patients achieved mTICI ≥ 2b recanalization (64%). Stent-retrievers were used in 13 cases (52%). At the end of the procedure, 24 patients (96%) achieved mTICI ≥ 2b with 18 patients (72%) achieving mTICI ≥ 2c. The average number of passes with the Q catheter, including when it was used for SOLUMBRA, was 2.1 ± 2.2 (range 1–10). The mean procedure time was 69 ± 32 mins (range 7–116 mins). No complications were associated with the MIVI Q. Conclusions: The MIVI aspiration system is a novel technology with regards to aspiration mechanical thrombectomy. The system is easy to use with early results comparable to other large-bore catheter systems. However, further studies are needed.

703 Koch’s triangle voltage mapping for cryoablation of slow pathway in children: preliminary data of a novel high density technique

Aims Different authors have described three-dimensional (3D) voltage mapping of the Koch’s triangle (KT) in order to find low-voltage bridges (LVBs) as targets for a successful transcatheter ablation (TCA) of the slow pathway (SP) in children. Recently, the advisor high density (HD) Grid™ mapping catheter was introduced as new multipolar catheter for HD mapping. The aim of the study was to describe our preliminary experience with the use of HD Grid™ catheter in LVB and electrophysiologically guided cryoablation of SP in children. Methods and results Twenty-one children (mean age 13 ± 3 years) with atrioventricular nodal re-entrant tachycardia (AVNRT) underwent cryoablation of SP guided by voltage HD mapping of the KT using HD Grid™ catheter. In order to better highlight the differences with conventional mapping, point collection was performed in each patient with this new multipolar catheter and with a quadripolar catheter. The conventional mapping collected 871 ± 262 points and used 211 ± 80 points in 887 ± 275 s, whereas HD mapping collected 7468 ± 2947 points, using 604 ± 165 points in 513 ± 181 s (P < 0.001). Moreover, the LVB area mapped with HD Grid™ was about one-half smaller and clearly delineated. Cryoablation acute success rate was 100%. Overall median fluoroscopy exposure was 0.08 (0.01–5.42) µGy/m2, with a median fluoroscopy time of 0.1 (0.0–0.6) min. During the follow-up (4.8 ± 3.7 months), there were no recurrences. No complications occurred. Conclusions Our preliminary experience shows that HD mapping is faster and offers higher spatial resolution and definition. Procedural time can be reduced maintaining the TCA safe, with reduced fluoroscopy use, and successful.