Spontaneous alveolo-pleural fistula in a case of COVID-19 pneumonia-challenges and solutions: case report

COVID-19 pneumonia has demonstrated a wide spectrum of clinical presentations that have yet to be completely uncovered. As this pandemic progresses, uncommon presentations of this disease have come into light. Development of broncho/alveolo-pleural fistula in a patient with COVID-19 pneumonia is a rare phenomenon with only 4 cases reported in literature till date. A 61-year-old gentleman presented to the emergency department with fever, cough, and shortness of breath. His initial chest X-ray was suggestive of a viral pneumonia that was later confirmed to be due to COVID-19. The patient was put on non-invasive ventilator support and treated with empirical antibiotics, glucocorticoids, anti-viral medications and convalescent plasma therapy. Four weeks into the patient’s hospital course, his vital parameters suddenly deteriorated with a subsequent chest X-ray showing a tension pneumothorax, for which a chest tube insertion was done. However, when the air leak did not resolve by the 3rd day, a chest computed tomography (CT) was planned which showed a spontaneous alveolo-pleural fistula (APF). The patient was managed with conservative treatment using negative suction applied to an underwater seal, had his chest tube removed 10 days later and was discharged subsequently. Spontaneous fistulisation between broncho-alveolar tree and pleura can occur rarely in patients with COVID-19 pneumonia and can be managed using underwater seal with negative suction, insertion of endobronchial valves or surgical closure, and needs to be individualised.

A comparative study of negative suction drainage in inguinal hernia operations at Saraswathi Institute of Medical Sciences, Pilkhua, Hapur Uttar Pradesh

Background: The inguinal area is the weakest region of the abdominal wall. So, this is the most common site for the development of hernias. Inguinal hernias are the commonest amongst all the hernias and hernia repair is the most frequently done operation worldwide. There is no agreement among surgeons regarding the need for drains. Some use sparingly and some use it routinely. This study aims to evaluate the use of negative suction drain in inguinal hernia surgery.Methods: We studied sixty patients of inguinal hernias both direct and indirect for one year and followed up for next 1-2 years. This prospective study aimed to see the effect of negative suction drainage in hernia surgery.Results: Both the groups did well postoperatively. It was beneficial to put a negative suction drain in those patients who had a bigger hernia, fatty patients with the thick fatty lower abdominal wall and older patients.Conclusion: It is advisable to put a negative suction drain in inguinal hernia surgery and strongly advocated if the dissection had been difficult, old patients and fatty lower abdominal wall

Shape Optimization of Costal Cartilage Framework Fabrication Based on Finite Element Analysis for Reducing Incidence of Auricular Reconstruction Complications

Skin necrosis is the most common complication in total auricular reconstruction, which is mainly induced by vascular compromise and local stress concentration of the overlying skin. Previous studies generally emphasized the increase in the skin flap blood supply, while few reports considered the mechanical factors. However, skin injury is inevitable due to uneasily altered loads generated by the intraoperative continuous negative suction and uneven cartilage framework structure. Herein, this study aims to attain the stable design protocol of the ear cartilage framework to decrease mechanical damage and the incidence of skin necrosis. Finite element analysis was initially utilized to simulate the reconstructive process while the shape optimization technique was then adopted to optimize the three-pretested shape of the hollows inside the scapha and fossa triangularis under negative suction pressure. Finally, the optimal results would be output automatically to meet clinical requirement. Guided by the results of FE-based shape optimization, the optimum framework with the smallest holes inside the scapha and fossa triangularis was derived. Subsequent finite element analysis results also demonstrated the displacement and stress of the post-optimized model were declined 64.9 and 40.1%, respectively. The following clinical study was performed to reveal that this new design reported lower rates of skin necrosis decrease to 5.08%, as well as the cartilage disclosure decreased sharply from 14.2 to 3.39% compared to the conventional method. Both the biomechanical analysis and the clinical study confirmed that the novel design framework could effectively reduce the rates of skin necrosis, which shows important clinical significance for protecting against skin necrosis.

Unifocal Langerhans Cell Histiocytosis Presenting as Spontaneous Pneumothorax

Langerhans cell is a rare disease affecting the lungs which has a 10 years survival chance having a prognosis of 85%. It is often linked with smoking. We discuss here the correct stepwise approach towards its diagnosis Presenting a 28-year-old male smoker with a history of shortness of breath for 2 months which worsened progressively. His chest X-ray showed spontaneous pneumothorax with greater severity towards the right side. HRCT revealed multiple innumerable well-defined cystic lesions of variable sizes in bilateral lung fields, more prominent in upper lobes. A negative suction Pleur-evac was advised but the patient refused it and eventually pleurodesis using bleomycin was done to prevent pneumothorax in the future. Pleurodesis can improve the symptoms of 88 percent of patients without causing any significant complications. Although pleurodesis does not have any effect on patients' survival, it has a positive impact on their lives continuously by enhancing the quality of life.

The Management of Subcutaneous Emphysema in Pneumothorax: A Literature Review

Purpose of Review Subcutaneous emphysema is often observed by clinicians in the context of pneumothorax. It is usually clinically insignificant, but in a few cases can progress to threaten the patient’s vision or airway. A variety of approaches to management of such cases are described in the literature. There no controlled trials and no guidelines on management, other than that the cause should be identified and treated wherever possible. The goal of this article is to review the described approaches to subcutaneous emphysema in pneumothorax and provide a reference to the clinician. Summary Treatment can be directed primarily towards treating an underlying pneumothorax and / or towards the subcutaneous emphysema. These are not mutually exclusive approaches. Management of the underlying pneumothorax includes conservative management; use of negative suction; siting of wider bore intercostal drains and definitive surgical management. Management of subcutaneous emphysema may include decompression techniques such as: ‘blow hole’ incisions or subcutaneous angio-catheters or tunnelled drains. In the current absence of controlled trials is not possible to comment on the efficacy of these techniques: no recommendations on management of subcutaneous emphysema in pneumothorax can be made. Management will be significantly influenced by local technical expertise and patient factors for the foreseeable future.

Shoulder Tip Pain in Laparoscopic Cholecystectomy with Active vs Passive Evacuation of Pneumoperitoneum

Objective: The objective of the study was to compare the frequency of severity of shoulder tip pain after active (gas suctioning) and passive removal of pneumoperitoneum among patient undergoing laparoscopic cholecystectomy. Methods: This Observational comparative study was directed in general surgery department of DOW university hospital beginning from February 2016 to February 2017. Two hundred and six patients undergoing standard 4 port laparoscopic cholecystectomy were enrolled equally in either groups. The surgeon evacuated the abdomen by using a multiporous suction tube limiting the negative suction pressure to - 40 mmHg for 2-5 minutes under direct vision in active aspiration group, while in control group, CO2 was removed passively. Pain scores were recorded using visual analog score at 16 hours post-operatively by residents of surgery blinded to the study. Results: Mean VAS pain score at 16 hours in intervention group was much inferior than control group 1.00 ±2.09 vs. 3.06 ± 2.58 ( p < 0.001). Conclusion: Active aspiration of CO2 is an effective method that removes most if not all gas from the abdominal cavity. This will cause statistically significant decrease post-operative discomfort, pain and decrease need of rescue analgesics. Key Words: Laparoscopic cholecystectomy, Pneumoperitoneum, Active Aspiration, shoulder tip pain, post- laproscopic cholecystectomy pain How to Cite: Arif A, Nofal S, Khan MA, Khan AW, Bhatti AM, Ishaq SH. Shoulder tip pain in laparoscopic cholecystectomy with active vs passive evacuation of pneumoperitoneum. Esculapio. 2020;16(04):116-119.

Management of Breast AbscessbyOpen Drainage with Primary Closure versus Standard Incision and Drainage- ARandomised Trial

Introduction: Breast abscess is a localised collection of purulent material within the breast, which can be a complication of mastitis. In women of reproductive age, these are predominantly lactational but non-lactational abscesses are also seen in premenopausal women. Abscesses generally require drainage in conjunction with antibiotics. For the treatment of breast abscesses, surgical incision and drainage are usually carried out under general anaesthesia, as a traditional method. Aim: To compare conventional incision and drainage versus open drainage with primary closure with negative suction drain modalities of treatment of breast abscess in terms of different aspects including duration and quality of healing, number of dressings required, length of hospitalisation, postoperative complications. Materials and Methods: The present study was a randomised study conducted in the Department of General Surgery, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. There were 30 patients in group A undergoing open drainage with primary closure with negative suction drain and 30 patients in group B undergoing conventional incision and drainage. They were evaluated for the study period of 18 months, between October 2018 and April 2020. The data collected were analysed with Statistical Package for the Social Sciences (SPSS) version 17.0. Results: The incidence of breast abscess was more common in age group of 21-30 years with right side affected more than left side. Both the surgical procedures were comparable with each other in terms of incidence of recurrence. The primary closure group fared better with less incidence of postoperative pain (duration of analgesics requirement 2.40 vs 5.43 days), reduced hospital stay (3.63 vs 6.67 days) and dressings requirement was also less (2.33 vs 12.27 days) compared to standard incision and drainage drainage which were statistically significant. Conclusion: Hence, it can be concluded that open drainage with primary closure with negative suction drain placement can be considered as a safe and effective alternative to the standard incision and drainage in patients with breast abscess.

Efficient Method on Energy Regeneration through Speed Breakers

From the last century speed breaker is been the sedulous thing in controlling the speed on roads. But as the technology and requirements in vehicular design increased over time, the design of vehicles having the ability to move at high speeds had ameliorated. Speed breakers with the intent of controlling speed had been doing great damage to the vehicular functioning and been gist in fuel wastage if the vehicle crosses the limits. To utilize the present exhausting resources efficiently, every black point has to be covered and recovery of lost energy has to be the main aim. So the energy lost by a vehicle in negotiating a speed breaker has to be recuperated. This can be brought to fruition by utilizing an energy regenerating speed breaker. Many attempts had carried out in creating an efficient energy regenerating speed breaker, every method proposed had involved in outlasting the energy generation and carried a hitch. This paper deals with a newfangled method in the renewal of energy involving the principles of negative suction.