3D Patient-Specific Virtual Models for Presurgical Planning in Patients with Recto-Sigmoid Endometriosis Nodules: A Pilot Study

Background and Objective: In recent years, 3D printing has been used to support surgical planning or to guide intraoperative procedures in various surgical specialties. An improvement in surgical planning for recto-sigmoid endometriosis (RSE) excision might reduce the high complication rate related to this challenging surgery. The aim of this study was to build novel presurgical 3D models of RSE nodules from magnetic resonance imaging (MRI) and compare them with intraoperative findings. Materials and Methods: A single-center, observational, prospective, cohort, pilot study was performed by enrolling consecutive symptomatic women scheduled for minimally invasive surgery for RSE between November 2019 and June 2020 at our institution. Preoperative MRI were used for building 3D models of RSE nodules and surrounding pelvic organs. 3D models were examined during multi-disciplinary preoperative planning, focusing especially on three domains: degree of bowel stenosis, nodule’s circumferential extension, and bowel angulation induced by the RSE nodule. After surgery, the surgeon was asked to subjectively evaluate the correlation of the 3D model with the intra-operative findings and to express his evaluation as “no correlation”, “low correlation”, or “high correlation” referring to the three described domains. Results: seven women were enrolled and 3D anatomical virtual models of RSE nodules and surrounding pelvic organs were generated. In all cases, surgeons reported a subjective “high correlation” with the surgical findings. Conclusion: Presurgical 3D models could be a feasible and useful tool to support surgical planning in women with recto-sigmoidal endometriotic involvement, appearing closely related to intraoperative findings.

ROLE OF ALPHA BLOCKER IN URETERORENOSCOPY.

Objective: To determine the efficacy of alpha blockers in successful management of lower and mid ureteral stones by ureterorenoscopy. Study Design: Comparative prospective study. Place and Duration of Study: Department of Urology, Combined Military Hospital Quetta Pakistan, from Jul 2018 to Dec 2019. Methodology: Total of 150 patients having mid and lower ureteric calculi requiring ureterorenoscopy were divided into two groups. Group A included patients without pre-treatment with alpha blocker was administered before they were subjected to ureterorenoscopy. Study group B included patients who received daily oral dose of alpha blocker, Tamsulosin 0.4 mg twice daily, for 1 week before ureterorenoscopy. Per-operative findings in both the groups were recorded. Results were analyzed by comparing the outcome between both groups in terms of ease of performing procedure, duration of procedure, complications, duration of hospital stay and need for stent placement. Results: Mean operative time was significantly shorter in group B as compared to group A, (15.9 ± 3.81 min vs. 21.9 ± 3.63 min; p≤0.001). Demographic and stone characteristics were comparable between the both groups. Success rate was 74 (98.7%), in group B as compared to 68 (90.7%) in group A, with statistically significant difference (p=0.020). Complications in group B were less frequent 1 (1.3%) vs 7 (9.3%) in group A (p-value=0.027). Conclusion: Use of alpha blockers for one week before performing ureterorenoscopy resulted in fewer complications and made the procedure easier to perform as well.

Analysis of intraoperative findings with clinico-pathological features in appendicitis-an observational study

Background: Appendectomy is the most common abdominal surgery performed today. Appendicitis consists of vast spectrum ranging from acute to chronic to recurrent forms however existence of recurrent and chronic appendicitis is still doubted by many. In spite of various scoring systems and appendectomy being the ultimate treatment, its timing remains still controversial especially in chronic and recurrent variants of appendicitis.Methods: A total of 100 consecutive cases of suspected appendicitis who were admitted investigated and treated at our centre were taken up for this observational study. Data pertaining to clinical, operative and histopathological findings were collected and tabulated. Mean and SD were used for continuous data and for categorical data, frequency and percentages were calculated. A chi-square test was used for categorical data to find statistical significance.Results: Per operatively the appendix appeared non-inflamed in 57% of patients suggestive of chronic (recurrent) form and inflamed in 43% of patients suggestive of an acute form of appendicitis. The histopathological studies revealed chronic inflammatory cells in 63% of the resected specimens, suggestive of chronic appendicitis and acute inflammatory cells in 37% of the specimens, suggestive of acute appendicitis.Conclusions: We conclude that the correlation of clinical findings, operative findings and the histopathological findings correlate with one another (p<0.001). The surgeon’s clinical and operative findings have specificity of around 87.30% and 90.47% respectively. Hence the diagnostic accuracy of the surgeon is directly dependent on the surgeons’ expertise and there is no substitution for an experienced surgeon’s judgement.

Intraoperative scoring system for grading severity of cholecystitis at laparoscopic cholecystectomy

Background: Various studies had been carried out to evaluate the risk of preoperative conversion in laparoscopic cholecystectomy. However, there was no grading or scoring of operative findings during surgery at present, making it difficult to compare the publications citing outcomes, including the conversion to open surgery. Sugrue in 2015 devised a scoring system based upon the intraoperative findings in Laparoscopic cholecystectomy. Aim of the study was to grade the severity of cholecystitis during laparoscopic cholecystectomy using intraoperative scoring system, to evaluate the spectrum of cholecystitis in cases of laparoscopic cholecystectomy in a tertiary center using the grades of intraoperative scores and to validate the scoring system devised by Michael Sugrue.Methods: This prospective cross sectional observatory study of 200 patients admitted for laparoscopic cholecystectomy was conducted in the Department of Surgery, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India over a period of 12 months. All patients directly planned for open cholecystectomy and carcinoma gall bladder were excluded from the study. Patients were subjected to the intra operative grading system for cholecystitis severity as devised by Micheal Sugrue and the grades were classified with a score of <2 - mild; 2 to 4 -moderate, 5– 7- severe and 8 to 10 – extreme.Results: The operative grading system showed a positive correlation with the severity of cholecystitis.Conclusions: Use of this intra-operative scoring system will help us to provide a trigger for a prompt early conversion to avoid intra-operative complications associated with difficult laparoscopic cholecystectomy.

P-EGS05 Assessment of acute cholecystitis management during COVID-19 pandemic in comparison to the CholeQuic approach : A single centre experience

Background Acute cholecystitis is an emergency condition, typically arising from gall bladder stones and often leading to unplanned surgical admissions to hospital. In the UK, gall stone disease accounts for approximately one third of all unplanned general surgical admissions. According to the The Royal College of Surgeons' Commissioning guidance, early management of acute cholecystitis in particular is the key to prevent further development of more serious complications that can lead to mortality (up to 10%). Therefore, urgent admission to secondary care and laparoscopic cholecytectomy are recommended once diagnosis is confirmed . Conservative management is not recommended as gallbladder inflammation often persists despite medical therapy which can lead to further attacks and risk of developing gall bladder perforation ( mortality in 30% of cases). Early laparoscopic cholecystectomy is also associated with reduced hospital costs and earlier recovery. During the first wave of COVID-19, the guidelines changed in order to limit the admission rates to free up spaces for possible COVID-19 infected patients. Crisis approach entailed conservative management with pain relief, antibiotics plus or minus cholecystostomy. However, reviews of this approach have not been widely published to assess the results and in turn planning our future management approach in case of other COVID-19 surge. Methods Our study included all the patients diagnosed with acute cholecystitis who needed surgical intervention in one medical Centre in the UK. The time table of the study is divided into 3 periods the pre- COVID era from 16/12/2019 to 15/03/2020 (group I), then during the first lock down era from 16/03/2020 to 30/06/2020 (group II) and, finally after the ease of the lock down from 01/07/2020 to 02/09/2020 (group III). Pre- and post-lockdown time periods the CholeQuIC approach was followed while during the lockdown era, patients were initially treated conservatively followed by surgical managemnt in case of failure to improve. Laparoscopic cholecystectomy was performed, however, in difficult cases conversion to open surgery occurred. The primary outcome was to Compare and perform analysis of the three distinctive periods regarding, delayed presentation, the degree of operative difficulty, which was quantified by analysing the operative time, blood loss, rate of drain insertion and rate of conversion into open surgery. Furthermore, a review of unfavourable intra-operative findings such as extensive adhesion to surrounding organs, hydrops, empyema, gangrene, and/or perforation of the gallbladder was done. The post-operative results were also analysed, according to the length of hospital stay, and the rate of post-operative complications. Results Operative difficulty The mean operative time before the lockdown was 71.6 minutes while it was 81.0 and 78.0 minutes during and post COVID respectively. In terms of conversion to open, the rate reached 10.5 % during the lockdown, while the figures were 4.9% and 3.13% during the pre and after lockdown respectively. Moreover, intra peritoneal drains were used in more than one quarter of the patients (28.9%) during the lockdown era compared to 11.5 % and 12.5% pre and post the lockdown respectively. Considerable blood loss occurred in 10.5%. Intra-operative findings During the lockdown, 28.9 % exhibited extensive adhesions between the gall bladder and surrounding structures. This level is almost three times the percentage during the pre and post-lockdown time periods (8.2% and 9.4% respectively). As for gangrenous cholecystitis, it was 18.4 % during the lockdown, 6.6% before and 6.3% after the lockdown respectively. Post-operative results Before the lockdown the average LOS was 2.9 days which increased to 8.9 days during the lockdown, followed by a decrease to 2.4 days following the ease of lockdown. The lockdown era depicted the highest rate of post-operative complications (bile leakage 7.9%, missed stones 5.3% and duodenal injury 2.6 %). Conclusions During crisis periods tough measures and decisions are made to deal with the situation, however, these decisions can lead to grave consequences on the medical staff and most importantly on patients. As shown in this study and supported by the previous studies, conservative management of acute cholecystitis led to serious complications as many patients were re-admitted for emergency surgery as a result of failure of the non-surgical approach. Moreover, delayed emergency surgery was associated with increased operative difficulties and higher percentage of serious intra and post-operative complications. All this led to longer hospital stay which can prove the failure of this approach. Unfortunately in our Unit, whilst closely studying acute gall bladder disease, we have found that the conservative approach appears to have back-fired and did the exact opposite. Therefore, we believe that there is nil to support conservative treatment of acute cholecystitis in our Unit. We believe that the evidence as displayed suggests that rapid surgery provides best outcome for individual patients and our system, perhaps especially when under strain for other reasons.

The impact of the Covid-19 pandemic on care of women with ectopic pregnancy in a tertiary London hospital

Background: In response to the COVID-19 pandemic, a central London tertiary referral hospital’s nurse-led Early Pregnancy & Acute Gynaecology Unit (EPAGU) suspended its walk-in service in favour of a telephone triage system with scheduled appointments. Objective: To assess if the pandemic and this adaptation to clinical services had an impact on the presentation, management and complication rate of ectopic pregnancies. Materials and Methods: A retrospective review was performed of ectopic pregnancies diagnosed in the EPAGU between 5th of March 2020 – 15th of July 2020 (pandemic) and 5th of March 2019 – 15th of July 2019 (pre-pandemic). Main outcome measures: Ultrasound findings, patient demographics, serum hCG concentrations, operative findings and complications. Results: There was a 36% reduction in attendances to the unit during the pandemic. Allowing for this, there was no significant difference in the diagnosis rate between the two periods. There was no significant difference in the gestation at diagnosis, serum hCG concentration or volume of mass at presentation. There was also no significant difference in rate of surgical intervention or complications including rupture of fallopian tube, haemoperitoneum or need for blood transfusion. Conclusion: This study suggests this is a safe means of caring for women with ectopic pregnancies which does not limit management options nor lead to higher complication rates. What is new: Other EPAGUs may choose to adopt a telephone triage system with reassurance of its safety.

Transection of the Common Carotid and Vertebral Arteries Following a Penetrating Neck Injury

A case of a 30-year-old man who was admitted following a penetrating neck injury is presented. A clinical examination and operative findings identified semi-comatose mentality, neck muscle laceration, and transection of the left common carotid and vertebral arteries and the internal jugular vein. During the operation, the carotid arteries were repaired by interposition grafting, and the internal jugular vein was ligated. The vertebral artery was managed by interventional embolization. Although the patient had some neurological deficit, he was discharged on postoperative Day 52. This surgical case prompted a discussion regarding neurological outcomes, and surgical and endovascular treatment following vascular neck injury.

Mesenteric cystic lymphangioma – A rare case report; National Center for Pediatric Surgery, Gezira State, Sudan; 2021

Cystic lymphangioma is a benign congenital malformation of the lymphatic vessels. At the National Center for Pediatric Surgery, Gezira State, Sudan; 2021; a female baby of 15 months old age presented complaining of abdominal distention of 10 days duration. Patient Looks unwell, not febrile, and not pale or jaundice; abdomen was distended with full flanks, there was a palpable mass in the epigastric region, no area of tenderness and no palpable organs. Abdomino-pelvic U/S showed very huge abdomino –pelvic cystic mass with multiple thick septa. CT abdomen showed huge abdomino-pelvic mass with multiple cysts that having variable sizes measuring up to 6*7 cm. An elective explorative laparotomy was done. Intra operative findings: Multiple cystic masses arise from the root of the small bowel mesentery matted together with multiple enlarged mesenteric lymph nodes involving segment of distal jejunum with multiple adhesions. Release of adhesion, resection of the masses along with 57 cm of the involving jejunum, anastomosis was done, and homeostasis was secured. Histopathology result showed dilated cystic spaces; lined by flat endothelial cells and multiple reactive lymph nodes, no evidence of malignancy. Features are in line with lymphangioma and associated mesenteric lymphadenitis. Discussion and Conclusion: Our case was 15 months old which is the age of presentation as mentioned internationally. Mesenteric cystic Lymphangiomas are more common among male unlike our case. Ultrasonography and CT abdomen were highly recommended to achieve early diagnosis and treatment of such cases.