Endoscopic retrograde cholangiopancreatography (ERCP) procedures performed during a 15 year period from February, 2001 to February, 2016 at the National Center for Minimal Access Surgery, were reviewed. From a total of 6,108 procedures performed during this period, 5,754 charts were reviewed; 2,205 (38%) were male patients, and 3,549 (62%) were female; 2,135 (37%) procedures were diagnostic and 3,619 (63%), therapeutic. The main indication was jaundice in 3,685 (64%) and the main final diagnosis was bile duct stones in 2,528 patients (44%), followed by malignant biliary strictures (28%). Endoscopic sphincterotomy (2,573) was the most frequently performed intervention, followed by bile duct stone extraction (1,360) and stent placement (1,233). Complications occurred in 159 cases, 135 (3.7%) during 3,619 therapeutic procedures and 24 (1.12%) during diagnostic ERCP. Death occurred in 12 (0.2%) patients, 10 (0.27%) during therapeutic ERCP and 2 (0.09%) from diagnostic ERCP. Our results show the high diagnostic utility and therapeutic success of ERCP with minimal risk and complications.
Raul Antonio Brizuela Quintanilla has completed his medical doctor studies in the Havana University School of Medicine at the age of 24 years, the PhD at the age of 38 years in the Sciences Academy of Cuba and postdoctoral studies from Havana University School of Medicine. He is the Head of Therapeutic Endoscopy and Gastroenterology Department in the National Center of Minimal Access Surgery. Havana. Cuba, a Titular Professor of Medicine from Havana University School of Medicine. He has published more than 51 articles in reputable journals and contributed in 4 textbooks specialty. Member of the Cuban Society of Minimal Access Surgery.
Background:Over a million gastric tubes are placed yearly for varying medical reasons including gastric decompression to decrease aspiration risk. In the OR, this is performed blindly and position is confirmed by auscultation, aspiration, or palpation by a surgeon. There is limited data in anesthesia literature about the incidence of intraoperative malpositioned gastric tubes, as well as feasibility of using Point-of-Care ultrasonography (POCUS) to confirm gastric tube placement in the OR. Methods: Prospective observational study with a total of 82 subjects, all over 18 years of age, undergoing surgery with general endotracheal anesthesia and intraoperative blind placement of a gastric tube by an anesthesia provider. The primary objective of this study is to examine the feasibility of using POCUS to determine the position of gastric tubes placed intraoperatively, as well as estimate the incidence of malposition of blindly placed gastric tubes by anesthesia providers. Results:In our analysis, we found that out of 89 patients 69 patients were successfully visualized; the incidence of malposition was 0.16 [95% CI, 0.09-0.26]. We did not find age, BMI, or sex to be associated with predisposing patients to intraoperative malposition of gastric tube. However, increasing years of experience of anesthesia provider correlated with higher malposition rates. Conclusions:In summary, we demonstrate that use of POCUS to visualize insertion of gastric tube is a feasible and reliable method to determine the real-time correct placement of gastric tube in the intraoperative setting
Clinical studies have observed that the level of endothelial progenitor cells (EPCs) in the circulation increases in patients with sepsis. Drop of EPC number during sepsis commonly occurs with deterioration of the disease, development of organ failure, and increase in mortality. Conversely, a greater number of circulating EPCs is associated with improved outcomes. Bone marrow houses an EPC pool, which releases EPCs into the circulation in response to stress challenges. To determine the significance of EPCs in host defense and explore molecular signaling mechanisms underlying the regulation of marrow EPC activity, septic infection was induced in mice by intravenous challenge with Escherichia coli. The marrow pool of EPCs bearing the lin-c-kit+Sca-1+VEGFR2+ (VEGFR2+LKS) surface marker rapidly expanded following septic infection. AP1 signaling downstream of the TLR4-JNK pathway mediated upregulation of Sca-1 expression, which played an imperative role in EPC activation. Sca-1 signaling participated in promoting EPC proliferation and endothelial differentiation, which appeared to involve the activity of TLR4-ERK1/2-cyclin D1 and TLR4-ERK1/2-SP1 pathways, respectively. EPCs in the expanded marrow VEGFR2+LKS cell pool exhibited a markedly enhanced angiogenic activity. Bone marrow-derived cells actively homed to the lung and integrated in the pulmonary microvasculature following septic infection. Fluid retention in the lung was severer in Sca-1 knockout mice than in wildtype mice following E. coli septicemia. These results show that the marrow-derived EPCs actively participate in maintaining/restoring the integrity of microvasculature in vital organ tissues during septic infection. The marrow EPC response constitutes an important component of host defense against septic infection.
Dr. Ping Zhang completed his MD in Bengbu Medical College and PhD in Third Military Medical University (now Army Medical University) in China. He also conducted postdoctoral training in Glasgow University, Scotland, UK and in Louisiana State University, Louisiana, USA. He is Watanakunakorn Chair and Professor in the Department of Integrative Medical Sciences and Professor in the Department of Surgery at Northeast Ohio Medical University College of Medicine, Ohio, USA. Dr. Zhang’s group focuses on studying molecular signaling mechanisms underlying the regulation of host defense against serious infections. He has 106 publications in this field.
Background: We evaluate the results after 13 years of Endolift Laser technique for the “soft” rejuvenation of face, neck and body, using a very thin optical fibre connected to a 1470nm diode laser, combined in the last years with Ultherapy® which allows in a single session to lift the muscles and the skin. Methods: We report our experience after more than 4000 areas treated with Endolift for the treatment of skin laxity of the face, neck and the body. A 200-300 micron fiber is used for the face and the neck; a 400-600 micron fiber is used for the body. The fiber is easily inserted, without incisions under the skin directly in the superficial hypo-derma. After Endolift, a Ultherapy® session is performed. Results: The areas of skin laxity of the face, neck and body, can benefits from the possibility that the Endolift Laser has to retract the skin and remodel the derma, activate the collagen production, stimulate the neo-angiogenesis. Ultherapy® helps to obtain the maximum result possible working more deeply the middle and deep hypo-derma up to the muscular fascia, permitting to obtain an immediate and a longterm lifting. Conclusions: Endolift laser combined with Ultherapy® is the the best non-surgical treatment for the areas of muscular and skin laxity of the face and the neck.
Dell’Avanzato Roberto is Specialist in Surgery with an University Master in Aesthetic Medicine and Surgery; Professor of Laser and Laser Assisted Liposuction, San Marino University (San Marino); University Diploma in Laparoscopic Surgery, Louis Pasteur University of Strasbourg (France); Honorary Member of the Israel Academy of Beauty; Honorary Member of the Italian Academy of Beauty; Certificate of excellence awarded from The Pakistan Medical Association, for humanitarian services rendered to the burnt and scarred victims of Pakistan; Certificate of Merit awarded from the Combined Military Hospital of Islamabad (Pakistan), for humanitarian services.
As a form of small-diameter arterial graft, we implanted the fresh autologous pericardium and similar tissue treated with 0.6% glutaraldehyde in the bilateral carotid arteries of dogs and then compared the time-related changes of the grafts explanted after the predetermined periods. The pericardial grafts were implanted in at least two animalsfor scheduled periods of 3 days, 2 weeks, 1 month, 3 months, and 6 months. The retrieved grafts were processed for light and electron microscopy analysis following gross observation. The glutaraldehyde-treated small-diameter pericardial vascular grafts showed a better endothelialization of the blood-contacting surface and a slower fragmentation of the collagen layers than the fresh grafts, although it has yet to be proven whether these differences are so significant as to affect the patency results between the groups.
Background Internship is the first step for medical graduates to become medical professionals. But evidences have showed majority of pre intern doctors do not feel well prepared for their first year of medical work; especially they are lackof clinical skills. Purpose of this study was identifying the self-perceived competency level in cannulation which is one of essential clinical skillsof an intern doctor. And thecollected information will be used to develop a demand oriented skill training programme to enhance essential clinical skills among pre intern doctors of Sri Lanka. Objective To describe self-perceived level of competency in cannulation among pre-intern doctors. Methods A descriptive cross sectional study was carried out among 367 pre intern doctors of Sri Lanka in November 2017. A self-administered questionnaire was used to assess the self-perceived level of competency on cannulation. The scale ranged from 1-4, with 1 being "able to perform skill without supervision" and 4 being "not able to perform skill and has not observed skill". Results Among 367 of pre intern doctors, 225(61.3%) stated that they can perform skill competently without supervision and 129(35.15%) participants stated that they can perform the skill competently with supervision.A minority of 13(3.5%) responded as they have observed the procedure but unable to perform it. Conclusion All the pre intern doctors have observed "cannulation" procedure during their academic periodand majority of them can perform skill competently without supervision. Keywords Cannulation, competency, pre intern doctors, Sri Lanka
Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure for the treatment of large rectal adenomas, early rectal carcinomas and atypical indications (benign rectal stenoses, rectal prolapse, extraction of impacted fecaloma at the rectosigmoid junction and presacral tumor). TEM of advanced rectal cancer remains a controversial issue although it has become a more attractive option because of the regular use of neoadjuvant therapy at several centers. This study was a retrospective review uses a prospectively maintained database of patients underwent TEM from 2004 to 2018. Age, gender, indications, operative time, tumor distance from the anal verge, tumor size, hospital stay, postoperative complications, overall estimated 5-year survival and the disease-free survival rate were included in a study. A total of 223 patients underwent TEM during a period of 14 years. Main indication of TEM was the presence of carcinoma: 122 (54.7%). The median age of patients was 63 years, median operative time was of 80 minutes (20–240), median specimen size was 3,4 cm and median hospital stay was of 1,3 days. The postoperative complications rate was 5,8%. After a median follow-up period of 75 months, 2 (4,7%) patients had local recurrences in the T1 group, 2 (6,4%) in the T2 group, and 1 (4,1%) in the T3 group with complete pathologic response after Neoadjuvant Chemoradiation. Overall estimated 5-year survival were 97%, 90.8% and 91,7% for T1,T2 and T3 groups respectively. TEM can be utilized for patient’s safety with excellent local recurrence and disease-free survival rate.
Javier Ernesto Barreras González has completed his PhD from Havana Medical University in Cuba and postdoctoral studies from Tuebingen University, Germany and Lankenau Medical Center, Philadelphia, USA. He is the chief of Laparoscopic and Endoscopic Surgery Department at National Center for Minimally Invasive Surgery in Havana, Cuba. He has published more than 40 papers in reputed journals. Member of the Cuban Society of General Surgery, Cuban Society of Endoscopic Surgery, Iberian Latin American Surgeons Society, Cuban Society of Coloproctology, National Committee of the Minimal Access Surgery (Cuba), European Association of Endoscopic Surgery and Society of American Gastrointestinal and Endoscopic Surgeons.
• A 7 years old child came with severe respiratory distress in June 2014.A huge fungating mass was present on left side of face and neck and the mass was completely occluding the oral cavity from inside.ENT surgeon communicated that It was impossible to ventilate or intubate the child but monitored anaesthesia care (MAC )was required for tracheostomy. The child was pre oxygenated in sitting position in operating room and was given ketamine in 5mg dilution incrementally till 50 mg .A 3.5 mm ETT was cut and used as nasopharyngeal airway and with its connector the circuit was attached and sevoflurane was started and spontaneous ventilaton was maintained till tracheostomy was secured.After tracheostomy, the patient went into asystole .The child revived after one minute of CPR and epinephrine. Possible causes for cardiac arrest could be sudden relieve of obstruction and acidosis due to hypercarbia. After revival, the patient was sedated and relaxed with Midazolam and atracurium. He was weaned off the ventilator in paeds ICU and was discharged on tracheal mask at 10lit/min oxygen .He expired at home within few days. This is the case report showing management of emergency tracheostomy under monitored anaesthesia care using small size ETT as nasopharyngeal airway in a child when it was impossible to ventilate or intubate the child.
Dr.Asiyah Aman is currently working as faculty (Senior Instructor) in Department of Anaesthesiolgy, Aga Khan University Hospital, Karachi,Pakistan. She completed post graduation training in 2013 followed by one year fellowship in “Obstetrics Anaethesia” from the same institute. She has been actively involved in Obstetrics anaesthesia services and fellowship teaching programme since then.
The primary goal of ambulatory anesthesia is rapid recovery with minimal side effects. Aim of this study was to compare efficacy of intrathecal isobaric ropivacaine with bupivacaine and to assess postoperative recovery profile in patients undergoing arthroscopic knee surgery. A total of 90 adult American Society of Anaesthesiologist physical status Classes1 and 2 patients were randomized into two groups to receive 2 ml plain solution of either 0.5% bupivacaine (Group B) or 0.75% ropivacaine (Group R). In the intraoperative period, onset, efficacy, duration, and regression of sensory and motor block were noted in both the groups at regular intervals. Postoperatively, the groups were compared for pain score, recovery profile, analgesic requirement and complications. Data analysis was performed using Chi-square test and Student’s t-test. The mean onset time of sensory block at L1 was significantly less (P = 0.025) and duration of sensory and motor block was significantly more (P = 0.001) with bupivacaine as compared to ropivacaine. Analgesic requirement on the 1st postoperative day (P = 0.011) and incidence of delayed voiding of urine (P = 0.022) was significantly more with ropivacaine. Postoperative recovery profile and discharge time was similar between the groups. To conclude, isobaric ropivacaine was associated with a longer onset and shorter duration of sensory and motor block, increased postoperative analgesic requirement, higher complication rate and similar discharge time as compared with bupivacaine. Therefore, isobaric bupivacaine may be preferred to isobaric ropivacaine for day care knee arthroscopy, especially in cases with anticipated longer duration of surgery.
Dr Vandana Talwar has completed her MD from Safdarjung Hospital, N. Delhi. Presently she is working as Professor and Consultant at Vardhman Mahavir Medical College and Safdarjung Hospital, a premier institution, and one of the largest central government hospitals in N. Delhi. She has published more than 20 papers in reputed journals and has been awarded many prizes for scientific presentations in conferences. She has served as editor of Indian society of Anaesthesiologists and as organizing chairperson of National level conferences.
Background:The superior hypogastric plexus block (SHPB) has been extensively used for treating pelvic cancer pain and chronic pelvic pain like endometriosis. Currently, postoperative analgesia following gynaecological laparotomies is managed mainly by parenteral NSAIDS, opioids or by epidural block. We proposed that the intraoperative superior hypogastric plexus block would be a safe and an effective method for managing postoperative pain in patients undergoing gynaecological laparotomies. Methods: This is a prospective randomised case control study. Sixty female patients of age 18-60 years belonging to ASA grade 1 and 2 undergoing gynaecological laparotomies were allocated equally into two groups, study and control group. Both groups received general anesthesia. During the end of surgery, the study group received SHPB and the control group did not receive SHPB. Postoperative pain was assessed with VAS score, patient’s vital parameters and amount of morphine consumed by patient controlled analgesia at 0,2,6,12,24 and 48 hours. Results: The VAS score for pain showed significant difference between cases and controls at 0 hours (P=0.033), 2 hours (P<0.0001), 6 hours (P<0.0001), 12 hours (P<0.0001) and 24 hours (P=0.003) but not at 48 hours (P=0.085). This showed that the block was more effective up to 24 hours.There was significant difference of 33.6% (p<0.0001)in morphine consumption between study (36.03 mg) and control (54.33mg) groups. Conclusions:We conclude that SHPB is an easy to place block thus reducing complications and has a short learning curve. It has a high success rate for majority of gynaecological laprotomies.
Nutcracker syndrome (NCS) is produced by the compression of the left renal vein, commonly between the aorta and the superior mesenteric artery (anterior nutcracker) or between the aorta and the vertebral spine (posterior nutcracker). This obstruction generates an impaired blood outflow resulting in venous hypertension and the formation of renal collaterals. It is a rare disorder, more frequent in young women who usually are tall and slim. Although some patients are asymptomatic, this illness is associated with a considerable morbidity. There are different clinical presentations as micro or macrohaematuria, proteinuria, pelvic pain, varicocele, pelvic venous congestion syndrome (chronic pelvic pain, dyspareunia, dysmenorrhea), that commonly appear after a physical activity. The diagnosis is difficult, delayed and always challenging. There have been used different diagnostic imaging techniques: venography, abdominal computed tomography, abdominal angioresonance, venography, but Doppler ultrasound is the most useful and helpful test due its noninvasive modality and it is used when this syndrome is suspected. The management varies from a conservative treatment like a simple observation to different kind of interventions like nephrectomy, an open surgical repair or endovascular stenting, depending on the severity of the symptoms. Because NCS is a rare entity, its diagnosis should be considered despite the variety of clinical presentation. Recognition and management is important to prevent other complications and to relieve the pain that is common in these patients.
Sandra Fernandez-Caballero is an Intensive Care Doctor and now finishing her second specialty, Anesthesiology. She has completed a Master in Anesthesia, Resuscitation and Pain Management. She has also published some papers in important journals and has done presentations at medical conferences.