2nd Postoperative Day Research Articles

ENDOSCOPIC STENTING IN THE TREATMENT OF RECURRENT EPIPHRENIC DIVERTICULUM AFTER LAPAROSCOPIC DIVERTICULECTOMY. CLINICAL CASE REPORT

Epiphrenic diverticulum, also known as a pulsion diverticulum, is a rare type of esophageal diverticulum occurring in the distal 10 centimeters of the esophagus. They are most commonly 4-10 cm above the gastric cardia representing 10% of all esophageal diverticula. Laparoscopic diverticulectomy has become the treatment of choice. This clinical case study is dedicated to minimally invasive treatment of recurrent epiphrenic diverticulum after laparoscopic diverticulectomy. A 74-year-old male patient was admitted to the hospital with complaints of dysphagia, regurgitation and halitosis. The examination revealed a 5 cm epiphrenic diverticulum with sings of inflammation. Laparoscopic transchiatal diverticulectomy, the Dor (anterior) fundoplication, cruroraphia and mediastinal drainage were performed. The patient was discharged on the 11-th postoperative day. The patient exhibited dysphagia relapse during a 3-month follow-up. Taking into account the previous surgical treatment and the habitus endoscopic esophageal stenting was chosen as the technique of choice for management. Under intravenous anesthesia a partially covered metal self-expandable stent 10 cm x 1.8 cm was inserted into the distal esophagus. Next day control fluoroscopy showed stable stent position and no evidence of leakage. The water-soluble contrast agent reached stomach freely. The patient was discharged on the 2nd post-operative day. Within 4 months after having a stent placed, the patient feels well and oral feeding is satisfactory. In terms of literature search we have not come across any reference to the post-epiphrenic diverticulectomy recurrence treatment, so the management was chosen individually based on the comorbid status of the patient. The installation of a partially covered metal self-expandable stent allowed to promptly eliminate dysphagia and design features enabled to achieve stent stable position. A partially covered metal self-expandable stent can be considered effective in the post-epiphrenic diverticulectomy recurrence treatment.

Post-Operative Complications after Thyroid Gland Surgery due to Different Pathologic Condition: A Prospective Study

Background: The outcome and complication rates of post-operative cases are largely dependent on different factors.
 Objective: The objective of this study was to determine the risk factors responsible for major postoperative complications after thyroid surgery.
 Methodology: This was a prospective cohort study which was carried out at the Department of Surgery, Bangabandhu Shiekh Mujib Medical University, Dhaka, Bangladesh. Adult patients undergoing elective surgery for various thyroid disorders were selected as study population. This study was carried out from March 2009 to June 2011 for a period of two years. The study was included patients of various thyroid disorders that required surgical intervention of different magnitude. They were evaluated by history, physical examination, biochemical tests, ultrasound scan and FNAC where indicated. Histopathology was done and patients were followed up for subsequent outcome.
 Results: Among 2(2%) of them developed reactionary haemorrhage. The most common immediate surgical complication following thyroidectomy is hypocalcaemia and 12 patients (12%) experiencing this problem. 11(11%) patients developed transient tetany (hypocalcaemia) on 2nd post-operative day which was improved later on and 1(1%) patient developed permanent hypoparathyroidism and the patient supplemented by vitamin-D more than 6 months follow-up . In this study the mortality rate is 0% and complication rate is acceptable in comparison to other study.
 Conclusion: Hypoparathyroidism is a relatively common complication after thyroid surgery.
 Journal of Current and Advance Medical Research, July 2021;8(2):119-124

Endoscopic Third Ventriculostomy for Hydrocephalus in Paediatrics

Background: Abnormal CSF accumulation within ventricles of brain leading to raised intracranial pressure is a potentially life-threatening state that is commonly seen in neurosurgical patients. Aim of this study is to assess the efficacy of endoscopic third ventriculostomy (ETV) in treatment of pediatric hydrocephalus in pediatrics. Materials and Methods: A total of sixty-two patients were included in this prospective study. Patients were generally discharged from the hospital on the 2nd or 3rd postoperative day unless some complication arose. All the information was recorded in a pre-structured proforma, and data were analyzed by SPSS. Statistical significance was defined as p-value less than or equal to 0.05. Results: At follow up, clinical improvement and radiological findings did not necessarily correlate with each other, as ventricular size was reduced in only 42 (67.7%) out of 62 patients. Remaining 20 (32.3%) patients had no change in the size of ventricles. The difference was not statistically significant. However, as observed by cine PC MRI, CSF flow was observed in all the patients. Conclusion: In non-communicating hydrocephalus, ETV is a simple technique and safe and effective treatment if done by an expert surgeon correctly. It is a reasonable alternate of VPS due to its simplicity and effectiveness.

A rare Case of Cesarean Section Scar Ectopic Pregnancy Managed by Laparotomy

Cesarean section scar ectopic pregnancy (CSEP) is defined as a pregnancy in which blastocyst is implanted within the scar of previous cesarean section. It is a rare form of ectopic but its frequency is increasing due to increasing rate of cesarean section. In this case, a 36 years old G3P2A0, married for 10 years, previous II C/Sections, LCB 7 years back, presented with ultrasound report of the viable pregnancy at 11+1 weeks with gestational sac incorporating into previous scar of cesarean section. She was otherwise asymptomatic and stable. Serum Beta hCG was 73664.78 IU/L. Laparotomy was done as an elective procedure. Dense adhesions were noted on opening the abdomen between anterior abdominal wall, uterus, bladder and gut. Scar ectopic pregnancy was excised after dissecting the adhesions. Her Serum Beta hCG 48 hour post-operatively was 1397.0 IU/L.Patient was discharged home on 2nd post-operative day in good condition. She was counselled about risk of a recurrent scar ectopic and rupture of uterus in next pregnancy. Her serum Beta hCG declined to normal by 4 weeks post operatively. Keywords: Cesarean section, scar ectopic, laparotomy

Comparison of Effectiveness of Cryotherapy and Neuromuscular Electrical Stimulation (NMES) on Pain, Range of Motion and Gait Speed in Early Post-Operative Phase in Subjects with Unilateral Total Knee Arthroplasty

Introduction: In acute phase after Total Knee Arthroplasty (TKA), physiotherapy, aims at reducing pain, local edema and muscle weakness. Among treatment techniques, cryotherapy increases pain tolerance, helping in uninhibited motor recruitment of quadriceps. Intermittent muscle fiber contraction with Neuromuscular Electrical Stimulation (NMES) improves blood flow, reduces pain and decreases quadriceps arthrogenic muscle inhibition. Exercise therapy causes muscle strengthening. Effects of perioperative cold therapy have conflicting evidences. Early NMES use, post TKA for pain and swelling reduction has shown paucity of literature. Hence, this study aims to compare the effectiveness of these techniques in improving function. Method: Interventional study was conducted with 30 subjects randomly allocated into two groups (Group A- cryotherapy and Group B- NMES). Both received standardized exercise therapy. On 2nd postoperative day- pain (using Visual Analog Scale), Range Of Motion (using universal goniometer) and gait speed (using 4 metre walk test) was measured. Treatment was given for 5 days according to allocated group. Post-treatment outcome measures were taken. Results: Out of 30 participants, both groups showed statistically significant (p<0.05) improvement in all outcomes. Comparing effectiveness between the groups, NMES showed statistically significant improvement for knee flexion ROM. Other outcome measures showed no statistically significant difference. Conclusion: Rehabilitation in acute phase is essential for improving patient’s strength in long term. Along with exercise therapy, both cryotherapy and NMES showed improved function. On comparison, NMES showed better results for improvement in knee flexion ROM. Keywords: Total Knee Arthroplasty, cryotherapy, neuromuscular electrical stimulation, exercise therapy, visual analog scale, range of motion, gait speed.

Retrospective Comparative Study of the Incidence of Hypocalcaemia in Total Thyroidectomy between Ain-Shams University as a Referral Center and Damanhour Medical National Institute

Abstract Background: Post-operative hypocalcaemia is one of the most serious complications of total thyroidectomy with variable degrees of morbidity. Aim of Study: The aim of this study was to to compare the incidenceandto examine several preoperative and imme-diate post-operative factorsfor development of hypocalcaemia after total thyroidectomy in patients who underwent total thyroidectomy in Ain-Shams University and Damanhour Medical National Institute. Patients and Methods: This retrospective study was conducted in Ain-Shams University Hospital and Damanhour Medical National Institute in the period between December 2015 and December 2019. It included 62 patients who under-went total thyroidectomy. The data was collected from patients' files in the Record Department. Results: There were 52 female and 10 male patients. The mean age was 38 years. Multi-nodular goiter was the most common indication of total thyroidectomy. The mean pre-operative serum Ca was 8.1mg/dl in group A and 8.3mg/dl in group B. 3 (9.7%) patients in group A and 7 (22.5%) in group B developed post-operative hypocalcemia. The highest fre-quency of transient hypocalcaemia was on 2nd post-operative day in group A and on 0 day in group B. There was only one patient 3.2% who required calcium and vitamin D supplement for more than six months. Conclusion: Hypocalcaemia is one of the major concerns following total thyroidectomy that can be prevented by me-ticulous surgical technique, identification and preservation of parathyroid glands and its vascularity. Post-operative monitoring of serum calcium & early treatment can prevent significant morbidity.

Multifocal Analysis of Acute Pain After Third Molar Removal.

Background: To analyze the pain modulation capacity profile in a Brazilian population, the relationship between opioid receptor (OPRM1) and Catechol-O-methyltransferase (COMT) 1polymorphisms and pain modulation capacity was determined through preoperative pain modulation tests and acute postoperative pain control evaluation, swelling, and trismus in 200 volunteers undergoing lower third molar removal. Methods: Psychologic and clinical parameters were measured. Patient DNA was sequenced for single nucleotide polymorphisms in OPRM1 and COMT, and the salivary concentration of interleukin (IL)-2 (IL)-6, interferon (IFN)-γ and tumor necrosis factor (TNF)-α was evaluated. Primary outcomes were the influence of all predictors on the fluctuation of pain intensity using a visual analogue scale (VAS), and swelling and trismus on the 2nd and 7th postoperative days. Preoperative pain modulation capacity (CPM), pain catastrophizing scale (PCS), body mass index (BMI), and surgery duration and difficulty were evaluated. Results: Salivary concentration of IFN-γ and IL-2 as well as the duration of surgery influenced the fluctuation of postoperative pain in the VAS, and in the sum of the differences in pain intensity test at 8, 48, and 96 h. BMI influenced swelling, while both BMI and COMT haplotype influenced trismus on the 2nd postoperative day. Conclusion: Polymorphisms in COMT, salivary concentrations of IL-2 and IFN-γ, BMI, and duration of surgery were predictors for pain fluctuation, swelling, and trismus on the 2nd day after lower third molar extraction. This therapy was effective in controlling inflammatory symptomatology after lower third molar extraction and ibuprofen was well tolerated by patients. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03169127.

Opioid-free anesthesia for patients with joint hypermobility syndrome undergoing craneo-cervical fixation: a case-series study focused on anti-hyperalgesic approach

BackgroundPatients with Ehlers-Danlos Syndrome/Hypermobility Type (EDS-HT/JHS) and Craneo-Cervical Instability frequently suffer from severe widespread pain which is difficult to control. Chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization may explain this painful condition. The aim of this study was to determine if opioid-free anesthesia plus the postoperative administration of lidocaine, ketamine and dexmedetomidine can reduce postoperative pain and the need of methadone rescues in comparison with opioid-based management in these patients undergoing Craneo-Cervical Fixation (CCF). The secondary aim was to assess the needs of opioids at hospital-discharge, incidence of gastrointestinal complications and the requirement of anxiolytic.MethodsA retrospective, consecutive case series study was designed. 42 patients with EDS-HT/JHS undergoing CCF were enrolled in two groups: an OFA-plus Group that received opioid-free anesthesia with propofol, lidocaine, ketamine and dexmedetomidine, and OP Group, opioid-based anesthesia-analgesia. The main variables: Preoperative Visual Analogue Score (VAS), postoperative VAS on the 1st, 2nd, 4th and 6th days, sufentanil or morphine requirements, need for methadone rescue, and VAS at hospital-discharge. Data was presented by mean ± SD, percentage, median or interquartile range. Chi-squared or Fisher’s test. 95% C.I and P values < 0.05.ResultsNineteen patients in OFA-plus, and 23 patients in OP group. VAS was lower in OFA-plus on the postoperative days evaluated (p < 0.001).VAS at hospital-discharge was lower in OFA-plus: 4.96 (4.54–5.37) vs. OP 6.39 (6.07–6.71) (p < 0.001). Methadone requirement was lower in the OFA-plus (p < 0.001). 78% of patients in OFA-plus didn’t need methadone rescue. 95% in OP group needed methadone rescues at high doses(> 15 mg/day). No differences regarding equivalent doses of sufentanil or morphine consumption on the 2nd, 4th, and 6th postoperative days were found. OFA-plus decreased ileus, nausea and vomiting (p < 0.001). 60.9% in OFA-plus group decreased opioid requirements at hospital-discharge compared with preoperative values. A 77% reduction of anxiolytics requirements was shown.ConclusionOFA-plus management for patients undergoing CCF with EDS-HT/JHS shows significant reduction in postoperative pain and at hospital-discharge compared with opioid-based anesthesia. OFA-plus management decreases the total doses of methadone rescues, reduces anxiolytic requirements and gastrointestinal side-effects, except for constipation. OFA-plus management is a feasible option to improve postoperative pain control, reducing the opioids’ use and their postoperative side-effects in patients undergoing CCF with EDS-HT/JHS.

Resección extendida de tumor rectal por puerto único transanal (Tamis)

&#x0D; Objetivo: Presentar la resección local a través de puerto único (TAMIS) de un tumor de recto (T2) que invade el 50% de la circunferencia.&#x0D; Caso Clínico: Varón de 93 años con múltiples antecedentes patológicos, con adenocarcinoma de recto (T2-N0-M0). Se realizó una resección completa y transmural por vía transanal (TAMIS), dejando la brecha abierta. No tuvo complicaciones intraoperatorias y fue dado de alta al segundo día postoperatorio. En el control endoscópico realizado al noveno mes del postoperatorio no se evidenció recurrencia local.&#x0D; Conclusiones: La resección completa y transmural por técnica TAMIS de los tumores rectales (T2), es una opción válida para aquellos pacientes con comorbilidades que impidan una cirugía radical.

THE INCIDENCE OF SURGICAL SITE INFECTION IN ACUTE NON PERFORATED APPENDICITIS

Background: Appendectomy is the most commonly performed emergency surgical procedure and has significant morbidity of surgical site infection (SSIs). Regarding this, there are conflicting reports and dilemma on use of optimal duration of antibiotics. The aim of this study was to evaluate the incidence of SSIs after three doses of perioperative prophylactic antibiot­ics (single dose before surgery and two doses postoperatively) after ap­pendectomy in acute non- perforated appendicitis (NPA).&#x0D; Methods: This cross-sectional study was conducted in the department of General surgery, Chitwan Medical College Teaching Hospital, from May 2018 to April 2019. All the cases received single dose of antibiotics (cef­triaxone and metronidazole) during the induction of anesthesia and two doses of the same antibiotics postoperatively within 24 hours. SSIs was assessed on 2nd and followed up till 7th postoperative day. The data col­lected was analyzed using SPSS version 16.&#x0D; Results: In the study of 100 patients, who received perioperative three doses of antibiotics, the overall frequency of SSIs on 2nd and 3rd post-operative day were 2% (p=.840) and 6% (p=.539) respectively, which was statistically not significant. In follow up after 3rd postoperative day, there was no evidence of SSIs. Statistically there was no significant difference in the incidence and grade of SSIs between age group, sex and duration of operation.&#x0D; Conclusions: A combined three doses of perioperative antibiotics was ad­equate for SSIs prevention in patients of any age group and sex with acute NPA after appendectomy in usual operative time.

A randomized, prospective trial to assess the safety and efficacy of hilotherapy in patients after orthognathic surgery

PurposeA post-operative cooling method in oral and maxillofacial surgery is the cooling with hilotherapy. The aim of this study was the post-operative comparison of cooling temperatures of 18°C and 22°C. The parameters of this trial were swelling and the post-operative pain levels.MethodsThis study included 156 patients, divided into two groups among whom a mono-one, bignathic osteotomy or genioplasty was indicated. The post-operative assessment of swelling was performed using a 3D optical scanner. This examination was repeated on post-operative days 1, 2, 3, 7, 14, 30, and 90. The examination on day 90 served as a reference value in respect of swelling and pain.ResultsGroup 1 (18°C, 78 patients) showed an increase in post-operative swelling on the 1st post-OP day of 52.06 ± 35.41ml. The maximum was reached on the 2nd post-OP day with 75.82 ± 38.97ml. On the 30th post-OP day, residual swelling measured 11.60 ± 12.62ml. Group 2 (22 °C, 78 patients) showed an increase in postoperative swelling on the 1st post-OP day of 76.07 ± 63.15ml. The maximum was reached on the 2nd post-OP day with 106.97 ± 69.63 ml. On the 30th post-OP day, residual swelling measured 14.36 ± 32.26ml. The differences between the two groups and between different visits were statistically significant.ConclusionThe study results indicate less residual swelling in group 1 on the 30th post-OP day, possible based on the lower cooling temperature. The post-operative pain exhibits a comparable level of pain intensity between the two groups. In overall terms, a subjectively more agreeable treatment was observed in group 1.

P32.01 Effect of Refined Nursing on Postoperative Early Ambulation in Patients with Thoracoscopic Surgery for Lung Cancer

In recent years, the incidence and mortality of lung cancer ranks the first among malignant tumors. At present, the first choice for treatment is surgery. As a minimally invasive technique, thoracoscopy is widely used in the treatment of lung cancer. Although thoracoscopic surgery has the advantages of less trauma and less pain, the stress response and complications of postoperative patients have become important factors affecting and restricting the surgical effect, postoperative rehabilitation and quality of life. Nursing intervention has played a positive role in improving the therapeutic effect and postoperative rehabilitation of patients. The purpose of this study is to investigate the effect of refined nursing on postoperative early ambulation in patients with thoracoscopic surgery for lung cancer. A total of 135 patients undergoing thoracoscopic surgery for lung cancer from August 2018 to January 2019 were randomly divided into a control group and an observation group, 67 in the control group and 68 in the observation group. The patients in the control group were given routine nursing, while those in the observation group were given refined nursing on the basis of routine nursing. The first time of getting out of bed, the ambulation distance on the 1st, 2nd and 3rd day after surgery, the time of anus exhaustion and defecation, the incidence of postoperative complications and quality of life scores on the 1st, 2nd and 3rd postoperative days were analyzed. The first time of getting out of bed (11.6土5.7h), the time of anus exhaust (24.1土8.6h) and defecation (35.0土8.9h) in the observation group were significantly shorter than those in the control group (P<0.05). The ambulation distance on the 1st, 2nd and 3rd day after operation in the observation group was significantly higher than those in the control group (P <0.01), and the quality of life was higher than that in the control group (P <0.05). The incidence of postoperative complications was 13.23%, which was lower than that (28.36%) in the control group (P <0.05). The application of refined nursing in patients undergoing thoracoscopic surgery for lung cancer can effectively shorten the time for patients to get out of bed after surgery, increase the ambulation distance, accelerate anal exhaust and defecation, reduce complications, improve quality of life, and promote rehabilitation of patients.

ANTERIOR NASAL PACKING POST SUBMUCOUS RESECTION (SMR): A COMPARISON BETWEEN REMOVAL ON 1ST VERSUS 2ND POST OPERATIVE DAY

Objective: To evaluate the effect of removal of nasal packs after sub mucous resection (SMR) on the first postoperative day versus second post operative day in terms of bleeding control and prevention of septal hematoma formation.&#x0D; Study Design: Comparative cross sectional study.&#x0D; Place and Duration of Study: ENT department, Combined Military Hospital Jhelum Pakistan, from Oct 2017 toOct 2018.&#x0D; Methodology: Total 100 patients of both genders, ages from 16 to 35 years with a deviated nasal septum wereincluded. Written informed consent was taken and hospital ethical committee approval was obtained. Patientswere randomly divided into two groups of 50 patients each by simple random sampling. Patients in both groupsunderwent submucous resection. Patients in whom sub mucous resection was combined with other procedureslike rhinoplasty, turbinectomy, polypectomy were excluded. In group A the nasal packs were removed on thefirst post operative day. In group B the nasal packs were removed on the second post operative day. Nasal packing in all patients was done with vaseline gauze rolls. The groups were compared for bleeding at the time of nasal pack removal and septal hematoma formation in the follow up period.&#x0D; Results: There was no statistically significant difference between the two groups in terms of bleeding (p-value0.40) and septal hematoma formation (p-value 0.49).&#x0D; Conclusion: After sub mucous resection, removal of nasal packs on 1st versus 2nd post operative day is notassociated with any significant difference in bleeding and septal hematoma formation.

β tricalcium phosphate as a bone substitute for fracture healing in goats

The study was conducted on twelve clinical cases of goats having long bone fracture, presented at Teaching Veterinary Clinical Complex, College of Veterinary Science and Animal Husbandry, Jabalpur, during the study period. In group I the fracture segment was immobilized by dynamic compression plate whereas, in group II after immobilization with dynamic compression plate gap at fracture site was filled with β tricalcium phosphate. There was a gradual decrease in exudates and pain at fracture site in both the groups from 2nd postoperative day onwards. A significant increase in weight bearing was observed from 7th post-operative day in both the groups of goat. Complete weight bearing by all the animals was observed on 30th day in group II. Radiographic examination on 15th post-operative day, depicted evidence of periosteal reaction on both the fracture segment, almost in all the cases of group II. Radiograph taken on 60th post-operative day, exhibited radiodense area at the fracture site, indicative of extensive periosteal and endosteal callus. The values of alkaline phosphatase increased non-significantly in both groups of goat up to 15th post-operative day. After reaching its maximum values, a decline in the values was observed in both the groups.

Complication in Time of COVID-19: Biloma

Purpose: After declaration of international health alert for COVID-19 pandemic, the diagnosis of non-viral diseases has decreased. ''Stay at home'' advice and the risk of coronavirus infection makes the patient afraid to approach hospital emergency department. Here is presented a rare complication related to gallbladder perforation with fistula to abdominal wall. A consequence of a subacute cholecystitis which the pacient did not came earlier to hospital because of the risk of virus infection. Methods: A 64-year-old woman developed an asymptomatic abdominal tumour located in the right hypochondrium, measuring 20 centimetres, which had been present for 3 weeks. A CT scan was performed showing an intermuscular cystic tumour in abdominal wall and hepatic subcapsular region. They were identified a perforation of the gallbladder fundus with a fistulous trajectory towards the abdominal wall and a dilatation of the left intrahepatic bile duct, secondary to extrinsic compression. Subsequently, percutaneous drainage of the collection was performed. Followed by scheduled cholecystectomy, which revealed a perforated and inflammated gallbladder and a large cavity with a pyogenic capsule. The anatomical pathology of the specimen was described as chronic cholecystitis. The patient evolved satisfactorily after operation and was discharged on the 2nd postoperative day. Results: After the start of quarantine, there has been a decrease in the number of visits to the emergency department. Acute pathologies such as cholecystitis present at diagnosis with more advanced and severe degrees of evolution compared to those diagnosed before the pandemic. Gallbladder perforation occurs in 12% of acute cholecystitis, with a mortality rate of 16%. In our case, according to Neimeier's classification, it is a subacute perforation type II (frequency 45.9%) with a pericholecystic collection and fistulization towards the abdominal wall, an unusual presentation. Conclusion: The new global epidemiological situation causes fear of infectious-contagious state to prevail over the appearance of new symptoms. This favours a delay in the diagnosis and treatment of acute and chronic pathologies, which then manifest in the patient in more advanced stages and require more complex treatments.

A comparative evaluation of bone regeneration using mesenchymal stem cells versus blood coagulum in sinus augmentation procedures.

Objective:The present study evaluated the quality and quantity of new bone formation in the maxillary sinus lift procedures and stability of implants in posterior atrophic maxilla.Materials and Methods:This prospective randomized controlled split-mouth study included 20 patients (16 males and 4 females having a mean age of 36.7 years) having atrophic maxilla. They were divided randomly into two groups: Group A using mesenchymal stem cells and Group B into blood coagulum. They were radiographically evaluated using cone-beam computed tomography (CBCT) for residual bone height preoperatively and availability of new bone formation around implants, density, and stability of implants 6 months postoperatively.Results:The placement of dental implants in posterior maxilla is challenging due to rapid resorption of alveolar bone after extraction of teeth due to pneumatization of maxillary sinuses. In both the groups, more pain and swelling were observed in the 2nd postoperative day which gradually decreased over a period of 7 days. Membrane perforation occurs in only four cases (20%). A significant gain in alveolar bone height was observed in Group A (7.69 mm ± 2.5 mm) and Group B (9.32 mm ± 2 mm) after 6 months. On comparing both the groups, there is a similar significant increase in bone density in Hounsfield units postoperatively at various levels buccally and palatally. Total 40 sinuses were lifted and 42 implants were placed, respectively. All implants showed primary stability.Conclusions:Such findings provide a significant contribution in future perspective studies that the use of stem cells had the same success rate as blood coagulum.

SHORTEN PREOPERATIVE FASTING AND INTRODUCING EARLY EATING ASSISTANCE IN RECOVERY AFTER GASTROJEJUNAL BYPASS?

ABSTRACT Rational: The metabolic response to surgical trauma is enhanced by prolonged preoperative fasting, contributing to increased insulin resistance. This manifestation is more intense on the 1st and 2nd postoperative days and is directly proportional to the size of the operation. Aim:To compare whether preoperative fasting abbreviation and early postoperative refeeding associated with intraoperative and postoperative fluid restriction interfere in the evolution of patients undergoing gastrojejunal bypass. Methods:Eighty patients indicated for Roux-en-Y gastrojejunal bypass were selected. They were randomly divided into two groups: Ringer Lactate (RL) group, who underwent a 6 hours solids fasting, with the administration of 50 g of maltodextrin in 100 ml of mineral water 2 hours before the beginning of anesthesia; and Physiologic Solution (PS) group, who underwent a 12 hours solids and liquids fasting. Anesthesia was standardized for both groups. During the surgical procedure, 1500 ml of ringer lactate solution was administered in the RL and 2500 ml of physiological solution (0.9% sodium chloride) in the PS. In both groups, the occurrence of bronchoaspiration was analyzed during intubation, and the residual gastric volume was measured after opening the abdominal cavity. In the postoperative period in Group RL, patients started a liquid diet 24 hours after the end of the operative procedure; whilst for PS group, fasting was maintained for the first 24 hours, it was prescripted 2000 ml of physiological solution and a restricted liquid diet after 36 hours. Each patient underwent CPK, insulin, sodium, potassium, urea, creatinine, PaCO2, pH and bicarbonate dosage in the immediate postoperative period, and 48 hours later, the exams were repeated. Results:There were no episodes of bronchoaspiration and gastrojejunal fistulas in either group. In the analysis of the residual gastric volume of the PS and RL groups, the mean volumes were respectively 16.5 and 8.8, which shows statistical significance between the groups. In laboratory tests, there was no difference between groups in sodium; PS group showed a higher level of serum potassium (p=0.029); whilst RL group showed a higher urea and creatinine values; CPK values were even for both; PS group demonstrated a higher insulin level; pH was higher in PS group; sodium bicarbonate showed a significant difference at all times; PaCO2 values in RL group was higher than in PS. In the analysis of the incidence of nausea and flatus, no statistical significance was observed between the groups. Conclusions:The abbreviation of preoperative fasting and early postoperative refeeding of Roux-en-Y gastrojejunal bypass with the application of ERAS or ACERTO Project accelerated the patient’s recovery, reducing residual gastric volume and insulin level, and do not predispose to complications.

Epidermoid cyst of the clitoris

An epidermoid cyst is a benign cyst resulting of implantation of superficial epidermal tissue into the dermis or subcutaneous tissue. They are commonly found on the scalp, face, neck, trunk and extremities; and rarely seen in the clitoral or vulvar region, most often associated with prior trauma or surgery to the area, particularly female genital mutilation. Epidermoid cyst of the clitoris is a very uncommon pathological entity, it can be spontaneous present at birth or develop later in life, or often secondary to surgery or trauma at the clitoral region. Herein, we report a case of 33-year-old multiparous woman, without past medical history of vulvar trauma or genital surgery, presented to the emergency department with a history of slowly growing clitoral mass over 11 months, which recently became responsible of sexual discomfort and difficulty in urination, without fever, vaginal discharge or other complaints. On perineal examination a painless midline cystic mass of 5 A— 3 cm was noted; it extended from the clitoral region up to the labia minora; the mass was mobile, nontender, well-circumscribed and with a smooth surface (A, B). The labia minora and majora were normal, and both the urethral and vaginal openings were normal in position and shape (B). There was no associated bleeding or discharge. The remainder of the physical examination was otherwise unremarkable. Ultrasound testing revealed normal internal genital and urinary tract without communication between the cystic structure and the urethra. The patient underwent a complete surgical excision of clitoral cyst under spinal anesthesia, without compromising the clitoral neurovascular bundle or hood. Histopathological examination revealed an epidermoid cyst lined with stratified squamous epithelium and filled with keratinous material. The final pathologic diagnosis was of a spontaneous nontraumatic epidermoid cyst of the clitoris. The patient´s postoperative course was completely uneventful and she was discharged from the hospital on the 2nd postoperative day without any complication. No recurrence of the cyst was noted 6 months later at a follow-up visit, and she had a normal cosmetic appearance of the external genitalia, with complete disappearance of genital and urinary complaints.

Kardiyak Cerrahide Mortalite Tayini: Kalp Cerrahi Skorlaması (CASUS) Sistemi Etkin mi?

Objective: This study was planned to evaluate effectiveness of cardiac surgery score (CASUS) system used for the prediction of mortality after the cardiac surgery and to compare it with EuroSCORE, a tested and approved method. Method: Fifty patients over the age of 18 who came to the intensive care unit (ICU) after open heart surgery and stayed in the ICU for more than 48 hours were prospectively included in the study. After the preoperative EuroSCORE evaluation of the patients, CASUS scoring systems were used for risk scoring from postoperative 0 day to the service or up to the 6th postoperative day (or possible mortality) in patients whose stay in ICU was prolonged. We evaluated the place of both models in the prediction of ICU mortality. Results: The study was conducted with 50 patients- 21 female, 29 male-, aged between 19 and 79 years (mean age: 60.38±12.50). Five (10%) cases exited.The areas under the ROC curve were estimated as follows: EuroSCORE, 45.3%; and for CASUS 0,1, and 2. day scores AUCs of ROC curve were 66,9%, 64,7%, and 79,8%, respectively. The CASUS 2nd day score was found to be valuable in predicting mortality (p&lt;0.01). A statistically significant relationship was observed between the days of stay in the ICU and mortality. Conclusion: Our results show that the rate of the accurate prediction of mortality of CASUS is insufficient on postop 0th and 1st day; however CASUS score on postoperative 2nd day has sufficient.predictive accuracy EuroSCORE is not found effective in the prediction of mortality. It is observed that if the duration of stay in ICU is prolonged, it statistically significantly increases the risk of mortality.

Continuous Epidural Analgesia and Continuous Femoral Nerve Block for Postoperative Pain after Unilateral Total Knee Arthroplasty: A Prospective Cohort Study

Introduction: Total Knee Arthroplasty (TKA) surgeries are associated with moderate to severe postoperative pain. Inadequate analgesia leads to patient distress, suboptimal knee mobilisation and complications due to delayed rehabilitation. Peripheral nerve blocks and central neuraxial techniques are in the vanguard of various analgesic strategies to minimise pain after TKA. Aim: To compare the effects of Continuous Epidural Analgesia (CEA) and Continuous Femoral Nerve Block (CFNB) on postoperative analgesia, knee rehabilitation and adverse effects after TKA surgeries. Materials and Methods: A prospective cohort study was conducted among 90 patients undergoing unilateral TKA at the Government Medical College, Kozhikode, Kerala, India. They were divided into two groups of 45 each. CEA (Group E) and CFNB (Group F) were given for postoperative pain management. Effectiveness of postoperative analgesia was measured by Numerical Rating Scale (NRS) scores at 6, 12, 24, 48 and 72 hours and also by need for rescue analgesics during the first 48 hours. Postoperative knee rehabilitation indices were measured on 1st, 2nd and 3rd Postoperative Days (POD). Incidence of adverse effects in each group was also noted. Continuous variables were analysed using students t-test, categorical variables using Chi-square test and NRS scores using Mann Whitney U test. Results: NRS scores were similar in both CEA (E) and CFNB (F) groups. On POD 1, 75.6% of group E and 71.1% of group F (p=0.630), on POD 2, 71.1% of group E and 68.9% of group F (p=0.818) and on POD 3, 62.2% of group E and 66.7% of group F (p=0.66) achieved specific rehabilitation indices. There was no statistically significant difference in pain scores, rescue analgesic requirement and rehabilitation indices between the two groups. No significant adverse effects were noted in either group. Conclusion: CFNB is as effective as continuous epidural block for postoperative analgesia and knee rehabilitation after TKA without any significant side-effects.