Left Lateral Decubitus Position Research Articles

Application of the Left Lateral Decubitus Position in Laparoscopic Right Posterior Lobectomy.

To investigate the value of the left lateral decubitus position in laparoscopic right posterior lobe tumor resection. The clinical data of patients who underwent laparoscopic right posterior lobectomy from January 2020 to March 2023 were retrospectively collected and divided into group A (left lateral decubitus position group, n=30) and group B (conventional position group, n=35) according to different body positions. Intraoperative and postoperative data were collected and compared between the 2 groups. The operation time (210.43±57.56 vs. 281.97±65.89, t =5.887, P <0.05), hilar occlusion time (23.97±14.25 vs. 35.79±12.62, t =4.791, P <0.05), intraoperative blood loss (162.14±72.61 vs. 239.65±113.56, t =5.713, P <0.05), postoperative feeding time (1.13±0.36 vs. 1.57±0.67, t =3.681, P <0.05), postoperative visual analog scale score (5.16±0.89 vs. 7.42±1.31, t =3.721, P <0.05), postoperative abdominal drainage tube indwelling time (4.58±1.34 vs. 5.42±1.52, t =4.553, P <0.05), incidence rate of complications (43.33% vs. 82.86%, χ 2 =11.075, P <0.05) in group A were lower than those in group B ( P <0.05). Symptoms/side effects (32.42±3.42 vs. 27.44±3.31, t =4.331, P <0.05), and there were significant differences in social function (33.55±2.56 vs. 29.31±3.32, t =4.863, P <0.05). For right posterior lobe tumors of the liver, the left lateral decubitus position has many advantages in laparoscopic right posterior lobectomy, such as a wide field of view, simple steps, a short operation time, less bleeding, and a high postoperative quality of life. It is an effective treatment for right posterior lobe tumors of the liver and is worthy of being widely popularized.

Effect of Patient Position during Spinal Anesthesia on the Incidence of Post-Dural Puncture Headache after Cesarean Section

Objective: To compare the incidence of post-dural puncture headache (PDPH) following spinal anesthesia in parturients undergoing elective cesarean section between the sitting and left lateral decubitus positions. Methodology: This quasi-experimental study was conducted at Holy Family Hospital, Rawalpindi, Pakistan, from May 2022 to October 2022. A total of 120 parturients undergoing elective cesarean section under spinal anesthesia were randomly assigned to either the sitting or left lateral decubitus position group. The primary outcome was the occurrence of PDPH within 5 days postoperatively. Secondary outcomes included adverse effects such as hypotension, nausea/vomiting, and bradycardia. Data were analyzed using SPSS version 25.0. Categorical variables were compared using the chi-square test or Fisher's exact test, as appropriate, with a significance level set at p &lt; 0.05. Results: The incidence of PDPH post-procedure was significantly higher in the sitting group compared to the left lateral decubitus group (33.3% vs. 6.7%). In the sitting position group, 63.3% of women experienced hypotension, 26.7% had bradycardia, and 30.0% reported nausea/vomiting, whereas in the left lateral decubitus group, these figures were 58.3%, 21.7%, and 23.3%, respectively. Conclusion: This study concludes that the left lateral decubitus position during spinal anesthesia for cesarean section is associated with a lower incidence of PDPH compared to the sitting position.

Effects of osteopathic manipulative treatment on maternal-fetal hemodynamics in third trimester pregnant women: A prospective study.

To evaluate the maternal-fetal hemodynamic effects after osteopathic manipulative treatment by measuring vital signs and Doppler velocimetry in third-trimester pregnant women. This is a prospective study with pregnant women undergoing outpatient follow-up and hospitalized in a ward at Instituto Fernandes Figueira/Fiocruz, between August 2021 to August 2022, during the SARS-CoV-2 pandemic. This study was registered in REBEC under Register Number RBR-9q7kvg and approved by the ethics committee under number 32216620.0.0000.5269. The study population was composed of 51 pregnant women between 28 and 40 weeks of gestation, over 18 years of age, allocated in a single group. Pregnancies with multiple fetuses, malformations, premature rupture of the membrane, and active labor were excluded. The procedures evaluated maternal-fetal hemodynamics using three consecutive measures of ultrasound examination with Doppler velocimetry, and three maternal vital signs measured by an electronic blood pressure monitor. Most vital signs changed after osteopathic treatment. However, only the systolic blood pressure (109.92 ±14.42 to 110.71±12.8, p = 0.033), diastolic blood pressure (79.8±11.54 to 77.57±9.44, p = 0.018) and heart rate (87.59±11.93 to 81.12±10.26, p = 0.000) in the sitting position, systolic blood pressure (110.75±13.26 to 108.59±13.07; p = 0.034) in the supine, and heart rate (83.22±11.29 to 80.39±11.0; p = 0.013) in left lateral decubitus reached statistical significance. The oximetry measures (98.55±0.64 to 98.67±0.68; p = 0.098) stayed stable during all three positions. All artery values remained stable after treatment, and no statistically significant difference was recorded in the artery results. Responses to osteopathic treatment in women in the third trimester of pregnancy did not affect uteroplacental and fetoplacental circulation. However, some maternal vital signs had statistically significant results, with a decrease in diastolic blood pressure and heart rate, and an increase in systolic blood pressure in the sitting position, a decrease of heart rate in the left lateral decubitus position, and systolic blood pressure in the supine position. All the results observed were maintained in the normal parameters. The study responses attest to the safety of using the osteopathic manipulative treatment for the fetus and for pregnant women with comorbidities.

Surgical Management of Osteochondritis Dissecans of the Glenoid via Autologous Bone Marrow Aspirate Concentrate and Extracellular Matrix Graft in an Eighteen-Year-Old College Pitcher

Background: Osteochondritis dissecans (OCD) affects the shoulder in only 0.6% of patients aged 2 to 19 years with disease most commonly in the humeral head. When the glenoid is affected, it is often in male overhead throwing athletes and treated with fixation via autologous osteochondral plugs following bone marrow aspirate. Indications: The primary indication for surgical management of OCD is failure of conservative management, often with imaging showing disruption of the glenoid subchondral plate. This patient is an 18-year-old male pitcher with over 2 years of chronic, deep-seated shoulder pain unresponsive to conservative management. Technique Description: We present a primary arthroscopic technique of autologous bone marrow aspirate concentrate graft for management of OCD in an 18-year-old college baseball pitcher. The patient was placed in the left lateral decubitus position with an axillary roll and standard portals were established. A loose fragmented flap with no underlying osseous material was debrided and a 3-cm central area of bony loss was identified. Bone marrow aspirate of 80 mL was taken from the anterior superior iliac crest. The aspirate was mixed with Biocartilage (Arthrex) to fill the defect flush with the surrounding tissue and sealed with fibrin glue. Ports were closed and an abduction sling was applied. Results: A recent review article demonstrated that athletes who underwent surgical management of OCD lesions returned to sports an average of 1.2 months sooner than those managed non-operatively, though this difference was not significant. This patient had a full return to play at 9 months. At 1-year follow-up, he made a full recovery and is currently playing professionally without shoulder pain. Discussion/Conclusion: Autologous bone marrow aspirate defect filling is a viable treatment of OCD, even in high-level overhead throwing athletes. It allows for arthroscopic treatment with long-term success in the treatment of pain and function. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

The Effect of Esophagogastroduodenoscopy on Intraocular Pressure.

Esophagogastroduodenoscopy (EGD) is an endoscopic examination of the upper gastrointestinal tract that requires insufflation with gas, leading to intra-abdominal hypertension (IAH). There is evidence suggesting that IAH positively correlates with intracranial pressure (ICP) and possibly with intraocular pressure (IOP). The aim of this study was to examine the effect of a routine screening EGD on the IOP. In this observational study, 25 patients were recruited; 15 males with a mean age of 50 ± 18 years and 10 females with a mean age of 45 ± 14 years. EGD was conducted under sedation in 21 subjects. Both eyes' IOP measurements were performed using Tonopen Avia in the sitting and left lateral decubitus positions before sedation and the start of EGD, and subsequently in the left lateral decubitus position when the endoscope reached the duodenum (D2) and at the end of the procedure. The final measurement was performed in the sitting position 10 min after the end of the procedure. The mean IOP in the sitting position was 15.16 ± 2.27 mmHg, and in the left lateral decubitus position, 15.68 ± 2.82 mmHg. When the gastroscope entered the D2, it was 21.84 ± 6.55 mmHg, at the end of the procedure, 15.80 ± 3.25 mmHg, and 10 min later, 13.12 ± 3.63 mmHg. There was a statistically significant IOP increase when the gastroscope entered the duodenum (p < 0.01). At the end of the gastroscopy, the IOP significantly decreased compared to the one registered when the gastroscope entered the D2 (p < 0.001) and it became similar to the values measured before the EGD, in the same left lateral decubitus position (p > 0.05). Significant changes in IOP were observed during the EGD. IOP fluctuations during EGD should be taken into account, especially in patients that need repeated EGDs during their life or in patients with glaucoma. Further studies are needed to better understand the short-effect and long-effect influence of an IOP increase in these patients.

Successful management of an atrio-esophageal fistula after atrial fibrillation ablation: a case report

Abstract Background Atrio-esophageal fistula is a rare but still a catastrophic complication of radiofrequency ablation of atrial fibrillation. We report a successful case of atrio-esophageal fistula with right posterolateral thoracotomy and right femoral cannulation of cardiopulmonary bypass. Case presentation A 67-year-old man underwent radiofrequency ablation for atrial fibrillation. Nineteen days later, he developed cerebral infarction, and computed tomography showed air in the left atrium. He was transferred to our hospital for surgery. The upper body was placed in the left lateral decubitus position, and the lower body was placed in the left hemilateral decubitus position. The surgical approach was a right posterolateral thoracotomy in the 5th intercostal space. At first, the esophagus was transected at the diaphragm and tracheal carina levels. Then, an arterial line was inserted into the right common femoral artery and venous line into the right common femoral vein. Three U-shaped sutures of 3-0 polypropylene were placed to stop bleeding from the atrium. The esophagus was removed while snaring the 3-0 polypropylene sutures. There were two holes in the esophagus. Four drains were placed to clean the repaired site. After chest closure, the patient was placed supine. Cervical esophagostomy and enterostomy were performed. Gastric tube reconstruction via the retrosternal route was performed on postoperative day 28, and the patient was transferred to another hospital for rehabilitation on postoperative day 99. Conclusions It is important to thoroughly discuss with esophageal surgeon how to reach the heart and esophagus, and how to reconstruct the esophagus later.

A70 INABILITY TO AMBULATE FOLLOWING COLONOSCOPY: AN UNEXPECTED COMPLICATION

Abstract Background The peroneal nerve innervates the lower extremities. Compression injury has been documented in the adult patients following the lithotomy position perioperatively, but has rarely been described in pediatric patients following colonoscopy. Aims To report a rare complication following colonoscopy and discuss possible aetiologies. Methods A chart review of a post-colonoscopy peroneal nerve injury in a pediatric patient was conducted along with a literature review. Results A 12 year old boy with ulcerative colitis underwent a colonoscopy for flare symptoms. He was in the left lateral decubitus position for 60 minutes. Immediately after the procedure, he experienced loss of sensation from the left knee to the plantar aspect of the foot, and left foot drop. He had no symptoms of weakness or paresthesia in the right lower extremity or the upper extremities. Prior to the procedure, he reported normal strength, function, and sensation of all extremities. He had no history of injury, joint inflammation or previous surgery affecting his left leg. He had no recent history of steroid use or systemic illness. Two months post procedure he had some symptom improvement and could independently ambulate. He had normal range of motion, strength, and sensation in the upper extremities and right lower extremity. His left leg had 4/5 strength on dorsiflexion and decreased pinprick and light touch sensation. He had difficulty with heel-toe walking. Reflexes were normal. Left leg X-ray and spine MRI were normal. Electrodiagnostic evaluation supported a left common peroneal nerve injury, predominantly demyelinating in nature with minimal axonal contribution, likely secondary to compression around the fibular head during the time of the colonoscopy. He showed full recovery and returned to baseline by 7 months. Conclusions Peroneal nerve injury post colonoscopy is very rare. A study focusing on pediatric colonoscopy found that 3 of 746 patients experienced postoperative neuropathies in their lower extremities. Procedure times were between 70-120 minutes. Presentations and recovery periods were variable, lasting several days to 3 months. The mechanisms of this injury are unclear and felt unlikely to be secondary to positioning alone. It is speculated that BMI, procedure length, frog leg position and position changes, as well as systemic inflammation may be contributory. Factors such as hypothermia, dehydration, hypotension, hypoxia, and electrolyte disturbances may further place patients at risk. Awareness of this rare event and potential modifiable risk factors is important. Funding Agencies None

Utility of gastroscopy in the left lateral semi-recumbent position: A blood-free coup!

Background and study aims The utility of esophagogastroduodenoscopy (EGD) in the left lateral semi-recumbent position in the setting of acute upper gastrointestinal bleeding (UGIB) with a persistent fundal pool of blood for adequate visualization and effective endotherapy has not been studied. This study aimed to evaluate the feasibility, efficacy, and safety of this position in such settings. Patients and methods A prospective study of patients presenting with acute UGIB with an uncleared fundal pool of blood was conducted. All underwent EGD in the left lateral decubitus and secondary left lateral semi-recumbent positions. Outcomes in secondary position in terms of adequate visualization of the fundus, identification of new or additional sources of bleeding, and effectiveness of endotherapy were studied. Results We screened 860 patients and included 44 patients (5.11%) with a persistent fundal pool of blood. Endoscopy in the primary position revealed the source of bleeding in 37 of 44 patients (84%). The source of the bleeding was not identified in seven of 44 patients (16%). Endoscopy in the secondary position showed clearance of fundal pool in all 44 patients (100%). A new source of bleeding was identified in all seven patients (100%) and an additional source could be identified in another five patients (13.6%). Endotherapy was performed in the secondary position for all 44 patients with 100% technical success and 94% clinical success. Conclusions These data show that endotherapy in the left lateral semi-recumbent position is feasible, safe, and effective. It should be done when endoscopy in the left lateral decubitus position reveals a pool of blood in the fundus and there is inadequate visualization of the fundus.

Cap-assisted colonoscopy can increase the rate of sessile serrated lesion detection at the left lateral decubitus position: A retrospective case-control study.

We investigated the effectiveness of cap-assisted colonoscopy conducted with the patient in the left lateral decubitus position at both the colonoscope's insertion and withdrawal timepoints compared to the effectiveness of colonoscopy without a cap conducted in the supine position at withdrawal. This was a case-control study, based on historical comparisons of patients over 2 time periods. The first group of patients underwent colonoscopies with a transparent cap and the patient was in the left lateral decubitus position at both the insertion and withdrawal timepoints from April to June 2019. The subsequent group underwent colonoscopies without a cap and with the patient in the supine position at withdrawal from July to September 2019. The rates of successful intubation, cecal intubation time, and number, size, shape, and location of the detected adenomas and sessile serrated lesions were compared between the 2 groups. Data from 644 colonoscopies (cap-assisted colonoscopy + left lateral decubitus position, n=320; other colonoscopies, n=324) were analyzed. The demographic characteristics and technical performances were similar. The SSL detection rate was significantly higher with cap-assisted colonoscopy and the left lateral decubitus position than with other colonoscopies (3.4% vs 0.93%, P=.029). The adenoma detection rates in the 2 groups were similar (31% and 28%, respectively, P=.43).Cap-assisted colonoscopy in the left lateral decubitus position may increase the detection rate of sessile serrated lesions compared to colonoscopy without a cap and supine position at withdrawal.

212. ROBOT ASSISTED ESOPHAGECTOMY WITH EXTENDED MEDIASTINAL LYMPH NODE DISSECTION

Abstract Background Radical surgical resection may play role in prognosis improvement of the esophageal squamous cell carcinoma (ESCC) patients. Because esophagectomy with radical lymphadenectomy is highly invasive, we introduced thoracoscopic esophagectomy in 1999, and have performed over 600 cases. In 2009, we developed a hybrid of the prone and left lateral decubitus positions for thoracoscopic esophagectomy with extended LN dissection and reported good long-term outcomes especially in cT1bN0M0 ESCC patients. We reported 3y and 5y RFS was 96% and 96%, and 3y and 5y OS was 94% and 92% in those patients. We introduced robot-assisted esophagectomy (RMIE) using daVinci Xi system in June 2018. We perform RMIE with the prone position instead of the hybrid position with same concept of thoracoscopic esophagectomy with extended LN dissection. Thanks to a three-dimensional magnified view, fully wristed dexterity and tremor filtration of da Vinci Xi system, the robotic system facilitates precise dissection especial for upper mediastinal lymph node dissection. We show safety introduction and technical pitfalls of robot-assisted esophagectomy with extended LN dissection. Methods: The patient is fixed on prone position. We use Monopolar curved scissors for superficial layer, bipolar cut for dissection with maryland bipolar forceps for deeper layer around Aorta and trachea, and Sharp dissection with Potts scissors around recurrent laryngeal nerves. After esophageal mobilization and mediastinal lymphadenectomy were completed, bilateral recurrent laryngeal nerve, bilateral subclavian artery, trachea, bilateral bronchus, aorta, left pulmonary artery and vein, left pleura, pericardium and hiatus are all skeletonized. Results: We could standardize surgical procedure in first 20 cases. Average operation time in the thoracic procedure is 234.4 min and 195.6 min in last 30 cases. Median blood loss is 0 mL. Postoperative pneumonia and vocal cord palsy were occurred only 4 case in last 50 cases. Conclusion: Robot assisted esophagectomy with extended LN dissection was safely introduced in our facility and it is feasible and beneficial for the lymph node dissection especially for lymph node dissection around the recurrent laryngeal nerve.

Successful resuscitation from acute coronary syndrome during mediastinoscope-assisted transhiatal esophagectomy: a case report

BackgroundAlthough unexpected cardiac arrest is a very rare intraoperative complication, strategies regarding preoperative screening and procedures to be taken in the event of an emergency need to be well established.Case presentationA man in his late 70 s diagnosed with thoracic esophageal cancer, cT3N1M0, and cStage III was admitted. His metabolic equivalents were 4 or more. Electrocardiogram (ECG), ultrasound cardiography, and hematological examinations revealed no severe abnormalities. Computed tomography (CT) showed highly calcified coronary arteries. We performed mediastinoscope-assisted transhiatal esophagectomy. Procedures in the mediastinum involving access from the neck and abdomen were completed uneventfully. Middle mediastinal lymph node dissection and gastrointestinal reconstruction with the patient in the prone position were scheduled for later. However, before the change in position, pulseless nonsustained ventricular tachycardia (VT) suddenly occurred and caused blood pressure to drop sharply to below 30 mmHg. The VT disappeared in approximately 20 s, and there was a return to sinus rhythm after cardiac resuscitation; however, the ECG showed a decrease in the ST segments of leads II, III, and aVF. Immediately thereafter, the patient was transferred to the cardiac catheterization laboratory for percutaneous coronary intervention. Cardiac catheterization revealed diffuse stenosis of 90% in the left anterior descending branch of the coronary artery (segment no. 6). Plain old balloon angioplasty and stent placement were performed. Dual antiplatelet therapy was needed. On the next day, thoracoscopic esophagectomy was performed in the left lateral decubitus position, followed by cervical esophagostomy in the supine position. He developed acute respiratory distress syndrome and thoracic aortic dissection on the 5th postoperative day (POD) and intraperitoneal bleeding on the 16th POD. On the 105th POD, laparoscopic-assisted cervical esophagogastric anastomosis was performed. Parkinson’s disease was diagnosed on the 126th POD. On the 313th POD, the patient was discharged.ConclusionSurgeons should be familiar with the guidelines for patient screening and management of intraoperative cardiac arrest. In patients with severe coronary artery calcification, further investigation such as coronary angiography CT may be necessary before esophagectomy. Furthermore, highly invasive surgery should be performed in well-equipped hospitals.

Intensive Management of Diffuse Peritonitis Caused by Spontaneously Healed Gastric Perforation: A Case Report

Background: Gastric perforation will cause acute peritonitis. Proper diagnosis and management, especially in ICU, are needed to prevent complications and even death from this event. This study aimed to describe the intensive management of diffuse peritonitis caused by gastric perforation.&#x0D; Case presentation: A 61 years old male patient presented with pain in the whole abdomen for 6 days before admission. The pain began at the epigastrium and suddenly spread to the whole abdomen. The pain was felt continuously and increased by movement. Routine blood examination revealed anemia, lekousitosis, and radiology examination found homogeneous confluence was found in the abdominal, dilated small intestine, psoas line was not visible, in the left lateral decubitus position, an air-fluid level and free air were found. The patient underwent diagnostic laparoscopic surgery + peritoneal lavage on emergency surgery for 2 hours, obtained a resolution of gastric perforation, and the patient was treated postoperatively in the ICU of Dr. M. Djamil General Hospital.&#x0D; Conclusion: Cases of spontaneous resolution of gastric perforation are not only in terms of surgical management but in terms of postoperative care. It also plays an important role in the success and good results in cases of gastric perforation.

Left lateral decubitus computed tomography before catheter ablation in patients with atrial fibrillation.

Aim The study aimed to determine the efficacy of cardiac computed tomography angiography (CCTA) for diagnosing left atrial appendage (LAA) thrombus before catheter ablation with the patient in the left lateral decubitus position and, also, to evaluate the risk factors for thrombus formation.Material and methods This retrospective, cohort study included 101 patients with atrial fibrillation. All patients underwent transthoracic echocardiography (TTE) and left lateral decubitus CCTA. Transesophageal echocardiography (TEE) was performed to confirm or exclude LAA thrombus. Patients with allergic reactions to iodinated contrast media, increased serum creatinine, hyperthyroidism, pregnancy, and age&lt;18 years were excluded. The CHA2‑DS2‑VASc and HAS-BLED scores were calculated for each patient.Results All LAA thrombi detected on CCTA were confirmed by TEE. Higher CHA2‑DS2‑VASc, HAS-BLED scores, enlarged LA, and the anteroposterior dimension of the left atrium were significantly associated with the presence of LAA thrombus. A LAA cauliflower shape was a predictor of thrombus. An increase of LAA volume by 1 ml increased the chances of LAA thrombus and cerebral ischemic infarct by 2 %. The growth of the LAA anteroposterior diameter by 1 cm increased the risk of LAA thrombus by 190 % and of cerebral infarct by 78 %. An increase in the CHA2DS2‑VASc score by 1 point increased the risk of thromboembolism and cerebral infarction by 12 %.Conclusions CCTA performed in the left lateral decubitus position of the patient is an optimal screening tool to detect or exclude LAA thrombus before catheter ablation because of atrial fibrillation. CCTA has predictive value for risk of thrombosis formation in LAA.

Determining Tuffier’s Line by Ultrasound in Pregnant and Non-pregnant Female Patients: a prospective cohort study

Objectives: The correct determination of the vertebral level is important in anesthesia management and the prevention of possible risks. It has been shown that estimation of L4/5 intervertebral lumbar level based on Tuffier’s line determined by palpation (palpated L4/5) is often inaccurate. In this study, it was aimed to investigate how Tuffier’s line changes in the lateral decubitus position due to pregnancy. Material and Methods: The patients were divided into two groups in this prospective cohort study. The pregnant patients were assigned to Group P (n = 75) while the non-pregnant patients were assigned to Group NP (n = 60). Lumbar ultrasound was conducted in both groups in the left lateral decubitus position to verify the vertebral level determined by Tuffier’s line that was detected by palpation. Demographic data, determination time of Tuffier’s line, ultrasound, and the detected vertebral levels were recorded in both groups. Results and Discussion: Vertebral levels detected by both techniques were compatible with 35 (46.6%) patients in Group P and 36 (60%) patients in Group NP (p = 0.165). The vertebral levels in Group P detected via ultrasound were determined at L2 in three (4%) patients, at L2/3 in three (4%) patients, at L3 intervals in three (4%) patients, and at the L3/4 interval in 31 (41.3%) patients. The vertebral levels of the patients in Group NP detected via ultrasound was at L2/3 in 2 (3.3%) patients, and at the L3/4 interval in 22 (36.7%) patients. For the risk of insertion from a risky injection site, the OR = 3.96–95 and GA = 0.82–19.05 in Group P were higher compared to Group NP (approximately 4 times higher). While Group P was significantly limited in the risk analysis, according to L3 (p = 0.087), the risk under this level was similar (p = 0.124). In this study, the verification of Tuffier’s line determined through palpation did not show the correct vertebral level in almost half of the patients in the lateral decubitus position, regardless of pregnancy and demographic data. Conclusion: We believe a possible spinal cord injury can be prevented by determining the needle insertion site via lumbar ultrasound in the pregnant patients. Bangladesh Journal of Medical Science Vol. 22 No. 03 July’23 Page : 529-535

An estimation of the endoscopist's musculoskeletal injury risk for right and left lateral decubitus positions during colonoscopy: a field-based ergonomic study

BackgroundColonoscopy exposes endoscopists to awkward postures and prolonged forces, which increases their risk of musculoskeletal injury. Patient positioning has a significant impact on the ergonomics of colonoscopy. Recent trials have found the right lateral decubitus position is associated with quicker insertion, higher adenoma detection rates, and greater patient comfort compared to the left lateral decubitus position. However, this patient position is perceived as more strenuous by endoscopists.MethodsNineteen endoscopists were observed performing colonoscopies during a series of four-hour endoscopy clinics. Durations of each patient position (right lateral decubitus, left lateral decubitus, prone, and supine) were recorded for all observed procedures (n = 64). Endoscopist injury risk was estimated by a trained researcher for the first and last colonoscopies of the shifts (n = 34) using Rapid Upper Limb Assessment (RULA), an observational ergonomic tool that estimates risk of musculoskeletal injury by scoring postures of the upper body and factors such as muscle use, force, and load. The total RULA scores were compared with a Wilcoxon Signed-Rank test for patient position (right and left lateral decubitus) and time (first and last procedures) with significance taken at p < 0.05. Endoscopist preferences were also surveyed.ResultsThe right lateral decubitus position was associated with significantly higher RULA scores than the left lateral decubitus position (median 5 vs. 3, p < 0.001). RULA scores were not significantly different between the first and last procedures of the shifts (median 5 vs. 5, p = 0.816). 89% of endoscopists preferred the left lateral decubitus position, primarily due to superior ergonomics and comfort.ConclusionRULA scores indicate an increased risk of musculoskeletal injury in both patient positions, with greater risk in the right lateral decubitus position.

Focused transoesophageal TOE (fTOE): A new accreditation pathway.

The concept of a focused ultrasound study to identify sources of haemodynamic instability has revolutionized patient care. Point-of-care ultrasound (POCUS) using transthoracic scanning protocols, such as FUSIC Heart, has empowered non-cardiologists to rapidly identify and treat the major causes of haemodynamic instability. There are, however, circumstances when a transoesphageal, rather than transthoracic approach, may be preferrable. Due to the close anatomical proximity between the oesophagus, stomach and heart, a transoesphageal echocardiogram (TOE) can potentially overcome many of the limitations encountered in patients with poor transthoracic ultrasound windows. These are typically patients with severe obesity, chest wall injuries, inability to lie in the left lateral decubitus position and those receiving high levels of positive airway pressure. In 2022, to provide all acute care practitioners with the opportunity to acquire competency in focused TOE, the Intensive Care Society (ICS) and Association of Anaesthetists (AA) launched a new accreditation pathway, known as Focused Transoesophageal Echo (fTOE). The aim of fTOE is to provide the practitioner with the necessary information to identify the aetiology of haemodynamic instability. Focused TOE can be taught in a shorter period of time than comprehensive and teaching programmes are achievable with support from cardiothoracic anaesthetists, intensivists and cardiologists. Registration for fTOE accreditation requires registration via the ICS website. Learning material include theoretical modules, clinical cases and multiple-choice questions. Fifty fTOE examinations are required for the logbook, and these must cover a range of pathology, including ventricular dysfunction, pericardial effusion, tamponade, pleural effusion and low preload. The final practical assessment may be undertaken when the supervisors deem the candidate's knowledge and skills consistent with that required for independent practice. After the practitioner has been accredited in fTOE, they must maintain knowledge and competence through relevant continuing medical education. Accreditation in fTOE represents a joint venture between the ICS and AA and is endorsed by Association of Cardiothoracic Anaesthesia and Critical care (ACTACC). The process is led by TOE experts, and represents a valuable expansion in the armamentarium of acute care practitioners to assess haemodynamically unstable patients.

The effect of sleep positional therapy on nocturnal gastroesophageal reflux measured by esophageal pH-impedance monitoring.

The aim of the study was to evaluate the effect of an electronic positional therapy wearable device on nocturnal gastroesophageal reflux measured by pH-impedance reflux monitoring. We performed a single-center, prospective, interventional study in 30 patients with nocturnal reflux symptoms and a nocturnal esophageal acid exposure time (AET) ≥1.5% measured off acid-suppressive medication by ambulatory pH-impedance reflux monitoring. Patients were treated with an electronic positional therapy wearable device for 2 weeks. The device vibrates in the right lateral decubitus position so it conditions patients to avoid that sleep position. After 2 weeks treatment, the pH-impedance study was repeated. Primary outcome was the change in nocturnal AET. Secondary outcomes include change in number of reflux episodes and reflux symptoms. Complete data were available for 27 patients (13 females, mean age 49.8 years). The median nocturnal AET decreased from 6.0% (IQR, 2.3-15.3) to 3.1% (0.1-10.8) after 2 weeks of treatment (p = 0.079). The number of reflux episodes was significantly reduced after 2 weeks of treatment (baseline: 8.0 (3.0-12.3) vs. end: 3.0 (1.0-8.0); p = 0.041). Treatment led to a statistically significant decrease in time spent in right lateral decubitus position (baseline: mean 36.9% ± 15.2% vs. end: 2.7% ± 8.2%; p = <0.001) and an increase in the left lateral decubitus position (baseline 29.2% ± 14.8% vs. end: 63.3% ± 21.9%; p = <0.001). Symptom improvement was reported by 70.4% of the patients. Sleep positional therapy using an electronic wearable device promotes sleeping in the left lateral decubitus position and improves reflux parameters measured by pH-impedance reflux monitoring.

Auricle Myxoma, Evidence from the Clinic to Cardiovascular Emergency Surgery, Triad: Cardiac, Systemic, Embolic

Cardiac tumors are infrequent, primary tumors, such as atrial myxoma, are estimated at 000017 to 0.13% of all cardiac neoplasms, postmortem records, n relation to its frequency, it is more than the other primary ones, in 67% the left atrial myxoma, 23% in the right atrium and less frequent the biaurals left. age group from 30 to 60 years, more in the female sex, in the childhood is more related to alterations in skin lentiginosis, nevi as Carney.autosomica dominant síndrome. In genetic studies, alterations in the PRKAR1A gene on chromosome 17 are found. We present the case of a patient with a request for pre-surgical evaluation, urological prolapse of the bladder, with systemic manifestations, weight loss, chronic anemic syndrome treated with vitamins and trace elements, by a private physician, without remission. It is worth mentioning that the physical and cardiovascular examination revealed semiotic onygomatic seizures of Duroziez in the mitral area, with auscultatory changes in the left lateral decubitus position, for which reason I propose the diagnosis of mitral valvular heart disease vs atrial myxoma, with 2 elements of clinical judgment of the classic triad of myxoma, in the performance of the transcutaneous echocardiogram, a cardiac mass was observed, at the level of the left atrium, spherical, of 5.5 cmt diameter, hyperechogenic. Great mobility in cycles cardiac, prolapse of the mitral valve in diastole with stenosis, the emergency consultation was made to cardiovascular surgery in a hospital of greater complexity, a procedure with complete excision of the tumor of approx 12 cmt by 5.5 cmt diameter, with satisfactory evolution of the patient

V01-08 ROBOTIC APPENDICEAL ONLAY FOR THE TREATMENT OF URETEROENTERIC STRICTURE

You have accessJournal of UrologyCME1 Apr 2023V01-08 ROBOTIC APPENDICEAL ONLAY FOR THE TREATMENT OF URETEROENTERIC STRICTURE Joseph J. Boyle, Ellen Cahill, Sai Krishnaraya Doppalapudi, and Sammy E. Elsamra Joseph J. BoyleJoseph J. Boyle More articles by this author , Ellen CahillEllen Cahill More articles by this author , Sai Krishnaraya DoppalapudiSai Krishnaraya Doppalapudi More articles by this author , and Sammy E. ElsamraSammy E. Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteroenteric anastomotic strictures (UES) are the most common complication requiring repeat surgery following radical cystectomy, occuring in up to 10% of patients. Untreated, they may result in loss of renal function and predispose patients to infection. Open revision of the stricture has been the gold standard, but is technically challenging. Minimally invasive surgical approaches (MIS) in stricture disease can afford greater visibility and maneuverability, while minimizing blood loss. Options for extended strictures or those located in the proximal or midureter have been historically limited to ileal ureter replacement or autologous kidney transplant, both having considerable morbidity. Onlay techniques utilizing buccal mucosa or appendix are options to repair rather than replace longer ureteral strictures. Appendiceal onlay flaps are an encouraging yet relatively under-described alternative for select patients in this group. In this video, we present a case of a 6 cm proximal right UES treated with robotic appendiceal onlay flap repair. METHODS: Procedure performed with Da Vinci Xi system. Patient placed in left lateral decubitus position. Veress needle technique used to insufflate the abdomen. Ports placed in standard position for robotic laparoscopic renal surgery, ensuring placement outside conduit margins. Right ureterolysis performed. 5-French ureteral catheter placed over a wire positioned through previously placed ureteral stent. Ureteroenteric anastomosis identified, with ureteral detubularization from anastomosis to just above stricture with a length of 6 cm. Increased ureteral caliber and vigorous saline efflux marked proximal stricture end. Appendix stapled at cecum and detubularized with preserving mesentery. Appendiceal flap sewn to detubularized segment of ureter. Intraoperative ureteroscopy demonstrated patent repair. JJ stent placed. RESULTS: No intraoperative complications. Case duration was 200 minutes. EBL was 25 mL. He was discharged POD 2 after an uncomplicated post-operative stay. Stent removed at 6 weeks. 3-month ultrasound and renal scan showed no obstruction. He was seen every 6 months with no signs or symptoms of UTI, flank pain, or hydronephrosis on ultrasound. Latest follow-up at 16 months. He reported resolution of chronic malodorous urine. CONCLUSIONS: UES remain a challenge following radical cystectomy. Robotic repair with appendiceal onlay is a safe, durable, and often overlooked treatment option. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e81 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph J. Boyle More articles by this author Ellen Cahill More articles by this author Sai Krishnaraya Doppalapudi More articles by this author Sammy E. Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...

V01-09 ROBOTIC URETEROURETEROSTOMY OF RETROCAVAL URETER

You have accessJournal of UrologyCME1 Apr 2023V01-09 ROBOTIC URETEROURETEROSTOMY OF RETROCAVAL URETER Rainjade Chung, Justin Lee, George W Moran, Miyad Movassaghi, Belinda Li, and Christina P. Carpenter Rainjade ChungRainjade Chung More articles by this author , Justin LeeJustin Lee More articles by this author , George W MoranGeorge W Moran More articles by this author , Miyad MovassaghiMiyad Movassaghi More articles by this author , Belinda LiBelinda Li More articles by this author , and Christina P. CarpenterChristina P. Carpenter More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retrocaval ureter, also known as “circumcaval ureter” or “preureteral vena cava,” is a relatively rare anatomical variant with an incidence of 0.13% that occurs when the right ureter courses posterior to the vena cava rather than anterior. More commonly seen in males, the etiology is a developmental abnormality of the vena cava, not the ureter. Many cases are clinically silent, but surgical reconstruction is indicated if the patient has severe hydronephrosis, significant functional obstruction, or pain. This patient presented with right flank pain, severe hydronephrosis, and a characteristic "S sign" on retrograde pyelogram (Figure 1). Our objective was to describe our approach to an uncommon case, robotic ureteroureterostomy of a retrocaval ureter. METHODS: The patient was placed in the left lateral decubitus position. The Da Vinci Xi system was utilized and 4 ports were placed in a linear fashion at the lateral border of the rectus 6 cm apart. A 5 mm AirSeal was placed between the 2nd and 3rd arm. ProGrasp Forceps are used in the 1st arm, Maryland bipolar forceps are used in the 2nd arm, and a monopolar curved scissor is used in the 4th arm. Vessel loops were placed on the proximal and distal ureter on either side of the vena cava and were pulled back and forth to allow for visualization and dissection (Figure 2). RESULTS: Successful robotic ureteroureterostomy of a retrocaval ureter. CONCLUSIONS: Robotic ureteroureterostomy is a minimally invasive procedure to manage ureteropelvic junction obstruction caused by a retrocaval ureter. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e82 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rainjade Chung More articles by this author Justin Lee More articles by this author George W Moran More articles by this author Miyad Movassaghi More articles by this author Belinda Li More articles by this author Christina P. Carpenter More articles by this author Expand All Advertisement PDF downloadLoading ...