Left Lateral Decubitus Position Research Articles

Rare Upper Mediastinal Oligometastasis from Early Esophagogastric Adenocarcinoma: A Case Report.

Esophagogastric junction (EGJ) adenocarcinoma is an aggressive cancer with poor prognosis. Metastasis to the upper mediastinal lymph nodes is rare, with reported rates of 3.8% to 6.1%. This case report highlights the diagnostic and therapeutic challenges of oligometastatic recurrence in EGJ adenocarcinoma, emphasizing the role of surgery in selected cases. A 63-year-old male underwent proximal gastrectomy for a Siewert type 2 poorly differentiated EGJ adenocarcinoma. Postoperative histopathology confirmed the diagnosis of stage 1 cancer. At 30 months, contrast-enhanced computed tomography (CT) scan detected a right paratracheal lymph node recurrence. Subsequent follow-up CT and positron emission tomography (PET) scan revealed progressive enlargement of the same lymph node with negative PET uptake. Owing to strong clinical and radiological suspicion of oligometastasis, thoracoscopic lymphadenectomy was performed with the patient in the left lateral decubitus position under one-lung ventilation. The postoperative histopathological examination confirmed metastatic adenocarcinoma. The patient was discharged uneventfully on postoperative day 5 and prescribed with adjuvant tegafur-gimeracil-oteracil (S-1). He remained asymptomatic during ongoing surveillance. This case highlights the challenges in diagnosing oligometastatic recurrence of EGJ adenocarcinoma, particularly when typical imaging signs are absent. It also demonstrates the importance of a multidisciplinary treatment approach, including careful surveillance and timely intervention. Surgery is one of the options for oligometastasis.

Effect of Intraoperative Posture on Accurate Diagnostic Rate of Intraoperative Nerve Monitoring During Esophagectomy

ABSTRACTBackgroundThe benefits of intraoperative nerve monitoring for identifying recurrent laryngeal nerves during esophageal cancer surgery have recently been reported. However, no standardized procedures have been established for the use of this system. This study aimed to identify factors affecting the diagnostic accuracy of intraoperative nerve monitoring for recurrent laryngeal nerve palsy and explore approaches to improve the precision and efficiency of intraoperative nerve monitoring in esophageal cancer surgery.MethodsWe analyzed 187 consecutive patients who underwent esophagectomy between 2011 and 2018, of whom 142 underwent intraoperative nerve monitoring. We evaluated factors affecting the diagnostic accuracy of intraoperative nerve monitoring for recurrent laryngeal nerve palsy.ResultsThe overall incidence of postoperative recurrent laryngeal nerve palsy was 22% (32/142). Univariate analysis identified the left lateral decubitus position (vs. prone position) and not using video laryngoscope during intubation as risk factors for discrepancies between intraoperative nerve monitoring findings and postoperative recurrent laryngeal nerve palsy diagnosis. Multivariate analysis confirmed that the left lateral decubitus position (odds ratio: 4.24; 95% confidence interval: 1.09–13.4, p = 0.019) and not using video laryngoscope during intubation (odds ratio: 9.51; 95% confidence interval: 2.94–15.9, p = 0.001) were independent risk factors for recurrent laryngeal nerve palsy diagnostic discrepancies.ConclusionAdequate contact between the intubation tube and vocal cord muscles is crucial for effective intraoperative nerve monitoring during esophagectomy. Additionally, the intraoperative posture significantly affects diagnostic outcomes and should be carefully considered.

Air embolism after CT-guided transthoracic interventional operation: Is it necessary to change the patient's position to prevent embolized air from entering the systemic circulation.

To investigate the influence of the patient's position on the entry of embolized air into the systemic circulation after air embolism (AE). 116 patients with AE were selected as study subjects, including 81 patients undergoing CT-guided transthoracic biopsy and 35 patients undergoing CT-guided localization of pulmonary nodule before video-assisted thoracoscopic surgery. While maintaining the patient's original position, 94 out of 116 patients underwent at least one follow-up CT within 5 to 15 minutes after AE. The following two situations were considered as embolized air entering into systemic circulation: (1) CT showed air in the aorta and/or branches; (2) Follow-up CT showed a decrease or disappearance of air in the left heart. The positions of the 116 patients with AE included 6 in supine position (SP), 70 in prone position (PP), 20 in left lateral decubitus position (LLDP) and 20 in right lateral decubitus position (RLDP). Embolized air entering the systemic circulation occurred in 33.3% (2/6) patients in SP, 47.1% (33/70) patients in PP, 70% (14/20) patients in LLDP, and 55% (11/20) patients in RLDP. The difference is not statistically significant (χ2=4.16, p = 0.24). The proportion of embolized air entering the systemic circulation is similar among patients in SP, PP, LLDP and RLDP within 5-15 minutes after AE. The above four positions can not effectively prevent the embolized air from entering the systemic circulation. Embolized air enters the systemic circulation within a few minutes in about half of patients with AE. Within 5-15 minutes after AE, the proportion of embolized air entering the systemic circulation is similar among patients in SP, PP, LLDP, and RLDP. Changing the patient's position after AE can not prevent embolized air from entering the systemic circulation.

Ultrasonography-guided catheter-over-needle insertion for caudal epidural catheter placement in adults: technical considerations

BackgroundCaudal epidural analgesia significantly reduces acute pain after anorectal surgery; however, caudal epidural catheter placement (CECP) remains challenging, and the safety of real-time ultrasonography-guided CECP is uncertain. This study aimed to evaluate the success rate and related complications of real-time ultrasonography-guided CECP and describe the technical considerations.MethodsThis prospective, single-center observational study included 233 patients catheterized in the left lateral decubitus position. The sacral hiatus was palpated and then confirmed using ultrasonography. A catheter-over-needle was inserted through the sacrococcygeal ligament under real-time ultrasonographic guidance, the metallic needle was withdrawn through the outer sleeve, and the epidural catheter was placed through the outer sleeve into the sacral canal epidural space. The primary outcome was the success rate of CECP; several surgical variables, the incidence of related complications, and improvement measures were also assessed.ResultsCECP through the sacral hiatus was successful in 231 patients. The sacral canal depth at the hiatus apex, the mean distance between the sacral cornua, and the distance from the skin to the inferior margin of the sacrococcygeal ligament were 5.07 ± 1.38, 8.00 ± 1.94, and 14.24 ± 4.18 mm, respectively. The sacral canal depth was > 3 mm in 94.4% of patients. No complications, such as epidural hematoma, dura puncture, and intraspinal infection during postoperative epidural catheter utilization, occurred.ConclusionUltrasonography-guided CECP through the sacral hiatus is a simple, feasible, safe, and effective technique for postoperative anorectal analgesia. Additionally, caudal epidural analgesia manages severe pain after anorectal surgery. Therefore, this technology merits comprehensive clinical application.Trial Registration numberNo. ChiCTR 2,000,038,918.

Awake micro-endoscopic discectomy without fluoroscopy performed in a 14-week pregnant lady in lateral decubitus position and use of gadolinium-soaked gauze to mark surgical incision: a case report and review of literature.

Severe lumbar radiculopathy pain during pregnancy requiring surgical intervention poses significant risks to foetal and maternal health from use of potentially teratogenic general anaesthetic drugs, prone positioning and intra-operative radiation from fluoroscopy. A 28-year-old 14 weeks primigravida patient suffering from severe lumbar radiculopathy due to right sided L5-S1disc herniation was offered a discectomy procedure after failed conservative treatment. A multidisciplinary team including anaesthetists, gynaecologist, radiologist and spine surgeon was constituted. A novel two-tier marking technique utilizing ultrasonography and magnetic resonance imaging (MRI) was used to accurately plan the L5-S1 surgical incision. The surgery was performed under spinal anaesthesia in left lateral decubitus position to avoid pressure on foetus and inferior vena cava. A tubular minimally invasive approach was used to access the L5-S1 disc. No intra-operative fluoroscopy marking was used. Post-operatively patient reported complete relief from radiating right leg pain and MRI confirmed adequate nerve decompression. Post-operative foetal scans were performed at regular intervals which were normal. Patient delivered a normal term baby girl without any complications. Our two-tier marking technique and use of regional anaesthesia in lateral decubitus position avoids potentially teratogenic general anaesthetic agents and intra-operative radiation. It can be used to effectively decompress lumbar spine disc herniation and represents an advancement in ensuring safe spine surgery in pregnant females.

Endoscopic treatment of choledocholithiasis in patients with metabolic syndrome

Aim. To study the results of endoscopic treatment of choledocholithiasis in patients with metabolic syndrome.Material and methods. A total of 49 patients with choledocholithiasis and metabolic syndrome were studied between 2021 and 2023. The patients were between 36 and 82 years old. There were 12 men and 37 women among the patients studied. Of the 49 patients who underwent surgery, 9 were admitted for elective surgery. These patients were diagnosed with choledocholithiasis without obstructive jaundice and chronic calculous cholecystitis. The remaining 40 patients were admitted on an emergency basis. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) using the FUJIFILM ED-580XT duodenoscope and Mobile Surgical C-ARM X-ray systems.Results. Endoscopic retrograde cholangiopancreatography and endoscopic papilosphincterotomy were performed under endotracheal anaesthesia in standard left lateral decubitus position. The average duration of surgery was 39±9.3 minutes. Postoperative complications were noted in 5 (%) patients and included bleeding from a papiltomous wound in 2 patients and postoperative pancreatitis in 3 patients. The average length of hospital stay after ERCP EPST was 2.6±1.6 bed days. The condition of the patients before and after surgery was satisfactory, haemodynamics were stable. No fatal outcomes were noted in the postoperative period.Conclusion. Endoscopic treatment of choledocholithiasis in patients with metabolic syndrome allows one to avoid the use of traumatic traditional approaches and perform the operation completely, even in cases where laparoscopic surgery is contraindicated.

Deteriorating Hypotension and Trepopnea During Left Lateral Decubitus Position Before Spinal Anesthesia.

Deteriorating Hypotension and Trepopnea During Left Lateral Decubitus Position Before Spinal Anesthesia.

Hemodynamics Effects of the Left Lateral Decubitus Position in Pregnancy as Assessed by Simultaneous Internal Jugular and Common Carotid Doppler Ultrasound.

Hemodynamics Effects of the Left Lateral Decubitus Position in Pregnancy as Assessed by Simultaneous Internal Jugular and Common Carotid Doppler Ultrasound.

Concurrent Renorrhaphy During Renal Mass Excision in Laparoscopic Nephron-Sparing Surgery: A Novel Surgical Technique.

Laparoscopic nephron sparing surgery (NSS) can be performed by mainly 2 methods, offclamp or on-clamp. Continuous bleeding during the off-clamp method may impair the clear visualization of the border between the tumor and parenchyma, even though it is done safely in experienced hands. Therefore, some surgical modifications may be needed during mass excision and renorraphy. In this video brief, we aimed to present a new off-clamp NSS technique and our case series. The difference of this technique from others is that renorrhaphy was performed during mass excision concurrently to reduce the amount of bleeding. Laparoscopic transperitoneal NSS was performed on a 40-year-old male patient with a lowcomplexity lower pole mass (2.5 × 2 cm) in the right kidney, characterized by a RENAL nephrometry score of 4p. On left lateral decubitus position, after port placement, the ascending colon was medialized and the right ueter was found. The renal pedicle was dissected, and the main renal artery was secured with the vessel loop. After opening Gerota's fascia, the mass was found on the lateral side of lower pole. The excision margin was determined by cautery. A 3-0 V-Loc suture was fixed to the anterior abdominal wall just before mass excision. Along the margin, the renal parenchyma was incised by scissors at a depth of 3-4 mm. Excision continued until there was enough place to pass the suture. Then renorrhaphy was started with the V-Loc suture to reduce bleeding. Suturing continued until reaching to excision limit. Excision continued until serious bleeding occurred. If serious bleeding occurred, suturing was performed again. If there was no bleeding, excision was completed after controlling the tumor base with suturing. Intraperitoneal air pressure was reduced to detect hidden bleeding. Anti-bleeding powder was applied to the excision area. Written informed consent was obtained from the patients who agreed to take part in the study. The total operative and renorraphy time was 85 and 10 minutes, respectively. The bleeding amount was 150 mL. The pathologic report confirmed a 2.5 × 2 × 2 cm clear cell renal cell carcinoma. No major complications were observed during surgery. After 46 months, there is no local recurrence or metastasis.

Quantitative Assessment of Postural Influence on Lung Function Using Deformable Image Registration-Based Breath-Hold CT Ventilation Imaging.

Purpose This study aimed to clarify which positions are beneficial for patients with pathological lung diseases, such as acute respiratory distress syndrome, by obtaining lung ventilation and deformable vector field (DVF) images using Deformable Image Registration (DIR). Methods Thirteen healthy volunteers (5 female, 8 male) provided informed consent to participate to observe changes in normal lungs. DIR imaging was processed using the B-spline algorithm to obtain BH-CTVI (inhale, exhale) in four body positions (supine, prone, right lateral, left lateral) using DIR-based breath-hold CT ventilation imaging (BH-CTVI). DVF imaging was created through DIR-based BH-CTVI, which obtained the displacement vector from expiration to inspiration for each lung lobe. Results In the DIR images for each body position, the areas with Jacobian values in the 75th percentile or higher, indicating highly functional areas, were distributed on the side of the patient in contact with the ground. DVF images showed the abdominal displacement vector to be oriented from dorsal to ventral in the supine position. However, in the prone position, the displacement vectors were nearly parallel to the ground, directed from head to feet, indicating that lung motion was unaffected by gravity. Conclusion We demonstrated that the prone position allows for lung ventilation with the least gravitational load compared with the supine, right lateral decubitus, and left lateral decubitus positions, based on a comparison of DIR-based BH-CTVI when the positions were converted. It is important to include the evaluation of DVF images, in addition to ventilation images, when assessing lung function using DIR-based BH-CTVI.

Anesthesia Management of Space-Occupying Lesion in the Pontine Region due to Brainstem Glioma in a Pediatric Patient: a Case Report

A space-occupying lesion (SOL) in the pontine region of the medulla oblongata, often suspected as a brainstem glioma, poses a complex diagnostic challenge. Brainstem gliomas, primarily diffuse intrinsic, afflict all age groups with a median survival of about 12 months, influenced by tumor characteristics. Comprehensive preoperative evaluation is essential to assess the patient's health status and identify potential complications, guiding optimal anesthesia management. This case report aimed to describe the author's anesthesia technique for managing patients with SOL in the pontine region of the medulla oblongata, focusing on those with suspected brainstem gliomas. A four-year-old girl weighing 20 kilograms presented with sudden left-sided weakness, difficulty swallowing, headaches, and speech difficulties. Examination revealed right cranial nerve paresis and decreased left extremity strength. MRI showed a pontine glioma. Surgery preparation included fasting, fluid calculation, and medication readiness. Anesthesia induction involved midazolam premedication, propofol induction, and remifentanil for intubation. Monitoring included EtCO2 and oxygen saturation maintenance. Intraoperatively, target-controlled infusion (TCI) propofol and compressed air sustained oxygenation. Paracetamol and tranexamic acid were administered. The surgery lasted five hours in the left lateral decubitus position. Postoperative analgesia included fentanyl and oral paracetamol. The patient spent seven days in the PICU on a ventilator before discharge on the eighth day. In summary, the case of the four-year-old girl with left-sided weakness and difficulty swallowing, diagnosed with pontine glioma, showcases the intricate multidisciplinary approach essential in pediatric neurosurgery.

Bullectomy with video-assisted thoracic surgery and minimally invasive repair of pectus excavatum simultaneously

IntroductionPectus excavatum (PE) is the most common chest wall deformity. Surgical treatment with minimally invasive repair (MIRPE) is the most preferred surgical procedure. In the presence of additional pulmonary pathologies, simultaneous surgical procedures have been considered, but there are few cases reported in the literature.Case presentationMIRPE was planned for a 15-year-old male patient due to PE. The day before the surgery, the patient developed sudden onset of shortness of breath. Pneumothorax was observed on the right side in the chest radiograph. Thereupon, the surgery was brought forward. Video-assisted thoracoscopic surgery (VATS) bullectomy was performed in the left lateral decubitus position. MIRPE was then performed through the same incision in the semi-lateral decubitus position. The patient was planned to be discharged on the 7th day, but on the day of discharge, a pneumothorax on the left was observed on the chest x-ray. VATS bullectomy was performed in the left semi-lateral decubitus position. The patient was discharged on postoperative day five.ConclusionSince the long-term results of simultaneous surgical procedures are unknown. With MIRPE, results such as less pain, shorter hospital stays, and earlier involvement in social life are achieved. Keeping in mind that these advantages may be lost with additional procedures, we think that simultaneous procedures should be planned.

Abstract 219: Cerebral Air Embolism After Coronary Artery Bypass Graft: A Case Report and Systematic Review of Current Literature

Introduction Cerebral air embolism (CAE) is a rare but serious complication of cardiac procedure, often leading to significant neurological deficits. The study presents a case of CAE after coronary artery bypass graft (CABG) and a systematic review to highlight the incidence, symptom presentation, and outcomes associated with CAE following cardiac surgeries and interventions. Case Presentation We present a case of a 71‐year‐old African‐American male with a past medical history of hypertension, hyperlipidemia, high‐degree AV block with a pacemaker, and cerebrovascular accident who presented with a non‐ST segment elevation myocardial infarction. Following a successful CABG, the patient had a normal postoperative neurological exam and was ambulating independently. During a physical therapy session one day after the operation, however, the patient suddenly lost consciousness requiring intubation. CT brain demonstrated diffuse bilateral hemispheric air emboli. CTA head and neck ruled out large vessel occlusion but was concerning for cortical vein embolism. Despite immediate interventions, including Trendelenburg and left lateral decubitus positioning and high‐flow oxygen therapy, the patient developed seizures and progressive neurological deterioration. On postoperative day two, the patient had absent cranial nerve reflexes and an MRI brain revealed anterior and posterior circulation, diffuse bilateral hemispheric ischemic infarcts including bilateral thalami, and brainstem. The patient's condition continued to deteriorate and was transitioned to hospice care. Method A systematic review was performed following PRISMA guidelines. The extracted data included diagnostic modalities, procedural factors, and neurological outcomes related to CEA. A descriptive analysis of such variables was performed. Result There were 20 articles with 43 patients of whom 27 were male (62.8%). The average age of the patient population was 57.3 (± 20). CAE was diagnosed primarily through clinical suspicion with iatrogenic air bubbles (27.9%) and air visualized on CT (20.9%). Other diagnostic criteria included clinical suspicion with iatrogenic air bubbles (4.7%) and clinical suspicion with air visualized intraprocedural (4.7%). The most common procedures associated with CAE were cardiac ablation (23.3%), CABG (20.9%), valve repair (14.0%), and a repair of cardiac structural anomaly (14.0%). Less common procedures included angiography (2.3%) and cardiac bypass surgery with biventricular assist device placement (2.3%). The presenting neurological symptoms included motor deficit (37.2%), decreased consciousness (20.9%), language deficit (11.6%), visual deficit (2.3%), and coma (2.3%). 12 patients died with a mortality rate of 27.9%. Conclusion This case and systematic review highlight the importance of early recognition and intervention in managing CAE, particularly in high‐risk cardiac surgical patients. Given the detrimental neurological outcomes, CAE must be identified as a potential cause of acute stroke following cardiovascular procedures. Timely diagnosis can aid in targeted neuroprotective strategies and tailored surgical interventions to mitigate cerebral injury and improve patient outcomes in this rare but devastating complication.

Robot-assisted minimally invasive esophagectomy for esophageal cancer in the left lateral decubitus position

BackgroundThe use of robot-assisted minimally invasive esophagectomy (RAMIE) in the prone position for esophageal cancer has been currently increasing worldwide. In future, as surgical-assisted robots become more widespread, it is estimated that only two methods of transthoracic approach will remain: RAMIE and open thoracotomy for thoracic esophageal cancer. RAMIE in the left lateral decubitus position (RAMIE-LLDP) has the same field of view as open thoracotomy, is safe in emergency situations, and provides education on open thoracotomy.MethodsBetween September 2020 and April 2024, RAMIE-LLDP was performed in 64 consecutive patients with esophageal cancer. RAMIE-LLDP was performed with the operating table rotated and tilted 45° to the ventral side under artificial pneumothorax. The hand-control setting of the surgical-assist robot system was reversed left to right when the Patient Cart was rolled from the same direction as the RAMIE in the prone position.ResultsThe mean total surgery and console times during the thoracic procedure were 254-min overall and 225 min in the last 24 cases and 195-min overall and 178- min in the last 24 cases, respectively. The mean amount of blood loss was 203.4 g overall and 28.3 g in the last 24 cases. Postoperative recurrent laryngeal nerve palsy with Clavien–Dindo classification (CD) was ≥ 2 in six patients (9.4%). Postoperative pneumonia with CD ≥ 2 was observed in 11 patients (17.2%). Conversion to open thoracotomy was observed in three patients (4.7%). In all three patients, an immediate conversion to thoracotomy without patients’ position change was actually possible and no serious complications were noted. No mortality occurred within 30 days postoperatively.ConclusionRAMIE-LLDP which facilitates emergency thoracotomy has perioperative results comparable to those of conventional thoracoscopic esophagectomy and is educational for open surgery. RAMIE-LLDP is the safest and most optimal surgery for esophageal cancer.

A case of retrocaval ureter with robot-assisted ureteral reconstruction.

Retrocaval ureter is a rare congenital anomaly that causes ureteral obstruction. Because of the rarity of retrocaval ureter, only a few cases of open, laparoscopic, or robot-assisted surgery have been reported. We herein report a case of retrocaval ureter that was successfully reconstructed with robot-assisted surgery. A 24-year-old woman was incidentally diagnosed with right hydronephrosis on ultrasonography. Computed tomography revealed retrocaval ureter, and the right hydronephrosis was attributed to the retrocaval ureter. The patient underwent robot-assisted right ureteral reconstruction in the left lateral decubitus position. No intraoperative or postoperative complications occurred, and no right hydronephrosis was observed 6 months after the operation. The present case demonstrated the feasibility and efficacy of robot-assisted ureteral reconstruction for retrocaval ureter.

453. ROBOT ESOPHAGECTOMY WITH EXTENDED MEDIASTINAL LYMPH NODE DISSECTION FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA

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 and have performed for 80 cases. 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 234.4min and 190.2min in last 30 cases. Median blood loss is 0ml. Postoperative pneumonia and vocal cord palsy were occurred only 6 case in 80 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. https://www.dropbox.com/scl/fi/w8na39w6bo9ivwwz7x2rh/Hirofumi-Kawakubo-ISDE-2024.mp4?rlkey=p9mvt7dotyeaj6xfwvud8vcmr&dl=0

Surgical management of iSGS in pregnant patients: Survey among North American expertise centers

Surgical management of iSGS in pregnant patients: Survey among North American expertise centers

Case report: incarcerated gestational uterine rectal prolapse managed with manual reduction and Thiersch procedure

Case report: incarcerated gestational uterine rectal prolapse managed with manual reduction and Thiersch procedure

Rapid alleviation of perioperative airway obstruction through positional adjustments in a patient with a giant anterior mediastinal mass: A case report

Rationale: This case describes the rapid resolution of acute airway obstruction after anesthesia induction in a young man with a massive 12.7 × 9 × 12 cm anterior mediastinal tumor. It emphasizes the remarkable effectiveness of positional adjustments in immediately alleviating airway compression caused by large mediastinal masses. The crisis was resolved quickly and without invasive measures through only positional tactics, without the need for emergency invasive interventions. This highlights the decisive role of strategic patient positioning as a primary technique for perioperative management of mediastinal masses, ensuring adequate ventilation and preventing catastrophic outcomes. Patient concerns: Due to the unique anatomical location of mediastinal tumors, the anesthesia risks for patients with mediastinal tumors are very high. These tumors can cause airway compression, leading to severe cardiovascular dysfunction and even mortality during general anesthesia. Diagnoses: Combining the patient’s medical history, symptoms and signs, fiberoptic bronchoscopy and excluding other causes, it was confirmed that the tumor compressed the airway and blocked the airway. Interventions: Ventilation was rapidly improved by adjusting the patient’s position, ultimately to the left lateral decubitus position with head-up tilt. Outcomes: Through positional adjustment, the patient’s airway obstruction symptoms rapidly improved. Airway pressure decreased significantly, end-tidal carbon dioxide returned to 40 mm Hg, and oxygen saturation increased to 95%. The mediastinal tumor was ultimately successfully resected. The surgical procedure went smoothly with successful extubation on the first postoperative day. The patient had a smooth recovery and was discharged on the seventh postoperative day without any lingering postoperative complications. Lessons: This case provides an important educational illustration of how mediastinal mass patients can develop sudden catastrophic airway obstruction after induction despite being asymptomatic preoperatively. It demonstrates an effective crisis rescue technique through positioning that may help inform management of similar high-risk cases.

Relationship between epidural catheter migration beneath the skin and subcutaneous fat thickness assessed using postoperative CT imaging: a retrospective cross-sectional study.

The causes of epidural catheter migration beneath the skin have not been previously investigated. We hypothesized that greater subcutaneous fat thickness might be associated with increased catheter migration beneath the skin. We conducted a retrospective cross-sectional study of patients who had undergone combined general and epidural anesthesia, selecting individuals who received thoracic and abdominal CT scans within the first 5 postoperative days. Needle depth was defined as the distance from the needle tip to the skin surface when the anesthesiologist determined that the needle tip had reached the epidural space. We measured the length of the epidural catheter from the skin surface to the epidural space (catheter length), and subcutaneous fat thickness (fat thickness) using CT imaging. Migration distance was calculated by subtracting needle depth from catheter length. We analyzed 127 patients (72 males), all undergoing epidural catheter insertion in the left lateral decubitus position via a paramedian approach. The median age of the patients was 71years. Epidural catheters were postoperatively found to substantially curve beneath the skin. Regression analysis revealed no significant influence of fat thickness on catheter length (regression coefficient 0.10, 95% confidence interval [CI]: - 0.17, 0.38). However, it indicated a positive correlation between fat thickness and needle depth (regression coefficient 0.50, 95% CI: 0.30, 0.70), and a negative correlation between fat thickness and migration distance (regression coefficient - 0.40, 95% CI: - 0.65, - 0.14). We found a negative correlation between epidural catheter migration beneath the skin and subcutaneous fat thickness. Anesthesiologists should be aware of the possibility of substantial subcutaneous curving of the catheter, especially in patients with scant subcutaneous fat.