Left Lateral Position Research Articles

OGC SO06 - Novel Non-metallic Fiducial marker for Radiotherapy in Oesophageal Cancer

Abstract Background Early oesophageal tumours are technically difficult to delineate on the planning computed tomography (pCT) for Image Guided Radiotherapy (IGRT). We describe the use of a novel non-metallic fiducial marker for this purpose. Method Non-metallic fiducial marker (NFM) (BioXmark) was used in 17 patients from April 2021 to November 2022 for marking tumour site prior to radical or palliative radiotherapy. NFM was injected in the sub-mucosal plane using fluoroscopy under general anaesthesia, with the patient supine and using regular injection catheter and syringes. After the initial series, further modifications to the technique improved the injection and shortened operative time. These include left lateral positioning, an ultra-fine injection catheters and micro-dosing syringes. Feedback from the treating radiation oncologists was sought for all the patients. Results Injection was successful in all the patients. In the initial series before the modifications to the technique, often the marker was a larger than anticipated due to a combination of poor visibility when the patients were supine and use of larger bore injection catheters. Once the patient position was changed along with the changes in the injection catheters and the syringes, marking was very precise. Conclusion Previously used fiducial markers are gold based. While these were visible on pCTs, they are known to cause distortion along with being expensive and cumbersome to inject. In comparison, NFM is easy to inject without the artefacts seen with metallic markers. We refined the technique further by changing the patient’s position to left lateral which afforded a improved fluoroscopic visibility. Introducing finer injection catheters and micro-dosing syringes further led to usage of lesser volume and precise marking respectively. In summary we present a series of patients whose early oesophageal tumours were marked with a NFM aiding precise delivery of radiotherapy.

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.

Defibrillation success with a second generation intercostal extravascular ICD lead and commercially available left pectoral pulse generator

Abstract Background/Introduction An investigational intercostal extravascular ICD lead has been developed for compatibility with commercially available pulse generators (PGs) that are placed in a left pectoral position in appropriate patients. This is substantially different from currently available extravascular ICD systems that require a custom PG placed in a left lateral position. Purpose The purpose of this analysis was to evaluate sensing and defibrillation of a second-generation intercostal, extravascular defibrillation lead (EV-ICD Lead) when used with currently available ICD PGs in a traditional left pectoral location. Methods Patients (n=20) undergoing an ICD implant or replacement underwent acute VF EV-ICD Lead connected to a left pectoral pulse generator. Induced VF was sensed and shocked using a 10 J safety margin, with subsequent higher-energy shocks delivered if required. Testing was also conducted in the left lateral pocket for a paired analysis with patients serving as their own control. Results Automatic sensing of acute, induced VF episodes from the left pectoral PG was successful in 19 of 20 patients (95%) whose pre-induction R-waves were greater than 1.0 mV and unsuccessful in one subject with a pre-induction R-wave of 0.3 mV. VF was successfully terminated with a 10 J safety margin in 17 of 20 (83%) patients, a 5 J safety margin in 2 of 20 (10%) patients and failed to convert one patient (BMI 32.9) from the pectoral pocket (however, conversion was successful from a lateral pocket with a 10 J shock, which provides a 30 J safety margin. With a left lateral ICD, 100% of patients demonstrated successful VF termination with ≥10 J safety margin. Conclusion(s) Sensing and defibrillation using a left pectoral PG location is feasible with a new intercostal, extravascular defibrillation lead.

The Effects of Different Nursing Positions During Preterm Infants Feeding on Gastric Residual Volume and Emptying Rate: A Systematic Review and Network Meta-Analysis.

Preterm infants need nutritional support due to their premature digestive system, undeveloped anatomy and functional limitations. Neonatal positioning in the proper position is one of the nurses' main principles that affect the residual volume. We performed our systematic review and network meta-analysis to determine the best feeding position for preterm infants in reducing gastric residual volume and increasing the rate of gastric emptying. We systematically searched PubMed, Cochrane, CINHAL, Scopus and Web of Science from their inception to August 2023. We included studies that assess the effect of different feeding positions for preterm infants on gastric residuals. The Cochrane risk of bias tool (ROB2) appraised the included clinical trials. Cohort studies were assessed by the NIH tool and quasi-experimental studies by the relevant items from (Downs and Black) checklist. RevMan Version 5.4 was used for analysing the pooled data. Our study included a frequentist network meta-analysis of the aggregate data to obtain network estimates for the outcomes of interest. Network meta-analysis was done using R software. We included 16 studies with 1139 premature infants, comparing six preterm feeding positions. The pooled MD and 95% CI for GRV at 30 min for right lateral, prone, right anterior oblique and left lateral compared to supine position were as follows: (-12.08 [-20.09, -4.07]), (-11.14 [-18.26, -4.01]), (-9.02 [-21.66, 3.61]) and (-0.18 [-7.87, 7.5]), respectively. Moreover, the pooled MD and 95% CI for GRV at 180 min for right lateral, prone and left lateral compared to supine position were as follows: (-0.69 [-1.29, -0.09]), (-0.56 [-1.22, 0.1]) and (0.09 [-0.63, 0.81]), respectively. Nevertheless, the pooled MD and 95% CI for GRV at 120 min for right anterior oblique, prone, right lateral and left lateral compared to supine position were as follows: (-6.09 [-11.33, -0.86]), (-5.07 [-7.71, -2.43]), (-3.08 [-5.89, -0.27]) and (-0.44 [-3.41, 2.53]), respectively. We concluded that the best nursing position after preterm infants feeding for lower gastric residuals and higher gastric emptying rate is the right lateral position after 30 and 180 min post-feeding. Also, the right anterior oblique was the best after 120 min. Although the prone position can lower the GRV better than the left lateral and supine positions, it is not advisable to use this position because it raises the SIDS risk. Our results could help healthcare professionals to provide the appropriate positioning of preterm infants.

Advanced ultrasound diagnosis of extrahepatic bile duct lesions.

Ultrasound (US) has high specificity and sensitivity, and it should be performed first for patients with suspicion of biliary tract cancer. However, the complicated anatomy in addition to the gas images makes it difficult to delineate the entire extrahepatic bile duct (EHBD). The keys to depiction of EHBD are the "J" shape manipulation in the left lateral decubitus position and the use of magnified images with high-frequency transducers. Furthermore, indirect findings such as gallbladder (GB) distension, BD dilatation, and debris echo in the GB and BD are also important for detecting occult lesions, particularly in the ampullary region of Vater. For the differential diagnosis of BD wall thickening, the spreading pattern in the long and short axial directions should be assessed first. Then, the characteristics of the innermost hyperechoic layer (IHL) and outermost hyperechoic layer (OHL) should be evaluated. Asymmetrical wall thickening, absence of IHL, and presence of irregularity or discontinuity in OHL are characteristic patterns of cholangiocarcinoma (CCA). Because CCA is the most common BD polypoid lesion, it is important to diagnose tumor extension and depth invasion in addition to differential diagnosis. Nodular-type CCA is usually hypoechoic and more likely to invade vertically. In contrast, papillary-type CCA is often hyperechoic and extends laterally. Contrast‑enhanced US may be useful for evaluating these findings. However, if the possibility of CCA cannot be ruled out or a definitive diagnosis is needed, a transpapillary biopsy or endoscopic US-guided tissue acquisition should be considered.

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

The 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. Between 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. The mean total surgery and console times during the thoracic procedure were 254-min overall and 225min 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 203.4g overall and 28.3g 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 30days postoperatively. RAMIE-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.

Gastroscopic treatment of acute gastric variceal rupture through the right lateral position.

Acute variceal bleeding is a life-threatening condition and a common cause of cirrhosis-related death, severe acute bleeding is difficult to treat and has a high mortality rate, drug treatment is often ineffective. We encountered a patient with cirrhosis with ruptured and bleeding gastroscopic varices requiring emergency endoscopic surgical treatment. However, in the routine left lateral position the treatment was interfered with by a fresh blood clot obscuring the gastric fundus. We were able to expose the gastric fundus by turning the patient to the right lateral position and eventually successfully treated the patient. This provides a new idea for the endoscopic treatment of acute gastric varices and may improve the success rate of treatment.

Shock wave damage from the ventral side in primary blast injury: An experimental study in pigs

Aim/PurposeThis study aimed to apply a shock wave from the ventral side of a pig and examine its effect to use the results for new body armor production for humans. MethodsSeven male hybrid pigs were used. Each pig was placed under general anesthesia on the experimental table in a blast tube to expose the left lateral position from the front chest area, and shock waves generated by compressed air at 3.0 MPa were applied. We examined changes in vital signs and arterial blood gas in the hyper-acute phase and computed tomography (CT) images, and autopsies were performed for organ damage after 3 h of observation. Pathological examination was performed for lung damage, which is considered a characteristic of shock wave injury. ResultsAll seven pigs survived. Respiratory arrest occurred in two pigs; however, spontaneous breathing resumed promptly afterward. Hypotension occurred at a frequency of 4. No bradycardia or cardiac arrest was observed in any pig. In the arterial blood gas analysis before and immediately after shock wave exposure and 1 hour later, PaO2 decreased immediately but tended to improve thereafter. CT revealed pulmonary contusions and multiple bulla-like lesions on the surface of the lungs. An autopsy showed lung injury in all pigs, particularly in five cases with bulla-like lesions of various sizes on the lung surface across all lobes. Pathological findings showed visceral pleural detachment with elastic fibers from the lung parenchyma, and the cavity lesion on the lung surface comprised bullae. The degree of intra-abdominal hemorrhage varied; however, all but one case showed splenic injury. ConclusionNone of the pigs exposed to shock waves from the ventral side died; however, most showed multiple bullae on the lung surface with lung contusion and splenic injury, which may have been greater than those exposed from the dorsal side. This may be due to the direct impact of the shock wave proceeding from the epigastrium and subcostal region, which are not protected by the skeletal structure of the thorax. These characteristics should be considered when producing new body armor for humans to protect the body from shock waves.

Fetuses with deceleration of growth improve their growth following maternal rest.

The purpose of this study was to determine if fetuses with deceleration of growth velocity resulting in an EFW <10th percentile increase their growth above the 10th percentile following 2 weeks of maternal rest in the left lateral recumbent position. This was a retrospective observational study of 265 fetuses with the prenatal diagnosis of an EFW <10th percentile. Fetuses were classified by four definitions of abnormal growth velocity: (1) a growth velocity less than 20 g/day, (2) 30 percentile decrease in the EFW, (3) 50 percentile decrease in the EFW, and (4) abnormal growth trajectory. Once the fetuses were identified with an EFW <10th percentile the patient was requested to begin 2 weeks of rest in the left lateral recumbent position during her waking hours following which the EFW was reassessed 2 week later to determine the effect of maternal rest on the EFW. Irrespective of the four types of decreased growth velocity described in the methods section, there was as significant increase (p < 0.001) in the EFW following 2 weeks of maternal rest as follows: (1) growth less than 20 g/day (75%); (2) decrease of 30 or more EFW percentiles (79%); (3) decrease of 50 or more EFW percentiles (64%); and abnormal growth trajectory (77%). This suggests an important role of increased maternal cardiac output as the result of resting in the left lateral recumbent position that may be associated with improved fetal growth. These observations should be the basis for future prospective randomized trials to test this hypothesis.

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.

The Effect of Upright Posture on Left Atrial Strain in Competitive Athletes.

Left atrial strain (LAS) assessment by speckle tracking echocardiography (STE) has been shown to be a remarkable means of quantifying LA function as an early marker of LV pathology. As exercise testing is also performed on a treadmill, the aim of this study was to investigate the effect of upright posture on LAS in healthy athletes. Fifty male athletes (mean age 25.7 ± 7.3 years) underwent transthoracic echocardiography (TTE) in the upright and left lateral positions. In addition to the conventional echocardiographic parameters, in all athletes, LA conduction strain (LAScd), contraction strain (LASct), reservoir strain (LASr), and maximum LA volume (LAVmax) were assessed by STE in both positions. Comparing upright posture and the left lateral position, LAScd (-14.0 ± 5.9% vs. -27.4 ± 7.1%; p < 0.001), LASct (-4.6 ± 3.5% vs. -11.3 ± 4.1%; p < 0.001), LASr (18.7 ± 7.6% vs. 38.7 ± 8.0%; p < 0.001), and LAVmax (24.4 ± 8.8% vs. 50.0 ± 14.2%) differed significantly. Upright posture has a significant effect on LA deformation, with decreased LAScd, LASct, and LASr. The results of this study contribute to the understanding of athletes' hearts and must be considered when performing echocardiography in healthy athletes on a treadmill.

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&amp;dl=0

Advanced Sensing System for Sleep Bruxism across Multiple Postures via EMG and Machine Learning.

Diagnosis of bruxism is challenging because not all contractions of the masticatory muscles can be classified as bruxism. Conventional methods for sleep bruxism detection vary in effectiveness. Some provide objective data through EMG, ECG, or EEG; others, such as dental implants, are less accessible for daily practice. These methods have targeted the masseter as the key muscle for bruxism detection. However, it is important to consider that the temporalis muscle is also active during bruxism among masticatory muscles. Moreover, studies have predominantly examined sleep bruxism in the supine position, but other anatomical positions are also associated with sleep. In this research, we have collected EMG data to detect the maximum voluntary contraction of the temporalis and masseter muscles in three primary anatomical positions associated with sleep, i.e., supine and left and right lateral recumbent positions. A total of 10 time domain features were extracted, and six machine learning classifiers were compared, with random forest outperforming others. The models achieved better accuracies in the detection of sleep bruxism with the temporalis muscle. An accuracy of 93.33% was specifically found for the left lateral recumbent position among the specified anatomical positions. These results indicate a promising direction of machine learning in clinical applications, facilitating enhanced diagnosis and management of sleep bruxism.

Laparoscopic resection for retroperitoneum ganglioneuroma with Supine hypotension syndrome

BackgroundSupine hypotension syndrome (SHS) has been reported to occur due to compression by a giant tumor such as ovarian tumor. We herein report a case of retroperitoneal ganglioneuroma with SHS treated with laparoscopic resection.Case presentationThe patient was an 11-year-old male with right-sided abdominal pain. He had a pale complexion and tachycardia while falling asleep. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a giant mass lesion (60 × 35 mm) with compression of the inferior vena cava (IVC) and duodenum ventrally and the right kidney caudally. The IVC was flattened by mass compression. Abdominal ultrasonography (US) revealed narrowing of the IVC due to the mass and accelerated blood flow after IVC stenosis in the supine and left lateral recumbent position. His pale complexion and tachycardia while falling asleep was thought to be due to decreased venous return caused by the tumor compressing the IVC, resulting hypotension. 123I-MIBG scintigraphy revealed no abnormal findings. Tumor markers were normal. He was diagnosed with SHS due to a right adrenal gland tumor. The tumor compressed the IVC from the dorsal side, and hemostasis was expected to be difficult during bleeding. Therefore, a guidewire was inserted from the right femoral vein into the IVC for emergency balloon insertion during bleeding. A laparoscopic tumor resection was performed. A histopathological examination confirmed the diagnosis of primary retroperitoneal ganglioneuroma.ConclusionsThe treatment of symptomatic retroperitoneal tumors requires a multidisciplinary approach.

Frequency of Airway Complications with Modified Recovery Position versus Conventional Recovery position for Extubation after General Anaesthesia.

To compare the frequency of respiratory complications encountered in two different positions used for extubation i.e. conventional recovery position versus the modified recovery position (recovery position with 10-degree left tilt and head-down). Comparative study. Place and Duration of the Study: Department of Anaesthesia, Combine Military Hospital, Kohat, Pakistan, from April 2022 to March 2023. Two hundred patients scheduled for elective nose and throat surgeries were equally divided into two groups (Group C and Group M). Patients with history of bronchial asthma, chronic obstructive pulmonary disease (COPD), recent respiratory infection, and gastro-oesophageal reflux disease (GERD) were excluded from this study. Patients with more than two intubation attempts were also excluded. Group C patients were extubated in a conventional left lateral recovery position, whereas Group M patients were extubated in a modified recovery position with patient in a left lateral position with 10-degree head-down and 10-degree left tilt. All patients were observed for persistent coughing (coughing that lasted for at least 2 minutes after extubation), breath holding for 20 seconds or more, desaturation (oxygen saturation less than 90%), laryngospasm, need for reintubation, vomiting, and regurgitation. Frequency of airway complications was significantly higher in Group C as compared to Group M. In Group C, 18 (18%) out of hundred patients had complications compared to 6 (6%) patients only in Group M (p = 0.009). Extubation in a modified recovery position is associated with reduced frequency of airway complications as compared to the conventional recovery position. Airway complications, Extubation, Cough, Laryngospasm, Recovery position.

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

ObjectiveTo identify, group and document the surgical management of idiopathic subglottic stenosis (iSGS) in pregnant women among North American centers with expertise in the treatment of airway stenosis. BackgroundIdiopathic subglottic stenosis is a rare airway disease that primarily affects women in their third to fifth decade of life. Symptoms of iSGS often worsen during pregnancy and can present as a threat to optimal maternal and fetal health; however there is a lack of evidence addressing the management of iSGS in pregnancy. Study designCross-Sectional Survey Study. MethodsA twenty-four question survey was designed to query the surgical management, ventilation, and perioperative considerations for pregnant patients with iSGS. Twenty-nine North American academic tertiary care centers with airway surgery expertise were identified. A designated surrogate for each center was contacted by email to distribute and obtain results of the survey. Results17 centers responded. Most centers include differences in perioperative assessment such as frequency of consultation with a maternal/fetal medicine specialist. There is occasional use of a tocometer and rarely a non-stress test. Ventilation with intermittent jet ventilation or high-flow nasal cannula is favored. The surgical protocols include positional modifications, with pregnant patients in the left lateral decubitus position. The preferred timing for intervention is in the second or third trimester. ConclusionThis is the first national survey describing surgical and perioperative considerations for the pregnant patient with iSGS among centers with airway expertise in the United States and Canada.

Influence of the examination position and distension medium on the rectal sensory test in patients with functional constipation

PurposeTo evaluate the impact of two different parameters (body position and distension medium) on the rectal sensory test in patients with functional constipation and provide data support for the development of standardized operating procedures in clinical practice.MethodsBased on a single-center process of the rectal sensory test, 39 patients with functional constipation were recruited for rectal sensory test under different body positions and distension mediums.ResultsAmong the items of the Constipation Scoring System, the score of frequency of bowel movements showed a negative correlation with the first constant sensation volume (r = -0.323, P = 0.045). Conversely, the score of painful evacuation effort showed a positive correlation with the desire to defecate volume (r = 0.343, P = 0.033). There was a statistically significant difference in the first constant sensation volume (when the distension medium was gas) measured in different body positions (left lateral position, sitting position, squatting position), and the data measured in the squatting position were significantly higher than those in left lateral position (P < 0.05). In terms of research on distension medium, it was found that the first constant sensation volume measured in the squatting position (when the distension medium was water) was significantly lower than that of gas (P < 0.05).ConclusionFor patients with functional constipation, there are differences in the results of rectal sensory tests between body positions and distension mediums. When conducting multicenter studies, it is necessary to unify the standard operating procedure (SOP) for operational details to ensure consistency and reliability of the test results.

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.

Scope transition and early arterial inflow control provide safe and comfortable dissection in robotic distal pancreatectomy.

We describe details and outcomes of a novel technique for optimizing the surgical field during robotic distal pancreatectomy (RDP) for distal pancreatic lesions, which has become common with potential advantages over laparoscopic surgery. For suprapancreatic lymph node dissection and splenic artery ligation, we used the basic center position with a scope through the midline port. During manipulation of the perisplenic area, the left position was used by moving the scope to the left medial side. The left lateral position is optionally used by moving the scope to the left lateral port when scope access to the perisplenic area is difficult. In addition, early splenic artery clipping and short gastric artery dissection for inflow block were performed to minimize bleeding around the spleen. We evaluated retrospectively the surgical outcomes of our method using a scoring system that allocated one point for blood inflow control and one point for optimizing the surgical view in the left position. We analyzed 34 patients who underwent RDP or R-radical antegrade modular pancreatosplenectomy (RAMPS). The left position was applied in 14 patients, and the left lateral position was applied in 6. Based on the scoring system, only the 0-point group (n = 8) had four bleeding cases (50%) with splenic injury or blood pooling; the other 1-point or 2-point groups (n = 13, respectively) had no bleeding cases (p = 0.0046). Optimization of the surgical field using scope transition and inflow control ensured safe dissection during RDP.