Left Oblique Position Research Articles

A Novel Esophagogastrostomy Technique for Laparoscopic Proximal Gastrectomy: Conical Remnant Gastroesophageal Side-overlap Fundoplication.

There is currently no universally-accepted, ideal method of esophagogastric reconstruction to address reflux esophagitis and anastomotic complications of esophagogastrostomy after proximal gastrectomy. In June 2022, two patients with Siewert type II carcinoma of esophagogastric junction underwent laparoscopic proximal gastrectomies, using a novel esophagogastrostomy technique of Conical remnant GastroEsophageal side-Overlap fundoplication (CGEO). On postoperative day 4, upper gastrointestinal fluoroscopy was performed, with patients in downward and left oblique positions, allowing gastrografin to accumulate within fundic reconstructions. No reflux into the esophagus was subsequently observed, and both patients were discharged (postoperative days 9 and 11). Six months after surgery, endoscopic view showed that the reconstructed cardia returned to its normal state, in the absence of any reflux symptoms. As of April 2023, we have operated on four patients using CGEO, and all of them recovered without obvious reflux symptoms. CGEO is a feasible and safe reconstructive esophagogastrostomy procedure following laparoscopic proximal gastrectomy for Siewert type II esophagogastric junction carcinoma.

Penerapan Evidence Based Practice Nursing (EBPN) Modifikasi Miring Kiri dan Miring Kanan Menurunkan Back Pain Post Percutaneous Coronary Intervention

This study aims to apply the identification of left and right oblique modifications to reduce back pain after percutaneous coronary intervention based on the results of Evidence-Based Practice Nursing (EBPN) research. The research method used is a case study. The case study in this innovative design is a case study by applying research results in identifying left and right oblique modifications to reduce back pain post-percutaneous coronary intervention. The results showed that adjusting the correct oblique and left diagonal positions was carried out after two hours of cardiac catheterization, namely for 30 minutes (15 minutes in the correct oblique position and 15 minutes in the left oblique position). In conclusion, giving accurate diagonal left oblique work is carried out in patients who experience post PCI back pain at the time of the study, having a pain scale of 5. After being given intervention, the pain scale is reduced to 3.
 
 Keywords: PCI, PJK, Right and Left Tilt Position

Influence of right coronary artery shape on TIMI frame count and lesion distribution

The shape of the right coronary artery (RCA) may vary between individuals. The aim of this study was to investigate whether the shape of RCA has any effect on TIMI frame count (TFC), TIMI flow score, and lesion distribution length in patients with ST-elevation myocardial infarction (STEMI) caused by RCA. The angiograms of 163 patients who applied to our hospital with STEMI caused by the RCA were included in the study. TFC's were calculated. The patients were divided into two groups according to the geometric shape of the RCA as C (124 pts, 101 males, mean age 66.1 ± 12.3 years) or S (39 pts, 30 males, mean age 60.0 ± 10.8 years) based on the angiographic view from the left oblique position. Lesion location was significantly higher in the proximal and mid regions compared to the distal region in patients with C-RCA (p < 0.001). TFC was significantly higher in the S-RCA group (p = 0.0014). There was a statistically significant difference between the groups in terms of mean age of p = 0.003. Lesion frequency was significantly higher in the proximal and mid regions in patients with C-RCA. TFC's were significantly higher in the S-RCA group. Longer S-RCA length compared to C-RCA and local shear stress characteristics may also explain these findings.

Feasibility of robotic assisted bladder sparing pelvic exenteration for locally advanced rectal cancer: A single institution case series.

Pelvic exenteration for locally advanced rectal cancer involving prostate has been performed via open surgery. Robotic pelvic exenteration offers benefits of better pelvic visualisation and dissection for bladder preserving prostatectomy with vesicourethral anastomosis, while achieving clear margins. To determine the feasibility of robotic assisted bladder sparing pelvic exenteration. We describe robotic assisted pelvic exenteration in three cases of locally advanced rectal cancer involving prostate and seminal vesicles (SV). The da Vinci S robotic system was used. Robotic console was docked at left oblique position for abdominal phase and redocked to between the patient's legs for pelvic phase. All three cases were performed fully robotically at Tan Tock Seng Hospital by colorectal and urological teams. Case 1: 67-year-old with low rectal tumour 3cm from anal verge involving the prostate. He underwent neo-adjuvant chemoradiotherapy and robotic abdominoperineal resection with en-bloc prostatectomy. Case 2: 66-year-old with low rectal tumour 3cm from anal verge involving prostate and bilateral SV. He underwent neo-adjuvant chemoradiotherapy and robot assisted ultra-low anterior resection with coloanal anastomosis and en-bloc prostatectomy. Case 3: 57-year-old with metachronous rectal tumour in the rectovesical pouch inseparable from the anterior mid rectum, prostate and bilateral SV. He underwent robot assisted ultra-low anterior resection with en-bloc prostatectomy. Bladder neck margin revealed cauterized tumour cells, and he underwent total cystectomy and ileal conduit creation. Histology revealed no residual tumour. All patients are currently disease free. Robot assisted bladder sparing pelvic exenteration can be safely performed in locally advanced rectal cancer with acceptable surgical outcome while preserving benefits of minimally invasive surgery.

EFEKTIFITAS PEMBERIAN POSISI MIRING KIRI DAN SETENGAH DUDUK TERHADAP KEMAJUAN PERSALINAN KALA SATU FASE AKTIF DILATASI MAKSIMAL PADA PRIMIGRAVIDA

Care for the mother dear has a strategic role to reduce stress and anxiety during labor. One of the implementations of the maternal love program is to recommend several positions during labor and delivery of the baby. This study was intended to determine the relationship between giving a sitting and half-sitting position to the progress of labor when the active phase is maximal dilated. The purpose of this study was to find out the effectiveness of giving a left and half sitting oblique position. The type of research used is correlational analytic research. Statistical analysis using Mann Withney. The results showed that the effectiveness of the left oblique position was more than 2 hours 1 respondent or 25%, while the progress of labor for 2 hours 3 respondents or 75%, while being positioned half sitting, getting progress of labor more than 2 hours 25%, while progress delivery for 2 hours is 75%. From the results of the study it was found that there was no difference between giving the left and half sitting oblique position. So that these two positions can be used to accelerate the progress of labor.Keywords: position, progress of labor

Sonographic Evaluation of Some Abdominal Organs in Sickle Cell Disease Patients in a Tertiary Health Institution in Northeastern Nigeria.

Background:Sonographic evaluation of abdominal organs is an important work up in managing sickle cell disease (SCD) patients. This study aimed at evaluating abdominal organs by sonography among SCD patients.Methodology:A cross-sectional study was carried out in Maiduguri, Nigeria from April 2014 to July 2015. Two hundred and fifty-two patients participated in the study, with 126 controls and 126 SCD patients. There were 131 (52%) males, and 121 (48%) females, with age range 3–38 years. Measurements were done using ultrasound machine with probe frequencies ranging from 1–4MHz and 4–9MHz in supine, right and left oblique positions for optimum visualization of the abdominal organs.Results:Participants within the age range of 10–15 years had the highest frequency with 88 (34.9%), followed by those within the age group of 17–23 years with 86 (34.1%), and the least were those within the age group of 30 years and above with 8 (3.2%). Hepatomegaly was found in 53 (75.7%), and increased echogenicity of the liver was found in 50 (94.3%) of the SCD patients, P = 0.000. Gallstones were found in 45 (17.9%), gallbladder sludge was found in 51 (21.4%) and thickened gallbladder wall was found in 84 (33.3%) of the SCD patients, P = 0.000. Autosplenectomy was found in 45 (17.9%), splenomegaly in 63 (24.9%), and calcified spleen in 18 (8.7%) of the SCD patients, P = 0.000. Enlarged kidneys in SCD patients were found in 61 (98.4%) and 63 (98.4%) on the right and left kidneys, respectively. Shrunken kidneys were found in 5 (2.0%) and 4 (1.6%) of the SCD patients on the right and left kidneys, respectively, P = 0.000.Conclusion:Abdominal sonography in SCD patients revealed varied remarkable changes in the size, echotexture, intraluminal deposits and wall thickness in the liver, gallbladder, kidneys, and spleen.

Mirror Mirror on the Wall: ERCP in a Patient with Situs Inversus Totalis

Situs inversus totalis is an extremely rare autosomal recessive disorder occurring in 0.01% of the population. The reversal of visceral organs poses technical difficulties for therapeutic intervention during endoscopic retrograde cholangiopancreatography (ERCP). We describe a unique case of a patient with situs inversus who underwent therapeutic ERCP for management of choledocholithiasis. A 37-year-old woman with a history of situs inversus totalis, complex congenital cyanotic heart disease, polysplenia and laparoscopic partial cholecystectomy performed 10 years prior, presented with post-prandial right upper quadrant pain and nausea. She had elevated bilirubin, and computed tomography (CT) scan showed cholelithiasis in the remnant gallbladder. An endoscopic retrograde cholangiopancreatography (ERCP) was performed for possible choledocholithiasis. Patient was placed in the left oblique position. There was altered anatomy of the gastric curvature and the ampulla was located in the 2 o'clock position. Biliary access was achieved by keeping the scope in the long position, rotating the duodenoscope 180o, and rotating the sphincterotome to the right side. Cholangiogram showed a mirror image of the transposed biliary tree and remnant gallbladder with filling defects consistent with cholelithiasis. Biliary sphincterotomy was performed and balloon sweep showed biliary stone fragments, consistent with choledocholithiasis. She subsequently underwent cholecystectomy for removal of the remnant gallbladder.Figure 1Figure 2Situs inversus is a rare benign congenital anomaly that may pose difficulty during ERCP. Different techniques have been used for biliary access in patients with situs inversus such as, a “mirror image” ERCP technique with the endoscopic maneuvers performed in an inverse fashion, or positioning the patient lying prone on her right side. In our case biliary access is easily achievable in patient s with situs inversus by keeping the patient in the left oblique position, along with maneuvering the duodenoscope and sphincterotome towards the inversed position of the ampulla.

Emission computed tomography of the left ventricle. Multiplanar ECG-triggered radionuclide ventriculography with a 7-pinhole collimator

Tomographic studies and time-dependent tomograms on phantoms and patients were carried out using a 7-pinhole collimator in order to study the clinical value of ECG-triggered tomographic radionuclid ventriculography. A suitable computer programme has been developed. The results have shown that it is possible to evaluate local contraction abnormalities by this method. Using a left oblique position of the collimator (LAO [45 degrees]-cranial [15 degrees] ), emission computer tomography is aligned with the longitudinal axis of the heart. In this way, a single projection is sufficient to show the motility of the anterior and posterior walls and of the septum. Hypokinesis, akinesis or dyskinesis can be recognised visually. The localisation and extent of the defect can be determined through the 7-pinhole collimator. Reconstructed images of the triggered radionuclid scintigrams show excellent marginal definition. In the RAO projection, the left ventricle can be seen without superimposition and images obtained which equal those of a first-pass technique.

Roentgenkymographic studies of myocardial infarction

Forty-five cases of myocardial infarction were studied with the multiple-slit, moving-film kymograph. Exposures were made in the posteroanterior and two left oblique positions, thus visualizing the movements of the anterior and posterolateral walls of the left ventricle. The technique is considered briefly and the physiologic interpretation of the ventricular wave as an index of ventricular volume changes is discussed. The changes observed varied from reversal of movement to absence of pulsation in the infarcted area, and correspond to those recorded by Tennant and Wiggers with the myocardiograph in experimental myocardial infarction in dogs. A comparison was made between kymographic and electrocardiographic localizations in 45 cases. In 41 of the 45 cases there were definite kymographic changes. In 25 the electrocardiographic and kymographic localizations corresponded exactly. In 6 cases the kymogram indicated involvement of both anterior and posterior walls, whereas the electrocardiogram suggested infarction of one or the other. In 3 cases in which no electrocardiographic evidence of damage to the ventricular wall could be obtained because bundle branch block was present, the kymogram showed an area of infarction. In 1 case the electrocardiographic and kymographic localizations disagreed, and in 4 cases with definite coronary thrombosis the kymograms were entirely normal. In 3 of these 4 cases, the infarction was of the posterior wall. In general, localization appeared more accurate with anterior wall infarcts than with posterior wall infarcts, probably due to better visualization of the anterior wall of the left ventricle. Six patients with coronary artery disease without definite clinical or electrocardiographic evidence of coronary thrombosis showed kymographic changes indicative of an area of infarction.

Cardiac Aneurysm

(1) The evolution of our knowledge of cardiac aneurysm and its morbid anatomy is shortly reviewed. (2) Cardiac aneurysms are usually due to coronary occlusion with resultant infarction, and rarely to syphilis, infective endocarditis, congenital defects, or trauma. A detailed necropsy report is given of a case ascribed to rheumatic necrosis of the myocardium. (3) Cardiac aneurysms, like infarcts, involve the left ventricle almost exclusively, and may best be classified as anterior or posterior, according to the coronary branch occluded. The great majority involve the anterior wall of the left ventricle, usually at or near the apex. (4) The clinical and radiological features of 15 cases of cardiac aneurysm are described, and in five of them the diagnosis was confirmed by necropsy. The significant clinical features are a history of coronary thrombosis, enlargement of the heart to the left, a normal or low blood-pressure, distant heart sounds, and an electrocardiogram most often indicative of anterior infarction (T1 type). Expansile pulsation separate from the apex-beat, or an extensive area of præcordial pulsation, are rare but suggestive signs. (5) Diagnosis depends mainly upon radiological examination. Anterior aneurysms cause enlargement of the heart to the left, with deformity of its contour. This deformity, seen from the front, may take the form of (i) broadening of the apex or angulation of the left border, giving the heart a square or rectangular appearance; (ii) elongation of the heart to the left; (iii) a diffuse bulge or, more rarely, a localised hump on the left border. In the right oblique position, “ledging” of the anterior heart border is of great diagnostic value. Posterior aneurysms are best seen in the left oblique position, and may displace the œsophagus. Aneurysm of the inter-ventricular septum has been known to cause enlargment of the heart to the right. Calcification of the aneurysmal wall, when present, is an invaluable sign. Radioscopy is essential to determine the optimum position for demonstrating the aneurysm, to observe the character of the pulsation, and to detect localised adhesion. (6) The differential diagnosis has to be made from an enlarged right ventricular conus, aortic aneurysm, especially that involving a sinus of Valsalva, calcified pericardium, loculated pericardial exudate or cyst, the para-apical triangle of fat, and from intrathoracic neoplasm or cyst.

The Roentgenologic Importance of the Left Oblique Position in Cholecystography

THE technical difficulty of obtaining satisfactory visualization of the gall bladder in all instances is the cause of much skepticism in clinicians' minds regarding the reliability of cholecystography. Their criticism of the test is justly correct because they have experienced instances of normal operative findings in cases diagnosed by the roentgenologist as pathologic. The purpose of this presentation is to illustrate that it is not, as a rule, the cholecystographic test that is at fault, but rather the procedure in which the examination is performed. Since most roentgenographs examinations are carried out by technicians in busy laboratories, one must expect a certain small percentage of failures due to technical errors. However, the technician often lacks the experience in knowledge of the technical difficulties which underlie the principle of shadow visualization. It is to be regretted, too, that the roentgenologist often lacks control of the case, especially in hospital routine, and information regarding the patient's reaction to the dye, vomiting, diarrhea, and dosage is rarely given much attention. The routine carried out in the roentgenologic laboratory is of the greatest importance because in most instances it is here that the cholecystographic test is poorly managed. The non-visualizing gall bladder and that overshadowed by the bowel are the types which usually afford the greatest difficulty in diagnosis. There can be no question of doubt that true non-filling of the gall bladder represents a pathologic state in the biliary tract. However, it must be emphasized that in order to obtain the roentgenographic shadow of the gall bladder, sufficient technical knowledge is essential, since the proper roentgen technic plays an important part in the portrayal of the cholecystogram. It has been shown, since the advent of cholecystography, that the gall bladder varies in position, and it also has been definitely established that it moves with respiratory excursions, the distance varying from one to three inches. Attention to the importance of obtaining views of the gall bladder in both inspiration and expiration must be pointed out, as it is often of considerable aid in the elimination of overlying shadows. Its importance is stressed (1) because its movement places the gall bladder in another position where it may be separated from overshadowing loops of colon; (2) by changing the position, gallstone shadow within the gall bladder will normally move with the vesicle, thus determining whether or not it is within or outside of it, and (3) at times the gall bladder is situated close to the spinal column and respiratory movements not infrequently separate them. Shifting of the x-ray tube will not infrequently separate the gall-bladder shadow from the colon; in most instances, however, this maneuver fails to accomplish the desired results. The routine roentgen technic for cholecystography has been fully described on numerous occasions.

Use of the barium-filled esophagus in the x-ray study of abnormalities of the heart and the aorta

1. 1. Posterior displacement of the barium-filled esophagus, as seen in the right oblique position, and its displacement to the right in the postero-anterior position are due to left auricular enlargement. 2. 2. Deviation of the esophagus to the left below the area of aortic indentation in the postero-anterior position, and posteriorly in the left oblique position, is due to elongation of the transverse portion of the aortic arch. 3. 3. The use of the barium-filled esophagus serves to differentiate elongation of the transverse portion of the aortic arch from left auricular enlargement.

Multiple Diverticula of the First Part of the Duodenum

Diverticula of the intestinal tract are well known, those of the colon being encountered most frequently. However, diverticula of the duodenum are comparatively rare. During our careful analysis of the literature we did not find even a single case with more than two diverticula arising from the first part of the duodenum; we assume, therefore, that our findings may prove to be of some interest. Case Report.—K. S., male, aged 56 years, had vague complaints and discomfort in the right upper quadrant of the abdomen for about fifteen years. He suffered from mild heartburn and gas eructation. Occasionally, he experienced a slight feeling of pressure in the epigastrium. His appetite was good. His bowels moved normally. He never had acute pains or cramps. His weight had been stationary for the past few years. He had no nausea or vomiting. The patient was well nourished; heart and lungs normal; blood pressure 140/80; abdomen soft; liver and spleen showed no sign of enlargement, no definite tenderness on palpation. On very hard pressure on the right side of the epigastrium he complained of slight discomfort. Stomach contents after alcohol test meal showed slight amount of mucus, free HCl 18, total HCl 32. The stomach contents showed no blood. Examination of the stools, following a meat-free diet of three days, showed no evidence of occult blood. The blood count was normal. X-ray Examination.—Esophagus normal. Stomach filled without delay, in hook form. The lower pole of the larger curvature situated in the interspinous line. The mucosal pattern of the stomach normal. Curvatures normal. Peristalsis increased. The pylorus opened immediately after the peristalsis reached it. The cap was filled readily. From the top of the cap, three small ducts leading into three diverticula, were visualized. The x-ray plates in the upright position showed these diverticula with horizontal fluid level and gas bubbles on top. The second portion of the duodenum was situated behind the antrum; the other part of the duodenum was normal and free from the presence of diverticula. The best view of the diverticula was furnished by the left oblique position. After two hours, a slight residue was observed in the stomach. The diverticula had not emptied, and the remainder of the barium was in the small intestines. After six hours the stomach was empty, and the diverticula were well filled, showing the same grape-like aspect. The remaining barium was in the ileo-cecal portion of the intestines. After 24 hours, the diverticula were empty, and there was only a filling of the colon. The treatment of the patient was limited to diet and alkali. The patient's condition improved to a certain extent, but all the complaints were not eliminated. An operation was suggested, but it met with the patient's opposition. A control examination six months later showed findings analogous to those already reported.

A radiological study of the pulmonary artery, with special reference to the main branches

It is our object to emphasize the fact that it is possible to visualize roentgenologically not only the pulmonary artery, but also its main branches in most normal and in many abnormal cases. The shadow of the main trunk and left pulmonary artery can usually be seen in properly exposed films taken in the left oblique position, or fluoroscopically. Obstruction anywhere in the pulmonary circulation (whether functional, as in congestive failure, or organic) will lead to dilatation of the pulmonary artery and its major and lesser branches. The size of the pulmonary artery and its lesser branches is of value in recognizing congenital lesions of the heart or pulmonary arterial system in the absence of clinical signs. Radioscopic examination can supply information not obtainable by other clinical means.

Distortion of the bronchi by left auricular enlargement

The left auricle has a peculiar anatomical position, in that it is the posterior and superior chamber of the heart, thereby being in closest relation to the esophagus and to the bifurcation of the trachea. By virtue of this position the left auricle may enlarge to the right as well as to the left and during the course of its enlargement may exert pressure on the esophagus and main bronchi. There are many reports in the literature illustrating these effects, the least known of which is the last. Compression and displacement of the bronchi but rarely give rise to lung changes, yet may be frequently found by x-ray, and together with displacement of the esophagus are usually attributable to the left auricular enlargement. Roentgenological methods demonstrating the occurrence of these three phenomena are described which make more accurate the diagnosis of enlargement of the left auricle. 1. 1. Observation of right border of the heart for double curve in anteroposterior films and fluoroscopy to verify that the upper curve is identical with the posterior superior curve of the heart, and to note asynchronous pulsations of the two curves. This last makes the diagnosis of left auricular enlargement quite definite. 2. 2. Observation of displacement of the esophagus. The esophagus is displaced posteriorly and to the right by left auricular enlargement. 3. 3. Demonstration of bronchial displacement, particularly as noted in the films made in the left oblique position—in obese patients, after an injection of lipiodol. Bronchial compression and displacement in left auricular enlargement occur frequently and can be demonstrated by x-ray study: (a) by left oblique views; (b) in anteroposterior views following lipiodol injection.