Novel Technique For Management Research Articles

Intrastromal Lenticule Rotation for Treatment of Astigmatism Up to 10.00 Diopters Ex Vivo in Human Corneas.

To evaluate the feasibility of intrastromal lenticule rotation (ISLR) as a novel technique for management of astigmatism up to 10.00 diopters (D). Eighteen human donor corneas were mounted on an artificial anterior chamber. After laser application and dissection, the lenticule was rotated 90° in the intrastromal pocket. Scheimpflug tomography (Pentacam HR; Oculus Optikgeräte GmbH, Wetzlar, Germany) was acquired preoperatively and following ISLR. The attempted astigmatic correction was twice the cylindrical magnitude of the lenticule referenced to the corneal plane: 4.80 D (5.00 D group, n = 9) and 9.32 D (10.00 D group, n = 9), respectively. The change in keratometric astigmatism was evaluated by vector analysis. In the 5.00 D group, ISLR caused a mean absolute surgical induced astigmatism (SIA) of 5.30 ± 1.14 D with a correction index (CI) of 1.14 ± 0.25 and an angle of error (AoE) of -0.80° ± 4.61°. In the 10.00 D group, the SIA averaged 9.57 ± 1.10 D with a CI of 1.03 ± 0.12 and an AoE of 2.75° ± 3.60°. The average total corneal refractive power (TCRP) increased 1.36 ± 0.67 and 1.95 ± 1.57 D in the 5.00 D and 10.00 D groups, respectively. Postoperative optical coherence tomography revealed stromal redistribution in the periphery of the optical zone with tissue addition in the preoperative steep meridian and tissue reduction in the preoperative flat meridian. ISLR seemed feasible and precise for management of regular astigmatism up to 10.00 D ex vivo in human donor corneas. A myopic shift was observed in TCRP. The in vivo corneal remodeling after ISLR warrants investigation. [J Refract Surg. 2019;35(7):451-458.].

A Novel Technique for the Surgical Management of Chronic Lateral Epicondylitis.

Lateral epicondylitis is the most common condition affecting the elbow and is self-limiting in most cases. However, when conservative treatment fails, surgery is required for resistant cases. In this study, we describe a novel technique for the management of chronic lateral epicondylitis. The advantage of our technique is that all the 3 major components of the disease (as also all types of failure described by Morrey) are simultaneously dealt with, that is, pathology of the tendon, posterior interosseous nerve compression and intra-articular pathology are all addressed. We prospectively reviewed 14 consecutive cases of resistant lateral epicondylitis operated with our technique at our Institute from 2008 to 2013 with a minimum 2 years follow up. We included patients between 18 and 65 years of age who in addition to lateral epicondylitis also had an intra-articular pathology along with symptoms/signs suggestive of posterior interosseous nerve compression and had undergone a conservative trial of atleast 12 months. Excluded were those cases with localized infection and severe ankylosis, whereas previous surgery on the same elbow was a relative contraindication. Postoperatively all patients showed improvement in the VAS score and grip strength. Twelve of the 14 patients (85.7%) in our series had good to excellent functional outcomes on the Mayo Elbow Performance Index. This technique can therefore be recommended for wider surgical use; however, prospective randomized studies with a longer follow-up would add further evidence about the effectiveness of our technique.

Neutral Zone: A Novel Technique for Management of Severely Resorbed Ridge.

Neutral Zone: A Novel Technique for Management of Severely Resorbed Ridge.

Pendular eyelid flap: a novel technique for the management of extensive congenital upper lid colobomas

We present a novel technique for the surgical management of sizeable medial upper eyelid colobomas that entails advancement of an ipsilateral upper lid flap sustained by a levator aponeurosis-Müller-conjunctiva pedicle and combined with a lateral semicircular flap from the affected lid. The technique was used in 4 consecutive pediatric patients of mean age 21.2months and mean coloboma size 12.3mm and resulted in sufficient cornea protection, rapid rehabilitation, and satisfying cosmesis.

Per Oral Endoscopic Myotomy in Children with Achalasia Cardia.

Background/AimsAchalasia cardia (AC) is a motility disorder, characterized by impaired lower esophageal sphincter relaxation and absence of esophageal peristalsis. AC is rare in children with unclear optimum management strategies. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with encouraging results in adult patients. The efficacy and safety of POEM is not known for pediatric AC. The aim of our study was to evaluate the safety and efficacy of POEM in children with achalasia cardiaMethodsThe data of all children (< 18 years) who underwent POEM at our center was retrospectively analysed. Symptoms were analysed using a validated score (Eckardt score) at regular predefined intervals. Objective parameters including high-resolution manometry, timed barium swallow and esophagogastroduodenoscopy were assessed before the procedure and at 1-year follow-up. Clinical success was defined as an Eckardt score ≤ 3.ResultsA total of 15 children underwent POEM during the specified period. Ten out of 15 (10/15) completed 1-year follow-up. Median operative time was 100 (38–240) minutes. Mean pre and post procedure LES pressure were 36.64 ± 11.08 mmHg and 15.65 ± 5.73 mmHg, respectively (P = 0.001). Mean Eckardt score before and after the POEM was 7.32 ± 1.42 and 1.74 ± 0.67, respectively (P = 0.001). Mean percentage improvement in barium emptying at 5 minutes was 63.70 ± 4.46%. All children had complete resolution of symptoms at 1 year. Median weight gain of children at 1 year was 0.65 kg (range, 0.0–4.6).ConclusionsPOEM is safe and effective for children and adolescents with achalasia. Future trials with larger sample size are warranted to establish its efficacy in pediatric AC.

Novel technique for management of prolonged mandibular dislocation

Novel technique for management of prolonged mandibular dislocation

The lateral crural rein flap: a novel technique for management of tip rotation in primary rhinoplasty.

An important consideration in rhinoplasty is maintenance of the applied tip rotation. Different techniques have been proposed to accomplish this. Loss of rotation after surgery not only results in a derotated tip but also can create a supratip deformity. As a supplement to dorsal reconstruction, the authors introduced and applied the lateral crural rein flap technique, whereby cartilage flaps are created from the cephalic portion of the lateral crura to control and stabilize tip rotation. Eleven patients underwent primary open-approach rhinoplasty that included the lateral crural rein technique; the mean follow-up time was 18 months. Excess cephalic portions of the lateral crura were prepared as medial crura-based cartilaginous flaps and were incorporated into the nasal dorsum (similar to spreader grafts) and stabilized to achieve the desired tip rotation. The lateral crural rein flap technique provided stability to the nasal tip while minimizing derotation in the postoperative period. Long-term follow-up revealed maintenance of the nasal tip rotation and symmetric dorsal aesthetic lines. The lateral crural rein flap technique is effective for controlling nasal tip rotation while reducing lateral crural cephalic excess. Longevity of the applied tip rotation is reinforced by secure attachment of the lower nasal cartilage complex to the midvault structures. 4.

Transurethral neo-orifice (TUNO) a novel technique for management of upper pole obstruction in infancy

Ureteral duplication is the most common urologic abnormality. The upper pole ureter can sometimes be associated with a ureterocele. In rare cases the ureteral insertion is extravesical and can result in significant hydroureteronephrosis. Patients can present with urinary tract infection, abdominal mass or urinary obstruction. Traditional procedures include ureteral reimplantation, ureteroureterostomy or heminephroureterectomy. These reconstructive procedures are technically challenging in small infants, especially when the hydroureteronephrosis is severe. In some cases a distal cutaneous ureterostomy is performed for immediate drainage followed by definitive surgery when the child is older. We describe our initial experience with a novel cystoscopic technique which provides drainage of the upper pole ureter and avoids the need for an incision or stoma. A 3 month-old boy presented with urinary tract infections and failure to thrive. Ultrasound revealed severe upper pole hydroureteronephrosis. Voiding cystourethrography did not reveal vesicoureteral reflux or the presence of a ureterocele. The patient underwent cytoscopy. The ectopic ureteral orifice was not identified. A transurethral, transvesical needle puncture and confirmatory ureteropyelography was used to access the dilated upper pole ureter. Guidewire passage, followed catheter dilation then allowed creation of a new ureteral orifice using a holmium laser. The patient tolerated the procedure well. He was discharged after overnight observation. The hydronephrosis improved, urinary tract infections have not recurred and the patient rapidly improved feeding and weight gain. Trans-Urethral Neo-Orifice creation is a minimally invasive option for initial decompression for patients with obstructive ureteral ectopia.

Outflow Vein Embolization: A Novel Technique for Management of Gastric Varices

Outflow Vein Embolization: A Novel Technique for Management of Gastric Varices

Medial rectus Botox injection with pterygium excision and autograft as a novel technique for management of recurrent pterygium

Medial rectus Botox injection with pterygium excision and autograft as a novel technique for management of recurrent pterygium

Active tension‐extension splints: A novel technique for management of congenital flexural deformities affecting the distal limb in the foal

SummaryA variety of methods are described for managing distal limb flexural deformities in the foal, including intravenous oxytetracycline and splint or cast use. This case series describes a novel technique that creates an ‘active tension‐extension splint’ by wiring the toe into a custom‐made fibreglass splint and therefore into active extension. A dorsal fibreglass splint is made by halving a cast that is set around the affected leg with padding underneath it, so that it is sculpted to a more appropriate anatomical shape. Cerclage wire is placed through the toe and the dorsal aspect of the splint, then tightened to pull the limb into active extension. Foals with distal limb flexural deformities that were treated in this way were followed up by examination of hospital records and telephone questionnaire. Records were examined for 13 foals treated between 2004 and 2010. One foal developed septic osteitis of the distal phalanx due to suspected laminar penetration; other post operative complications seen were bandage sores and minor cosmetic scarring. Out of 10 foals where follow‐up by questionnaire was available, 8 had complete resolution of their deformity following active tension‐extension splinting, one required inferior check ligament desmotomy for complete correction and one had carpal flexural deformities that did not resolve. All that survived to adulthood are sound and have achieved their intended purpose. This previously unpublished technique using a wire through the toe to create an active tension‐extension splint has a high success rate for correction of congenital flexural deformities affecting the distal interphalangeal and metacarpo‐/metatarsophalangeal joints in the foal. The majority of post operative complications are minor and easily managed. This is a simple technique that can improve the management of neonatal distal limb deformities both in a hospital situation and for equine practitioners in the field.

The Modified Nasal Trumpet: Revisiting a Novel Technique in Management of the Difficult Airway

Objective: 1) Highlight an underutilized method for use of the nasal trumpet in management of the difficult airway. 2) Review the application of this technique in multiple clinical scenarios. Method: Report of technique and application in airway management. Results: There are a multitude of techniques and devices available to assist with intubation and ventilation for both the difficult patient and those that do not pose a significant challenge in airway management. The use of a nasal trumpet with an endotracheal tube connector represents an additional means of establishing ventilation and providing inhalational anesthesia. This technique has proven extremely useful to the senior author over many years in the pediatric population in a wide variety of clinical scenarios. We review the technique and clinical application. Conclusion: The use of the modified nasal trumpet has been previously reported in the anesthesiology literature, but represents a critical skill and technique of airway management that should be familiar to all otolaryngologists.

Management of the Ventriculo-Peritoneal Shunt in Pediatric Patients During Robot-Assisted Laparoscopic Urologic Procedures

Infection or malfunction of ventriculo-peritoneal (VP) shunts is a severe complication during laparoscopic surgery involving the gastrointestinal or urinary tract. It has been recently suggested to externalize the shunt or convert into a ventriculo-atrial shunt to prevent this complication with laparoscopic approach. Herein, we present a novel technique for management of the VP shunt during robot-assisted laparoscopic (RAL) urologic procedures. After port placement and diagnostic peritoneoscopy, an Endopouch bag (Ethicon Endo-Surgery) was inserted into the peritoneal cavity and the distal end of the shunt was placed into the pouch. The Endopouch suture was synched around the shunt and the pouch was placed in the subhepatic space during the surgery. The intraperitoneal pressure was maintained at 12 mm Hg during the entire procedure. Metronidazole, gentamicin, and vancomycin were administered as prophylaxis. Following the completion of the surgery and profuse irrigation of the peritoneal cavity, the shunt was repositioned within the peritoneum. We evaluated perioperative shunt-related complications. We used this technique in four patients with VP shunt undergoing RAL cystoplasty and appendicovesicostomy and/or colonic enema channel formation. The average age of the patient at surgery was 10.8 (7-14) years. One patient was converted to open because of failure to progress due to multiple adhesions and the shunt was externalized temporarily. At a mean follow-up of 13 (3-20) months, no shunt-related complications were seen. In our preliminary experience, the use of an intracorporeal Endopouch bag with controlled pneumoperitoneal pressure to protect the VP shunt may be an effective alternative to prevent complications related to it during RAL urologic surgery involving the gastrointestinal or urinary tract. Further studies will be needed to confirm our results.

A Novel Technique for the Management of Pancreaticojejunal Anastomosis Dehiscence following Pancreaticoduodenectomy

Background: To report a novel technique for management of pancreaticojejunal anastomosis dehiscence after pancreaticoduodenectomy. Material and Methods: The anastomosis is disconnected and the blind jejunal limb is shortened and closed. A silicon tube in the pancreatic duct introduced in the first operation is fixed at the pancreatic stump. If no tube was placed during pancreaticoduodenectomy, it is placed at reoperation. The transected edge of the pancreas is stitched, and the distal part of the silicon tube is inserted into the jejunal loop and fixed in the jejunal wall. Drains and a catheter for continuous irrigation are placed. Results: All patients tolerated reoperation and experienced unremarkable postoperative courses. Follow-up ranged from 5 to 27 months, and all patients exhibited normal pancreatic function and no pseudocyst formation. Conclusion: This technique is an effective method for management of pancreaticojejunal anastomosis dehiscence that avoids complications associated with completion pancreatectomy and preserves pancreatic function.

Allograft Replacement for Peroneal Tendon Tears

Current treatment options for chronic ruptures of both the peroneus longus and brevis tendon with a large tendon defect are limited. Previous recommendations have included tendon transfer, tenodesis, or a 2-stage procedure. We present a novel technique for management of tendon defects greater then 4 cm with the use of peroneal allograft reconstruction. This has proven to be an effective single-stage treatment option when there is a well functioning proximal muscle, even in the face of large tendon gaps. This technique results in an anatomic reconstruction without violation of another tendon for transfer or tenodesis and is a one-stage procedure.

Novel technique for management of esophageal strictures: double “J” stents and the use of urologic dilators

Current management of esophageal strictures using multiple dilations is the standard of care for symptomatic relief and cure. Diverse arrays of techniques have been developed with similar success rates. In this study we suggest the use of urologic dilator as a safe, alternative method for the management of esophageal strictures. We report a case of a patient with a history of severe, recurrent esophageal stricture secondary to tracheo-esophageal fistula repair, treated using Amplatz urologic dilators and double J stent as a mechanical temporizer for an esophageal stricture at risk for complete stenosis. Under general anesthesia, a flexible endoscope was passed into the proximal esophagus to visualize the stricture. A glide wire was passed through the stricture and its placement was confirmed by fluoroscopy. The endoscope was then removed and a series of urologic dilators sizing from 12Fr to 32Fr were passed through the stricture under fluoroscopic vision. Following this, a double "J" stent was left in place for further dilation sessions and to prevent complete stenosis. In conclusion, urologic dilators demonstrate a novel and simple technique for the treatment of esophageal strictures. This patient had no reported complications, and patient was able to tolerate the double "J" stent during dilation sessions.

Fibreoptic Intubation under General Anaesthesia – a Simple Method Using an Endotracheal Tube as a Conduit

A novel technique for management of the difficult airway is described. The case report describes fibreoptic intubation of a patient who refused awake intubation. An endotracheal tube was advanced as far as the nasopharynx via the nostril of the patient, under anaesthesia. Connection of the anaesthetic circuit allowed maintenance of anaesthesia, oxygenation and assisted ventilation while flexible bronchoscopy was performed through the tube via a bronchoscopy connector The endotracheal tube was subsequently advanced over the bronchoscope into the trachea. This technique uses readily available materials and can be used where the placement of a laryngeal mask is contraindicated or impossible.

Novel Technique for Management of Bartholin Gland Cysts and Abscesses

Background: Definitive methods for treatment of a Bartholin cyst and abscess include placement of a Word catheter, marsupialization, application of silver nitrate, and surgical excision. Placement of a Word catheter is the most frequently employed technique for office and emergency department (ED) management. However, many institutions do not have the Word catheter available; in addition, the catheter has a tendency to dislodge before epithelialization, leading to recurrence of the cyst. Objective: We have developed a simple technique for management of Bartholin gland abscess or cyst using readily available materials. This technique involves using a small loop of plastic tubing, which is secured to prevent expulsion before epithelialization of a drainage tract. Case Report: A 25-year-old woman presented to the ED with a Bartholin gland abscess. After administration of local anesthetic, a loop of tubing was placed, allowing for drainage of the abscess. The patient was discharged home with a course of oral antibiotics. At 3-week follow-up, the Bartholin gland abscess was found to be healed; the device was removed without difficulty, leaving two drainage tracts. Conclusion: This technique may be used as an alternative to placement of a Word catheter for management of Bartholin gland abscess or cyst.

Buffer Coding for Reliable Transmissions over Wireless Networks

In-network caching is a useful technique for reducing latency and retransmission overhead of lost packets for reliable data delivery in wireless networks. However, in-network caching is challenging to implement in memory constrained devices such as RFIDs and sensors, and also in Wireless LAN (WLAN) gateways for large-scale deployments. In this paper we propose a novel technique for management of in-network caches using XOR coding for optimizing the use of limited buffer space in presence of random and burst packet losses. We identify two critical parameters, coding degree and coding distance for the coding scheme. As a case-study we implement our approach over Snoop and evaluate its performance for WLANs. We further propose a self-adaptive algorithm that tunes coding degree on the fly based on the measured coding behavior and packet loss probability. Using simulations in ns-2, we observe that in our simulation settings, when the size of the retransmission buffer in the gateway is less than 16 packets per TCP flow, the throughput can be enhanced by up to 30% for random losses and up to 20% for burst losses.

A Modified Supine Position to Speed Hand Assisted Retroperitoneoscopic Nephroureterectomy: The Johnnie Walker Position

To minimize the operative time of hand assisted retroperitoneoscopic nephroureterectomy by avoiding position change we report an especially designed surgical position. A total of 41 patients with upper tract transitional cell carcinoma who underwent hand assisted retroperitoneoscopic nephroureterectomy and bladder cuff resection were enrolled. Patients lay supine, and the flank and hip on the lesion side were elevated 30 degrees. The legs were extended and abducted in the Johnnie Walker position, allowing the operator to stand between them. Operation was completed via a 7 to 8 cm Gibson incision and 2 additional laparoscopic ports. All procedures were successful except 1 open conversion due to bleeding, in which there was no need to reposition the patient. Average patient age was 65.2 years (range 34 to 85), mean operative time was 207.6 minutes (range 130 to 345) and mean estimated blood loss was 166 ml (range 50 to 900). Simultaneous transurethral endoscopic procedures were performed in 11 patients in the same position. Time to oral intake and ambulation was 2.1 and 2.0 days, respectively. Two patients had postoperative complications, including pneumonia and wound hematoma in 1 each. No complication was related to the position. The Johnnie Walker position minimizes operative time by eliminating the delay caused by patient positioning and draping changes, allowing better coordination for the surgeon and assistant, and permitting more efficient use of the nondominant hand. The retroperitoneal approach prevents bowel interference in the visual field, making laparoscopic surgery in this modified supine position possible. Nephroureterectomy, bladder cuff resection and endoscopic procedures can be done with ease with the patient in this position.