Postoperative Day Research Articles

Capsular bag distension syndrome with sulcus IOL acting as a seal

Capsular bag distension syndrome (CBDS) is a rare complication following cataract surgery with posterior chamber intraocular lens (IOL) implantation. We describe the case of a 68-year-old female who developed early-onset CBDS of her left eye after manual small-incision cataract surgery with implantation of posterior chamber IOL in the sulcus (Excel PMMA IOL (polymethyl methacrylate), Manufactured by Excel Optics (P) Limited, Chennai). The patient had an uneventful cataract surgery performed by a resident in training. Her immediate postoperative uncorrected vision was 20/40, but it decreased to finger counting 1 m on postoperative day 7, for which she presented back to hospital. Slit-lamp examination revealed a quiet anterior chamber without any cells–flare with IOL in the sulcus with a relatively smaller capsulorhexis of about 5 mm, and IOL optic was covering the capsulorhexis in a symmetric fashion, thus causing a block. Distension of capsular bag was further confirmed by Anterion anterior segment optical coherence tomography (Heidelberg Engineering Technology, Germany), which showed a confined hyperechogenic fluid trapped between the IOL and the posterior capsule. She was diagnosed with CBDS secondary to retention of turbid fluid. Phased treatment was done; neodymium-doped yttrium aluminum garnet capsulotomy was tried in the first attempt, but failed as the posterior capsule was far too behind. This was followed by anterior chamber wash with redialing of the lens in the bag, which thereby improved vision to 20/20 (best corrected visual acuity) at 1-week postoperatively. Even with IOL in the sulcus, the postoperative CBDS may rarely happen at any point of time with a small capsulorrhexis and an intumescent mature cataract. Immense cortex wash should always be kept in mind in such a case, as the liquefied cortex is sometimes stuck at the equator and a little more duration of irrigation is required in such scenarios. Hence, complete clearance of turbid fluid of intumescent mature cataract variety also holds due importance similar to the need of removing viscoelastic substance to prevent CBDS.

Randomized Controlled Trial to Assess Negative Pressure Wound Therapy versus Standard-of-care Dressings in Breast Surgery: A Pilot Study.

Standard breast reduction dressings such as Prineo are used to cover surgical wounds, in combination with a binder or support bra. The Prevena Restor BellaForm is a negative pressure wound therapy dressing that covers the entirety of the breast mound and is purported to provide further support and reduce swelling. The aim of this study was to compare the Restor to standard-of-care dressings. The study was a randomized control trial of women undergoing bilateral breast reduction with one breast being dressed with the Prevena Restor BellaForm dressing and the other having standard of care (Prineo). Outcomes measured were drain outputs, postoperative length of stay, quality of scarring, patient preference for dressings, and adverse events. Follow-up was at 1, 2-6, and 26 weeks. The results show a reduction in postoperative days 1 and 2 average drain output on the Restor side compared with standard dressings. Patient-reported outcome measures showed less bruising. There was no difference in postoperative length of stay and no difference in appearance of scars at the 26-week follow-up period. One patient required removal of the dressing due to irritation and one patient required assistance with resealing of the vacuum. We have shown benefits to drain output and comfort using close incisional negative pressure therapy in breast reduction mammaplasty. We plan to continue to investigate close incisional negative pressure therapy in larger comparative trials for other breast procedures including implant-based reconstruction, where a reduction in drain output could be of great benefit to both healing and reduction of infection risk.

Posterior Reversible Encephalopathy Syndrome After Inadvertent Dural Puncture Vs Bupivacaine-Induced Adverse Drug Reaction: A Case Report

A case involving a 29-year-old female patient with a known case of hypothyroidism at 38 weeks gestation. She developed a fronto-occipital, postural type of headache. This ensued on the second postoperative day after undergoing an unintended dural puncture with the introducer needle during spinal anesthesia for an elective cesarean section. It was initially treated as a post-dural puncture headache until she developed generalized tonic–clonic seizures the next day. Magnetic resonance imaging (MRI) of the brain exhibited features of posterior reversible encephalopathy syndrome (PRES). With anticonvulsants and antibiotics, the neurological symptoms subsided, and the patient was discharged home symptom-free. We call attention to the importance of suspecting PRES in obstetric cases with an inadvertent dural puncture in a normotensive patient. Neuroimaging plays a crucial role in making a diagnosis of headaches, especially during the peripartum period. Lastly, keeping in view, the potential medicolegal implications in such cases, further research seems vital, especially in the Asian population.

Machine learning models including preoperative and postoperative albumin-bilirubin score: short-term outcomes among patients with hepatocellular carcinoma

BackgroundWe sought to assess the impact of various perioperative factors on the risk of severe complications and post-surgical mortality using a novel maching learning technique. MethodsData on patients undergoing resection for HCC were obtained from an international, multi-institutional database between 2000 and 2020. Gradient boosted trees were utilized to construct predictive models. ResultsAmong 962 patients who underwent HCC resection, the incidence of severe postoperative complications was 12.7% (n = 122); in-hospital mortality was 2.9% (n = 28). Models that exclusively used preoperative data achieved AUC values of 0.89 (95%CI 0.85 to 0.92) and 0.90 (95%CI 0.84 to 0.96) to predict severe complications and mortality, respectively. Models that combined preoperative and postoperative data achieved AUC values of 0.93 (95%CI 0.91 to 0.96) and 0.92 (95%CI 0.86 to 0.97) for severe morbidity and mortality, respectively. The SHAP algorithm demonstrated that the factor most strongly predictive of severe morbidity and mortality was postoperative day 1 and 3 albumin-bilirubin (ALBI) scores. ConclusionIncorporation of perioperative data including ALBI scores using ML techniques can help risk-stratify patients undergoing resection of HCC.

An Approach to Controlling Inflammation and Coagulation in Pig-to-Baboon Cardiac Xenotransplantation.

Inflammatory responses and coagulation disorders are a relevant challenge for successful cardiac xenotransplantation on its way to the clinic. To cope with this, an effective and clinically practicable anti-inflammatory and anti-coagulatory regimen is needed. The inflammatory and coagulatory response can be reduced by genetic engineering of the organ-source pigs. Furthermore, there are several therapeutic strategies to prevent or reduce inflammatory responses and coagulation disorders following xenotransplantation. However, it is still unclear, which combination of drugs should be used in the clinical setting. To elucidate this, we present data from pig-to-baboon orthotopic cardiac xenotransplantation experiments using a combination of several anti-inflammatory drugs. Genetically modified piglets (GGTA1-KO, hCD46/hTBM transgenic) were used for orthotopic cardiac xenotransplantation into captive-bred baboons (n = 14). All animals received an anti-inflammatory drug therapy including a C1 esterase inhibitor, an IL-6 receptor antagonist, a TNF-α inhibitor, and an IL-1 receptor antagonist. As an additive medication, acetylsalicylic acid and unfractionated heparin were administered. The immunosuppressive regimen was based on CD40/CD40L co-stimulation blockade. During the experiments, leukocyte counts, levels of C-reactive protein (CRP) as well as systemic cytokine and chemokine levels and coagulation parameters were assessed at multiple timepoints. Four animals were excluded from further data analyses due to porcine cytomegalovirus/porcine roseolovirus (PCMV/PRV) infections (n = 2) or technical failures (n = 2). Leukocyte counts showed a relevant perioperative decrease, CRP levels an increase. In the postoperative period, leukocyte counts remained consistently within normal ranges, CRP levels showed three further peaks after about 35, 50, and 80 postoperative days. Analyses of cytokines and chemokines revealed different patterns. Some cytokines, like IL-8, increased about 2-fold in the perioperative period, but then decreased to levels comparable to the preoperative values or even lower. Other cytokines, such as IL-12/IL-23, decreased in the perioperative period and stayed at these levels. Besides perioperative decreases, there were no relevant alterations observed in coagulation parameters. In summary, all parameters showed an unremarkable course with regard to inflammatory responses and coagulation disorders following cardiac xenotransplantation and thus showed the effectiveness of our approach. Our preclinical experience with the anti-inflammatory drug therapy proved that controlling of inflammation and coagulation disorders in xenotransplantation is possible and well-practicable under the condition that transmission of pathogens, especially of PCMV/PRV to the recipient is prevented because PCMV/PRV also induces inflammation and coagulation disorders. Our anti-inflammatory regimen should also be applicable and effective in the clinical setting of cardiac xenotransplantation.

Exergame-based rehabilitation for cancer patients undergoing abdominal surgery: Effects on pain, anxiety, depression, and fatigue - A pilot study

PurposeThis study aimed to determine the efficacy of an exergame rehabilitation program on pain, anxiety or depression, and fatigue in oncology patients undergoing abdominal surgery. MethodsThe randomized controlled trial evaluated the efficacy of exergame rehabilitation on Pain, Anxiety, Depression, and Fatigue in oncology patients undergoing abdominal surgery. Patients were recruited from October 2022–March 2023 and were randomly assigned to the intervention group (postoperative traditional rehabilitation plus an exergame rehabilitation program) or control group (postoperative traditional rehabilitation). Data were collected at three different times: on admission, in the first 48 h, and on the 7th day after surgery.Primary outcomes were evaluated and monitored with different validated instruments: numeric rating scale (NRS) for pain, Hospital Anxiety and Depression Scale (HADS) to assess the level of anxiety and depression, and the Fatigue Assessment Scale (FAS) to assess physical and psychological fatigue. The length of stay and program completion were secondary outcomes. ResultsA total of 128 postoperative patients were recruited. Of these, 58 patients were excluded from the study due to clinical complications related to the surgical procedure (n = 53) or healthcare staff-related reasons (n = 5). Both the control and intervention groups were the same size (n = 35). Lower pain scores were observed on the 7th postoperative day in the group subject to the “exergame rehabilitation program” (p = 0.006). No statistically significant differences were observed for anxiety and depression between the 2 groups. Regarding fatigue, statistically significant differences were observed on admission (p = 0.03), which disappeared 48 h after surgery (p = 0.143). Differences between the groups were observed again on the 7th day after surgery (p = 0.005). ConclusionsThe intervention using exergames was effective in reducing the postoperative pain of the patient undergoing major abdominal surgery and in restoring the levels of fatigue before surgical intervention. However, no differences were observed for anxiety or depression. Future studies with larger samples should be carried out.

Comparative clinical experience of subcostal VATS versus conventional uniportal lateral VATS approach.

The present study reports the first clinical experience with subcostal uniportal VATS (suVATS) compared with the conventional lateral uniportal VATS (luVATS) approach. All patients who underwent suVATS between January 2019 and April 2020 were included. Patients who had undergone luVATS for similar indications were included as the control group. The data were prospectively and retrospectively analysed. The suVATS group included 38 patients with a mean age of 61 (30-83) years. The luVATS group included 33 patients (mean age, 69 years; range: 46-89 years). An intercostal block was performed intraoperatively in the luVATS group. Local infiltration under anaesthesia was performed around the incision in the suVATS group. The duration of the surgery was significantly longer in the suVATS group. However, the chest tube treatment and hospital stay duration were significantly shorter in the suVATS group. The routinely recorded Visual Analogue Scale scores on the first post-operative day and the day of discharge were significantly lower in the suVATS group. Subcostal uniportal VATS enables a shorter drainage treatment duration and hospital stay and significantly reduces post-operative pain. Thus, a faster patient recovery can be achieved.

Treatment options for patients with pilonidal sinus disease: PITSTOP, a mixed-methods evaluation.

There is no consensus on optimal management of pilonidal disease. Surgical practice is varied, and existing literature is mainly single-centre cohort studies of varied disease severity, interventions and outcome assessments. A prospective cohort study to determine: • disease severity and intervention relationship • most valued outcomes and treatment preference by patients • recommendations for policy and future research. Observational cohort study with nested mixed-methods case study. Discrete choice experiment. Clinician survey. Three-stage Delphi survey for patients and clinicians. Inter-rater reliability of classification system. Thirty-one National Health Service trusts. Patients aged > 16 years referred for elective surgical treatment of pilonidal disease. Surgery. Pain postoperative days 1 and 7, time to healing and return to normal activities, complications, recurrence. Outcomes compared between major and minor procedures using regression modelling, propensity score-based approaches and augmented inverse probability weighting to account for measured potential confounding features. Clinician survey: There was significant heterogeneity in surgeon practice preference. Limited training opportunities may impede efforts to improve practice. Cohort study: Over half of patients (60%; N = 667) had a major procedure. For these procedures, pain was greater on day 1 and day 7 (mean difference day 1 pain 1.58 points, 95% confidence interval 1.14 to 2.01 points, n = 536; mean difference day 7 pain 1.53 points, 95% confidence interval 1.12 to 1.95 points, n = 512). There were higher complication rates (adjusted risk difference 17.5%, 95% confidence interval 9.1 to 25.9%, n = 579), lower recurrence (adjusted risk difference -10.1%, 95% confidence interval -18.1 to -2.1%, n = 575), and longer time to healing (>34 days estimated difference) and time to return to normal activities (difference 25.9 days, 95% confidence interval 18.4 to 33.4 days). Mixed-methods analysis: Patient decision-making was influenced by prior experience of disease and anticipated recovery time. The burden involved in wound care and the gap between expected and actual time for recovery were the principal reasons given for decision regret. Discrete choice experiment: The strongest predictors of patient treatment choice were risk of infection/persistence (attribute importance 70%), and shorter recovery time (attribute importance 30%). Patients were willing to trade off these attributes. Those aged over 30 years had a higher risk tolerance (22.35-34.67%) for treatment failure if they could experience rapid recovery. There was no strong evidence that younger patients were willing to accept higher risk of treatment failure in exchange for a faster recovery. Patients were uniform in rejecting excision-and-leave-open because of the protracted nursing care it entailed. Wysocki classification analysis: There was acceptable inter-rater agreement (κ = 0.52, 95% confidence interval 0.42 to 0.61). Consensus exercise: Five research and practice priorities were identified. The top research priority was that a comparative trial should broadly group interventions. The top practice priority was that any interventions should be less disruptive than the disease itself. Incomplete recruitment and follow-up data were an issue, particularly given the multiple interventions. Assumptions were made regarding risk adjustment. Results suggest the burden of pilonidal surgery is greater than reported previously. This can be mitigated with better selection of intervention according to disease type and patient desired goals. Results indicate a framework for future higher-quality trials that stratify disease and utilise broad groupings of common interventions with development of a patient-centred core outcome set. This trial is registered as ISRCTN95551898. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/17/02) and is published in full in Health Technology Assessment; Vol. 28, No. 33. See the NIHR Funding and Awards website for further award information.

Lessons Learned with Enhanced Recovery for Open Abdominal Aortic Aneurysm Surgery: A Long Term Regional Network Experience

This enhanced recovery programme (ERP) aimed to achieve early recovery for patients undergoing major surgery. Results of a standardised ERP protocol for open infrarenal abdominal aortic aneurysm (AAA) repair within a hub and spoke regional network are presented. In this monocentric prospective study (January 2004 - December 2021), consecutive AAAs (≥ 55 mm) were included in the ERP (patient discharge on post-operative day [POD] 4). The four phases of the ERP were pre-admission, pre-operative, intra-operative, and post-operative. Exclusion criteria were BMI > 35 kg/m2, functional capacity < 4 MET, previous aortic or abdominal surgery, and life expectancy < 5 years. Transperitoneal surgery was undertaken with routine AAA resection, graft interposition, and closure. Consecutive patients (n = 778) were enrolled into the study (mean age 72.3 ± 3.2 years; n = 712 men); 160 (20.5%) were treated in spoke hospitals. Median follow up was 78 (IQR 28, 128) months; median length of stay, procedure time, and blood loss were 4 days (IQR 3, 5), 190 min (IQR 170, 225), and 564 mL (IQR 300, 600). Infrarenal clamping and tube graft configuration were used in 96.5% (n = 751) and 72.5% (n = 564) of patients; 30 day mortality and complication rates were 0.4% (n = 3) and 9.2% (n = 72). Discharge after POD 4 occurred in 15.0%, and most significant predictors for discharge after POD 4 were haemotransfusion, re-intervention, and ileus over 3 days. Overall survival was: 98.2% at 1 year, 85.0% at 5 years, and 59.9% at 10 years. Freedom from re-intervention was 97.9% at 1 year, 94.1% at 5 years, and 86.8% at 10 years. Short and long term outcomes were comparable between hub and spoke hospitals. The ERP protocol was associated with low short and long term mortality and complication rates. Future studies should apply the ERP protocol to other vascular centres.

Laparoscopic Repair Versus Open Repair for Perforated Peptic Ulcers: Quality of Life Assessment

PurposeThis study was designed to assess the relative efficacy of laparoscopic repair (LR) as opposed to open surgical repair (OR) in the treatment of perforated peptic ulcer (PPU) and its impact on quality of life. BackgroundStudies reporting patient-centered outcomes, including quality of life and satisfaction, in PPU treatment are insufficient. MethodsThis investigation performed a retrospective review of patients who underwent treatment for PPU at a secondary care hospital from December 2016 to November 2020. Patients were categorized into two separate groups according to the type of surgical procedure received: LR and OR. Comparisons were made based on a variety of factors, such as demographic data, intra- and postoperative metrics, pain control, patient contentment, and quality of life indicators. ResultsIn the analysis, there were no statistically significant differences in demographic or clinical characteristics between the LR (n=35) and OR (n=62) groups (p > 0.05). Conversely, the rates of incisional hernia and surgical site infection were significantly greater in the OR group (p < 0.05). Moreover, the LR exhibited benefits such as a shorter length of hospital stay (p < 0.05), more rapid resumption of a normal diet, and fewer surgical site infections—factors that contributed to a lower rate of overall postoperative complications. According to the quality of life questionnaire, the LR group exhibited significantly greater scores for physical function, role, pain, and general health by the 30th postoperative day (p=0.003, p<0.001, p=0.006 and p=0.001, respectively), and by the 1-year follow-up, the LR group showed substantial improvements in physical function, physical role, emotional role, pain and general health (p=0.047, p=0.004, p=0.039, p=0.001, p=0.021, respectively), indicating its effectiveness in patient recovery and quality of life enhancement postsurgery. ConclusionThis study showed that LR could provide certain benefits in managing PPUs, such as reduced lengths of hospital stay and lower incidences of surgical site infections. Although LR reported promising directions in patient satisfaction and quality of life indicators, the limited duration of postoperative monitoring necessitates caution in broadly applying these results.

Trocar-site Herniation after Laparoscopic Myomectomy via Culdotomy Extraction

Abstract Trocar-site hernia is a rare and life-threatening complication of laparoscopic abdominal surgery; 5-mm trocar-site bowel herniation is rarer than ≥ 10-mm trocar-site herniation. We present a 41-year-old female patient on the postoperative 6th day with laparoscopic myomectomy admitted to our emergency department with severe vomiting and nausea. At the end of the evaluations, she was diagnosed with 5-mm trocar-site small bowel herniation. A herniated small bowel segment was rescued through the laparotomy. After full recovery, the patient was discharged on the 3rd day of hospitalization. Although there is no consensus on the closure of small fascia incisions (&lt;10 mm) routinely, we suggest that all fascia incisions should be assessed in patients at risk to prevent trocar-site hernias. According to our investigation for trocar-site hernia in the literature, laparoscopic myomectomy may be considered a risk factor.

Low preoperative hemoglobin A1c level is a predictor of perioperative infectious complications after esophagectomy: A retrospective, single-center study.

This retrospective, single-center study aimed to evaluate the impact of blood glucose (BG) markers on perioperative complications after esophagectomy in a cohort of 176 patients. Study analyses included the correlation of daily maximum BG level and hemoglobin A1c (HbA1c) with clinicopathological factors. Maximum BG levels were significantly higher on postoperative day (POD) 0 than on PODs 2, 3, 5, and 7 (p < 0.05). Additionally, maximum BG levels on PODs 1, 2, and 7 were significantly higher in patients with preoperative HbA1c levels of ≥ 5.6% than in those with preoperative HbA1c levels of < 5.6% (p < 0.05 for all). The rates of any complications and infectious complications were higher in patients with preoperative HbA1c levels of < 5.6% than in those with preoperative HbA1c levels of ≥ 5.6% (p < 0.05 for both). A preoperative HbA1c level of < 5.6% was a significant predictor of infectious complications after esophagectomy by logistic regression analysis (p < 0.05). Maximum BG level after esophagectomy remained high in patients with high preoperative HbA1c levels, whereas a normal HbA1c level was an independent risk factor for infectious complications.

The Efficacy of Ketorolac Buccal Infiltration Following Surgical Removal of The Impacted Mandibular Third Molar on Postoperative Pain and Trismus

Surgical extraction of the mandibular third molars are widely carried out in dental practice. The procedure is associated with postoperative complications such as pain and trismus. Objective: The study aimed to assess ketorolac's analgesic and anti-inflammatory efficacy after surgical extraction of the mandibular third molar. Methods: The study was designed as a double-blinded, randomized prospective clinical study in which 44 patients who required surgical removal of an impacted mandibular third molar were included. They were randomly distributed into two groups (the study and the control/placebo groups), with 22 patients in each group. Immediately after the last stitch, the study group received 30mg/1 ml of ketorolac, while the control group received 1 ml of normal saline at the buccal mucosa near the extraction site of both groups. The mouth openings of the patients were recorded preoperatively, and on the 2nd and 7th postoperative days, a comparison between the two groups was made. The pain level was assessed postoperatively using the numeric rating scale. Results: The comparison between the two groups by pain score showed that there was a statistically significant difference (P = 0.001) in postoperative pain between the study and control groups at all times after the operation. Regarding the trismus, there was no significant difference (p&gt;0.05) between both groups on the 2nd and 7th postoperative days. Conclusion: Ketorolac buccal infiltration is effective for postoperative pain following third molar surgery but has no significant effect on trismus.

EVALUATION OF DEMOGRAPHIC PROFILE AND VISUAL OUTCOMES OF CATARACT PATIENTS OPERATED IN A CHARITABLE CAMP HOSPITAL IN CENTRAL INDIA

Aim: To Study the Demographic Profile and visual Outcomes of Cataract Patients Operated in a Charitable Camp in Central India Introduction Cataract is a leading cause of preventable blindness globally. Developing countries account for three quarters of cataract blindness worldwide. Despite the large number of corrective surgeries being performed globally cataract blindness is believed to be increasing by1–2 million/year. The present study was conducted in the patients residing in a peripheral rural area of Indore division (central India) to study the demographic and clinical profile of patients with cataract. This study supplements to understand the outcomes of such patients who were operated in camp at a tertiary care center. Study Design: It is a prospective descriptive study conducted on camp patients at a charitable tertiary eye care hospital (Central India) from December 2019 to February 2020.Wirtten informed consent was taken from patients for participation in this study. Setting: Department of Ophthalmology Choithram Netralaya, Indore from December 2019 to February 2020. Material and Methods: During the study period 139 surgeries were performed by the surgeon. All patients above 40 years of age having senile cataract with stable systemic condition were included. Patients with age less than 40 years of age, uncontrolled systemic condition, Patients with other ocular comorbidities, undergone previously any ocular surgery in the selected eye or not giving written informed consent were excluded.All the patients were screened for cataracts in the camps in the periphery by the trained optometrist and referred to the base hospital. Detailed pre-operative ocular examination of all the patients was performed and medical checkup with routine pre-operative profile was also done. Patients medically fit for cataract surgery underwent small incision cataract surgery with Posterior capsular IOL implantation (PCIOL) under local anesthesia. All the cataract surgeries were performed by a single surgeon using the same technique to avoid any bias. Results: It was observed that the mean age of presentation was 61.5 years with female preponderance of nearly (56.8%) . out of 139 patients 63 patients (45.3,%) had systemic comorbidities, which included ,33 patients (23.74%) with hypertension and 28 patients(20.14%) with Diabetes mellitus. Majority of patients i.e.101 (72.66%) patients had onset of ocular symptoms between 3 to 6 months . In this study bilateral immature nuclear cataract was commonly encountered cataract in 88.48% of patients and only 8 patients had mature cataract and 7 patients presented with hyper mature cataract respectively .On post-operative day one, 19 patients and 8 patients had blood clot in anterior hamber,5 patients had cortical matter in Anterior chamber On follow up at one week, majority of patients i.e 110 (79.13%) had visual acuity between 6/9-6/12.Patients after re-surgery had visual acuity of minimum up to 6/24 with possibility of getting better on further visits. Conclusion: In our study, increasing age and female gender were commonly associated with cataract. Most of the patients had bilateral cataract and low vision at presentation. Hypertension and type 2 diabetes mellitus were commonly associated systemic disorders with cataract.This study highlights that high quality cataract surgery with a low intra-operative complication rate and good visual outcome can be attained even in camp patients operated in the base hospitals with standard protocols.

Challenges of Thyroidectomy Anaesthesia for a Huge Retrosternal Goitre in a Jehovah’s Witness: A Case Report

In potential haemorrhagic surgical procedures, refusal of allogenic blood infusion poses a challenge to anaesthetists. This report is about a 65-year-old male, of the Jehovah’s Witness (JW) religious sect, known hypertensive, who presented with an anterior neck mass with retrosternal extension of three years. Laboratory investigations were normal, and the haemoglobin concentration was 13gm/dl. He consented to acute normovolaemic haemodilution (ANH). Therefore, two units of blood were drawn and replaced with isoplasma. The patient had a general anaesthesia relaxant technique. Intravenous tranexamic acid, morphine, and paracetamol were administered. A right-lobal thyroidectomy and sternotomy were performed. After securing haemostasis, the two blood units were infused, and the estimated blood loss was 1.5 litres. The surgery lasted for five and a half hours. After surgery, the patient was reversed of the neuromuscular blockade, extubated, transferred to the intensive care unit (ICU), and monitored for 24 hours. He had supplemental oxygenation, analgesia, and other supportive care. He was discharged on postoperative day seven and had attended the outpatient clinic for two months.

Challenges of Thyroidectomy Anaesthesia for a Huge Retrosternal Goitre in a Jehovah’s Witness: A Case Report

In potential haemorrhagic surgical procedures, refusal of allogenic blood infusion poses a challenge to anaesthetists. This report is about a 65-year-old male, of the Jehovah’s Witness (JW) religious sect, known hypertensive, who presented with an anterior neck mass with retrosternal extension of three years. Laboratory investigations were normal, and the haemoglobin concentration was 13gm/dl. He consented to acute normovolaemic haemodilution (ANH). Therefore, two units of blood were drawn and replaced with isoplasma. The patient had a general anaesthesia relaxant technique. Intravenous tranexamic acid, morphine, and paracetamol were administered. A right-lobal thyroidectomy and sternotomy were performed. After securing haemostasis, the two blood units were infused, and the estimated blood loss was 1.5 litres. The surgery lasted for five and a half hours. After surgery, the patient was reversed of the neuromuscular blockade, extubated, transferred to the intensive care unit (ICU), and monitored for 24 hours. He had supplemental oxygenation, analgesia, and other supportive care. He was discharged on postoperative day seven and had attended the outpatient clinic for two months.

ОЦЕНКА РЕЗУЛЬТАТОВ ПРИМЕНЕНИЯ АЛГОРИТМА ВЫБОРА ОПТИМАЛЬНОГО ХИРУРГИЧЕСКОГО ДОСТУПА К ЗАБРЮШИННОМУ ПРОСТРАНСТВУ У ПАЦИЕНТОВ С РАЗЛИЧНЫМИ ПАРАМЕТРАМИ КОНСТИТУЦИИ.

Relevance. Despite the rapid development and predominance of endovideosurgical techniques in the treatment of pathologies of organs and structures of the retroperitoneal space, the implementation of transperitoneal or retroperitoneal approaches for open surgical interventions remains a routine activity. Surgical treatment of various pathologies of retroperitoneal localization leads to the development of nonspecific life-threatening complications in 23.8% - 30% of clinical observations, and associated mortality - 7.2% - 11% of cases. Previously, our works presented the results of comparing the number of this type of complications when using laparotomy or retroperitoneal access, depending on the constitutional parameters of the patient. An assessment was made of the significance of the influence of constitutional parameters on the development of nonspecific life-threatening complications, on the basis of which an algorithm for choosing the optimal surgical access to the structures of the retroperitoneal space was developed [patent application No. 2024113445 dated May 17, 2024]. Purpose of the study. To evaluate the effectiveness of using an algorithm for selecting the optimal surgical approach in the surgical treatment of pathologies of organs and structures of retroperitoneal localization. Materials and methods. Comparative analysis of the results of surgical treatment of patients with various surgical pathologies of the retroperitoneal space. Group I (n = 167), where the choice of surgical approach was determined using the “optimal surgical approach selection algorithm.” Group II (n = 284), in which the choice of access to the structures of the retroperitoneal space was not unified and was chosen without taking into account the constitutional parameters of the patient. In the perioperative period, the duration of surgical intervention, the volume of intraoperative blood loss, the number of days of stay in the intensive care unit, the time of postoperative respiratory support, the duration of postoperative intestinal paresis and the number of postoperative bed days were assessed. Criteria assessed in the postoperative period: development of myocardial infarction, acute cardiovascular failure, ARDS with the development of respiratory failure, acute kidney injury; cases of development of ischemic colitis and small intestinal obstruction, requiring repeated interventions, as well as the phenomenon of multiple organ failure. Wound complications included failure of retroperitoneal and laparotomy wounds, including eventration. To calculate quantitative characteristics, the median (Me) and percentiles (Q0.25 - Q0.75) were determined. Calculation of statistical significance between groups was performed using the Mann-Whitney U test**, for comparison of qualitative indicators - the Chi-square test* in IBM SPSS Statistics 25 software. Results. In group I, compared with group II, there was a shorter surgical intervention time [140.8 vs 179.5] min, p = 0.031**, a smaller volume of intraoperative blood loss [280.4 vs 413.3] ml, p = 0.024* *; postoperative respiratory support [4.5 vs 8.5] hours, p = 0.041**; length of stay in the intensive care unit [1.8 vs 3.4] days, p = 0.021**; postoperative intestinal paresis [1.2 vs 4.8] days p = 0.024**; and duration of total postoperative hospital stay [9.1 vs 16.4] days p = 0.003**. The number of postoperative nonspecific life-threatening and wound complications in group I was 24 (14.4%), and in group II - 64 (22.5%) cases (p = 0.023*). The number of complications-related deaths in group I was 9 (5.4%); in group II - 32 (11.26%) cases (p = 0.037*). Conclusion. The use of an algorithm for selecting the optimal surgical approach for surgical treatment of pathologies of organs and structures of the retroperitoneal localization of the access leads to a reduction in the number of nonspecific life-threatening complications to 14.4%, and associated deaths to 5.4%.

Surgical Management of a Non-Obstetric Vulvar Hematoma

Purpose: To describe the successful management of a rare non-obstetric vulvar hematoma. Background: While vulvar hematomas are common in obstetric cases, vulvar hematomas due to non-obstetric trauma are rare, representing only 0.8% of all gynecological emergencies. The vulva is made primarily of loose connective tissue richly supplied by branches of the pudendal artery, so it is susceptible to injury by multiple different types of trauma. Because non-obstetric vulvar hematomas are so rare, there is no established consensus for management. In this article, we shall present a patient who, after sustaining multiple injuries from a motor vehicle collision, developed a large vulvar hematoma that was successfully treated with surgical evacuation. Case Description: A healthy 26-year-old female presented to the emergency department following a broadside motor vehicle collision. CT with contrast described multiple pelvic fractures as well as a small volume retroperitoneal hemorrhage anterior to the bladder. There was no evidence of bladder injury or other areas of extravasation. On hospital day 1, she underwent uncomplicated open reduction and internal fixation of pelvic and sacral ring fractures. On hospital day 3, the patient began noticing a painful, rapidly expanding labial hematoma, and OBGYN services were consulted. Despite conservative management with ice and analgesics, the patient described the pain as 10 out of 10. On physical exam the right vulva was found to have a 14 cm hematoma expanding down to the perineum and extending to include the labia majora and labia minora. The area was extremely edematous and tender to light palpation. Swelling distorted the anatomy, occluding the vaginal introitus and obscuring the left labia. A Foley catheter was draining clear urine from the bladder. The following morning, the hematoma had continued to expand and Hgb significantly decreased, so the decision was made to proceed with surgical management. Pre-operative antibiotics were given, and the patient was prepped and draped according to hospital protocol. Hart’s line was injected with a marcaine/lidocaine/epinephrine premixed solution for hemostasis. A 3 cm vertical incision was created along Hart’s line, and the space was bluntly entered using a hemostat. Clotted blood was evacuated from the labial space, and active bleeding was ligated with using Vicryl. Once hemostasis was noted, the incision was loosely closed with interrupted stitches placed widely apart to allow for drainage. The vagina and left labia were examined and found to be normal. The right labial space was packed using kerlix, and the patient was prescribed a 7-day course of oral antibiotics. The patient tolerated the procedure well and reported no vulvar pain on post-op day 1. The vulvar packing was removed without incident, and no bleeding was noted from the incision site. The patient was reevaluated by the OBGYN team on post-op day 8 and was healing very well. She reported very little pain and had no issues with spontaneous urination. On physical exam, the hematoma was nontender to palpation and measured approximately 10 x 5 x 2.5 cm with decreased bruising and areas of discoloration. The patient was discharged with no further issues. Despite multiple attempts to schedule an outpatient appointment, the patient was unfortunately lost to follow-up. Discussion: Non-obstetric vulvar hematomas due to non-obstetric trauma are rare, and with improper management, may lead to significant morbidity. However, there is no established consensus for management, and little literature is available for guidance. Some small studies have reported success with conservative management. Benrubi et al, however, observed that conservative management of vulvar hematomas may be associated with longer hospital stays and increased need for antibiotics and blood transfusions10. A recent retrospective analysis also suggests a preference for surgical management, as a significantly reduced mortality rate was observed in patients who underwent surgical intervention for non-obstetric vulvar trauma. The same study found that while the surgical cohort tended to require a slightly longer hospital stay, there were no differences in ICU days, ventilator days, or rates of UTI between cohorts who had undergone surgical management and those who had undergone conservative management1. Arterial embolization has also been described as an alternative to surgical intervention in select patients, but this approach requires equipment and specialized personnel that may not be readily available to all institutions. Some case studies suggest using rate of expansion or hemodynamic instability as indications for surgical management. Size of the hematoma may also be considered as evidence suggests vulvar hematomas with a diameter greater than 4 cm have a higher potential for skin necrosis. Even when surgical management is clearly indicated there is little data regarding an optimal surgical approach. Conclusion: In this article, we discuss the successful surgical management and short-term follow up of a very large non-obstetric vulvar hematoma. We hope that our surgical approach can add to the small pool of literature available on these rare gynecological cases and help guide future research into developing standardized management guidelines.

Primary Posterior Uterine Rupture in Labor: Case Report and Literature Review

Purpose: To report a rare case of primary posterior uterine rupture in a healthy term multigravida. Methods: Case report. Results: We present the case of an otherwise healthy 35-year-old gravida 4 para 3 with no reported medical or surgical history and three prior uncomplicated term vaginal deliveries who presented in labor at 39 weeks gestation. After four hours of oxytocin augmentation, the fetus was noted to have recurrent late decelerations and then became bradycardic with a baseline of 60 bpm. The patient’s cervix was found to be 7 cm dilated, 90% effaced, and -1 station. Standard resuscitative measures were undertaken at which point the patient’s cervix was rechecked and found to be 9 cm dilated, 90% effaced, and -1 station. Attempts at manually reducing the cervix while the patient pushed were unsuccessful. With the fetus still bradycardic with a baseline of 60 bpm, the patient was taken for an emergency Cesarean delivery. Within seven minutes of calling the emergency Cesarean delivery, surgery had started. However, there was difficulty with delivering the fetus, who had flipped to transverse back down. The fetus was rotated to breech before being delivered through a “T” incision made on the uterus to facilitate delivery of the head. Three tight nuchal cords were reduced at time of delivery. Examination of the uterus after delivery of the fetus revealed a full thickness, cruciate-shaped laceration in the posterior lower uterine segment extending ~9 cm in the vertical plane, involving the vagina, and ~5 cm in the transverse plane. The rupture was repaired, and the remainder of the surgery proceeded without further complication. Blood loss was estimated at 2500 mL, and she required transfusion of 4 units of packed red cells, 2 units cryoprecipitate, 1 unit fresh frozen plasma, and 1 unit of platelets. The infant was atonic upon delivery with a weight of 3785g and APGARs of 1/5/7. Umbilical artery blood gas analysis was normal with a pH of 7.19 and a base deficit of 7.9 mmol/L. The infant initially required intubation, but quickly improved and was extubated to room air at 1 hour of life. Imaging and neurological exams indicated possible moderate encephalopathy, and the infant underwent therapeutic hypothermia for four days at which point cooling was discontinued after improvement was noted. The remainder of his NICU stay was unremarkable and he was discharged on day nine of life. The mother required 2 additional units of packed red cells during the remainder of her postpartum course, but otherwise did well and she was discharged on post-op day five. Conclusion(s): Uterine rupture is the complete separation of all three layers of the uterus. It is a life-threatening event for both the fetus and the mother. Most uterine ruptures occur in a previously scarred uterus. Uterine rupture in a previously unscarred uterus (primary uterine rupture) is rare and estimated to occur in ~1:20,000 pregnancies. Over 90% of primary uterine ruptures occur in the anterior lower uterine segment. Although this patient did not have any reported medical or surgical history, her status as a multipara and being of advanced maternal age did pose a higher risk of primary rupture. This patient also underwent 3 ½ hours of oxytocin infusion at the time the Cesarean was called. Although she was not on oxytocin for long, its use is associated with primary uterine rupture more so than secondary rupture. Normal indicators of uterine rupture include non-reassuring fetal heart rate tracing, sudden unexplained abdominal pain, unexplained vaginal bleeding, and loss of fetal station. In this patient, fetal bradycardia was the only sign that her uterus was compromised. Although the uterine arteries were not involved in this patient’s rupture, blood loss was still profound due to the extensive uterine defect. This case highlights that, while rare, uterine rupture can occur in any patient, regardless of uterine surgical history and physicians must be prepared to intervene quickly.

Adnexal Torsion of a 28 cm Paratubal Cyst: A Case Report

Objective: To report a rare case of a 28 cm left adnexal torsion requiring surgical intervention including detorsion and salpingectomy Methods: Case report. Results: An 18-year-old nulliparous female with morbid obesity presented to the emergency department complaining of one week of sharp right lower quadrant pain with nausea and vomiting that had acutely worsened. Vital signs were notable for tachycardia, but otherwise within normal ranges. She had a significant leukocytosis. Her pregnancy test was negative. A CT abdomen/pelvis was obtained that demonstrated a large multiloculated complex cystic mass measuring 28.5 x 19.8 x 13.3 cm with possible origin from the ovaries that could represent a serous cystadenoma. Additionally, the scan was remarkable for a heterogeneous and enlarged left ovary measuring 7.6 x 5.9 x 7.2 cm, surrounded by free fluid and mesenteric edema. On examination, she did not demonstrate any surgical abdomen findings. Her pain improved with pain medication. She was admitted, tumor markers obtained, and an ultrasound ordered. The ultrasound demonstrated normal appearing right ovary with present doppler flow and a simple cyst measuring 6.6 x 5.1 x 6.1 cm. The left adnexa was noted to have a complex versus solid mass with unclear boundaries of the ovary. Also noted on the ultrasound were two large simple midline cysts measuring 10.5 x 9.1 x 11.8 cm inferiorly and 18.2 x 15.5 x 17.2 cm superiorly. No free fluid was seen within the right upper quadrant on ultrasound. The view of the left upper quadrant was suboptimal. Due to these findings, Gynecologic Oncology service was also consulted and after discussion, decision made to proceed urgently to diagnostic laparoscopy with robotic assisted cystectomy versus oophorectomy. Upon laparoscopic entry into the abdomen, a large necrotic-appearing left adnexal mass was visualized coming from the left fallopian tube. Both the left fallopian tube and left ovary were necrotic, with the left ovary being torsed numerous times. After resection of the large left fallopian tube and cyst, the left ovary was detorsed, and the decision was made to leave the ovary in situ. It still appeared necrotic, but its blood supply was intact. There was a large simple paratubal cyst on the right fallopian tube that was also drained and excised. Postoperatively, her right lower quadrant pain resolved, and she was discharged on post-operative day 1. She prescribed a two-week course of doxycycline and metronidazole as pelvic inflammatory disease could not be ruled out. At outpatient follow-up, she was asymptomatic and ready to begin working again. Her pathology report confirmed a large left paratubal cyst with associated findings of ischemia due to torsion and a large right paratubal cyst. Conclusions: Adnexal torsion is a rare gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support, which can negatively impact fertility. Prompt diagnosis is key, but definitive diagnosis is only by direct visualization. The differential diagnosis for acute onset of severe pelvic pain with nausea and vomiting is broad and includes ectopic pregnancy, pelvic inflammatory disease, endometriosis, ruptured ovarian cyst, urologic issues and gastrointestinal issues. Commonly, ultrasound is used to help evaluate a possible torsion with several classic findings that were not noted in this case, other than a mass. The two best known risk factors for adnexal torsion are a mobile ovarian mass and a history of prior torsion. Although large ovarian masses greater than 5 cm are more likely to cause torsion, some experts hypothesize that very large masses are less likely to torse given the constraints of the pelvis. However, such was not the case here. Additionally, it has been observed that adnexal torsion typically affects the right adnexa due to theoretical protection from the descending colon on the left. Given that the case presented did not have any of the typical imaging findings for adnexal torsion and that her pain was on the right but the torsion on the left, it is important to maintain a high level of suspicion when evaluating patients with acute onset pelvic pain of any location with nausea and vomiting.