Postoperative Day Research Articles

Laparoscopic endoscopic cooperative surgery for gastric subepithelial lesion during laparoscopic sleeve gastrectomy for severe obesity

BackgroundThe frequency of pathologies detected incidentally before, during, and after a bariatric surgery, such as subepithelial lesion (SEL) of the stomach, is likely to rise as bariatric surgery becomes more common.Case presentationA 49-year-old female patient presented with severe obesity, for which laparoscopic sleeve gastrectomy (LSG) was planned. During a preoperative examination, endoscopy revealed a 10 mm SEL in the posterior wall of the upper body of the stomach. Excision of the SEL was performed simultaneously with the LSG. Endoscopy demonstrated that the SEL was situated on the remnant side of the stomach. Endoscopic resection using laparoscopic endoscopic cooperative surgery was performed for the SEL, and the thinned gastric wall was closed by hand-sewing. Thereafter, LSG was performed. Pathological analysis of the SEL led to a diagnosis of leiomyoma. The patient was discharged on postoperative day 6.ConclusionSurgeons should be prepared to manage incidentally detected pathologies before, during, and after bariatric surgery and to choose the surgical method most suitable to the individual patient.

Seroma incidence and risk factors in women undergoing mastectomies as surgical breast cancer treatment.

Seroma is the most common early complication following surgical breast cancer treatment. Its development is associated with pain, scar complications, adjuvant therapy delays, the need for outpatient visits, and increased care costs. Assess seroma incidence and risk factors in women undergoing mastectomies. This study comprises a prospective cohort encompassing women aged 18 or over undergoing mastectomies as a breast cancer treatment. Patients underwent physiotherapy on the 1st, 7th, and 30th postoperative days for kinetic-functional, skin, and wound healing assessments and were attended to by nurses for surgical wound care, draining liquid on the 7th, 14th, and 21st postoperative days. Seroma was defined as the presence of local fluctuations requiring puncture, regardless of the punctured volume. A total of 249 women were evaluated, with a mean age of 57.5 (SD = 11.8). A total of 77.1% were classified as overweight or obese, 60.2% were hypertensive, 21.3% were diabetic, 66.7% underwent neoadjuvant chemotherapy and 62.7% underwent axillary lymphadenectomies. Seroma incidence was 71.1%, requiring, on average, two aspiration punctures until condition resolution. Overweight or obese women and those who underwent axillary lymphadenectomies exhibited 1.92- and 2.06-fold higher risk for seroma development (OR = 1.92; 95% CI 1.02-3.61; p = 0.042; and OR = 2.06; 95% CI 1.17-3.63; p = 0.012), respectively. Seroma incidence was very high. Being overweight or obese and undergoing axillary lymphadenectomy comprise independent seroma development risk factors. This study is part of a randomized clinical trial evaluating the effectiveness of applying compressive taping to prevent post-mastectomy seroma, which was approved by the Brazilian National Cancer Institute, Research Ethics Committee (2,774,824), and it is registered in the ClinicalTrials.gov (NCT04471142, on July 15, 2020).

Impact of elevated direct factor Xa inhibitor plasma levels on perioperative blood loss in patients undergoing urgent surgery.

Data on the perioperative bleeding risk associated with elevated plasma levels of direct factor Xa inhibitors (FXa inhibitors) are limited. This study examines perioperative red blood cell (RBC) loss in patients undergoing urgent surgery with a residual FXa inhibitor level exceeding 100 mcg/L and without preoperative FXa inhibitor reversal. This retrospective analysis includes data from 32 patients who underwent urgent noncardiac surgery between 2018 and 2022. This study aims to analyze perioperative RBC loss in patients undergoing urgent surgery with a residual FXa inhibitor level exceeding 100 mcg/L and without preoperative FXa inhibitor antidote-based reversal or unspecific treatment with 4-factor prothrombin complex concentrate (PCC). All patients were managed using a watch-and-wait strategy. The last determination of FXa inhibitor plasma concentration prior to surgery showed a median of 245 mcg/L (IQR 144-345), with a median time interval of 3.8 h (IQR 2.4-7.2) before incision. Median RBC loss during surgery was 49 mL (IQR 0-253), 189 mL (IQR 104-217) until POD1 and 254 mL (IQR 58-265) until POD3. Only one patient required intraoperative treatment with 4-factor-PCC and none required reversal with andexanet alfa. Linear regression models found no significant influence of FXa inhibitor plasma levels on intraoperative RBC loss. Rivaroxaban was associated with higher RBC loss until postoperative Day 1 compared with apixaban. No thromboembolic events were observed. Despite markedly elevated plasma concentrations of residual direct FXa inhibitors, perioperative RBC loss was limited in patients undergoing urgent noncardiac surgery. The intraoperative watch-and-wait strategy with selective intraoperative FXa inhibitor reversal or treatment only when required appears to be an appropriate approach.

Hypoxia-Inducible Factor-1α Potentiates Multiterritory Perforator Flap Survival by Augmenting Vascular Endothelial Growth Factor Expression in the Choke II Zone.

Hypoxia-inducible factor-1α (HIF-1α), regulated by prolyl hydroxylase, plays a central role in tissue adaptation to ischemia. This study investigates the impact of HIF-1α on angiogenesis in the Choke II zone of multiterritory perforator flaps. Ninety male Wistar rats were allocated into 3 groups, with 30 rats in each group: the dimethyloxalylglycine (DMOG) group, the 3-(5-hydroxymethyl-2-furyl)-1-benzylindazole (YC-1) group, and the normal saline (NS) group. All rats underwent multiterritory perforator flap surgeries on their dorsal side. Subsequently, they received intraperitoneal injections of DMOG (40 mg/kg), YC-1 (10 mg/kg), and normal saline on postoperative days 1, 2, and 3, respectively. After treatment, angiogenesis in the Choke II zone of the flap on day 7 was observed through transillumination tests and lead oxide/gelatin x-ray angiography. Histological features were determined using hematoxylin and eosin staining, and the expression of HIF-1α and vascular endothelial growth factor (VEGF) in the Choke II region of the flap was assessed via immunohistochemistry and western blotting. Compared to the YC-1 and NS groups, the DMOG group exhibited significant angiogenesis, resulting in a denser vascular network in the Choke II zone of the flap. The DMOG group showed significantly higher microvessel density in the Choke II zone than the YC-1 and NS groups (7.10 ± 0.99 vs 24.30 ± 3.65; 14.30 ± 2.40 vs 24.30 ± 3.65, both P<0.05). Additionally, the DMOG group demonstrated higher expression of VEGF and HIF-1α in the flaps than the other groups (P < 0.05). In summary, HIF-1α enhances the expression of VEGF, promoting angiogenesis in the Choke II zone of the multiterritory perforator flap, thus increasing the survival area.

Alveolar bone healing patterns in chronic kidney failure and kidney transplant recipients: A pixel intensity and fractal analyses.

To assess and compare radiographically the alveolar bone after tooth extractions in individuals with chronic kidney failure undergoing hemodialysis (CKFh), those submitted to kidney transplantation (KT), and those without kidney disease (CG) by using fractal analysis (FA) and pixel intensity (PI). Periapical radiographs of 48 CKFh individuals (87 extracted teeth), 12 KT individuals (26 extracted teeth and 29 control individuals [76 extracted teeth] were analyzed at 7 and 60 days after tooth extraction. Fractal dimension (FD) and PI were assessed to evaluate the alveolar trabecular bone structural complexity and mineral content. The difference in FD values between the 7th and 60th postoperative days in KT individuals (0.03±0.08) was significantly lower compared to those of CKFh individuals (0.09±0.10) and controls (0.15±0.06). As for the difference in PI values, KT (4.55±10.24) and CKFh groups (9.88±15.90) showed significantly lower values compared to those of the control group (17.93±11.86) in the same period. These results indicate a lower gain in the trabecular bone complexity and bone density in the alveolus of KT individuals compared to the other groups. Overall mineral content and thickness of the bone in the plane of the x-ray beam were lower in KT and CKFh individuals compared to controls, reflecting the need for careful consideration in recommending rehabilitation with dental implants for these patients. Particular attention should be given to the potential challenges in oral rehabilitation of KT patients.

A neglected case of chronic suppurative otitis media presented with a chest wall abscess

The objective of the study was to present a neglected case of chronic suppurative otitis media presented to us with a chest wall abscess. We encountered a case of complicated chronic suppurative otitis media in a 16-year-old male, who presented with abscess extending from the mastoid region up to the ipsilateral chest. Incision and drainage of the chest wall and mastoid abscess was under local anesthesia and approximately 250 ml pus was collected. The patient was given intravenous injections of meropenem and regular dressings. Right modified radical mastoidectomy with type 3 tympanoplasty was performed under general anesthesia after four weeks. The patient was discharged on postoperative day 6. The case is an eye-opener as having several complications at the time of presentation that reflects inattention at the community level health provider and patient. Through this article, we emphasis on early diagnosis and proper management of disease so as to avoid life-threatening complications. High index of suspicion and timely intervention is needed for any patient presenting with neck or chest swelling as it may be a complication of COM.

Prospective Study of Preoperative Negative Affect and Postoperative Pain in Patients Undergoing Thoracic Surgery: The Moderating Role of Sex.

Objective: Preoperative negative affect is a risk factor for worse postoperative pain, but research investigating this association among patients undergoing thoracic surgery is inconsistent. Additionally, female patients often report greater negative affect and postoperative pain than males. This prospective observational study investigated the association between preoperative negative affect and postoperative pain after thoracic surgery and whether this association differed by sex. Methods: Patients (n = 105) undergoing thoracic surgery completed preoperative assessments of pain and negative affect (PROMIS anxiety and depression short forms). Patients reported their daily worst pain over the first 7 postoperative days, and an index score of acute postoperative pain was created. Six months after surgery, a subsample of patients (n = 60) reported their worst pain. Results: Higher levels of preoperative anxiety (r = 0.25, p = 0.011) and depression (r = 0.20, p = 0.042) were associated with greater acute postoperative pain, but preoperative negative affect was not related to chronic postsurgical pain (anxiety: r = 0.19, p = 0.16; depression: r = -0.01, p = 0.94). Moderation analyses revealed that the associations between both preoperative anxiety (b = 0.12, 95% CI [0.04, 0.21], p = 0.004) and depression (b = 0.15, 95% CI [0.04, 0.26], p = 0.008) with acute postoperative pain were stronger among females than males. Similarly, the association between preoperative anxiety and chronic postsurgical pain was stronger among females (b = 0.11, 95% CI [0.02, 0.20], p = 0.022), but the association between preoperative depression and chronic pain did not differ based on sex (b = 0.13, 95% CI [-0.07, 0.34], p = 0.201]). Conclusions: Our findings suggest that negative affect may be especially important to the experience of pain following thoracic surgery among female patients, whose degree of preoperative anxiety may indicate vulnerability to progress to a chronic pain state. Preoperative interventions aimed at reducing negative affect and pain may be particularly useful among females with high negative affect before thoracic surgery.

Evaluation of Oral Pregabalin as a Preemptive Adjuvant for Postoperative Pain in Patients Undergoing Coronary Artery Bypass Grafting With General Anesthesia and High Thoracic Epidural: A Randomized Controlled Study.

Aim This study aimed to evaluate the effectiveness of oral pregabalin as a preventive supplement in managing postoperative pain in patients undergoing coronary artery bypass grafting (CABG) with a combination of general anesthesia and high thoracic epidural anesthesia. Material and methods This 18-month randomized controlled study at a tertiary hospital's anesthesiology department included 62 American Society of Anesthesiologists (ASA) II or III patients aged 35-75 with left ventricular ejection fraction >35%. Placebo (Group B, n = 31) or pregabalin (Group A, n = 31) was randomly allocated. Group A got 150 mg of pregabalin the night before surgery and 75 mg on postoperative days 0 and 1, whereas Group B received a placebo. Postoperative pain was evaluated using the Verbal Numerical Scale and Visual Analogue Scale, while sedation was assessed with the Ramsay Sedation Scale. Statistical analysis was performed using SPSS for Windows, Version 16.0 (Released 2007; SPSS Inc., Chicago). Results In this study, pregabalin significantly reduced postoperative pain on Day 0 and Day 1 (p < 0.001) compared to the placebo. The pregabalin group exhibited higher sedation scores on Day 0 (p < 0.001), but there were no significant differences on Day 1. Inotrope requirements were similar between both groups. Conclusions CABG patients' postoperative pain was greatly reduced by pregabalin without impacting sedation or inotrope needs. These data imply that pregabalin was a useful supplementary analgesic for CABG patients' multimodal pain treatment.

Determinants of late recovery following elective colorectal surgery.

Despite the implementation of enhanced recovery protocols, a significant proportion of patients experience delayed recovery. Identifying potential determinants of delayed recovery is crucial for optimizing perioperative protocols and tailoring patient pathways. This study aims to identify possible determinants of delayed recovery. Retrospective observational study based on a prospectively collected dedicated register spanning from 2015 to 2022. Twenty-two Italian hospitals specializing in high-volume colorectal surgery and trained in enhanced recovery protocols. Patients undergoing elective colorectal resection for cancer or benign disease. Recovery status on postoperative day 2. Late recovery was defined as the failure to meet at least two indicators of postoperative recovery (oral feeding, removal of the urinary catheter, cessation of intravenous fluids, and mobilization) on postoperative day 2. A total of 1535 patients were analyzed. The median overall adherence to pre- and intraoperative enhanced recovery protocol items was 75.0% (range: 66.6%-83.3%). Delayed recovery was observed in 487 (31.7%) patients. Multiple regression analysis revealed six enhanced recovery protocol items that independently positively influenced postoperative recovery: pre-admission counseling (adjusted odds ratio [aOR] 2.596), a preoperative carbohydrate drink (aOR 1.948), intraoperative fluid infusions < 7ml/kg/h (aOR 1.662), avoidance of thoracic epidural analgesia (aOR 2.137), removal of nasogastric tube at the end of surgery (aOR 4.939), and successful laparoscopy (aOR 2.341). The rate of delayed recovery progressively decreased with increasing adherence to these six positive items, reaching 13.0% when all items were applied (correlation coefficient [r] = - 0.99, p < 0.001). This study is limited by its retrospective analysis of a register containing data from multiple centers and a diverse patient population. Adherence to specific pre- and intraoperative enhanced recovery protocol items, including counseling, preoperative carbohydrate intake, restrictive intraoperative fluid management, avoidance of thoracic epidural analgesia, early removal of nasogastric tube, and successful laparoscopy, appears crucial for promoting early recovery following elective colorectal resection.

Cerebrovascular pulsatility indicates preoperative subcortical cognitive impairment and an increased risk for postoperative delirium in elderly patients undergoing elective spine surgery.

Advances in spine surgery enable safe interventions in elderly patients, but perioperative neurocognitive disorders (pNCD), such as post-operative delirium (POD) and cognitive dysfunction (POCD), remain a serious concern. Pre-operative cognitive impairment is a major risk factor for pNCD. Comprehensive pre-operative cognitive assessments are not feasible in clinical practice, making effective screening methods desirable. This study investigates whether pre-operative cerebrovascular duplex sonography can assess subcortical (vascular) cognitive impairment and the risk for POD. This prospective single-center study recruited patients aged ≥60 years scheduled for elective spine surgery at a German university hospital. Patients underwent pre-operative assessments including cognitive abilities (CERAD test battery), structural MRI, and cerebrovascular duplex sonography. POD screening was conducted three times daily for at least 3 days. The primary hypothesis, that the mean pulsatility index (PI) of both internal carotid arteries (ICA) predicts POD risk, was tested using logistic regression. Secondary analyses examined the association between POD risk and ICA flow (time-averaged peak velocities, TAPV) and correlations with cognitive profiles and MRI characteristics. POD occurred in 22% of patients (n = 22/99) within three postoperative days. Patients with POD were significantly older (75.9 ± 5.4 vs. 70.0 ± 6.9 years, p < 0.01) but did not differ by gender (p = 0.51). ICA PI significantly predicted POD risk (OR = 5.46 [95%CI: 1.81-16.49], p = 0.003), which remained significant after adjustment for age and duration of surgery (ORadj = 6.38 [95% CI: 1.77-23.03], p = 0.005). TAPV did not inform the POD risk (p = 0.68). ICA PI Pre-operative cognitive scores were significantly associated with ICA PI (mean CERAD score: r = -0.32, p < 0.001). ICA PI was also significantly associated with total white matter lesion volume (τ = 0.19, p = 0.012) and periventricular white matter lesion volume (τ = 0.21, p = 0.007). This is the first study to demonstrate that cerebrovascular duplex sonography can assess the risk for POD in elderly spine surgery patients. Increased ICA PI may indicate subcortical impairment, larger white matter lesion load, and lower white matter volume, predisposing factors for POD. Pre-operative cerebrovascular duplex sonography of the ICA is widely available, easy-to-use, and efficient, offering a promising screening method for POD risk. Increased ICA PI could supplement established predictors like age to adjust surgical and peri-operative procedures to individual risk profiles.

Assessing the clinical efficacy of phacoemulsification cataract extraction in treating acute primary angle closure and fellow primary angle closure suspect eyes using AS-OCT.

This study aimed to compare anterior segment parameters pre-and postoperatively in acute primary angle closure (APAC) and fellow primary angle closure suspect (PACS) eyes using anterior segment optical coherence tomography (AS-OCT) and evaluate the clinical effectiveness of cataract extraction in the treatment of APAC and fellow PACS eyes. Quantitative measurements of various parameters, including anterior chamber depth (ACD), anterior chamber volume (ACV), lens vault (LV), iridocorneal angle contact index (ITCI), iris thickness (IT), iris volume (IV), and iris curvature (IC), were obtained using Tomey CASIA2 AS-OCT on 60 eyes from 30 patients (APAC eyes and their fellow PACS eyes) before and after surgery. Simultaneous analysis of the differences between the APAC eyes and fellow PACS eyes in these parameters, visual acuity (VA), and intraocular pressure (IOP) were performed. After surgery, both the APAC eyes and fellow PACS eyes (a total of 60 eyes) showed a significant increase in ACD and ACV, compared to preoperative measurements. Furthermore, LV and ITCI significantly decreased postoperatively. In the PACS group, IC significantly decreased postoperatively, while there was no statistically significant difference in the APAC group. In the APAC group, there was a significant decrease in IOP and improvement in VA at 1 day, 1 week, and the final follow-up compared to preoperative levels. The IOP values in the PACS group were within the normal range across various time points. VA in the PACS group showed significant improvement at 1 week postoperatively and at the final follow-up compared to preoperative levels. Significant differences of VA were observed in the initial, preoperative, first postoperative day, first postoperative week, and final follow-up, with better outcomes observed in the PACS group compared to the APAC group. Lens extraction surgery can significantly improve anterior segment crowding in APAC and PACS eyes. For APAC eyes, combined cataract extraction with intraocular lens implantation and gonioscopy-assisted goniosynechialysis under direct visualization is feasible and safe. Further, in the fellow PACS eye of APAC patients with either significant or mild cataracts, phacoemulsification can maintain or improve preoperative visual acuity to varying degrees and stabilize IOP.

The Combined Effect of Western Diet Consumption and Diclofenac Administration Alters the Gut Microbiota and Promotes Anastomotic Leakage in the Distal Colon.

Obesity, Western diet (WD) consumption, and the use of non-steroidal anti-inflammatory drugs (NSAIDs) are co-occurring and modifiable factors associated with microbiome dysbiosis and anastomotic leakage. We studied the combined effect of a Western-type diet (WD) and diclofenac, a standard NSAID used in surgical patients, on anastomotic healing and gut microbiota composition following distal colon resection. Forty-two rats were fed a WD for 6 weeks, after which they were randomized to either parenteral diclofenac 3 mg/kg/day or saline started on the day of surgery and continued for three days. The surgical procedure involved distal colon resection with anastomosis. Animals were sacrificed on postoperative day (POD)-3 or POD-5. Anastomotic healing was assessed and correlated with diclofenac treatment and gut microbiota composition, analyzed by 16S rRNA marker gene amplicon sequencing. Mucosal integrity of the anastomosis was evaluated by histological analysis. Anastomotic leakage rate was 100 percent (8/8) in diclofenac-treated rats and 10 percent (1/10) in saline-treated controls on POD-5. Diclofenac administration in WD-fed animals induced a shift in microbiota composition, characterized by an increase in microbiota diversity on POD-5 and a significant 15-fold, 4-fold, and 16-fold increase of Proteobacteria, Bacteroidetes, and Verrucomicrobia, respectively. Diclofenac use in WD-fed animals caused mucosal erosion on POD-5, a phenomenon not observed in control animals. Consumption of a Western diet combined with diclofenac administration shifts the microbiota composition, associated with clinically relevant AL in the distal colon of rats.

Plate osteosynthesis of phalanx fractures using wide-awake local anesthesia no tourniquet technique is cost-effective and associated with less postoperative pain.

The wide-awake local anesthesia no tourniquet (WALANT) technique, which is based on the local infiltration of lidocaine and epinephrine, is widely used in hand and wrist surgery. However, few studies have been conducted on the cost-benefit analysis of phalanx fracture surgery using the WALANT technique. This study aimed to investigate the clinical condition, time spent on anesthesia and operation. We also perform an economic analysis among general anesthesia, local anesthesia with a tourniquet, and the WALANT technique for plate fixation of phalanx fractures. This retrospective study included all patients with single phalanx fractures who underwent open reduction internal fixation with plating between January 2015 and December 2019. Patients were divided into three groups according to the anesthesia method: general anesthesia with a tourniquet (GA group), local anesthesia with a tourniquet (LA group), and the WALANT technique (WALANT group). Data, including demographics, anesthesia and surgical time, postoperative pain score, and vomiting ratio, were collected and analyzed. A total of 62 patients were included in this study. Of the 62 patients, 15 were included in the GA group, 32 in the LA group, and 15 in the WALANT group. No complications were reported during surgery or follow-up in either group. The GA group exhibited a significantly longer anesthesia time than the other two groups, with an average of 32.4 min. However, no significant difference in surgical time was observed among the three groups. The WALANT group exhibited a significantly lower postoperative pain score than the other two groups. The additional cost of general anesthesia was approximately 350 US dollars (USD), accounting for approximately one-third to one-fourth of the total expenses for phalanx surgery. Open reduction with plate fixation of phalanx fractures using the WALANT technique and local anesthesia was cost-effective compared with general anesthesia. Patients who underwent phalanx fracture surgery using the WALANT technique experienced less pain on the first postoperative day than those who underwent surgery using general or local anesthesia with a tourniquet because of the adequate tumescent technique and not using a tourniquet during surgery.

Effects of Extracorporeal Membrane Oxygenation Combined with Emergency PCI in Resuscitating Acute Myocardial Infarction-Related Cardiac Arrest

Objective:To analyze resuscitation strategies for cardiac arrest following acute myocardial infarction, focusing on the treatment effects of extracorporeal membrane oxygenation (ECMO) combined with emergency percutaneous coronary intervention (PCI). Methods: From January 2023 to June 2024, 100 cases of cardiac arrest following acute myocardial infarction were included and randomly divided into two groups: the control group (50 cases) received conventional cardiopulmonary resuscitation (CPR) combined with emergency PCI, while the observation group (50 cases) received ECMO combined with emergency PCI. The resuscitation effects, return of spontaneous circulation (ROSC) rate, Glasgow Coma Scale (GCS) score, vital signs, and complication rates were compared between the two groups. Results: The observation group had a survival rate of 90.00% and ROSC rate of 94.00%, which were higher than the control group's 70.00% and 76.00% (P &lt; 0.05). The GCS scores on postoperative days 1, 2, and 3 were higher in the observation group (P &lt; 0.05). The heart rate on postoperative days 1, 2, and 3 was lower in the observation group (P &lt; 0.05), while the mean arterial pressure was higher (P &lt; 0.05). The complication rate was lower in the observation group (P &lt; 0.05). Conclusion: The combination of ECMO and emergency PCI for cardiac arrest following acute myocardial infarction significantly improves survival rates and ROSC rates, enhances consciousness levels and vital signs, and reduces complications.

Penile Mondor's disease after open hernia repair surgery: A case report.

Penile Mondor's disease (PMD) is a rare syndrome characterized by sclerosis after superficial thrombophlebitis of the superficial penile veins. The most usual appearance of PMD is a tender, palpable, painful, and sometimes visible cord on the dorsal surface of the penis. Its pathogenesis is still unclear, and a standardized treatment has not been established. A 54-year-old male patient presented with a left-sided indirect reducible inguinal hernia. The patient underwent Lichtenstein's procedure for inguinal hernia repair. On the tenth postoperative day, he returned with PMD confirmed by Doppler ultrasonography examination. Treatment with 4000 UI low molecular weight heparin (LMWH) daily for three weeks resolved the symptoms, but mild venous ectasia just to the proximal part of the penis remained. The exact cause of PMD is not well understood, but various studies have identified certain factors associated with an increased risk of the condition. Out of various potential factors that could trigger PMD, the repair of an inguinal hernia has been reported only once. Treatment may involve pain management, anti-inflammatory medications, anticoagulants, and, in some cases, surgery. PMD after open hernia repair surgery is a very rare benign condition. Correct diagnosis and prompt treatment allowed symptom resolution. Residual venous ectasia has no clinical significance other than a cosmetic appearance.

The effect of intraoperative methadone on postoperative opioid requirements in children undergoing orchiopexy: A randomized clinical trial

AbstractBackgroundChildren undergoing outpatient surgery are at risk of inadequate postoperative pain control. Methadone has a long duration of action and an intraoperative dose may provide stable analgesia throughout the postoperative period. Intraoperative methadone has been shown to improve pain control in adolescents but its use for postoperative pain in pediatric patients undergoing outpatient surgery has not been studied before. Therefore, we conducted a double‐blind randomized placebo‐controlled trial to investigate the effects of a single dose of intraoperative methadone in children aged less than 5 years undergoing orchiopexy for undescended testis.MethodsA total of 68 children were randomized to receive either methadone (0.1 mg/kg) or isotonic saline following induction of anesthesia. Exclusion criteria included preterm birth, previous scrotal surgery, and parents' inability to consent. Primary outcomes were opioid requirements (first primary outcome) and pain intensity in the post‐anesthesia care unit. Secondary outcomes included episodes of desaturation and time until readiness to discharge from the post‐anesthesia care unit, sleep on the first postoperative night, pain intensity, and opioid requirements at home until the evening on the first postoperative day. Follow‐up was 4 days.ResultsSixty children completed the study (age, mean ± SD, 26.2 ± 13.9 months), 29 children received methadone, and 31 children received placebo. Eighteen children required opioids in the post‐anesthesia care unit, five children in the methadone group (proportion = 0.17, 95% confidence interval (CI): 0.07, 0.36) compared to thirteen patients in the placebo group (0.42, 95% CI: 0.26, 0.60) (mean difference = −0.24 and 95% CI: −0.03, −0.47) (p = 0.037). Five children in the methadone group (0.17, 95% CI: 0.03, 0.31) versus ten in the placebo group (0.32, 95% CI: 0.16, 0.49) had a face, legs, activity, cry, consolability score of ≥5 in the post‐anesthesia care unit (mean difference = −0.15, 95% CI: −0.36, 0.06) (p = .179). More children in the placebo group woke up due to pain the first night following surgery (seven children vs. one child). The methadone group had a longer stay in the post‐anesthesia care unit. There were no differences between the two groups regarding the other secondary outcomes.ConclusionA single dose of intraoperative methadone reduces short‐term postoperative opioid requirements in children after orchiopexy for nondescended testes but prolongs the duration of their stay in the post‐anesthesia care unit.

Rectus Abdominis Sheath Hematoma Following Cesarean Section: A Case Series

This case series describes two patients who underwent Cesarean section complicated by a rectus abdominis sheath hematoma that did not immediately resolve following exploratory laparotomy. One of the patients required an additional procedure by interventional radiology. Both patients had similar presentations. Both were noted to have symptomatic anemia on postoperative day 1 with an acute drop in hemoglobin. This was accompanied by severe abdominal pain and distension on physical exam. Computerized tomography (CT) abdomen/pelvis demonstrated evidence of active bleeding within the anterior abdominal wall musculature. Due to increasing concern for intrabdominal hemorrhage in the setting of an acute abdominal exam, the decision was made to proceed with an exploratory laparotomy. A substantial amount of blood was evacuated from the abdomen with greater than 1500 cc of estimated blood loss in both cases. A Jackson-Pratt drain was placed and had increased output immediately postoperatively. Both patients received blood products. One developed a consumptive coagulopathy. Interventional Radiology was consulted following exploratory laparotomy to consider intravascular embolization of the inferior epigastric arteries, which was eventually performed in one of the cases. The patients were discharged on hospital day 5 in good condition. Rectus abdominis sheath hematomas are a rare complication that can lead to significant postpartum hemorrhage. Prompt recognition and management is vital to avoid significant morbidity and mortality. Algorithms exist to guide treatment and standardize patient care. Despite using sound clinical judgment in line with existing algorithms, both patients had delayed resolution of their bleeding following initial management, requiring additional intervention.

Compliance of enhanced recovery after surgery (ERAS) protocol in emergency and elective colorectal cancer surgery with a perspective from a developing country.

To evaluate compliance with enhanced recovery after surgery protocol of patients undergoing colorectal carcinoma surgery, and to compare its effect on outcomes. The retrospective study was conducted at the Maroof International Hospital, Islamabad, Pakistan, and comprised data from July 15, 2016, to March 20, 2022, of patients of either gender undergoing elective or emergency colorectal carcinoma surgery. Data included age, gender, tumour site, type of surgery, surgical approach, compliance with each of the 25 components of the enhanced recovery after surgery protocol, length of hospital stay, surgery duration, 30-day readmission rate and perioperative mortality. Data was analysed using SPSS 23. Of the 96 patients with mean age 50.03±14.86 years (range: 20-79 years), 65(67.7%) were males, 70(72.91%) were aged at least 40 years, and 75(78.12%) underwent elective surgery. Most common tumour site was rectum and sigmoid 49(51%). Laparoscopic surgery was performed in 17(17.7%) patients. No compliance was seen with carbohydrate loading of patients or limiting use of opioids in standard anaesthesia protocol. No nutritional supplementation was started from postoperative day 1. Mean compliance with all the protocol components was 74.9%±37.652 for both elective and emergency cases. Mean duration of surgery was 192.50±75.33 minutes, while mean length of hospital stay was 5.52±1.57 days. Re-admission within 30 days was needed in 2(2.1%) cases. There was no perioperative mortality. Better compliance with enhanced recovery after surgery protocol resulted in better perioperative outcomes.

A new approach for perioperative parathyroid hormone (PTH) measurement to establish cure in patients with primary hyperparathyroidism.

In this study, we analyse the possibility to omit pre-incision PTH measurement since we routinely measure it at the time of pre-surgery ambulatory admission. A total of 435 patients were enrolled. All patients with pHPT included underwent pre-surgical PTH level assessment as part of the pre-admission preparation to surgery. Intraoperative PTH was routinely assessed after induction of the anaesthesia (pre-incision PTH) and 15min after resection of the enlarged gland(s) (post-excision PTH). Moreover, calcium and PTH levels were routinely assessed on the first postoperative day. Cure was defined as an intraoperative drop of > 50% or into normal range on first post-operative day. The median value of the preoperative and pre-incision PTH were both 127 pg/ml (p = ns). Thirty-two patients (7.3%) exhibited a not appropriate drop of post-excision PTH level. Nevertheless, nineteen of them (59.3%) showed a satisfying PTH drop on 1st POD. Ten patients (2.3%) experienced a persistent disease with six achieving cure through reoperation. Additionally, three patients (0.6%) showed normalization of calcium and PTH values during the follow-up. Three patients, apparently deemed cured after an adequate PTH-drop on the day of surgery, showed persistence. Cure rate at primary surgery was 98.4%. Accuracy of our simplified protocol is 99.3%. Pre-incision PTH is not superior to preoperative PTH blood test and can be omitted without compromising the sensitivity of cure prediction. One blood sample 15min after resection, along with the postoperative PTH value on the day after surgery, is sufficient to predict the surgical outcome bearing the cost of a very low reoperation rate.

Minimal Invasive Resection of Large Retrosternal Thyroid Goiter.

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic approach is linked to higher postoperative morbidity, reaching up to 30% when compared to the transcervical approach. Although alternative options like thoracoscopic resection have shown promising results, the morbidity of mediastinal dissection remains a concern. Thoracoscopic-assisted transcervical approach might be a feasible, less invasive alternative. This video outlines the steps and potential pitfalls of the procedure. The patient is positioned supine with an extended neck. Initially, the endocrine surgeon mobilizes the thyroid gland through cervical access. If a transcervical resection is not feasible, the patient is mobilized into a lateral decubitus position, and a second team thoracoscopically guides the mediastinal tumor through the thoracic inlet. This allows a stepwise controlled transcervical dissection of the retrosternal mass until complete resection is achieved, thus eliminating the need for mediastinal dissection. To demonstrate the procedure, we present the case of an 84-year-old male with lymph node-positive oncocytic thyroid carcinoma and a large retrosternal goiter extending posteriorly into the mediastinum up to the aortic arch. Thoracoscopic-assisted transcervical resection was performed. The recurrent laryngeal nerve was identified and monitored with a neurostimulation device during dissection. No palsy was noted in the postoperative evaluation. The patient had an uneventful postoperative course and was discharged on the second postoperative day. Thoracoscopic-assisted transcervical resection of large retrosternal goiter seems a feasible alternative to mitigate risks associated with thoracotomy, sternotomy, or thoracoscopic mediastinal dissection. Potential advantages include decreased postoperative morbidity and length of stay. This technique requires thoracoscopic expertise and may be limited depending on the goiter's size and mediastinal positioning.