Procedure Of Choice Research Articles

Protocolo diagnóstico y terapéutico de la hemoptisis

The medical record allows us to make a precise diagnosis and evaluate the severity of an episode of hemoptysis. A simultaneous evaluation and approach are essential for treatment success. The main objective is to ensure adequate ventilation, oxygenation, and intravenous access. A multidisciplinary team will be activated to stabilize and control bleeding in life-threatening hemoptysis and admission to the intensive care unit. Intubation must not be delayed if a large-bore tube is not available. A chest x-ray should be the first imaging test performed. A multidetector computed tomography (CT) scan of the chest must be performed in stable patients. A flexible bronchoscopy is the diagnostic and treatment procedure of choice in unstable patients. A rigid bronchoscopy is only used when greater blood suction capacity and visualization of the airway is needed. Emergency surgery is reserved for failed bronchoscopy and embolization interventions.

Comparison of Mini Tightrope Intermetatarsal Fixation and Inter-Cuneiform Screw Fixation in Lapidus

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: First metatarso-cuneiform joint arthrodesis for treatment of metatarsus primus varus was originally introduced by Lapidus in 1934. In his technique, fixation was achieved using heavy chromic sutures between the first and second metatarsals to achieve parallel alignment. Since then, the indications and technique for Lapidus procedure have considerably evolved and many modifications have been introduced to Lapidus’s original description. Despite these modifications, recurrence of hallux valgus remains relatively common, either due to malunion at the TMT arthrodesis or through intercuneiform instability. This has informed the approach for additional fixation between the 1st and 2nd rays. This study aims to compare outcomes of inter-cuneiform screw fixation (ICS) and suspensory intermetatarsal fixation (SIM) using a mini-tightrope in terms of deformity correction and maintaining the correction over time. Methods: This was a retrospective comparative study of prospectively collected data for patients who have underwent a Lapidus procedure for hallux valgus between 2012-2022. The electronic medical records were reviewed for demographics, radiologic parameters, and operative data. Radiographic parameters were intermetatarsal angle (IMA), hallux valgus angle (HVA), and sesamoid station on preoperative, 3 months postoperatively and final follow-up. Hallux valgus station was graded from normal, mild, moderate, and severe based on the method used by Agrawal et al. Using a multivariate regression model, a comparison was conducted between suspensory intermetatarsal fixation(SIM) and inter-cuneiform screw fixation(ICS). Univariate linear regression analysis was conducted with the inclusion of covariates' age, smoking, diabetes, and BMI. Comparison of HVA and IMA was conducted using t-test. Results: 65 patients met the inclusion criteria; 20 had ICS, and 45 had SIM. The pre-op IMA improved from 13.57 (3.84) to 6.14 (2.41) degrees postoperatively in the ICS group (p), and from 13.37(3.84) to 6.16 (2.74) degrees postoperatively in the SIM group (p). The final follow-up IMA was 5.9 (2.1) in the ICS group and 6.84 (2.31) in the SIM group, with no difference from post-op values, p=0.123 and, respectively. There was no statistically significant difference between ICS and SIM groups in IMA at pre-op (p=0.41), post-op (p=0.49), and final follow up (p=0.62). There were no statistically significant differences between SIM and ICS groups in HVA preoperatively [37.47(12.21) vs. 40.38(13.59), p=0.19], postoperatively [18.2(10.82) vs. 18.95(10.1),p=0.36] or at final follow up [20.12(9.72) vs 19.33(9.16) ,p=0.38]. Conclusion: Lapidus procedure remains the procedure of choice for severe hallux valgus with predictable correction. Supplementing the first tarsometatarsal arthrodesis with suspensory intermetatarsal fixation using a mini-tightrope achieved similar deformity correction and preservation of correction to intercuneiform screw fixation.

CLINICAL PICTURE AND CURRENT MANAGEMENT OF PITUITARY TUMORS: A REVIEW

The pituitary is a pea-sized complex gland located below the hypothalamus at the base of skull in the sella turcica, is composed of three types of cells. Pituitary being the centre of all the stimulating hormones of various organs, its overgrowth leads to hormone excess syndromes, like acromegaly, Cushing disease, central hypothyroidism, and hyperprolactinemia etc. so studies involving pituitary tumors have mainly focused on hormone production. Pituitary Adenoma is the most common (~85%) tumor in the sellar-suprasellar region. Their prevalence is growing which has risen over the last 20 years probably due to improved imaging techniques and treatment outcomes. Due to the tumors growth in size Compression of adjacent anatomical structures especially optic nerves in close vicinity can lead to focal neurologic deficits such as diplopia, visual field defects and loss of visual acuity typically bitemporal hemianopsia. The surgical procedure of choice is a trans-sphenoidal micro surgically or endoscopically performed by a neurosurgeon leaving transcranial approach for large and invasive pituitary neoplasm with sellar remnants. Even in the case of recurrent tumor or progression of residual tumor tissue after surgery, a second operation and/or radiotherapy should be considered.

Efficacy of Revision Using Distal Inflow in Patients with Symptomatic Dialysis Access-Associated Steal Syndrome.

Objectives: In this study, we aim to assess the efficacy of revision using distal inflow (RUDI) in patients with symptomatic dialysis access-associated steal syndrome (DASS). Materials and Methods: All consecutive patients who were diagnosed with grade 3 or 4 DASS and have undergone RUDI in 4 years were included in this study. Results: In total, 35 patients were included in this study; participants had a mean age of 47.5±7.52 years and 54% (n=19) were males. As per our findings, significant improvement was noted in terms of paresthesia (81.2%, p-value: 0.012), coolness (79.4%, p-value: 0.006), pain (78.1%, p-value: 0.006), discoloration (76.4%, p-value: 0.044), paresis (71.4%, p-value: 0.016), and ulcer healing (50%, p-value: 0.044). Gangrene did not further progress in all patients (n=35). Reduction in fistula flow rate after RUDI was 57.5% (682±121 ml/min, p-value: 0.001). Digital systolic pressure was noted to improve by 71.4% (60±9.2 mmHg, p-value: 0.002) after RUDI. Peak systolic velocity increased in both ulnar (66.1±8.2 cm/s, p-value: 0.04) and radial (64.2±7.6 cm/s, p-value: 0.024) arteries of the wrist. Cumulative patency of RUDI graft was 100%, 91.4%, and 85.7% at 3, 6, and 12 months, respectively. Conclusion: RUDI has resulted in significant improvements in terms of DASS symptoms. Using a native vein as conduit, RUDI should be considered a procedure of choice for patients with high-flow DASS.

Monocular Diplopia Associated with Peripheral Iridotomy

Laser iridotomy is the procedure of choice for primary angle-closure glaucoma. Ms. CS, a 47-year-old Caucasian female with a history of migraines, came to the clinic for an increased frequency of intermittent headaches, halos, and blurry vision in both eyes. Gonioscopy was performed in both eyes to assess the angles

Perioperative use of tranexamic acid in elderly patients undergoing hemiarthroplasty for neck of femur fractures: Is it worth using in every patient? An updated systematic review and Meta-analysis

Hemiarthroplasty becomes the procedure of choice for hip fracture in elderly population with blood loss as its complication. Tranexamic acid (TXA) has been used with no systematic review conducted to evaluate its efficacy and safety. The PRISMA guidelines were followed to conduct literature screening and selection. Main outcomes were extracted for qualitative analysis and quantitative analysis. Blood loss level and haemoglobin drop was significantly reduced in TXA group as compared to the control group. TXA is also deemed as protective factor for transfusion requirement. TXA use may be considered in every patient undergoing hemiarthroplasty procedure unless absolute contraindication exists.

International registry on aortic balloon occlusion in major trauma: Partial inflation does not improve outcomes in abdominal trauma

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) is a method for temporary hemorrhage control used in haemodynamically unwell patients with severe bleeding. In haemodynamically unwell abdominal trauma patients, laparotomy remains the initial procedure of choice. Using REBOA in patients as a bridge to laparotomy is a novel option whose feasibility and efficacy remain unclear. We aimed to assess the clinical outcome in patients with abdominal injury who underwent both REBOA placement and laparotomy. MethodsThis is a retrospective study, including trauma patients with an isolated abdominal injury who underwent both REBOA placement and laparotomy, during the period 2011–2019. All data were collected via the Aortic Balloon Occlusion Trauma Registry database. ResultsOne hundred and three patients were included in this study. The main mechanism of trauma was blunt injury (62.1%) and the median injury severity score (ISS) was 33 (14–74). Renal failure and multi-organ dysfunction syndrome (MODS) occurred in 15.5% and 35% of patients, respectively. Overall, 30-day mortality was 50.5%. Post balloon inflation systolic blood pressure (SBP) >80 mmHg was associated with lower 24-h mortality (p = 0.007). No differences in mortality were found among patients who underwent partial occlusion vs. total occlusion of the aorta. ConclusionsOur results support the feasibility of REBOA use in patients with isolated abdominal injury, with survival rates similar to previous reports for haemodynamically unstable abdominal trauma patients. Post-balloon inflation SBP >80 mmHg was associated with a significant reduction in 24-h mortality rates, but not 30-day mortality. Total aortic occlusion was not associated with increased mortality, MODS, and complication rates compared with partial occlusion.

Solid pseudopapillary epithelial neoplasm of pancreas presenting as an abdominal lump: a case report

Solid pseudopapillary epithelial neoplasm (SPEN) of the pancreas is a rare cystic exocrine tumour of the pancreas that predominantly affects women between 30 and 40 years of age. This case report aims to describe clinical presentation and management of SPEN. We report a case of 20 years old female who presented with palpable lump in upper abdomen and continuous dull aching pain. Preoperative contrast enhanced computed tomography (CECT) abdomen was suggestive of large solid mass of size 11×10×10 cm with liquified content in relation to tail of pancreas with a possibility of retroperitoneal tumour or gastrointestinal tumour (GIST). Spleen sparing distal pancreatectomy with segmental resection of transverse colon with colo-colic anastomosis was performed and the diagnosis of SPEN was subsequently confirmed on histopathology examination. SPEN is a slow-growing tumour with a low-grade malignant potential found incidentally in asymptomatic patients. The average tumour size is about 4 to 6 cm in diameter at presentation. Distal pancreatectomy with splenectomy is the procedure of choice as described in literature. SPEN should be kept as a differential diagnosis in a young female patient presenting with vague abdominal pain and retroperitoneal lump in relation to the pancreas. Complete surgical resection is the definite treatment with a 5-year survival rate of 95%.

Spare the Nipple: A Systematic Review of Tumor Nipple-Distance and Oncologic Outcomes in Nipple-Sparing Mastectomy.

Preserving the nipple-areolar complex (NAC) in breast cancer surgery improves patient satisfaction and quality of life. The oncologic safety of NSM in tumors < 2cm from the nipple remains in question. We conducted a systematic review to determine whether TND < 2cm was associated with increased risk of LRR in patients undergoing NSM. We included studies of invasive or in situ breast cancer < 2cm from NAC undergoing NSM which reported LRR rates. LRR rates were stratified by TND and culminated across studies. Cohort study quality was assessed using Newcastle-Ottawa Criteria. Meta-analysis was not possible due to heterogeneity in reporting survival outcomes. We identified seven retrospective cohort studies with 2295 patients and 18 case series with 3507 patients. Direct tumor involvement of NAC was considered an absolute contraindication to NSM in all studies. In cohort studies, median follow-up was 31-112 (range 14-204) months. Cohorts with TND < 2cm did not have a significantly higher rate of LRR. Amongst case series, 275 patients had TND < 2cm. Combined LRR in case series was 2.6%, with median follow-up 10.4-71 (range 0-158) months. Our systematic review did not identify TND < 2cm as a significant risk factor for LRR. NSM appears oncologically safe in select patients with TND < 2cm. Given the improved quality of life associated with NSM compared to skin-sparing mastectomy, we suggest NSM as the procedure of choice in appropriately selected patients.

The Angle of His as a Measurable Element of the Anti-reflux Mechanism

BackgroundGastroesophageal reflux disease (GERD) is a common condition, resulting from the loss of the anti-reflux barrier. Laparoscopic fundoplication is the surgical procedure of choice for treatment of GERD; however, there remains a debate on the exact mechanism through which it prevents reflux. ObjectivesOur aim was to understand the relationship between reflux, fundoplication, and the angle of His on an experimental model. MethodsThe study was conducted on four groups of fresh explanted swine stomachs: control group, myotomy, myotomy with Nissen fundoplication, and myotomy with Toupet fundoplication. The stomachs were placed in a specially designated container on an inclinable platform which would increase the hydrostatic pressure on the esophago-gastric junction. Measurements of the angle of His using fluoroscopy and the esophago-gastric orifice area using endoscopy were performed, and the occurrence of reflux was documented. ResultsEach group of the study contained nine swine stomachs. In the control and myotomy groups, the angle became wider as the incline level increased the pressure and was significantly different between the groups (p < .001). Both groups demonstrated an increase in the orifice area as the incline level increased the pressure. There was a significant correlation between the angle of His and the area of the esophago-gastric orifice (p < .001). In the control group, the reflux began at the 0°. In the myotomy group, it began at the + 15° incline (less pressure). Reflux rarely occurred in the Nissen and Toupet groups, with the breaking point being mostly defined as “beyond − 30°”. A significant difference was noted in the occurrence of reflux between fundoplication and the non-fundoplication groups (p < 0.001), while there was no significant difference between the Toupet and Nissen groups (p = 0.134). Analysis showed a significant independent correlation between both the angle of His and the orifice area with the presence of reflux (p = .002 and p = .024 respectively). ConclusionsIn this study, we developed an experimental model to enable careful evaluation of the elements of the anti-reflux mechanism, of which, the angle of His has a measurable element. We demonstrated that as the angle of His becomes wider the esophago-gastric orifice area becomes larger. Additionally, a wider angle of His and a larger esophago-gastric orifice area were correlated independently with more reflux. This suggests that the fundoplication creates an acute angle of His which is correlated with a smaller area of the esophago-gastric orifice and eventually with a lower incidence of reflux.

Conversion rate and the probable factors for conversion from laparoscopic to open cholecystectomy

Background and objective: In western countries, the incidence of Cholelithiasis is found to be more than 10% in general populations. After performing the first successful laparoscopic cholecystectomy (L.C.) in Germany by Muhe in 1986, it rapidly became the procedure of choice in treating symptomatic gall stone. L.C. has a lot of advantages, including minimal trauma, rapid recovery, less analgesic requirement with a good esthetic outcome, however even in the hands of a best surgeon still there is a small percentage of conversion to open laparotomy, some risk factors has been recognized as a reason for the conversion to open laparotomy. This study aims to evaluate the rate with the underlying risk factors that increase the chance of conversion to open cholecystectomy. Methods: A total of 1400 patients for whom L.C. was attempted, 54 were enrolled in this prospective study from January 2014 to January 2020. The exclusion criteria were malignancy or existence of gallbladder polyps detected pathologically. Patient demographics, indications for cholecystectomy, concomitant diseases, and histories of previous abdominal surgery were collected. The rates of conversion to open cholecystectomy with the underlying reasons for conversion were analyzed. Results: The overall rate of conversion to open cholecystectomy was 3.86% (54 patients). Out of 54 cases nearly two-thirds (61.1%) of the patients (33) were males and 38.9% of the patients (21) were females. Male: female ratio is 1.57:1. In the study sample, the conversion rate among obese (14/54) patients was 25.9% compared with the rate of 74.1% among non-obese (40/54) patients. Out of 3.86% of the conversion rate, 2.86% were non-obese and 1% were obese patients. The commonest etiology for conversion was thickened gall bladder due to severe gall bladder inflammation with fibrosis (21 patients) 38.9% followed by Acute cholecystitis (8 patients) 14.8%, then fibrosis (7 patients) 13% with aberrant anatomy at the calot’s triangle (6 patients) 11.1%. Conclusion: A thickened gall bladder was found to be the commonest risk factor for conversion to open cholecystectomy, the conversion from L.C. to O.C. should not be regarded as a failure of the procedure or as a complication, rather it should be regarded as a prudent maneuver for achieving the desired objective namely safe removal of the gall bladder.

Diagnostic Yield of Endoscopy in Upper Gastrointestinal Bleeding in Pediatrics

Introduction Esophagogastroduodenoscopy is currently considered the first-line diagnostic procedure of choice for upper gastrointestinal (GI) bleeding; however, the etiology of bleeding remains unknown in a subset of patients. This study aims to evaluate the diagnostic yield of upper gastrointestinal endoscopy in upper gastrointestinal bleeding in pediatrics and determine the clinical predictors for unreached diagnosis during endoscopy. Methods Cross sectional study, conducted at pediatric endoscopy unit, Ain Shams University, Cairo, Egypt, where 100 patients were recruited, as they were referred for diagnostic upper GI endoscopy due to overt upper GI bleeding in the form of hematemesis and/or melena. Full medical history, examination, laboratory investigations, endoscopic and histopathologic findings were documented. Results :100 patients with ages ranging from 3 months to 15 years, median age 4 years, 47% males and 53% females, 65% presented by hematemesis only, 7% with melena only, and 28 % presented with both hematemesis and melena. In 38 % of cases no endoscopic diagnosis was reached. While patients with a positive diagnostic yield 62%, had variable diagnosis, the most common of which was H pylori gastritis and reflux oesophagitis in 23% and 11% of cases respectively. Followed by nonspecific gastritis (8%), oesophageal varices (4%), and others (16%).. Melena was a negative predictor to reach a diagnosis by upper GI endoscopy. Conclusion Diagnostic yield of upper GI endoscopy in pediatric patients with upper GI bleeding was only 62%. Combining upper GI endoscopy with other tools in cases presenting with melena alone is highly recommended since bleeding from a source in the small bowel or right colon may also be the cause.

Safety of Ultrasound Guided Endovenous Management of Varicose Veins and How to Avoid Potential Complications

Background Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) have been used to treat superficial venous insufficiency, Ablation of veins has replaced operative saphenectomy as the procedure of choice for the treatment of superficial venous insufficiency. This change has likely taken place due to the minimally invasive nature and acceptable safety of endovenous ablation while remaining as efficacious and durable as saphenous ligation and stripping. Pattern of complications had been changed over the past decade, due to shifting from surgical stripping of varicose veins to endovenous procedures. The incidence of complications vary widely based on the level of operators as ecchymosis incidence post endovenous procedure range from (52-100%), parathesia (0.5 - 41.5%), phlebitis (0.5 – 5.5%), burn (0.46%), DVT (0.27%), and pulmonary embolism in 0.02% of cases. Aim of the Work assessing the incidence of complications during endovenous procedures of varicose veins and possible preventive measures. Assessing incidence of complications during Endovenous laser ablation (EVLA), radiofrequency ablation and injection sclerotherapy. Assessing the preventive measures that could be conducted to decrease the incidence of complications of endovenous surgeries. Patients and Methods Type of study retrospective cohort study study setting the study will be conducted at Ain Shams University Hospitals, interventional radiology department study period 2 years study population patients admitted in interventional radiology department during the past 2 years and scheduled for varicose veins treatment. Results was conducted on 20 patients, 70.0% were males and 30.0% were females with mean age of the study group was 45.35 ± 11.34 years ranged from 28 to 65 years. Most patients with no known medical or surgical history 65.5%, 25.0% were diabetic and 5.0% were hypertensive. Conclusion because most of the side effects are minor, and major complications are rare, EVLA is a safe and minimally invasive procedure with excellent efficacy in the treatment of varicose veins. Because optimizing laser parameters and the EVLA procedure may reduce the incidence and severity of complications associated with EVLA, additional research is warranted.

Volvulus of the Sigmoїde Colon: Epidemiological Aspects and Management in the General Surgery Department of the Hôpital National Ignace Deen, CHU de Conaky (Guinea)

Introduction: The aim of this study was to report our experience in the management of Volvulus of the sigmoїde colon in the general surgery department of the Ignace Deen National Hospital, CHU de Conaky, Guinea. Patients and Methods: This was a retrospective study, descriptive type, covering a 5-year period (January 2018 to December 2022), concerning the records of patients admitted and operated on for Volvulus of the sigmoїde colon at the general surgery department of the Ignace Deen National Hospital, Guinea. Results: We collected 72 cases representing 4% of digestive surgical emergencies (n=1800) and 25.35% of intestinal obstructions (n=284). The mean age was 49.4± 15.8 years (extremes: 18 and 74 years); we noted a male predominance (80.6%) with a sex ratio of 4.14. Merchants were predominant (34.7%). Abdominal pain was the main symptom in all patients. Ideal colostomy was performed in 84.7% of patients, followed by Hartmann colostomy (12.5%). Overall morbidity was 12.5%, with Surgical site infection was the only post-operative complication observed. Overall mortality was 2.8%. Average hospital stay was 11.5 ± 5.7 days. Conclusion: Volvulus of the sigmoїde colon is a common condition. Therapeutic methods are numerous, but ideal colectomy remains a procedure of choice in our context due to difficult socio-economic conditions.

PET-CT SUVmax and Endobronchial Ultrasound Features for Prediction of Malignancy: A Prospective Study

IntroductionAccurate and early staging of lung cancer has a critical impact on its prognosis. EBUS-TBNA is often the procedure of choice for mediastinal staging. Comprehension of the likelihood of malignancy of each lymph node (LN) can assist puncture decision-making during EBUS and offer insight of the procedure expected diagnostic yield. MethodsProspective analysis of mediastinal LN of patients undergoing EBUS-TBNA from April 2021 to May 2022. The relationship between PET-CT SUVmax levels, EBUS features, and malignancy on LN was investigated. For statistical analysis, patients were assigned to 3 groups: suspected malignancy (diagnosis and/or staging), confirmed malignancy (staging) or suspected benign disease. ResultsA total of 363 LN from 132 patients (71% male, mean 62 years old) were analyzed. Among those with suspected benign disease, no LN puncture resulted in a diagnosis of malignancy. PET-CT SUVmax and short axis size were independent factors for malignancy in LN of patients who underwent EBUS for suspected (p < .001 and p = .047, respectively) or confirmed malignancy (p < .001 and p < .001, respectively). All malignant LN presented SUVmax≥1.85 (≥2.85 for staging EBUS cases) and/or short axis size ≥4.28mm. Vascularized LN were more often malignant in either those with suspected (p = .087) or confirmed (p = .095) malignancy, although not statistically significant. LN that were simultaneously vascularized and lacked central hilar structure were also more commonly malignant (p = .013). ConclusionLN that has higher SUVmax and are larger should be prioritized for puncture, followed by those vascularized and lacking central hilar structure. In staging EBUS cases, a systematic sampling (N3-N2-N1) is required and must precede any malignancy yield rationale.

Fistulotomy versus fistulotomy with marsupialization, a randomized controlled trial.

Objective: To compare the efficacy of fistulotomy and fistulotomy with marsupialization in the management of simple anal fistula. Study Design: Randomized Controlled study. Setting: Department of Surgery, District Head Quarter Hospital, Mardan, Pakistan. Period: 1st September 2021 to 31st August 2022. Material &amp; Methods: A total of 60 Patients coming to hospital with simple anal fistula were randomized into two equal groups. In group A, 30 patients were treated with fistulotomy, while in group B, 30 patients were treated with fistulotomy with marsupialization. The primary outcome was set as time required for complete wound healing. Secondary outcomes were operation time, postoperative pain, anal incontinence, incidence of recurrence and patient satisfaction. Results: The mean wound healing time after 6 weeks was shorter in group B in comparison to group A (4.7± 0.74 versus 6.4± 0.85 weeks; p=0.0001). There was no significant difference in mean operation time between Group B and Group A. The difference in mean pain score was also not statistically significant. There was no significant difference in the incidence of anal incontinence, incidence of recurrence and patient’s satisfaction among two groups. Conclusion: Fistulotomy with marsupialization is more effective procedure than fistulectomy alone in shape of early wound healing without increase in operation time and therefore can be taken as surgical procedure of choice for the simple anal fistula.

Ultrasound-Guided Needle Biopsy as an Alternative to Chamberlain's Mediastinotomy and Video-Assisted Thoracoscopic Surgery (VATS) in the Diagnosis of Anterior Mediastinal Neoformations: A Retrospective Analysis.

(1) Background: The prompt diagnosis of anterior mediastinal lesions is a challenge due to their often being categorized as malignant tumours. Ultrasound-guided Transthoracic Core Needle Biopsy (US-TCNB) is an innovative technique that is arousing increasing interest in clinical practice. However, studies in this area are still scarce. This study aims to compare the diagnostic accuracy and complication rate of US-TCNB with those of traditional surgical methods-Anterior Mediastinotomy and Video Assisted Thoracoscopic Surgery (VATS)-in patients with anterior mediastinal lesions. (2) Methods: This retrospective study involved patients evaluated between January 2011 and December 2021 who had undergone US-TCNB at the Interdepartmental Unit of Internal and Interventional Ultrasound, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy. Personal data, diagnostic questions, and technical information concerning the bioptic procedure, periprocedural complications and histological reports were collected. (3) Results: Eighty-three patients were included in the analysis. Histological examination was performed in 78 cases, with an overall diagnostic accuracy of 94.0% (sensitivity 94%; specificity 100%). Only in 5 patients was a diagnosis not achieved. Complications occurred in 2 patients who were quickly identified and properly treated without need of hospitalization. The accuracy of US-TCNB was comparable to the performance of the main traditional diagnostic alternatives (95.3% for anterior mediastinotomy, and 98.4% for VATS), with a much lower complication rate (2.4% vs. 3-16%). The outpatient setting offered the additional advantage of saving resources. (4) Conclusions: a US-guided needle biopsy can be considered effective and safe, and in the near future it may become the procedure of choice for diagnosing anterior mediastinal lesions in selected patients.

Etiological Profile of Lower Gastrointestinal Bleeding in Children and Adolescents from Kashmir; A Tale of 5 Years.

Background: Lower gut bleeding is an alarming sign among caregivers. Determining the etiology is of utmost importance for further management. This is the first study conducted in northernmost India. Methods: This cross-sectional study was conducted at the Department of Pediatrics, Government Medical College, Srinagar. This study aimed to describe the etiology of lower gastrointestinal bleeding in the age group of 1-18 years over the past 5 years from June 2017 to June 2022. Results: A total of 310 children presented with hematochezia (53.5%), blood mixed with loose stools for > 2 weeks (39.3%), melena (1.9%), and occult blood in stools (0.3%). The mean age was 5.12 years. The age group of 1-6 years was 73.5 %. The most common findings were rectosigmoid polyps n=104 (33.5%), anal fissure n=47 (15.1%), lymphoid nodular hyperplasia (LNH) n=38 (12.2%), trichuris dysentery syndrome n=30(9.7%), cow's milk protein allergy n=27(8.7%), non-specific colitis n=18(5.8%), solitary rectal ulcer syndrome n=14(4.5%), inflammatory bowel disease n=6 (1.9%),intestinal tuberculosis n=3(0.9%), duodenal dieulafoy lesion 1(0.3%), and blue bleb nevus rubber syndrome n=1(0.3%). 21 patients had a normal colonoscopy. The colonoscopy yield was 93.3 %. Among the colonoscopy-negative patients, 6(1.6%) had Meckel's diverticulum, and 1(0.3%) had a duodenal dieulafoy lesion. Conclusion: Lower GI bleeding most commonly presents as hematochezia, and the most common cause is a rectosigmoid polyp. Colonoscopy is the procedure of choice to evaluate the etiology of lower GI bleeding. Anal fissures, LNH, Trichuris trichiura, and cow's milk protein allergy are other common causes of lower gut bleeding in Kashmir, northernmost India.

Four Petal Evisceration Inphthisical Eyes

Objective: Four Petal Evisceration Inphthisical Eyes. Study Design: Retrospective Study. Place And Duration of Study: Armed Forces Institute Of Ophthalmology, Rawalpindi Pakistan, from Jan 2022 to Apr 2022. Methodology: A total of 20 subjects underwent evisceration with four petal technique. The record was collected from record room and data was analyzed. After 360º conjunctival peritomy, a larger orbital implant was placed for good cosmesis and to achieve maximum ocular motility. Axial length (AL) of normal eye was measured and compared with AL of atrophic eye. An orbital implant 3mm smaller than the axial length of the normal eye was placed. Implant was closed with 4 coverings to prevent extrusion. SPSS version 22.0 was used for data analysis. Results: Out of n=20 patients with atrophia bulbi, females 11(55%) and males 9(45%). About 12(60%) were right eyes and 08(40%) were left eyes. Mean SD age of patient was 35.1±17.01 years. An implant of 18mm, 20mm and 22mm were used after calculation of axial length. Axial length of normal eye was used for the selection of size of implant. However, follow up was done from 4-18 months respectively. Conclusion: Evisceration with four petals remains the procedure of choice due to better cosmesis and good motility.

Surgeon experience with insurance barriers to offering gastric bypass as an evidence-based operation for pathologic GERD.

Obesity is an increasingly prevalent public health problem often associated with poorly controlled gastroesophageal reflux disease. Fundoplication has been shown to have limited long-term efficacy in patients with morbid obesity and does not address additional weight-related co-morbidities. Roux-en-Y gastric bypass (RYGB) is the gold standard operation for durable resolution of GERD in patients with obesity, and is also used as a salvage operation for GERD after prior foregut surgery. Surgeons report access to RYGB as surgical treatment for GERD is often limited by RYGB-specific benefit exclusions embedded within insurance policies, but the magnitude and scope of this problem is unknown. A 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD was developed and piloted by a SAGES Foregut Taskforce working group. This survey was then administered to surgeon members of the SAGES Foregut Taskforce and to surgeons participating in the SAGES Bariatrics and/or Foregut Facebook groups. 187 surgeons completed the survey. 89% reported using the RYGB as an anti-reflux procedure. 44% and 26% used a BMI of 35kg/m2 and 30kg/m2 respectively ascutoff for the RYGB. 89% viewedRYGB as the procedure of choice for GERD after bariatric surgery. 69% reported using RYGB to address recurrent reflux secondary tofailed fundoplication. 74% of responders experienced trouble with insurance coverage at least half the time RYGB was offered for GERD, and 8% reported they were never able to get approval for RYGBfor GERD indications in their patient populations. For many patients,GERD and obesity are related diseases that are best addressed with RYGB. However, insurance coverage for RYGB for GERD is often limited by policies which run contrary to evidence-based medicine. Advocacy is critical to improve access to appropriate surgical care for GERD in patients with obesity.