Background
Limited evidence exists describing the optimum protocol for intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). Images saved during surgery often fail to ...highlight the necessary anatomical landmarks and documentation is variable. Our aim was to identify the key characteristics of an optimal IOC and evaluate current practice at our institution.
Methods
A literature search identified quality indicators for performing IOC and documenting key findings. A standardised proforma for scoring IOC was developed. Retrospective analysis was conducted of consecutive IOCs performed during elective LC. Visual documentation of seven anatomical landmarks on the captured IOC images and textual reporting in the operation note were assessed.
Results
One hundred IOCs were evaluated. Only 32 (34%) of captured images had all 7 landmarks present. All cases failed to document all seven landmarks. There was a significant difference between landmarks that could be identified on the captured images and their documentation.
Conclusions
This study suggests that IOC image capture of the key seven landmarks and their textual reporting in this cohort is sub-optimal. We believe IOC technique, minimal data set for reporting and image capture should be standardised to allow better communication of findings and facilitate meaningful comparative research relating to the subject.
To assess the outcomes of newborn screening for 5 lysosomal storage disorders (LSDs) in the first cohort of infants tested in the state of Illinois.
Tandem mass spectrometry was used to assay for the ...5 LSD-associated enzymes in dried blood spot specimens obtained from 219 973 newborn samples sent to the Newborn Screening Laboratory of the Illinois Department of Public Health in Chicago.
The total number of cases with a positive diagnosis and the incidence for each disorder were as follows: Fabry disease, n = 26 (1 in 8454, including the p.A143T variant); Pompe disease, n = 10 (1 in 21 979); Gaucher disease, n = 5 (1 in 43 959); mucopolysaccharidosis (MPS) type 1, n = 1 (1 in 219 793); and Niemann-Pick disease type A/B, n = 2 (1 in 109 897). Twenty-two infants had a positive screen for 1 of the 5 disorders but could not be classified as either affected or unaffected after follow-up testing, including genotyping. Pseudodeficiencies for alpha-L-iduronidase and alpha-glucosidase were detected more often than true deficiencies.
The incidences of Fabry disease and Pompe disease were significantly higher than published estimates, although most cases detected were predicted to be late onset. The incidences of Gaucher disease, MPS I, and Niemann-Pick disease were comparable with previously published estimates. A total of 16 infants could not be positively identified as either affected or unaffected. To validate the true risks and benefits of newborn screening for LSD, long term follow-up in these infants and those detected with later-onset disorders will be essential.
Background
The management of choledocholithiasis evolves with diagnostic imaging and therapeutic technology, facilitating a laparoscopic approach. We review our first 200 cases of laparoscopic ...exploration of the common bile duct, highlighting challenges and lessons learnt.
Methods
We retrospectively studied the first 200 cases of laparoscopic cholecystectomy with common bile duct exploration between 2006 and 2019. The database contains demographics, clinicopathological characteristics, diagnostic modalities, operative techniques, duration and outcomes.
Results
We compared two approaches: transcystic vs. transcholedochal in our 200 cases. Choledocholithiasis was suspected preoperatively in 163 patients. 21 cases found no stones. Of the remainder, 111/179 cases were completed via the transcystic route and the remaining were completed transcholedochally (68/179); 25% of the transcholedochal cases were converted from a transcystic approach. CBD diameter for transcystic route was 8.2 vs. 11.0 mm for transcholedochal. Total clearance rate was 84%. Retained or recurrent stones were noted in 7 patients. Length of stay was 5.8 days, 3.5 days in the transcystic route vs. 9.4 days after transcholedochal clearance. Eight patients required re-operation for bleeding or bile leak. No mortalities were recorded in this cohort, but 2 cases (1%) developed a subsequent CBD stricture.
Conclusion
Concomitant laparoscopic common bile duct clearance with cholecystectomy is feasible, safe and effective in a district general hospital, despite constraints of time and resources. The transcystic route has a lower complication rate and shorter hospital stay, and hence our preference of this route for all cases. Advancements in stone management technology will allow wider adoption of this technique, benefitting more patients.
Dr. Pandit noted that despite the differences in health care financing and infrastructure, both systems faced a significant backlog of elective surgical procedures, a dwindling workforce, and ...challenges with supply chains. Dr. Eva Parker examined the impact of the operating room on global climate change, from the production of carbon emissions to the inexplicable waste headed to our landfills. Presenter Lecture title Curtis Choice, MD, MS Implementation Science and Anesthesia Practice Nabil Elkassabany, MD, MSCE, MBA Big Data, Perioperative Outcomes, and Acute Pain Medicine Allison Janda, MD Applications of the MPOG Database for Quality and Safety Nasrin Aldawoodi, MD Perioperative Patient Optimization Hamdy Awad, MD, FASA Pharmacogenomics: ERAS Pathways Senthil Sadhasivam, MD, MPH, MBA, FASA Pharmacogenomics of Opioids Peter Nichol, MD Surgical instrument utilization rates, errors, and waste Laura Bellaire, MD Employee safety and economic security Jaideep Pandit, MD Jason S. Lane, MD Leadership Keynote Lecture Eva Parker, MD Environmental Sustainability in Anesthesia and Critical Care Elizabeth Duggan, MD, MS Myths and Magic of Teams Paul Taheri, MD Private Equity and Healthcare Management Aditee Ambardekar, MD, MSEd The Anesthesiology Milestones 2.0 Richard Urman, MD Training in Perioperative Medicine Rob Isaak, DO Anesthesiology Learners and Luddites in the 21st century Jim Stobinski, PhD, RN, CNOR, CNAMB, CSSM(E) Developing Positive Synergy with Non-Physician Colleagues Mike Burns, MD Anesthesiologist Staffing Ratio and Surgical Mortality Brian Allen, MD Practical Methods to Make an Acute Pain Service Profitable Mandisa-Maia Jones, MD Diversity, Inclusion, and Leadership in Anesthesiology Table 1 AACD 2023 Perioperative Leadership Summit.
Despite the grave challenges faced by all medical specialties over the past two years, all participants at the Summit noted that anesthesiology remains at the forefront of patient safety as well as ...the agile operational processes necessary to support a health care system beset on all sides by internal and external disruptive forces. Dr. David Nelson from Thomas Jefferson University Hospital was the first-place winner in the abstract competition with his group's innovative project which studied the length of stay and cost of care of patients who remain in the post-anesthetic recovery room due to either staffing or room shortages posed by pandemic-related challenges. More details about future Leadership Summits and the FAACD designation may be found on the AACD website at https://aacdhq.org/.Declaration of Competing Interest The authors are members of the board of the Association of Anesthesia Clinical Directors (AACD).
Background
Laparoscopic common bile duct exploration (LCBDE) is relatively a new approach for clearing choledocholithiasis. The aim of this study is to assess the safety of this approach to clearing ...common bile duct (CBD) stones on an index admission including emergency setting.
Methods
Retrospective data collection and analysis were carried out for 207 consecutive cases of LCBDE performed in Royal Cornwall Hospital over 6 years (2015–2020). Patients were divided into two groups (Index admission vs elective) then both groups compared.
Results
A total of 207 cases of LCBDE were performed in our unit during the time period. One hundred twenty-two operations were performed on the index admission and 85 on a subsequent elective list. Mean operative time was 146 ± 64 min in the index admission group and 145 ± 65 min in the elective group (
p
= 0.913). Length of stay post-operatively was 3.3 ± 6.3 days in the index admission cases and 3.5 ± 4.6 days after elective cases.
Successful clearance was achieved at the end of the operation in 116 patients in the index admission group, clearance failed in one case and negative exploration in 5 patients. In the elective group 83 patients had a successful clearance at the end of the operation, and 2 patients has had a negative exploration.
Twelve patients (index admission group) and 8 patients of the elective cases required post-operative Endoscopic Retrograde Cholangiopancreatography (ERCP) to manage retained stones, recurrent stones and bile leak (
p
= 0.921). Three patients required re-operation for post-operative complications in each group.
Conclusion
Common bile duct exploration in index admission is safe with high success rate if performed by well-trained surgeons with advanced laparoscopic skills.
Surfactant Protein B Deficiency is a rare but lethal monogenetic, congenital lung disease
of the neonate that is unresponsive to any treatment except lung transplantation. Based on
the potential that ...gene therapy offers to treat such intractable diseases, our objective
was to test whether an electroporation-based gene delivery approach could restore
surfactant protein B expression and improve survival in a compound knockout mouse model of
surfactant protein B deficiency. Surfactant protein B expression can be shut off in these
mice upon withdrawl of doxycycline, resulting in decreased levels of surfactant protein B
within four days and death due to lung dysfunction within four to seven days. Control or
one of several different human surfactant protein B-expressing plasmids was delivered to
the lung by aspiration and electroporation at the time of doxycycline removal or four days
later. Plasmids expressing human surfactant protein B from either the UbC or CMV promoter
expressed surfactant protein B in these transgenic mice at times when endogenous
surfactant protein B expression was silenced. Mean survival was increased 2- to 5-fold
following treatment with the UbC or CMV promoter-driven plasmids, respectively. Histology
of all surfactant protein B treated groups exhibited fewer neutrophils and less alveolar
wall thickening compared to the control groups, and electron microscopy revealed that gene
transfer of surfactant protein B resulted in lamellar bodies that were similar in the
presence of electron-dense, concentric material to those in surfactant protein
B-expressing mice. Taken together, our results show that electroporation-mediated gene
delivery of surfactant protein B-expressing plasmids improves survival, lung function, and
lung histology in a mouse model of surfactant protein B deficiency and suggest that this
may be a useful approach for the treatment of this otherwise deadly disease.
Impact statement
Surfactant protein B (SP-B) deficiency is a rare but lethal genetic disease of neonates
that results in severe respiratory distress with no available treatments other than lung
transplantation. The present study describes a novel treatment for this disease by
transferring the SP-B gene to the lungs using electric fields in a mouse model. The
procedure is safe and results in enough expression of exogenous SP-B to improve lung
histology, lamellar body structure, and survival. If extended to humans, this approach
could be used to bridge the time between diagnosis and lung transplantation and could
greatly increase the likelihood of affected neonates surviving to transplantation and
beyond.
Despite having a high risk of acquiring sexually transmitted infections, people who inject drugs (PWID) often do not receive recommended HPV screenings due to barriers to healthcare. Guideline-based ...cervical HPV screening and vaccination can prevent cervical cancer. Low-cost, low-barrier methods for cancer screening and prevention are important for vulnerable communities such as PWID.
We examined acceptability of HPV self-sampling at a syringe services program (SSP). Participants with a cervix (n = 49) participated in patient education followed by a survey to assess willingness to perform HPV self-sampling versus standard of care.
59% found self-sampling to be acceptable, citing privacy, ease, and quickness. Among those opting for HPV screening delivered by a provider (n = 16), participants cited concerns about adequate sampling (81%) and test accuracy (75%). Notably, only 18% of participants reported complete HPV vaccination.
Cervical HPV self-sampling was acceptable to PWID. SSP-based efforts to provide preventative health services could place tools for cancer screening into the hands of PWID, a need-to-reach community.
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