Post-Covid tracheal resection – first case in India

Prolonged intubations result in tracheal damage and stenosis, the treatment for severe cases is resection and anastomosis. With the progress of the Covid-19 pandemic, this incidence kept rising but the timing and precautions for such aerosolising surgeries remained unclear. To report the first case of tracheal resection and anastomosis in India done during the Covid-19 pandemic along with its rationale. We report a case of 30/male with prolonged intubation and tracheostomy done for Covid-19 pneumonia and ARDS with failure to decannulate and complete loss of voice. After thorough preoperative work-up, he underwent tracheal resection of 4 rings with cricotracheal anastomosis during the covid-19 pandemic in October 2020. He was extubated on table and was asymptomatic after 3 months of follow-up with excellent voice. With good team effort and appropriate precautions, aerosolising airway surgeries resection anastomosis can be safely performed.

Magnitude and Determinants of Treatment Outcome Among Surgically Treated Patients with Intestinal Obstruction at Public Hospitals of Wolayita Zone, Southern Ethiopia: Across Sectional Study

Background: Procedures to treat intestinal obstruction range from minimally invasive laparoscopic surgery to more complicated open surgical procedures. It may end with high morbidity and mortality because of different reasons. It is very important to know about the determinants of favorable outcome of surgical management for intestinal obstruction however, little is known about this problem at public hospitals of Southern Ethiopia. Methods: Facility based cross sectional study was conducted. A total of 230 medical records which fulfill the inclusion criteria were used for this study. Variables with p value of less than 0.25 in the bivariate analysis were entered in multivariable logistic regression to control confounding. Finally, odds ratio with 95% confidence interval was used to identify variables which were significantly associated with dependent variable. Results: According to this study the magnitude of favorable surgical management outcome of intestinal obstruction was 177(77.0%) [95% CI, 71.4, 82.4]. Having small bowel obstruction (AOR=2.49) [95% CI 1.91, 5.12], having simple bowel obstruction (AOR=4.32) [95% CI, 2.00, 9.35], early presentation of patients (AOR=4.44) [95% CI, 1.99, 9.92] and intraoperative procedure other than resection and anastomosis was performed (AOR=0.45) [95% CI, .21, .96] were significantly associated with favorable outcome among surgically treated patients.Conclusion: The overall magnitude of favorable surgical management outcome of intestinal obstruction was moderate compared to other study. Having small bowel obstruction, having simple bowel obstruction, other procedure other than resection and anastomosis done, and early presentation of patients were significant predictors. Physicians should diagnose intestinal obstruction early and appropriate interventions should be taken on time before the complication happened. On time consultation and decision at the hospital setting is also recommended.

Mortality rate comparison of enterotomy and resection and anastomosis (enterectomy) in dogs with foreign-body obstructions

PICO question In dogs with gastrointestinal foreign-body obstruction undergoing surgical correction, is the mortality rate in the perioperative period for those receiving resection and anastomosis higher, lower, or equivalent to those receiving an enterotomy? Clinical bottom line Category of research question Outcome The number and type of study designs reviewed Four retrospective studies were reviewed Strength of evidence Weak Outcomes reported It would appear that the mortality rate for resection and anastomosis for the purpose of foreign-body removal is higher than that of enterotomies performed for the same reason Conclusion There is insufficient evidence directly comparing enterotomies with resection and anastomoses in foreign-body obstructions to definitively state that the mortality rate is higher among resection and anastomosis procedures How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

An Experimental Study on Timing in Tracheal Stenosis Surgery

Background TNF-α, IL-6, and TGF-β are important bio mediators of the inflammatory process. This experimental study has investigated inflammatory biomarkers' efficacy to determine the appropriate period for anastomosis surgery in tracheal stenosis cases. Methods First, a pilot study was performed to determine the mean stenosis ratio (SR) after the surgical anastomosis. The trial was planned on 44 rats in four groups based on the pilot study's data. Tracheal inflammation and stenosis were created in each rat by using micro scissors. In rats of groups I, II, III, and IV, respectively, tracheal resection and anastomosis surgery were applied on the 2nd, 4th, 6th, 8th weeks after the damage. The animals were euthanized 8 weeks later, followed by histopathological assessment and analysis of TNF-α, IL-6, and TGF-β as biochemical markers. Results Mean SR of the trachea were measured as 21.9 ± 6.0%, 24.1 ± 10.4%, 25.8 ± 9.1%, and 19.6 ± 9.2% for Groups I to IV, respectively. While Group III had the worst SR, Group IV had the best ratio (p = 0.03). Group II had the highest values for the biochemical markers tested. We observed a statistically significant correlation between only histopathological changes and TNF-α from among the biochemical markers tested (p = 0.02). It was found that high TNF-α levels were in a relationship with higher SR (p = 0.01). Conclusion Tracheal anastomosis for post-traumatic stenosis is likely to be less successful during the 4th and 6th weeks after injury. High TNF-α levels are potentially predictive of lower surgical success. These results need to be confirmed by human studies.

Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection

Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.

P-EGS03 Curious Case of Life Threatening Gastrointestinal Bleed

Background Gastrointestinal stromal tumors are mesenchymal in origin, being derived from the interstitial cells of Cajal. These can be found anywhere in the gastrointestinal tract and are commonly found in the stomach followed by the small bowel. Gastrointestinal stromal tumors are usually asymptomatic and are often found incidentally. Chronic bleeding is one of the most common presentation. Gastrointestinal stromal tumors presenting with massive gastro intestinal haemorrhage and mimicking arteriovenous malformation on radiology are rare with only few cases reported. Methods Herein we present such a case of a 45-year-old gentleman with massive gastro intestinal bleeding. At presentation, patient was in congestive heart failure due to severe anaemia with a hemoglobin of 2.9g/dL. CECT Angiography localised the bleed to be from a jejunal mass lesion with radiological features consistent with those of arteriovenous malformation. Patient underwent laparoscopy assisted resection and anastomosis. Results Histopathology examination revealed a low risk jejunal gastrointestinal stromal tumor with no evidence of arteriovenous malformation. The mass was removed completely and the patient was discharged on 5th post-operative day. Patient was followed up in the out-patient department and was found to be doing well. Conclusions Gastrointestinal stromal tumors though relatively uncommon should be kept as important differentials for acute torrential gastrointestinal bleeding. It is highlighted that a presentation of gastrointestinal stromal tumors similar to that of arteriovenous malformations on cross sectional imaging should be kept in mind. The present case is reported in hope of expanding the knowledge of a rare occurrence, its aetiology, clinical impact and treatment.

Cecal volvulus in rural Kenya: delayed presentation contributes to high mortality

Background Cecal volvulus, which is a torsion involving the cecum, terminal ileum, and ascending colon around its own mesentery, results in a closed-loop obstruction. It is a rare reported cause of adult intestinal obstruction. This study aimed to review the clinical presentation, management, and outcomes at a rural, resource-limited referral center. Methods We performed a retrospective review of all patients with a diagnosis of cecal volvulus between January 1st, 2009 and December 31st, 2019 at Tenwek Hospital in Bomet, Kenya. The outcome of survival was compared by the time to presentation. Mortality was also compared with prior reports of intestinal obstruction at our institution. Results Thirteen patients were identified with a mean age of 52 years and a mean symptom duration of 5 days. All patients presented with abdominal pain and distension. Seven patients (54%) presented with perforation, gangrene, or gross peritoneal contamination. Identified risk factors were Ladds bands with malrotation, adhesions, and a sigmoid tumor. Procedures included primary resection and anastomosis (7), damage control (3) with anastomosis on second-look in 2 of these, simple surgical detorsion (1), and surgical detorsion and cecopexy (2). There were four mortalities (31%), of which all had delayed presentation with perforation and fecal contamination. Delays to presentation were associated with mortality (p = 0.03). Cecal volvulus resulted in increased perioperative mortality compared to all intestinal obstructions presenting to the institution (p < 0.0001). Conclusions Cecal volvulus carries a high risk of mortality. A high index of suspicion and early consideration in the differential diagnosis of intestinal obstruction should be considered to reduce the mortality associated with the delay in preoperative diagnosis.

A rare case of idiopathic multiple small bowel strictures in Indian subcontinent: a case report

Small bowel ulcers and strictures are uncommon but when they occur they can be an important cause of morbidity. We reported a case of a multiple strictures in small bowel that was treated surgically pain for 15 years. She also had hypoalbuminemia and iron deficiency anemia. A diagnosis of small bowel stricture was made on CT and surgery was advised. Resection of the 100 cm long segment of small bowel was done. Approximately 10 smooth strictures were identified in the resected segment. Histology did not identify any specific cause. A 43 year old Indian female was diagnosed with subacute small bowel obstruction. She had a history of chronic abdominal pain for 15 years. She also had hypoalbuminemia and iron deficiency anemia. A diagnosis of small bowel stricture was made on CT and surgery was advised. Resection of the 100 cm long segment of small bowel was done. Approximately 10 smooth strictures were identified in the resected segment. Histology did not identify any specific cause. Subacute small bowel obstruction can be associated with various factors. Multiple idiopathic small bowel strictures can be considered as one of the causes. In present case no cause of ulcers and strictures could be found. Idiopathic multiple bowel strictures with fecalith is rare. Histopathology and other investigations revealed no specific cause. We recorded no postoperative complications 2 months after surgery by resection and anastomosis.