Unique method for removal of knotted lumbar epidural catheter: A case report

BACKGROUND

Combined spinal-epidural (CSE) anesthesia is the preferred anesthesia method for cesarean delivery. The use of an epidural catheter is essential for administering additional drugs intraoperatively and managing postoperative pain. However, the insertion of epidural catheters is associated with various complications, such as total spinal anesthesia, symptoms indicative of spinal nerve root irritation, and challenges in epidural catheter removal.

CASE SUMMARY

We present a case report of a challenging epidural catheter removal due to knotting. The lumbar computed tomography scan results revealed that the catheter formed a tight knot in the epidural space. We used a novel extubation method and successfully removed the catheter.

CONCLUSION

The operator can use opposite forces to "spiral" apart the spinal joints by positioning the patient's body in a specific position. The findings indicate that, when combined with imaging examination results, this method is effective for the removal of epidural catheters.

Can we predict urethral length of boys? - An observational study

INTRODUCTION

An additional knowledge about normal anatomy of urethra in boys can improve clinical outcome of any urological interventions. This will also reduce catheter related complications like intra vesical knotting and urethral injuries. At present there is no systematic data available which has studied the urethral length of boys. We have done this study to analyse the length of urethra in boys.

AIM

The aim of the study is to measure the urethral length in Indian children from the age of 1 year till 15 years and plot a nomogram. Furthermore to analyse the influence of anthropometry on urethral length and derived a formula to predict the urethral length in boys.

STUDY DESIGN

This is a single institution prospective observational study. After obtaining clearance from the institutional review board, a total of 180 children from the age of 1-15 were recruited for the study. The urethral length was measured during Foley's catheter removal. Other data like age, weight, and height of the patient are collected and the obtained values were analysed with SPSS software. The acquired figures were further used to derive formulae to predict urethral length.

RESULTS

A nomogram of urethral length based on age was plotted. With collected figures, five separate formulae were derived to calculate the urethral length based on the age, height and weight. Furthermore for day-to-day use we have deduced a formulas to calculate urethral length which are simplified forms of original formulae.

DISCUSSION

The length of urethra of a new-born male is 5 cm, which attains 8 cm by three years of age and to 17 cm by adulthood. There were attempts to measure the urethral length in adults using cystoscopy, Foley's catheter and different imaging techniques like Magnetic Resonance Imaging and dynamic retrograde urethrography. Simplified formulae which has been derived from this study for clinical use is Urethral length = 8.7 + Age (in year) × 0.55 CONCLUSION: Our results will complement the current anatomical understanding of the urethra. This evades some rare complications of catheterisation and facilitate reconstructive procedures.

Ileosigmoid knotting: A case report of unique cause of acute abdomen in a Nepalese patient

Introduction and importance

Ileosigmoid knotting is a surgical emergency. Common in Asian males, it is presented with signs and symptoms of diffuse peritonitis. Aggressive resuscitation with intravenous fluids and antibiotics followed by workup enable the patient hemodynamically stable. Explorative laparotomy followed by colo-colic anastomosis and double barrel ileostomy is curative.

Case presentation

A 32-year-old-male from Nepal with a chief complain of diffuse abdominal pain for a day and signs of peritonitis presented to Emergency room. After assessing and stabilizing the patient, explorative laparotomy was performed. Ileal and sigmoid resection followed by colo-colic anastomosis and double barrel ileostomy was done. On regular follow-up, he is in his usual state of health.

Discussion

The incidence of ileosigmoid knotting is reported to be about 1.6 cases per year. It is often misdiagnosed as non-specific intestinal obstruction which confers poor prognostic value to the patient. It should be identified promptly and intervened timely.

Conclusion

Ileosigmoid knotting is a rare but dangerous differential of acute abdomen not to be missed. Early assessment and quick decision making is the key to provide excellent prognosis to the patient in need, provided adequate surgical skills are demonstrated.

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Ileosigmoid knotting is a surgical emergency.

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It is common in Asian males.

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Patient presents with signs and symptoms of diffuse peritonitis.

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Explorative laparotomy should be done.

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Ileal and sigmoid resection followed by colo-colic anastomosis with double barrel ileostomy was performed.

Ileosigmoid knotting: An update for Atamanalp classification

Ileosigmoid knotting (ISK) is an extremely rare double-loop bowel obstruction. ISK is treated by emergency surgery with a relatively poor prognosis. Although some classification methods have been developed for ISK to date, the most comprehensive method was defined in 2018. Then, some subjects concerning this issue were evaluated in the literature. The aim of this paper is to update the last classification method in light of both the evaluations in the literature and our clinical experience with 80 ISK cases, which is one of the largest published single-centre ISK series.

Learning curves, potential and speed in training of laparoscopic skills: a randomised comparative study in a box trainer

Background

The effectiveness of practical surgical training is characterised by an inherent learning curve. Decisive are individual initial starting capabilities, learning speed, ideal learning plateaus, and resulting learning potentials. The quantification of learning curves requires reproducible tasks with varied levels of difficulty. The hypothesis of this study is that the use of three-dimensional (3D) vision is more advantageous than two-dimensional vision (2D) for the learning curve in laparoscopic training.

Methods

Forty laparoscopy novices were recruited and randomised to a 2D Group and a 3D Group. A laparoscopy box trainer with two standardised tasks was used for training of surgical tasks. Task 1 was a positioning task, while Task 2 called for laparoscopic knotting as a more complex process. Each task was repeated at least ten times. Performance time and the number of predefined errors were recorded. 2D performance after 3D training was assessed in an additional final 2D cycle undertaken by the 3D Group.

Results

The calculated learning plateaus of both performance times and errors were lower for 3D. Independent of the vision mode the learning curves were smoother (exponential decay) and efficiency was learned faster than precision. The learning potentials varied widely depending on the corresponding initial values and learning plateaus. The final 2D performance time of the 3D-trained group was not significantly better than that of the 2D Group. The final 2D error numbers were similar for all groups.

Conclusions

Stereoscopic vision can speed up laparoscopic training. The 3D learning curves resulted in better precision and efficiency. The 3D-trained group did not show inferior performance in the final 2D cycle. Consequently, we encourage the training of surgical competences like suturing and knotting under 3D vision, even if it is not available in clinical routine.

The role of Ataturk University in data and publication production for sigmoid volvulus and ileosigmoid knotting

Objective

Sigmoid Volvulus (SV) and Ileosigmoid Knotting (ISK) are rare intestinal obstruction forms, but Turkey is endemic for these diseases. The aim of this study was to evaluate the role of our publications in the world literature.

Methods

We electronically searched Web of Science database to evaluate the manuscripts published during June 1966 to July 2018.

Results

Total 788 manuscripts have been published by 289 different organizations (2.7 items per organization) around the world. Among them, 71 (9.0%) are from 31 different institutions in Turkey, while 37 manuscripts (4.7% of total and 52.1% of Turkish items), including 27 on SV and 10 on ISK, have been published by our clinic. Of our publication, 19 items (51.4%) were original articles, 10 (27.0%) were published in Turkish Journal of Medical Sciences, 30 (81.1%) were published over a period spanning from 2009 to 2018, and in 32 of which (86.5%) the corresponding author was Atamanalp.

Conclusion

Arising from our 1,008-case SV and 80-case ISK experiences over a 52-year period between June 1966 and July 2018, our clinic has an important role in the data production and publication for SV and ISK. It seems that our clinic may provide several more documents in the years to come.

Ileosigmoid knotting: One of the largest single-center series

Ileosigmoid knotting (ISK) is the wrapping of the ileum or sigmoid colon around the base of the other structure, causing a double-loop intestinal obstruction. The disease generally presents as an intestinal obstruction with volvulus triad, including abdominal pain/tenderness, distention, and obstipation. Abdominal X-ray findings are not pathognomonic, and computerized tomography (CT) and magnetic resonance imaging (MRI) are more useful in the diagnosis. A patient with ISK generally requires an emergency laparotomy following resuscitation. Based on the viability of the ileum and sigmoid colon, different resectional or non-resectional surgical techniques may be used. In this report, one of the largest single-center ISK series in the world, an eighty-case series, is concisely presented.

Knotting of a Cervical Epidural Catheter in the Patient with Post-Herpetic Neuralgia: A Rare Complication

Epidural block is achieved either by single injection of local anesthetic through an epidural needle or as a continuous block by infusion pump through an epidural catheter. Complications associated with epidural catheters include breakage, entrapment, and knotting. Knotting of epidural catheters is very rare, but knotting in lumbar epidural catheters has been reported in a number of studies, and most of these cases involved removal difficulty. We report a case in which we inserted a cervical epidural catheter in a patient who was experiencing severe post-herpetic neuralgia and then removed the knotted catheter without complications.

Identical wave forms of vena cava and pulmonary artery during pulmonary artery catheter insertion due to kinking: a case report of a rare complication

BACKGROUND

We experienced a rare malposition of a pulmonary artery catheter due to kinking in a 63-year-old male who was scheduled for an off-pump coronary artery by-pass graft.

FINDINGS

Given the difficulty to obtain stable pulmonary artery waveform, we discovered that the two waveforms of the distal and proximal ports of the pulmonary artery catheter were completely identical. Subsequent fluoroscopy revealed that because the catheter had formed a kink around the apex of the right ventricle, the distal port faced the proximal port of the catheter.

CONCLUSIONS

We recommend that both ports of the pulmonary artery catheter need to be monitored simultaneously in case neither portable fluoroscopy nor transesophageal echo is available.

Ileosigmoid knotting

Ileosigmoid knotting (ISK) is the wrapping of the ileum around the sigmoid colon and its mesentery or vice-versa. The incidence of ISK is not well known, but it generally occurs in areas with a high incidence of sigmoid volvulus, and it is common in adult males. The etiology of ISK is controversial. The main symptoms are abdominal pain, distention, obstipation, and vomiting, while the main signs are abdominal distention and tenderness. There are no specific blood tests for diagnosing ISK. Plain abdominal X-ray radiographs demonstrate a dilated sigmoid colon and multiple small intestinal air-fluid levels. Abdominal CT demonstrates a twisted and dilated sigmoid colon with whirled sigmoid mesentery, in addition to twisted and dilated small intestinal segments. The accurate preoperative diagnosis of ISK is difficult. After rapid and prompt resuscitation, emergency surgery is needed in the treatment of ISK. In gangrenous cases, resection with primary anastomosis is preferred, while, in nongangrenous cases, untying of the knot may be performed as a sole surgical procedure, or a volvulus-preventing procedure may be added. The mean mortality rate for ISK is 6.8-8% in nongangrenous and 20-100% in gangrenous cases.