Cerebral Air Embolism During a Flight

Introduction: We report a case of a 67 year old lady with an acute drop in conscious level whilst on a transatlantic flight. She had a background history of TII DM and recent mild COVID. Past surgical history of a gastric bypass, at which time a CXR had incidentally shown a bulla, with no underlying respiratory symptoms, or history of COPD. Method(s): On arrival in the emergency department, her GCS was 7/15, and she required immediate intubation. Non-contrast CT head showed multiple tiny gas locules in keeping with air emboli. CT Chest, Abdo, Pelvis showed an 88mm bulla within the left lung lingula with a bronchus and many large pulmonary vessels running on its edge. Result(s): It was thought the change in air pressure during the flight caused a communication to open between the bulla and the pulmonary circulation resulting in the release of air emboli. Conclusion(s): She required ITU admission for 8 days. After initial stabilisation she was stepped down to HASU. Neurologically she was dysphagic, dysarthric, quadriplegic and GCS 14 due to confusion. MRI whole spine ruled out spinal cord pathology. Repeat CT head showed air initially present had completely resorbed leaving multifocal, small areas of cortical and subcortical ischaemia in both cerebral hemispheres. MRI head confirmed innumerable small early subacute embolic ischaemic infarcts across multiple vascular distributions.

Irish Section Conference , Impact of Nutrition Science to Human Health: Past Perspectives and Future Directions

The proceedings contain 78 papers. The topics discussed include: Socio-demographic and environmental factors associated with adolescent overfat and obesity in Ireland - preliminary analysis from the national teens' food survey ii;pilot study: use of a novel portion control device and dietetic app in a six-week weight management intervention;using mixed methods to investigate the weight change, dietary intake and physical activity of black pregnant women, incorporating a participant and public involvement approach;effects of misreporting on agreement of methods to measure sodium status in the national diet and nutrition survey;a mixed method assessment on the acceptability of an online cancer nutrition resource (OCNR);the influence of timing of eating on weight loss in gastric bypass patients;and vitamin D and the COVID-19 pandemic: Notified supplements in Ireland before and during the pandemic.

One Anastomosis Gastric Bypass (OAGB) as a bariatric procedure in a teaching tertiary hospital in Athens during COVID-19 pandemic

Emmanouil Onoufrios Sgouromallis ATHENS1, Konstantinos Livanos Chalandri1, Georgios Xenakis ATHENS1, Melissanthi Bechraki- Triantafyllou ATHENS1, Parmenion Patias Athens1, Ilias Margaris Athens1 2nd Surgical Dept, George Gennimatas General Hospital, Athens, Greece1 Background: OAGB is a bariatric procedure with excellent results while presumed to have a lower learning curve than classic RYGB. COVID-19 pandemic has severe ramifications in the global health system and this effect is amplified in obesity management due to both the fear of perioperative mortality of bariatric patients and the social stigma that often follows. Methods: We retrospectively analyzed the data of 67 consecutive OAGBs performed in our center from March 2020 to end of December 2021. Results: 47 patients were female, mean age was 41.64 while mean preoperative BMI was 50.45. Mean Hgb decrease was 1.43 postoperatively with mean hospital stay of 4.47 days. All procedures were performed by an attending surgeon as supervisor and two 5th year residents with bariatric surgery experience. There were 3 postoperative leaks, 2 of which resolved with conservative management. No patients were infected during their hospital stay while one patient was admitted to the COVID clinic due to a mild infection two months post operatively with an uneventful course. During the short follow-up period hypertension, diabetes and obstructive sleep apnea were significantly improved or disappeared while no patient reported symptoms of reflux esophagitis. Conclusion: OAGB is feasible as a procedure, with an acceptable learning curve in tertiary centers. COVID pandemic did not decrease bariatric procedures;however one patient who was the only death in our study was admitted in ICU with 24 hours delay due to the decreased availability of ICUs during the pandemic, a factor to be considered during this period.

Laparoscopic Paraoesophageal Hernia, Gastric Bypass and Peroral Endoscopic Myotomy in a patient with Achalasia and Gastroesophageal reflux after Sleeve Gastrectomy

Daniel Slack Charlotte NC1, Paul Colavita Charlotte NC1, Abdelrahman Nimeri Charlotte NC1 Carolinas Medical Center, Atrium Health1 We present a 55-year-old female with class II obesity and a previous history of sleeve gastrectomy who developed significant gastroesophageal reflux disease refractory to medical management. After a covid infection in fall of 2020 she began to report new symptoms of dysphagia that progressed from solids to liquids. She underwent extensive workup including upper endoscopy, upper GI barium swallow, manometry, pH impedence and EndoFlip leading to a diagnosis of Achalasia type II as well as a paraesophageal hernia. Given these findings she underwent a combined paraesophageal hernia repair with conversion of sleeve gastrectomy to Roux-en-Y gastric diversion and an intra-operative Peroral Endoscopic Myotomy. Intra-operatively she was noted to have significant lower abdominal adhesions leading to performing the Roux-en-Y reconstruction through a supramesocolic defect in a retrocolic fashion. The patient tolerated the procedure well and recovered with improvement of both her reflux and achalasia.

Prompt Diagnosis and Intervention of Oxalate Nephropathy to Salvage Kidney Function

Hyperoxaluria can be primary due to defective glyoxylate metabolism leading to hepatic oxalate overproduction or secondary due to increased intestinal oxalate absorption. Oxalate nephropathy is the deposition of calcium oxalate crystals leading to tubular injury, interstitial fibrosis, and AKI or CKD. This describes three cases of renal oxalosis. First is a 60 year old male with stroke, hypertension, diabetes who presented with AKI of 4.5 mg/dL from 1.6 that rose to 11 mg/dL. Serologies for glomerulonephritis and paraproteinemia were negative. Biopsy showed tubular oxalate crystal deposition with tubular injury and interstitial nephritis. His renal failure required dialysis. Second is a 58 year old female with gastric bypass surgery who presented for edema and AKI from 1.3 to 3.6 mg/dL. Serologies were also negative. Biopsy showed interstitial nephritis with tubular calcium oxalate deposition. She was started on prednisone 60 mg. Creatinine stabilized to 2.2 mg/dL, not requiring dialysis. Third is a 82 year old male with obesity and sarcoma of the scalp treated with pembrolizumab who presented with dyspnea, edema and an AKI from 1 to 8.6 mg/dL. Urine sediment was bland with negative serologies. Differential included AIN due to pembrolizumab. Patient was started on high dose prednisone and biopsy showed interstitial nephritis and calcium oxalate crystal deposition. Patient endorsed taking frequent vitamin C as prophylaxis for Covid. Creatinine stabilized to 2.9 mg/dL not on dialysis. Classic etiologies of hyperoxaluria include dietary oxalate from ascorbic acid and fat malabsorption from gastric bypass surgery. Treatment includes increased fluid intake, oral calcium supplements and low oxalate diet. Oxalate nephropathy remains an under recognized cause of kidney failure, as such, early biopsy and intervention are necessary. (Figure Presented)

Anaesthetic management of a parturient with Klippel-Trenaunay syndrome

Introduction: Klippel-Trenaunay syndrome (KTS) is a rare congenital vascular disease which is characterised by capillary, venous and lymphatic malformations. We describe the anaesthetic management of a 36 year old parturient with COVID-19 and KTS, who underwent an elective caesarean section. Very few such cases have been described and the multi-system nature of condition poses various challenges to both the obstetrician and the anaesthetist. Case Report: We had a 36-year-old woman who had experienced three previous normal vaginal deliveries and an elective caesarean section (CS) four years previously under general anaesthetic(GA) at 36 weeks gestation. She was told by a vascular surgeon that she was not suitable for regional anaesthesia. There was no recent imaging of her back to rule out arteriovenous(AV) malformations. Her past history included gastric bypass surgery under GA two years ago. She also had depression, varicose veins and three previous deep venous thrombosis andwas on prophylactic lowmolecularweight heparin. She had tested positive for COVID-19 4 days previously, and had mild symptoms of cough and sore throat. After a multi-disciplinary discussion involving an obstetrician, vascular surgeon, haematologist and anaesthetist, a decision was made to proceed with GA despite recent COVID-19, because of the possibility of AV malformations, in agreement with the patient. After securing two wide bore cannulae and adequate preoxygenation, a modified Rapid Sequence Induction was performed, and a tracheal tube was secured. Anaesthesia was maintained with oxygen, nitrous oxide and sevoflurane. After delivery of the baby, oxytocin 5U, followed by an infusion, midazolam, morphine, ondansetron and dexamethasone were administered. Extubation was performed when the patient was fully awake. In recovery, further opioids were given for pain. There were no concerns for the newborn. Estimated blood loss was 200 mL. Discussion: Gestation and its physiology may further exacerbate the manifestations of KTS, with increased obstetric risk. The success in the management of these patients requires the participation of a multidisciplinary team, consisting of obstetrician, anaesthetist, urologist, haematologist and vascular surgeon, with appropriate collaboration among the professionals involved. Periodic imaging and clotting tests are recommended to evaluate the evolution of vascular malformations in the pelvis, uterus and vagina, and identify neuraxial changes, to guide the safest way of delivery and anaesthesia.

Roux-en-Y gastric bypass surgery induced oxalosis and acute kidney injury: A case report.

INTRODUCTION AND IMPORTANCE: Diabetes mellitus and hypertension are two conditions that can coexist in obese individuals. Roux-en-Y gastric bypass (RYGB) surgery, are used to control obesity. Complications such as steatorrhea, hyperoxaluria, and decreased bone mineral density, may occur after RYGB. CASE PRESENTATION: A 58-year-old woman referred to the emergency department complaining of pain on the right side of her lower abdomen. Her past medical history was RYGB surgery, COVID-19 with 40% pulmonary involvement, and Chronic Kidney Disease (CKD). Rapid progressive glomerulonephritis (RPGN) was predicted based on extensive laboratory test results. A kidney biopsy demonstrated oxalate nephropathy. Along with the findings from the kidney biopsy, acute tubulointerstitial nephritis with tubular injury secondary oxalosis was diagnosed. CLINICAL DISCUSSION: RYGB surgery and chronic kidney disease, can increase the risk of secondary oxalosis. Recent studies introduce enteric hyperoxaluria as an important marker for diagnosing end-stage kidney disease. Renal biopsy is often prescribed for absolute recognition of oxalosis. On the other hand, our patient has a recent history of COVID-19 infection. The use of anti-Covid-19 drugs in patients with renal insufficiency should be considered with caution. CONCLUSION: It is important to monitor kidney function following RYGB surgery, particularly in patients with underlying diseases such as diabetes or hypertension.