Pancreatic anastomosis training models: Current status and future directions.

Postoperative pancreatic fistula (POPF) is a major cause of morbidity and mortality after pancreatoduodenectomy (PD), and previous research has focused on patient-related risk factors and comparisons between anastomotic techniques. However, it is recognized that surgeon experience is an important factor in POPF outcomes, and that there is a significant learning curve for the pancreatic anastomosis. The aim of this study was to review the current literature on training models for the pancreatic anastomosis, and to explore areas for future research. It is concluded that research is needed to understand the mechanical properties of the human pancreas in an effort to develop a synthetic model that closely mimics its mechanical properties. Virtual reality (VR) is an attractive alternative to synthetic models for surgical training, and further work is needed to develop a VR pancreatic anastomosis training module that provides both high fidelity and haptic feedback.

Potential clinical utility of intraoperative fluid amylase measurement during pancreaticoduodenectomy.

Backgrounds/Aims: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a source of major morbidity and mortality. Early diagnosis and treatment of POPF is mandatory to improve patient outcomes and clinical risk scores may be ombined with postoperative drain fluid amylase (DFA) values to stratify patients. The aim of this pilot study was to etermine if intraoperative fluid amylase (IFA) values correlate with DFA1 and POPF. Methods: In patients undergoing PD from February to November 2020, intraoperative samples of intra-abdominal fluid adjacent to the pancreatic anastomosis were taken and sent for fluid amylase measurement prior to abdominal closure. Data regarding patient demographics, postoperative DFA values, complications, and mortality were prospectively collected. Results: Data were obtained for 52 patients with a median alternative Fistula Risk Score (aFRS) of 9.9. Postoperative complications occurred in 20 (38.5%) patients (five Clavien grade ≥ 3). There were eight POPFs and two patients died (pneumonia/sepsis). There was a significant correlation between IFA and DFA1 (R2 = 0.713; p < 0.001) and DFA3 (p < 0.001), and the median IFA was higher in patients with POPF than patients without (1,232.5 vs. 122; p = 0.0003). IFA > 260 U/L predicted POPF with sensitivity, specificity, positive and negative predictive values of 88.0%, 75.0%, 39.0%, and 97.0%, respectively. The incidence of POPF was 43.0% in high-risk (high aFRS/IFA) and 0% in lowrisk patients (low aFRS/IFA). Conclusions: IFA correlated with POPF and may be a useful adjunct to clinical risk scores to stratify patients during PD. Larger, prospective studies are needed to determine whether IFA has clinical utility.

Influence of middle hepatic vein resection during right or left hepatectomy on post hepatectomy outcomes.

Backgrounds/Aims: Middle hepatic vein (MHV) is usually preserved as a part of the right or left hepatectomy in order preserve the venous outflow of remnant liver. The aim of this study was to evaluate if resection of MHV could influence post-resection outcomes of standard right or left hepatectomy. Methods: Patients who underwent standard right or left hepatectomy between January 2015 and December 2019 were included. Anatomical remnant liver volumes were measured retrospectively using the Hermes workstation (Hermes Medical Solutions AB, Stockholm, Sweden). Uni- and multi-variate analyses were performed to assess the difference in outcomes of those with preservation of MHV and those without preservation. Results: A total of 144 patients were included. Right hepatectomy was performed for 114 (79.2%) and left hepatectomy was performed for 30 (20.8%) patients. MHV was resected for 13 (9.0%) in addition to the standard right or left hepatectomy. Median remnant liver volume was significantly higher in the MHV resected group (p < 0.01). There was no significant difference in serum level of bilirubin, international normalized ratio, alanine aminotransferase, creatinine on postoperative day 1, 3, 5, or 10, ≥ grade IIIa complications (p = 0.44), or 90-day mortality (p = 0.41). On multivariable analysis, resection of the MHV did not influence the incidence of post hepatectomy liver failure (p = 0.52). Conclusions: Resection of the MHV at standard right or left hepatectomy did not have a negative impact on postoperative outcomes of patients with adequate remnant liver volume.

Thromboelastography demonstrates progressive hypercoagulability in COVID-19 patients admitted to ICU with respiratory failure.

Thromboembolic complications are associated with COVID-19 owing to the hypercoagulable nature of the disease. Although patients with COVID-19 often have higher levels of fibrinogen and D-dimers, hypercoagulability has been attributed to various other factors too. In this prospective observational study conducted between April 2020 and June 2020, we compared coagulation parameters using thromboelastography in COVID-19 patients to non-COVID-19 patients admitted to ICU with respiratory failure. This study demonstrated a significant difference between the cohorts in functional fibrinogen (CFF) progressively from third day of ICU admission whilst there was no difference in the Clauss fibrinogen levels. COVID-19 patients also demonstarted supranormal R time indicating hypocoagulability. These mixed coagulation changes suggest targeting fibrinogen or platelets may prevent thromboembolic complications in COVID-19.

Yoga and other meditative movement therapies to reduce chronic pain.

CLINICAL QUESTION: In adults with chronic pain, do yoga and other meditative movement therapies to improvement in chronic pain symptoms? ANSWER: Yes. However, in each of the studies reviewed, yoga classes were included as part of the pain management regime, sometimes alone and sometimes in tandem with DVDs or audiotapes. We feel that no exercise therapy program should be undertaken without professional coaching from certified, registered and qualified instructors. DATE ANSWER WAS DETERMINED: August 2014, June, 2015, August 2015. LEVEL OF EVIDENCE FOR THE ANSWER: A. SEARCH TERMS: chronic pain, yoga, exercise therapy, meditative movement therapy. INCLUSION CRITERIA: Adults; meta-analyses; systematic reviews; cohort studies; randomized controlled trials; practice guidelines; articles from 2010 to present. EXCLUSION CRITERIA: Children younger than 18 years of age, Pilates.

Engineering Crack Formation in Carbon Nanotube-Silver Nanoparticle Composite Films for Sensitive and Durable Piezoresistive Sensors.

We report highly sensitive and reliable strain sensors based on silver nanoparticle (AgNP) and carbon nanotube (CNT) composite thin films. The CNT/AgNP was prepared by a screen printing process using a mixture of a CNT paste and an AgNP ink. It is discovered that the sensitivity of such sensors are highly dependent on the crack formation in the composites. By altering the substrate use and the relative ratios of AgNPs and CNTs, the formation and propagation of cracks can be properly engineered, leading to piezoresistive strain sensors with enhanced sensitivity and robustness.

Combined spinal epidural anaesthesia for gastroschisis repair.

SUMMARY: Gastroschisis is a congenital anomaly with a high perioperative mortality. Administration of general anaesthesia to these high risk neonates is associated with several problems including postoperative apnoea and the need for mechanical ventilation. Central neuraxial blocks, and more recently, combined spinal epidural have been administered for major abdominal surgery in neonates. We present the case of a neonate posted for gastroschisis repair conducted under combined spinal epidural anaesthesia and discuss the several advantages of this technique.