Optimizing Total Laparoscopic Hysterectomy for the Geriatric Population: A Practical Case Study and Comprehensive Literature Review.

Elderly patients represent a large cohort of patients requiring gynaecological surgery for benign and malignant indications. In recent years, several conventional gynaecological procedures have shifted towards minimally invasive alternatives such as laparoscopy, hysteroscopy, and robotic surgery. A recent Surveillance, Epidemiology, and End Results (SEER) analysis compared the outcomes of 25,000 women undergoing laparotomy versus laparoscopic approach to hysterectomy and found that laparoscopy is associated with a shorter duration of hospitalization (three days versus five days), less postoperative complications (76%), less requirement for blood transfusion, reduced operational costs, faster recovery, and an overall safer surgical experience. Although geriatric patients are affected by age-related comorbidities, physiologic changes, and altered pharmacodynamics and pharmacokinetics of administered drugs, these patients benefit most from minimally invasive surgery. In this paper, we present a comprehensive account of the interdisciplinary perioperative approaches employed to accomplish a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection in an 82-year-old patient who was diagnosed with grade I endometrial adenocarcinoma and multiple age-related medical comorbidities.

The Effect of a Simple Perioperative Video on Maternal Anxiety and Satisfaction Before Regional Anesthesia in a Caribbean Setting: A Randomized Controlled Trial.

BACKGROUND: Anxiety before regional anesthesia and surgery is common among women undergoing cesarean section. Although perioperative education has been shown to reduce this level of anxiety, the optimal form and timing of this intervention are not known. The goal of this study was to evaluate the efficacy of an educational anesthetic video on reducing anxiety and improving maternal satisfaction in patients scheduled for elective cesarean section under regional anesthesia. METHODS: Eighty patients scheduled for cesarean section at a tertiary-level obstetric center were randomized to either an interventional group (viewed an educational video on the evening before surgery) or the control group (no educational video). Both groups received a standard preoperative assessment on the morning of surgery. Anxiety was assessed using the Spielberger State-Trait Anxiety Inventory (STAI) and the visual analog scale for anxiety (VAS-A). Maternal satisfaction was assessed using the Maternal Satisfaction Scale Score for Cesarean Section (MSSSCS). Anxiety was assessed at baseline (the evening before surgery) and immediately before surgery. Maternal satisfaction was assessed on the first postoperative day. Patients in the intervention group also had their state anxiety measured immediately after viewing the educational anesthetic video using the VAS-A. RESULTS: Both groups were equally matched at baseline, and a statistically significant reduction in anxiety measured using VAS-A was seen in the intervention group vs. the control group (6 vs. 4.6, p = 0.018). State-trait anxiety measured using STAI, however, was not significantly lower in the intervention vs. control group (44 vs. 46, p = 0.99). VAS-A immediately after looking at the video was also not significantly different (5 vs. 4, p = 0.323) from the control group. Maternal satisfaction was also higher in the intervention group (113 vs. 104.5, p = 0.015). CONCLUSION: The use of a simple educational anesthetic video may be associated with reduced anxiety and improved maternal satisfaction in patients scheduled for elective cesarean section under regional anesthesia.

Perioperative challenges following management of spontaneous hepatic rupture in a parturient with severe pre-eclampsia - A case report.

Spontaneous hepatic rupture in pregnancy (SHRP) is a rare but often fatal condition associated with pre-eclampsia or HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome. SHRP is linked to significant maternal and perinatal morbidity and mortality, and maternal complications can extend past the initial intraoperative period. This case report describes the challenging perioperative course of a 35-year-old woman with SHRP. She underwent five laparotomies during a prolonged and complicated course in the intensive care unit. Despite these challenges, maternal and fetal outcomes were good. This case report serves to highlight key perioperative multidisciplinary issues in the care of these patients.

A Practical Approach to Total Laparoscopic Hysterectomy in a Morbidly Obese Patient: A Case Report and Literature Review.

Morbid obesity, traditionally considered to be a contraindication to total laparoscopic hysterectomy, is now evolving into an indication. Innovations and advancements in minimally invasive surgical techniques have significantly improved patient morbidity and mortality rates, reduced operational costs, and provided patients with an overall safer surgical experience. Although the laparoscopic approach is associated with several physiologic and technical challenges in the morbidly obese, it is plausible that these patients stand to benefit the most from minimally invasive surgery. This report highlights the methods of preoperative optimization, intraoperative considerations, and postoperative management strategies employed to achieve a successful total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection in a patient with a BMI of 45kg/m2, diagnosed with grade 1 endometrial adenocarcinoma and several obesity-related comorbidities.

The Hangman's Tourniquet: A Safe and Practical Approach for Reducing Blood Loss During Uterine Myomectomy.

STUDY OBJECTIVES: The application of a pericervical uterine artery tourniquet is a useful method of reducing intraoperative haemorrhage during abdominal myomectomy. However, the utilization of a single combined pericervical uterine artery and infundibulopelvic ligament tourniquet is a more effective and influential method of temporarily occluding the uterine vasculature to decrease intraoperative blood loss, reducing the requirement for blood products, the risk of conversion to hysterectomy, and patient morbidity and mortality during fertility-sparing leiomyoma surgery. Our objective of this retrospective review was to assess the effectiveness of the combined uterine artery and infundibulopelvic ligament tourniquet, which we coin as the "Hangman's uterine tourniquet", in reducing intraoperative blood loss during abdominal myomectomy, thereby reducing the need for blood products. METHODS: This retrospective study included 39 patients diagnosed with symptomatic subserosal, intramural, and/or submucosal uterine leiomyoma (>3 cm) who underwent an abdominal myomectomy between January 2021 and December 2022. RESULTS: Thirty-nine patients met the eligibility criteria for our study. The average patient age included in our study was 36 years. All myomectomies were completed with a mean intraoperative blood loss of 252.60 ml and the average number of fibroids removed was seven. The largest fibroid removed measured 27 x 20 cm in diameter while the most significant number of fibroids removed was 41. Moreover, the mean duration of the tourniquet application was 45.31 minutes, and the mean duration of operation was 80.44 minutes. Thirty-six patients (92.3%) had an estimated blood loss <500 ml. The number of fibroids removed was a statistically significant risk factor influencing estimated blood loss (p = 0.019). However, there was no statistical significance between estimated blood loss and the size of the largest fibroid removed (p = 0.178) nor estimated blood loss and a history of previous surgery (p = 0.412). The postoperative blood transfusion rate was 2.5% and no patients suffered grade III or higher surgical complications according to the Clavien-Dindo classification. CONCLUSION: This study showed that the utilization of a temporary intraoperative combined pericervical uterine artery and infundibulopelvic ligament tourniquet is an effective, practical, and economical approach to limiting intraoperative blood loss during abdominal myomectomy.

Thoracic endometriosis masquerading as Meigs' syndrome in a young woman: A case report and literature review.

Thoracic endometriosis is an exceedingly rare condition characterized by the presence of endometriotic deposits on the diaphragm, lungs or pleural space. Patients may present with massive hemothorax, pneumothorax, hemoptysis or pulmonary nodules. It is a complex condition that often proves to be a diagnostic challenge, resulting in under-diagnosis, delays in treatment and significant morbidity in women of reproductive age. We report a case of endometriosis causing massive pleural effusion and ascites, with a left adnexal fibroid mass mimicking Meigs' syndrome in a nulliparous woman in her late 30s. The patient was successfully managed with hormonal therapy following fertility-sparing surgical treatment. This case highlights the diagnostic and therapeutic challenges associated with thoracic endometriosis because of its close resemblance to more sinister gynecological conditions. Hormonal therapy is the long-term treatment of choice in patients with thoracic endometriosis to reduce the risk of symptom recurrence and preserve fertility.

A Case Report of the Largest Submucosal Uterine Leiomyoma Removed by Single-Session Hysteroscopic Myomectomy in the Caribbean.

Minimally invasive gynecological surgery is rapidly evolving in the Caribbean. Hysteroscopic myomectomy is the procedure of choice for the removal of submucosal uterine leiomyomas. In Trinidad and Tobago, advancements in minimally invasive surgery have allowed submucosal myomectomies to be performed hysteroscopically with results that are on par with international standards of care. This report highlights a successful hysteroscopic myomectomy performed for the largest submucosal uterine leiomyoma documented in the Caribbean.

Perioperative anesthesia management of a pregnant patient with central airway obstruction: a case report.

Mediastinal masses in pregnancy, although rare, can present with life threatening central airway obstruction if general anesthesia is required. In patients with central airway obstruction who are classified as being high risk for anesthesia, specific cardiothoracic interventions are usually required when there is no alternative to general anesthesia. We describe the case of a young female who presented in her second trimester with severe tracheal compression and worsening dyspnea secondary to a mediastinal mass. Intravenous dexamethasone was started, following which her symptoms improved and a drastic reduction in her tracheal compression was observed. The patient subsequently underwent successful vaginal delivery under epidural anesthesia. We discuss the complexities in perioperative decision making for this rare presentation and potential therapeutic options.

Perioperative Venous Excess Ultrasound Score (VExUS) to Guide Decongestion in a Dilated Cardiomyopathy Patient Presenting for Urgent Surgery.

Venous excess ultrasound score (VExUS) is a recently described ultrasound-based scoring system that quantifies systemic congestion using Doppler flow indices of the hepatic and portal vein in addition to inferior vena cava assessment. There are many potential and emerging applications of this modality. We discuss the case of a severely congested heart failure patient presenting for urgent non-cardiac surgery where VExUS parameters were used to monitor and guide his decongestive therapy postoperatively.

Epidemiology and Management Trends of Patients With Sepsis and Septic Shock in the Intensive Care Unit: A Prospective Trial in the Caribbean.

Objectives To investigate the epidemiology, management, and predictors of mortality in severe sepsis and septic shock in the intensive care units (ICUs) of Trinidad, Trinidad & Tobago. Methods A prospective observational study in four ICUs over a one-year period (August 2017-August 2018) was conducted. Physiologic variables, treatment data, and outcomes were collected on admission to ICU and daily until 28 days. The 28-day mortality and ICU mortality were recorded. Subgroup analysis was performed based on survival, and predictors of mortality were determined through logistic regression. Results Outcome data were available for 163 patients. The 28-day mortality rates for sepsis and septic shock were 42% and 47%, respectively. ICU mortality rate for sepsis was 34%. The most common suspected source of infection was pneumonia (33%). Acute kidney injury (AKI) was common and present in 71% of patients, with renal replacement therapy only being used in 30% of cases. Mechanical ventilation was required in 84% of cases. Moderate-to-severe acute respiratory distress syndrome (ARDS) (OR: 4; 95% CI: 1.9-8.8; p < 0.001) and the development of AKI (all stages) (OR: 10; 95% CI: 3.9-30.2; p < 0.001) were found to be predictive of mortality. Incidence of mechanical ventilation, moderate-to-severe ARDS, stage 3 AKI, septic shock, and failure to achieve a mean arterial pressure of > 60 mmHg within the first 24 hours of admission were higher in patients who did not survive (p < 0.05). Conclusions Sepsis and septic shock are associated with a high 28-day mortality. Organ dysfunction with renal and pulmonary involvement was an important factor in predicting a higher mortality.

A Comparison of Three Methods of Height Estimation and Their Impact on Low Tidal Volume Ventilation in a Mixed Ethnicity Intensive Care Unit: A Real-World Experience.

Background Height measurement is crucial for calculating predicted body weight (PBW) and establishing low tidal volume ventilation (LTVV). However, standing height is usually unavailable in critically ill patients and supine height may be difficult to obtain. Objective We investigated whether there were any significant differences in tidal volumes (VT) obtained using PBW derived from supine, forearm, and lower leg lengths in an intensive care unit (ICU) setting. Methods Supine, forearm and lower leg lengths were measured in 100 mechanically ventilated patients. Limb lengths were converted to height and PBW calculated using published formulae. The 6 mL/kg VT for the supine (sVT), forearm (fVT), and lower leg (lVT) methods were compared to each other and to visually estimated VT (estVT). Results Forearm length produced the greatest height estimate, leading to a significantly greater tidal volume fVT (437.6 ± 62.1 mL) compared with sVT (385.5 ± 63.8 mL) and lVT (369.1 ± 66.4 mL), (p < .001). There was no significant difference between lVT and sVT, (p = .169). On Bland Altman analysis, the lowest bias was found between lVT and sVT (-16.4 ± 36.0 mL, 95% limits of agreement (LOA) [-86.9, 54.1]), whereas fVT had a bias of 52.1 ± 41.5 mL, 95% LOA [-29.1, 133.4] compared to sVT. The fVT was significantly greater than sVT and lVT in all sexes and ethnic groups (p < .05). Conclusion Lower leg length may be a suitable alternative to supine height to facilitate the application of LTVV in an ICU setting.

Fatal Autochthonous Hepatitis E Induced Acute on Chronic Liver Failure Presenting with Multiorgan Failure in a Non-endemic Country: Brief Review of Intensive Care Unit Management.

Hepatitis E is usually a self-limiting disease that is considered rare in western countries. Outside of endemic regions, hepatitis E is seldom considered a cause of liver failure. We describe the first reported case of hepatitis E induced acute liver failure in the Caribbean island of Trinidad and the wider Caribbean; all traditionally considered non-endemic regions. The patient was a previously well young female who, upon investigation, was found to have radiographic signs suggesting underlying chronic liver disease. Subsequent testing yielded a positive hepatitis E immunoglobulin (Ig) M leading to the diagnose of hepatitis E induced acute on chronic liver failure. The patient's condition quickly deteriorated following the expected pattern of multiorgan failure associated with the disease. She died after a six-day intensive care unit (ICU) stay.

Detecting Major Complications and Death After Emergency Abdominal Surgery Using the Surgical Apgar Score: A Retrospective Analysis in a Caribbean Setting.

OBJECTIVE: The Surgical Apgar Score (SAS) is a simple 10-point scoring system that has been shown to be predictive of major postoperative complications and death after surgery. We evaluated the predictive ability of this score in a cohort of patients undergoing emergency abdominal surgery in a Caribbean tertiary hospital. METHODS: The SAS was calculated retrospectively from the anaesthesia records of all patients undergoing emergency abdominal surgery during a 12-month period. The postoperative surgical records of these patients were then examined for the presence of major complications and death. The association between the SAS and outcomes was tested using binary logistic regression, and the SAS discriminatory ability was determined from the receiver-operating curve (ROC) analysis. RESULTS: Of the 220 patients studied, 72 (33%) suffered an in-hospital major complication or death. The highest complication rate occurred in the low-scoring groups, with 68% of those scoring <4 being affected. Low-scoring patients (<4) had four times the risk of major complications when compared to higher-scoring groups (relative risk [RR], 4.21; 95% confidence interval [CI], 2.5-7.3; p<0.001). The odds ratio (OR) for major complications or death per unit increase in the SAS was 0.58 (95% CI, 0.47-0.72; p<0.001). The c-statistic of the SAS for predicting major complications or death was 0.71 (95% CI, 0.68-0.73; p<0.0001). CONCLUSION: The SAS is a simple 10-point score that can be used in patients undergoing emergency surgery in a Caribbean setting to help identify those that are at a higher risk of postoperative complications. Due to its ease in calculation, it can be added to other commonly used criteria to help triage the postoperative patient.

Corrigendum to "Miliary Tuberculosis Presenting with ARDS and Shock: A Case Report and Challenges in Current Management and Diagnosis".

[This corrects the article DOI: 10.1155/2017/9287021.].

Miliary Tuberculosis Presenting with ARDS and Shock: A Case Report and Challenges in Current Management and Diagnosis.

Miliary tuberculosis, complicated by ARDS and septic shock, is a rare and lethal presentation of this disease. Here we present a case of such a patient, following which we discuss the management of tuberculosis in the ICU and some of the challenges that may be faced. A young HIV negative female presented to us with an acute history of worsening shortness of breath on a background of weight loss, nonproductive cough, and fever. CXR and CT scan showed bilateral miliary type opacities and the patient was admitted to the hospital. Within forty-eight hours of admission she became hypoxemic and was intubated and transferred to the ICU. There she experienced worsening organ dysfunction and developed circulatory shock. Despite escalating doses of noradrenaline, she continued to decline and died before specific anti-TB treatment could be started. Timely diagnosis and treatment initiation are the keys to improving outcomes in critically ill TB patients. However there are many challenges in doing so, especially in a general ICU located in a country with a low TB incidence.