Perception & Psychophysics

Aggarwal S., Siddiqui H., Gagen A.

ABSTRACT Perforation of the duodenum is a rare, life-threatening complication of balloon dilation of duodenal strictures, which is managed surgically. Our case is of duodenal perforation as a complication of endoscopic balloon dilation for duodenal stricture. The perforation and stenosis were successfully managed by placement of an 18 mm × 12.3 cm WallFlex fully covered stent secured by clips to prevent migration. A follow-up endoscopy with stent removal revealed no perforation and resolution of the duodenal stricture. Our case emphasizes endoscopic stenting as an alternative to conventional surgical repair for iatrogenic duodenal perforations secondary to recurring duodenal strictures.

Dahman M., Ratermann C., Rozzo A.

ABSTRACT Introduction Postoperative nausea and vomiting (PONV) is a complication after surgery, and more significantly after bariatric surgery (up to 79%) leading to increased treatment costs associated with prolonged hospital stays. In a community hospital setting, a standard prophylactic regimen was compared with the addition of aprepitant. Methods A retrospective chart review of PONV among patients who underwent laparoscopic sleeve gastrectomy. Primary outcomes: efficacy of aprepitant 80 mg plus standard prophylaxis on PONV by measuring the number of antiemetics administered postoperatively to a standard prophylactic regimen. Results A total of 354 patients showed that the aprepitant group required significantly fewer doses in four time periods: within 1 hour of post-anesthesia care unit (PACU) admission [74 vs 97 (p = 0.049)], 12 hours [192 vs 234 (p = 0.049)], 24 hours [293 vs 426 (p < 0.001)], and total doses during admission 365 vs 581 (p < 0.001). Average length of stay (LOS) was 1.19 days for the aprepitant group and 1.33 days for the control group (p < 0.001). Conclusion Aprepitant significantly reduced antiemetic use postoperatively and should be considered in addition to a standard PONV prophylaxis regimen to prevent PONV in patients undergoing laparoscopic sleeve gastrectomy and to potentially reduce LOS.

Abou Shaar B., Qureshy K., Almalki Y., Khan N.

ABSTRACT Tinnitus is a condition in which patients perceive sound without an external stimulus. It can be classified into either pulsatile or nonpulsatile tinnitus. This condition affects around 14% of the global population, and the severity of tinnitus can range from barely noticeable to devastating. In most cases, tinnitus is benign and nonpulsatile in nature. The diagnostic role of imaging is to detect treatable and specific pathology. Therefore, a comprehensive clinical assessment, which includes a meticulous examination for associated symptoms like hearing loss, vertigo, or headaches, along with a thorough physical examination, otoscopy, and audiologic testing, is imperative before considering any imaging studies as the choice of imaging will depend on various factors. Nonpulsatile or continuous tinnitus is most commonly associated with presbycusis but can also be caused by functional injuries due to ototoxic medications or exposure to loud noise and usually requires no imaging evaluation. Unlike nonpulsatile tinnitus, imaging patients with pulsatile tinnitus typically reveals perceptible findings. The cause of pulsatile tinnitus is usually a vascular tumor, vascular malformation, or vascular anomaly. Other causes of tinnitus include idiopathic intracranial hypertension, otosclerosis, Paget’s disease, and Meniere’s disease. One of the main challenges is that the underlying cause of tinnitus is often unknown. Another challenge is that tinnitus can have a significant effect on a person’s quality of life, yet the condition is not life-threatening and there is no cure. We present a clinical review of the most prevalent causes of tinnitus along with an emphasis on the diagnostic imaging workup and management of common presentations.

Alawfi H.G., Yang S.Y., Alessa M.Y., Helmi H.A., Sakr A., Kim N.K.

ABSTRACT Introduction Anastomotic leakage following rectal surgery is a major complication, which may occur due to insufficient vascular supply. We aimed to evaluate the efficacy of using indocyanine green fluorescence angiography for intraoperative assessment of vascular anastomotic perfusion in robotic low anterior resection. Methods This was a retrospective cohort study that included consecutive patients undergoing robotic low anterior resection for rectal cancer between March 2017 and February 2019. Intraoperative use of indocyanine green fluorescence for assessment of bowel perfusion was performed in patients operated after April 2018. Those who underwent the surgery before that comprised the control group. The primary outcome was the occurrence of anastomotic leakage between the two groups. Results Each group included 48 patients. There were no significant differences between the two groups in terms of demographic data or tumor characteristics. The planned anastomotic site was revised in 1 of 48 patients who received indocyanine green fluorescence based on the surgeon's subjective finding of a hypo-perfused distal segment. Postoperative anastomotic leakage was confirmed clinically and radiologically in one patient (2.8%) in the indocyanine green group compared with two patients (4.16%) in the control group. Conclusion Indocyanine green fluorescence may be considered a useful intraoperative tool for assessment of vascular perfusion of bowel during robotic rectal surgery. Change in the site of resection and/or anastomosis may be indicated, possibly affecting the incidence of anastomotic leakage.

Galzerano D., Alamro B., Moreo A., Bossone E., Vriz O., Alenazy A., Alshehri A., Al Amri M., Alhamshari A., Al Sergani H.

ABSTRACT Transcatheter native mitral valve replacement (TMVR) is a novel procedure that has the potential to overcome some of the current limitations associated with the transcatheter edge-to-edge mitral valve (MV) repair technique. The aim of this study was to describe the key steps in periprocedural echocardiographic guidance of TMVR with the Tendyne system, emphasizing potential caveats and areas of difficulty. The imaging pathway can be schematized in four fundamental steps: baseline evaluation of mitral regurgitation (MR), preprocedural screening and planning, intraprocedural guidance, and follow-up. Baseline evaluation of MR in TMVR includes the guidelines-recommended imaging pathway of MR assessment. A dedicated preprocedure cardiac multimodality imaging screening and planning for TMVR is able to determine patient eligibility according to the anatomic characteristics and measurements, provide information for appropriate valve sizing, and detect features that can predispose to potential hazard or complications. Cardiac computed tomography and two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) are the main actors in this phase. The road map for intraprocedural TMVR guidance includes the following: (1) apical access assessment: 2D TEE assessment of the site for optimal left ventricular apical access as planned by the preprocedural computed tomography; (2) support for catheter and sheath localization, trajectory, and positioning; and (3) valve positioning and radial orientation. Thereafter, the prosthesis is withdrawn toward the left ventricle and deployed intra-annularly. Post-deployment includes assessment for correct clocking and hemodynamics, perivalvular leakage, and left ventricular outflow tract obstruction. Two-dimensional and 3D TEE and fluoroscopy provide intraprocedural guidance. The follow-up of the Tendyne device includes the guidelines-recommended imaging pathway of bioprosthesis. Knowledge of multimodality imaging use is key for the interventional imagers and crucial in the success of the procedure.

Albalkhi I., Saleh T., Khan J., Saleh W.

Abstract Introduction Avascular necrosis of the rib is a rare presentation of sickle cell anemia's vaso-occlusive crisis. This report describes the case of a 45-year-old man known to have sickle cell anemia presenting with rib avascular necrosis complicated by osteomyelitis. The patient came to the outpatient department with left lateral chest wall pain. Antibiotics produced no improvement. A computed tomography scan of the chest revealed a left sixth rib fracture with a thick fluid collection consistent with pus. The patient was taken to surgery and underwent necrotic bone debridement and pus drainage. The patient showed improvement and became afebrile after the surgery. Conclusion The lack of distinct clinical indicators and low occurrence of rib avascular necrosis can lead to misdiagnosis and mismanagement of the disease.

Al Shammari A., Askar G., Al Masri T., Shoukri M., Ishaq M., Saleh W.

ABSTRACT Introduction Laryngotracheal stenosis (LS) is most commonly caused by iatrogenic injury, namely, tracheal intubation. The goal of treatment is the maintenance of a patent airway, which is mostly achieved by surgical intervention. Our objective was to study the effect of perioperative variables on tracheal resection anastomosis (TRA)/cricotracheal resection anastomosis (CTRA) surgical outcomes by identifying statistically significant factors associated with postoperative complications and failure of surgery, i.e., restenosis. Methods Data from the medical records of 33 patients who underwent TRA/CTRA was analyzed by univariate and multivariate logistic regression. The data included perioperative variables such as the etiology of stenosis, comorbidities, and postoperative or long-term complications. Results The study included nine females and 24 males, and most (29, 87.88%) were intubated prior to surgery. Nineteen patients (57.57%) developed one or more postoperative complications, including, but not limited to, surgical site infection and hematoma. Of all patients, six (18.18%) developed long-term restenosis. Multiple factors were significantly associated with the development of postoperative complications. Univariate analysis revealed the following factors as statistically significant: age (p = 0.05), diabetes (p = 0.00001), hypertension (p = 0.00001), and myocardial infarction (p = 0.03). Multivariate analysis showed that age (p = 0.046) and myocardial infarction (p = 0.00001) were independent factors. The study had an overall survival of 97%. Conclusion TRA/CTRA is a complex surgical procedure, and its outcomes can be affected by many factors. More studies with bigger sample sizes are needed to better understand contributing factors and to confirm the already established associations.

Kurdi W., Ibrahim L.

ABSTRACT Fetal pleural effusion is a rare condition easily diagnosed by antenatal ultrasound. It can be classified into two categories: primary and secondary. Primary pleural effusion is mainly attributed to defective lymphatic drainage in the fetus. Secondary pleural effusion can be caused by conditions that affect the fetal cardiac function, fetal anemia, fetal infections, chromosomal aberrations, genetic diseases, or congenital malformations that disrupt the lungs and mediastinal architecture. The clinical course is variable depending on the severity, underlying cause, gestational age at diagnosis, and the presence or absence of other congenital abnormalities. We present a case of isolated fetal pleural effusion where in utero therapy included thoracocentesis followed by the insertion of a thoracoamniotic shunt.

Alsheikh H.A., Zahlan A.M., AlMana F., Almutairi R., Alqahtani H., Al Doumani M.A., AlBawardi E.A., Alkattan K., Alotaibi N.H.

ABSTRACT Introduction Live teaching via online platforms during the COVID-19 pandemic has proved to be an innovative solution during the crisis, yet limitations were still observed. Teaching challenges during the pandemic must be accurately studied to come up with evidence-based solutions. We aimed to assess the effectiveness of virtual or online teaching in delivering educational objectives to otorhinolaryngology, head and neck surgery (ORL-HNS) clerkship students (undergraduate medical students) during the COVID-19 pandemic. Methods This was a cross-sectional questionnaire study with a survey designed to evaluate undergraduate medical students' responses toward online ORL-HNS classes. The same set of questions was sent to two different groups who were in ORL-HNS clerkship rotation under different quarantine restrictions levels during the pandemic. Results In total, 95 responses were analyzed; 32 responses were collected from the first group of students who were in the clinical rotation exclusively through online means under strict lockdown measurements. The remaining 63 responses were from the second group of students who were in the rotation after modifications to the COVID-19 lockdown protocols; the modifications allowed more in-person meetings under social distancing measures. The overall feedback about the scientific benefit of the ORL-HNS clerkship course was positive, with the majority of students agreeing that they felt prepared for future examinations, but not as much for clinical practice. In addition, students reported that lab skills sessions held after quarantine protocol modifications helped enhance their knowledge and better prepare them for future clinical practice and exams. Conclusion Online teaching technologies might be able to compete with conventional teaching methods, but further improvements must take place to close the gaps between traditional and online classrooms. We believe advanced methods and simulation techniques can be implemented to aid in teaching complex topics in medicine, especially in otorhinolaryngology.

AlSaigh A., Kurdi W.

Verhoeff K., Mocanu V., Fang B., Dang J., Kung J.Y., Switzer N.J., Birch D.W., Karmali S.

ABSTRACT Introduction Systematic reviews of retrospective studies suggest that indocyanine green (ICG) angiography reduces anastomotic leak (AL) and improves postoperative outcomes. This systematic review and meta-analysis evaluates colorectal surgery outcomes following ICG use with comparison of results found in randomized controlled trials (RCTs) and retrospective studies. Methods A systematic search was conducted of studies evaluating ICG in colorectal surgery with more than five patients. Systematic search of MEDLINE, Embase, Scopus, and Web of Science was conducted in August 2021 and this study followed PRISMA and MOOSE guidelines. Primary outcome was AL. Meta-analysis was conducted with RevMan 5.4. Results Overall, 2403 studies were retrieved with 28 total studies including three RCTs meeting criteria. RCTs included 964 patients, whereas other studies comprised 7327 patients with 44.6% receiving ICG. The ICG and non-ICG cohorts were similar with respect to age (62.6 vs 63.1 years), sex (45.1% vs 43.1% female), smoking (22.4% vs 25.3% smokers), and diabetes (13.4% vs 14.2%), respectively. Anastomotic height (6.5 vs 6.8 cm) and technique (78.7% vs 74.8% stapled) were also comparable. With retrospective studies included, ICG was associated with AL reduction (odds ratio [OR] 0.41; 95% CI, 0.32–0.53; p < 0.001) and reoperation for AL (OR 0.64; 95% CI, 0.43–0.95; p = 0.03), with pronounced effects for rectal anastomoses (OR 0.31; 95% CI, 0.21–0.44; p < 0.001). RCT evidence suggests a much smaller effect size (OR 0.64; 95% CI, 0.42–0.99; p = 0.04), and no reduction in AL reoperation (OR 0.72; 95% CI, 0.29–1.80; p = 0.48) or length of stay (LOS). Conclusion Retrospective studies suggest reduced AL, reoperation for AL, and LOS with ICG angiography. However, RCTs suggest a smaller effect size and do not demonstrate reduced reoperation or LOS. Additional RCTs are required before widespread ICG uptake.

Alrujaib M., Bakheet D.

Aloun A., Al Abeidi F., Alzahrani A., Swied A.M.

ABSTRACT Accessing the biliary ducts for performing endoscopic retrograde cholangiopancreatography (ERCP) and relevant interventional procedures after gastric bypass surgery is technically difficult and frequently unsuccessful due to anatomical alterations. To overcome such technical challenges, laparoscopic-assisted ERCP (LA-ERCP) is used to approach the biliary ducts via nonperoral reliable access for performing different endoscopic biliary interventions. In this case series, we report a total of three patients with different anatomical alterations who underwent LA-ERCP.