Day 3 :
Keynote Forum
Ranendra Hajong
NEIGRIHMS, India
Keynote: Spontaneous inguinal enterocutaneous fistula as a complication of incarcerated Richter’s hernia - Report of two cases
Time : 09:00-09:30
Biography:
Ranendra Hajong is an Associate Professor in General Surgery at NEIGRIHMS, India. He has around 40 publications in various indexed journals and has presented papers in various scientific forums. His activities involve teaching undergraduate and postgraduate medical students, patient care services and research.
Abstract:
Rarely inguinal hernia may present with rare complication of pontaneous faecal fistula. Non-availability of proper medical care and unawareness of the condition are the major factors having potential for transformation of a relatively benign condition of inguinal hernia into complicated state of incarceration and strangulation. Case 1: A 50 year old female patient presented with passage of faecal material from the left inguinal region since the last one week. It was preceded with the history of a painful swelling in the same region about two weeks back for which incision and rainage was done. Magnetic resonance imaging showed features of left sided direct inguinal hernia with intact femoral canal. The patient did not opt for any surgical intervention, so was managed conservatively. Case 2: A 53 years old man presented to us with history of on and off discharge of yellowish debris from the left groin region since the last three years. Contrast fistulogram with urografin showed communication of the cutaneous opening with the jejunal loops. Magnetic resonance fistulogram confirmed the diagnosis. Patient underwent lower midline laparotomy. Mid-jejunum was found to be communicating with the fistula in the left iliac region which was dismantled and jejunum was repaired primarily. The fistulous tract was laid open and curetted. Postoperatively the patient developed SSI and was discharged on 14th postoperative day. Richter’s hernia is an uncommon condition in which only a circumference of the antimesenteric bowel wall is incarcerated within the hernia sac leading to ischemia, gangrene and perforation of the hollow viscus. It has an early misleading presentation with tendency to early strangulation and the lack of obstructive symptoms which may lead to delay in diagnosis and hence increased mortality. Any part of intestine may get incarcerated but most commonly involves distal ileum, caecum and sigmoid colon. As only a segment of bowel is involved, luminal continuity is maintained, thus there is only partial intestinal obstruction with minimal clinical signs.
Keynote Forum
Nahla Gomaa
University of Alberta, Canada
Keynote: A snapshot on the competency-based medical education in surgical specialties at Faculty of Medicine, University of Alberta, Canada; Where to start?
Time : 09:30-10:00
Biography:
Nahla Gomaa has interest in Para-surgical leadership by studying Quality Assurance in Medical Education. With her fellowship at the University of Iowa, USA, and working in other international medical institutes, she became interested in surgical education. Since her appointment as an Assistant Professor at University of Alberta, Canada, she has spearheaded a number of leadership and students-lead projects. She is representing the Department of Surgery in the Faculty Development Committee, and Strategic Planning at the Faculty level, specifically Competency-Based Medical Education (CBME). She is currently a member of the international collaborators of CBME, and serving on the Human Research Ethics Board (HREB) at University of Alberta.
Abstract:
The University of Alberta as well as many Canadian universities is starting Cohorts of competency-based medical education (CBME)-training of residents soon. The last couple of years were spent on intensive resource preparation for this initiative. Grand rounds for faulty development and open sessions for questions and answers have been running. The Royal College of Canada has provided a parallel intensive training for the program directors and a tremendous support with the e-portfolio. Where are we heading in the coming decade of medical education with this initiative? Is it going to change the face of surgical training, and what are the expectations of our surgical educators? This is a short talk about the conceptual framework of competency by design (CBD) and CBME, efforts that have been put into this change in medical education, and some questions waiting for answers.
- Transplantation Surgery | Cardiothoracic Surgery | General Surgery and its Specialties | Oral & Maxillofacial Surgery
Location: London
Chair
Nahla Gomaa
University of Alberta, Canada
Session Introduction
Chamila Pilimatalawwe Wijekoon
Sri Jayewardenepura General Hospital, Sri Lanka
Title: Issues with renal transplantation in lower-middle-income countries like Sri-Lanka
Time : 10:00-10:25
Biography:
Chamila Pilimatalawwe Wijekoon is a Consultant Anaesthesiologist at Sri Jayeawardenepura General Hospital, Sri Lanka. After her Post-graduate qualification in Anaesthesiology, she underwent further training at the Royal Victoria Infirmary and Freeman hospital in Newcastle Upon Tyne, UK. She has been a Consultant since 2011. Her interests are Anaesthesia for Kidney transplantation, where she has played a leading role in establishing the deceased donor programme in Sri Lanka, and Cardiac Anaesthesia. She is also a Council Member of the College of Anaesthesiologists and Intensivists of Sri Lanka.
Abstract:
The burden of Chronic Kidney Disease (CKD) continues to rise globally with an estimated 500 million people suffering worldwide, of whom majority live in LMIC like Sri-Lanka. Estimated 60,000 (0.3%) of the population of Sri Lanka suffer from CKD with nearly 3000 in end-stage renal failure (ESRF). Despite the rise in trends of CKD, the causes are yet to be clearly defined due to variability in quality of reporting, inconsistent methods of defining and absence of a centralized reporting system. Although the etiology of the disease is heterogeneous, prevalence of chronic kidney disease of unknown etiology (CKDu), is unique to countries such as Sri-Lanka. Since the first reporting of this group of patients in 1990 the incidence has escalated dramatically. In Sri-Lanka CKDu is mainly seen in the north central and northwest provinces, affecting more than 15% of its population mainly in the 20-30- year age group. They are predominantly agricultural workers with a male preponderance. Etiology may be attributed to quality and presence of arsenic and cadmium in the water, and frequent droughts affecting these areas. CKD has become a huge burden to the country with 4% of the public health budget being spent on non-curative aspects of CKD alone. In 2007 there were only about 180 dialysis machines in the entire country when the requirement was over 1000. Renal transplantation is probably the more tenable longterm treatment option for ESRD in LMIC as it is both cheaper and provides a better outcome for these patients. In Sri-Lanka less than 5% of this group receives a transplanted kidney. Besides the technical challenges of surgery and consequences of immunosuppression, LMIC like Sri-Lanka have the need to improve the deceased-donor program, which is currently at its infancy due to an ill-defined legal framework, taboos, and multicultural, multi-religious believes.
Kanishka Indraratna
Sri Jayewardenepura General Hospital, Sri Lanka
Title: A proposed strategy for enhanced recovery after cardiac surgery
Time : 10:25-10:50
Biography:
Kanishka Indraratna is the Senior Consultant Anesthesiologist at Sri Jayewardenepura General Hospital, Sri Lanka. After his Post-graduate examinations, he was further trained in England. Subsequently he did a long term locum consultant appointment at St. Bartholomews Hospital and the Royal London. His research interests include “Cardiac anaesthesia, neuro anaesthesia, and critical care”. He is also the President of the College of Anaesthesiologists and Intensivists of Sri Lanka.
Abstract:
While there are established strategies and guidelines for enhanced recovery after general surgical procedures, there is no such strategy for cardiac surgery. This is probably because of the complexity of the procedure and the wide range of complications which can occur. To achieve enhanced recovery, the aims should be to have a conscious, rational, alert patient as soon as sedation is reduced, hemodynamically stable, pain free, without other complications, and ready to be mobilized. Multi organ complications and problems are quite common after cardiac surgery such as myocardial infarctions 22%, delirium 46% and AKI 30%. Pre-operative optimization of correctable factors, optimal amount of anesthetic and analgesic, goal directed fluid therapy, maintenance of cerebral perfusion are strategies to be employed. For this, monitoring of cardiac output, fluid status, depth of anaesthesia, cerebral function, cerebral oximetry, cardiac function, coagulation function, level of Hb, in addition to usual routine monitoring would be required. Adequate pain relief and optimal sedation, physiotherapy, early mobilizations are required in the post-operative period.
Rosalee Zackula
Kansas School of Medicine-Wichita, USA
Title: Methodological evaluation of in-hospital mortality as an indicator of treatment effectiveness
Time : 11:20-11:45
Biography:
Rosalee Zackula is a Statistician with expertise in research design, measurement, and data analysis. She is a Senior Research Analyst in the Office of Research at the University of Kansas School of Medicine-Wichita. As a Research Consultant, she works across all departments to design and conduct research with Anesthesiology, Family and Community Medicine, Obstetrics and Gynecology, Preventive Medicine, Psychiatry, Radiology, and Surgery.
Abstract:
Using in-hospital mortality as an outcome for comparing treatment in a trauma population is misleading and may put patients at risk. Researchers in many medical specialties, including surgery, often utilize this measure as a marker of treatment equivalence. However, mortality does not always relate to quality of care, and treatment equivalence is only one aspect associated with patient outcomes. Perhaps a more important factor is treatment efficacy. Complex factors influence whether a treatment is effective. Patient status prior to trauma (age, BMI, co-morbidities, access to care), nature of trauma (mechanism of injury, injury severity), time to treatment, medical intervention (hospital and physician type, procedures), quality of care (length of stay, hospital acquired complications, radiation exposure), and post-intervention care (access), all contribute to treatment outcome (mortality and/or quality of life). Further, a measure of time from trauma event to a mortality outcome, specifically in- hospital, demonstrates why using trauma-related deaths could be biased. For example, the in-hospital and 30-day rates of mortality may differ substantially and favor hospitals with shorter lengths of stay. Our current research interests include evaluating methodological issues associated with treatment comparison that include measures of efficacy, along with statistical measures of equivalence. We critically appraised unpublished and published articles that suggested trauma centers were equivalent based on in-hospital mortality. Findings included: issues with statistical methodologies and misinterpretations of results and lack of quality indicator evaluation. Subsequently, we are conducting a systematic review and meta-analysis of recent literature related to pediatric trauma outcomes. This work will contribute to best practice research methodology for evaluating trauma care. Specifically, we will discuss alternative measures and methods for determining treatment efficacy that may reduce risk to patients.
Sadanori Takeo
Kyushu University, Japan
Title: A new technique for dissecting the pulmonary vessels and handling scissors
Time : 11:45-12:10
Biography:
Sadanori Takeo has completed his PhD at Kyushu University in Immunological Sciences. He was one of the pioneers in Thoracic surgery and VATS surgery in Japan. He and his team were the first to report Original video-assisted thoracoscopic extended thymectomy for thymoma. He later became the Chairman of the Department of Thoracic Surgery at National Hospital Organization Kyushu Medical Center. He has served on the editorial boards of many scientific journals, and on the advisory panels of many academic and government institutions. He is a member of board of the many academic association and has published more than 90 papers in lung cancer and mediastinal tumor fields. He is the Director General of Clinical Department at National Hospital Organization Kyushu Medical Center.
Abstract:
The pulmonary artery (PA) is the weakest vessel in the human body, and many think that it should never be grasped with forceps. We earlier described a technique for safe, rapid dissection of the PA and pulmonary vein (PV) that simply handles scissors in a novel way. Since 2001, this method has been applied in more than 800 cases of segmentectomy, lobectomy, and pneumonectomy during both open surgery and video-assisted thoracic surgery (VATS). It employs Mayo-type scissors for sharp dissection of the PA and PV. Sheaths on the surfaces of the central parts of the pulmonary vessels are dissected using scissors approximately 5 mm long. The vessel is then ligated with 2-0 silk at the same site. The surgeon directly grasps the blood vessel with vascular forceps just distal to the first ligation site and retracts it to the central side. The distal side of the blood vessel is exposed aggressively with Mayo-type scissors by dissecting the sheaths surrounding the vessel with the associated connective tissue including perivascular lymph nodes. These maneuvers are possible when using this novel handling of the scissors (e.g., right-angle forceps for VATS). None of the patients exhibited blood vessel injury. The procedure easily exposes about 2 cm of small vessels and >3 cm of larger vessels. It is useful in most circumstances—e.g., tumor invasion of an area surrounding a blood vessel or with a perivascular enlarged lymph node without direct invasion. Almost all right upper lobectomies (ND2a) are completed within 2 hours (small thoracotomy) to 2.5 hours (complete VATS). Surgery duration can be dramatically shortened when using this method. This technique and the new method for handling the scissors will be demonstrated in a video.
Mein-Woei Suen
Asia University, Taiwan
Title: The influence of the obesity-Related stereotypes on evaluations of different body shapes in high school girls
Time : 12:10-12:35
Biography:
Mein-Woei Suen studied at University of Birmingham. He has been involved with studies related to stereotype threat effects and stereotype boost effects. The subject of research includes: The impact of gender stereotypes on the dominance of men or the dominance of women, the impact of racial stereotypes on the performance of Taiwanese students in mathematics, and the influence of Aboriginal stereotypes on the performance of aboriginal and non-Aboriginal students in school and sports performance. In addition, the relevant academic objectives are as follows: gender, ethnicity, age, and medical care, and so on, and there is an inconsistent influence mechanism between the two effects based on the collating of the literature, such as the academic performance, the athletic performance, the cognitive operation, and so on.
Abstract:
Obesity is an important problem of health in teenagers. The obesity-related stereotypes become more important issue nowadays, which gets the idea that the person is lazy, sporting less, greedy etc. Thus, this study aims to establish an obesity-related stereotypes scale and to examine the effect of the obesity-related stereotypes among Taiwan and Macau senior high school girls. In this research, this pilot study (N=138) selects an appropriate figure scale and the standard and obesity figures were occupied in main experiment. Then, the main experiment (N=221; 103 Taiwan & 118 Macau girls) conduct a Chinese–version obesity-related stereotype scale with three factors (with 13 items), which are: Unwell personal performance (6 items), poor interpersonal perception (4 items), and ―inappropriate life style (3 items). Results show that: girls in stereotype activation condition show high scores of stereotype scores; there is no significant difference between Taiwan and Macau sample; girls with underweight and normal-weights tempt to expect lower body weight rather than standard body weight group, but not with overweight. The senior high school girls have the obesity-related stereotypes. While stereotypes have been activated by using the obesity figures, girls will show obvious stereotype on the scale. There is no difference between Taiwan and Macau girls.
Olivier Lieger
University of Bern, Switzerland
Title: Biomechanical evaluation of different angle-Stable locking plate systems for mandibular surgery
Time : 12:35-13:00
Biography:
Olivier Lieger, MD, DMD, is a faculty in the Department of Craniomaxillofacial Surgery at University of Bern, Inselspital, CH-3010 Bern, Switzerland.
Abstract:
Purpose: To compare the initial stability and stability after fatigue of three different locking systems (Synthes®, Stryker® and Medartis®) for mandibular fixation and reconstruction.
Method: Standard mandible locking plates with identical profile height (1.5 mm), comparable length and screws with identical diameter (2.0 mm) were used. Plates were fixed with six screws according a preparation protocol. Four point bending tests were then performed using artificial bone material to compare their initial stability and failure limit under realistic loading conditions.Loading of the plates was performed using of a servo hydraulic driven testing machine. The stiffness of the implant/bone constructwas calculated using a linear regression on the experimental data included in a range of applied moment between 2 Nm and 6 Nm.
Results: No statistical difference in the elastic stiffness was visible between the three types of plate. However, differences were observed between the systems concerning the maximal load supported. The Stryker and Synthes systems were able to support a significantly higher moment.
Conclusion: For clinical application all systems show good and reliable results. Practical aspects such as handling, possible angulation of screw fixation, possibility of screw/plate removal, etc. may favor one or the other plating system.
Harry S Goldsmith
University of California, USA
Title: Success of mental transposition to the brain of Alzheimer patients
Time : 14:00-14:25
Biography:
Harry S Goldsmith is Clinical Professor of Neurological Surgery at the University of California in Sacramento. He has been a Full Professor of Surgery and Neurosurgery since 1970. He has written 260 published papers, has edited four surgical texts, and was the Editor of Goldsmith's Practice of Surgery in twelve volumes from 1976-1988. His main interest at present is in the treatment of Alzheimer's disease and in new treatment for acute and chronic spinal cord injuries using the omentum.
Abstract:
Introduction: The surgical placement of an intact vascularized omental pedicle directly on the human brain can result in a significant increase in cerebral blood flow (CBF). Placing an omental pedicle on the brain of Alzheimer (AD) patients, who are known to have a decreased CBF, may explain the cognitive improvement that has followed this surgical procedure.
Methods: The omentum is surgically lengthened with its blood supply remaining intact. Following this lengthening process the omentum is brought up through a subcutaneous tunnel placed along the chest and neck up to the head. A craniotomy is performed and the dura mater is opened. The omentum is then simply laid on the brain without the need for any anastomoses.
Results: Omental transposition (OT) to the brain allows omental arteries to penetrate directly and deeply into the brain resulting in a marked increase in CBF. Of twenty-five advanced Alzheimer patients who underwent OT to the brain six patients showed no postoperative improvement, ten demonstrated slight changes with nine patients demonstrating marked cognitive improvement.
Conclusion: There is increasing interest that AD is the result of decreased CBF which negatively effects the intra-neuronal mitochondria which directly influences the production of neuronal adenosine triphosphate (ATP) which is the energy source of neurons. The increased CBF originating from the omentum may explain the improved cognition that has followed OT to the brain of AD patients.
Tanja Anguseva
The Special Hospital for Surgical Diseases “Filip Vtoriâ€, Macedonia
Title: Intraoperative 3D transoesophageal valvular evaluation
Time : 14:25-14:50
Biography:
Tanja Anguseva is Subspecialist cardiologist in Special Hospital for surgical diseases ZanMitrev. Scientific work titled “SyScheechan”, Clinic of Obstetrics, Faculty of Medicine, SkopjeGraduation at the Faculty of Medicine within Ss. Cyril and Methodius Skopje, Macedonia. Doctor – general practitioner, Military Outpatient Clinic, Veles. Specialization in internal medicine at the University Ss. Cyril and Methodius Assistant at the Department of emodialysis - Department for Internal diseases, Military Hospital, Skopje. Postgraduate studies at the Clinic of Cardiology, Faculty of Medicine, Skopje. Topic: Immunoactivity of patients in end-stage ischemic heart failure. Intensive Care Unit – Department of Internal Diseases, Military Hospital, Skopje. Coronary (cardiac) stress test, Echocardiography, 24-hour ECG and ABP Holter monitoring – Department of Internal Diseases, Military Hospital, Skopje. Doctor in charge at the Intensive Care Unit, PHI FILIP VTORI, Skopje.
Abstract:
The aims of this study were to evaluate the feasibility of real-time 3-dimensional (3D)transesophageal echocardiography in the intraoperative assessment of valvular pathology and to compare this novel technique with 2-dimensional (2D) transesophageal echocardiography.
Methods:1450 consecutive patients undergoing valvular were studied prospectively. Intraoperative 2D and 3D transesophageal echocardiographic (TEE) examinations wereperformed using a recently introduced TEE probe that provides real-time 3D imaging. Expert echocardiographersblinded to 2D TEE findings assessed the etiology of MR on 3D transesophageal echocardiography. Similarly, experts blinded to 3D TEE findings assessed 2D TEE findings. Both were compared with theanatomic findings reported
by the surgeon.
Results: At the time of surgical inspection, ischemic MR was identified in 12% of patients, complex bileafletmyxomatous disease in 31%, and specific scallop disease in 25%, aortic stenosis in 20% and insuffitienty in 12% of patients. Three-dimensional TEE image acquisitionwas performed in a short period of time (60 _ 18 seconds) and was feasible in all patients. Three-dimensional TEE imaging was superior to 2DTEE imaging in the diagnosis of P1, A2, A3, and bileaflet disease (P _ .05), as well as in aortic stenosis
and insuffitienty evaluation ( leaflet morphology).
Conclusions: Real-time 3D transesophageal echocardiography is a feasible method for identifying specific valvular pathology in the setting of complex disease and can be expeditiously used in the intraoperativeevaluation of patients undergoing valvular repair surgery. (J Am Soc Echocardiogr 2009;22:34-41.)
Keywords: Real-time 3D TEE, Mitral valve, Aortic Valve Diagnosis.
Zhi Zhong
Medical University of South Carolina, USA
Title: Role of mitochondrial dysfunction in primary graft non-function after transplantation of marginal liver grafts: Study with novel intra vital confocal/multi-photon microscopy
Time : 14:50-15:15
Biography:
Zhi Zhong is an Associate Professor in College of Pharmacy, Medical University of South Carolina, SC, USA. Her expertise is in hepatic ischemia/reperfusion injury and experimental liver transplantation. She obtained her Doctoral degree at University of North Carolina, Chapel Hill. She has been conducting basic and translational research on the role of reactive oxygen and nitrogen species in mitochondrial dysfunction in various liver injury/diseases and published ~100 papers in the field. She is also a Reviewer and Editorial Board Member of many scientific journals.
Abstract:
Background & Aim: The mitochondrial permeability transition (MPT) has been implicated in liver injury in vivo after ischemia/ reperfusion (I/R). Reactive oxygen and nitrogen species (ROS & RNS) can trigger onset of the MPT. Hepatic I/R occur in organ harvesting, cold storage, and implantation surgery during liver transplantation. This abstract describes studies investigating mitochondrial depolarization caused by the MPT in vivo and its relationship to occurrence of primary non-function after transplantation of marginal liver grafts.
Methods: Fatty liver transplantation was performed in rats and non-heart-beating liver transplantation was performed in mice. Mitochondrial depolarization was monitored using intra vital confocal/multi-photon microscopy, a novel technology that allows direct visualization of mitochondria in living animals.
Findings: Inducible nitric oxide synthase (iNOS) expression, alanine aminotransferase release, total bilirubin, hepatic necrosis, TUNEL-positive cells and cleaved caspase-3 were higher in fatty liver grafts (FG) induced by ethanol treatment than in lean grafts (LG). After implantation, viable cells with depolarized mitochondria were 3-fold higher in FG than in LG. 1400W, a specific iNOS inhibitor, prevented mitochondrial depolarization, decreased graft injury and improved graft survival 3.5-fold. In another study, iNOS expression, mitochondrial depolarization and liver injury and dysfunction were substantially higher in grafts from cardiacdeath donors (CDD) than in grafts from non-cardiac death donors. Mitochondrial depolarization and graft injury in CDD grafts were markedly attenuated by iNOS-deficiency.
Conclusion & Significance: Mitochondrial dysfunction occurs in marginal liver grafts, leading to graft failure after transplantation. Mitochondrial dysfunction in marginal grafts is, at least in part, due to increased iNOS expression and excessive RNS formation. Prevention of mitochondrial dysfunction and inhibition of RNS formation are promising strategies to improve the outcomes of marginal liver transplantation.