Comparative evaluation of VATS assisted combined mechanical and chemical pleurodesis with chemical pleurodesis—is it worthwhile?

Introduction

Malignant Pleural Effusion (MPE) is a common terminal clinical problem in patients with advance cancer. Treatment options for MPE include observation, thoracocentesis, or pleurodesis. In the current study, we compared the effectiveness and safety of combined mechanical and chemical pleurodesis by Video Assisted Thoracoscopic Surgery (VATS) with chemical pleurodesis via intercostals tube alone, using talc as pleurodesis agent in both.

Material and methods

In this prospective study, diagnosed patients of MPE having Eastern Cooperative Oncology Group (ECOG) performance score 3 or less 3, expected life expectancy of more than 3 months, and having lung re-expansion after drainage were selected for pleurodesis. Patients with ability to undergo general anesthesia were considered for VATS assisted combined mechanical & chemical pleurodesis (Group A). In the remaining chemical pleurodesis was performed at bedside (Group B).

Results

The duration of this study was 1 year. The total number of patients was 30. There were 15 patients each in both the groups. Pleurodesis was achieved in 4.47?±?0.92 days in group A and 6.33?±?0.90 days in group B. This difference was highly significant (p?<?0.0001). Post procedural complaints were more or less same in both the groups.

Conclusion

Combined mechanical and chemical pleurodesis (VATS assisted) appears to be superior to chemical pleurodesis, as it offers less morbidity, lesser hospital stay, and complete response in follow up. This modality may be used in patients of MPE for palliation, who are fit for general/ regional anesthesia.     

Needs analysis for developing a virtual-reality NOTES simulator

Introduction and study aim

Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical technique that requires a cautious adoption approach to ensure patient safety. High-fidelity virtual-reality-based simulators allow development of new surgical procedures and tools and train medical personnel without risk to human patients. As part of a project funded by the National Institutes of Health, we are developing the virtual transluminal endoscopic surgery trainer (VTEST?) for this purpose. The objective of this study is to conduct a structured needs analysis to identify the design parameters for such a virtual-reality-based simulator for NOTES.

Methods

A 30-point questionnaire was distributed at the 2011 National Orifice Surgery Consortium for Assessment and Research meeting to obtain responses from experts. Ordinal logistic regression and the Wilcoxon rank-sum test were used for analysis.

Results

A total of 22 NOTES experts participated in the study. Cholecystectomy (CE, 68 %) followed by appendectomy (AE, 63 %) (CE vs AE, p = 0.0521) was selected as the first choice for simulation. Flexible (FL, 47 %) and hybrid (HY, 47 %) approaches were equally favorable compared with rigid (RI, 6 %) with p < 0.001 for both FL versus RI and HY versus RI. The transvaginal approach was preferred 3 to 1 to the transgastric. Most participants preferred two-channel (2C) scopes (65 %) compared with single (1C) or three (3C) or more channels with p < 0.001 for both 2C versus 1C and 2C versus 3C. The importance of force feedback and the utility of a virtual NOTES simulator in training and testing new tools for NOTES were rated very high by the participants.

Conclusion

Our study reinforces the importance of developing a virtual NOTES simulator and clearly presents expert preferences. The results of this analysis will direct our initial development of the VTEST? platform.     

Penile Incarceration with Metallic Foreign Bodies: Management and Review of Literature

Introduction

Penile strangulation from constricting metallic objects disorders is an uncommon urological emergency which requires prompt intervention to prevent complications. The treatment modalities are diverse and characterized by lack of consensus.

Material and Methods

Three cases with penile incarceration due to constricting metallic objects who presented to our department were included in this study. All 3 patients required different management options highlighting the diversity of clinical presentation and need for customization of treatment as per the clinical scenario.

Results

The 3 patients required different approach for treatment. First patient could be managed by degloving of penile skin while second patient required mechanical removal of the foreign body and debridement of local necrotic tissues. The third patient had to undergo excision of gangrenous penile skin and skin grafting.

Conclusion

The study emphasizes the diversity of clinical presentations and the need for employing different surgical techniques to achieve the desired results.Key Words: Penile strangulation, Constricting objects, Penile amputation     

Subcutaneous drain insertion in patients with post-operative extensive subcutaneous surgical emphysema: a single centre experience

Objective

Extensive surgical subcutaneous emphysema (ESE) albeit a benign condition could cause patients distress and in many cases temporary vision impairment. We describe the role and value of early subcutaneous drain insertion (SCD) in the management of ESE and patients’ experience in this cohort study.

Methods

Extensive surgical subcutaneous emphysema is that which extends to the neck and/or the peri-orbital region. A cohort study of a prospectively collected data was conducted between December 2009 and January 2012. All patients with extensive post-operative surgical emphysema who had SCD (size ≥24 French gauge) were included.

Results

1069 thoracic procedures were performed. 21 patients (1.96 %) were diagnosed with extensive surgical emphysema, there were 16 males, median age was 65 (54–82 years). There were 16 VATS and 5 open procedures. All patients had chest surgical emphysema, 16 patients had peri-orbital and neck swelling and 5 had neck swelling. Surgical emphysema occurred within a median of 3 days post-operatively. 14 (67 %) patients had 1 subcutaneous drain inserted, and 7 (33 %) had bilateral SCD insertion (1 drain each side). 19 (90 %) patients experienced improvement of their symptoms with resolution of neck and peri-orbital swelling within 1 day of SCD insertion, 2 patients had their symptoms improved within 2 days. All patients were satisfied with the outcome following insertion of SCD.

Conclusions

ESE should always be investigated and treated promptly. Early SCD insertion has a valuable role in the management of ESE with improvement of patients’ experience.     

Association study of the vesicular monoamine transporter gene SLC18A2 with tardive dyskinesia

Tardive dyskinesia (TD) is an involuntary movement disorder that can occur in up to 25% of patients receiving long-term first-generation antipsychotic treatment. Its etiology is unclear, but family studies suggest that genetic factors play an important role in contributing to risk for TD. The vesicular monoamine transporter 2 (VMAT2) is an interesting candidate for genetic studies of TD because it regulates the release of neurotransmitters implicated in TD, including dopamine, serotonin, and GABA. VMAT2 is also a target of tetrabenazine, a drug used in the treatment of hyperkinetic movement disorders, including TD. We examined nine single-nucleotide polymorphisms (SNPs) in the SLC18A2 gene that encodes VMAT2 for association with TD in our sample of chronic schizophrenia patients (n = 217). We found a number of SNPs to be nominally associated with TD occurrence and the Abnormal Involuntary Movement Scale (AIMS), including the rs2015586 marker which was previously found associated with TD in the CATIE sample ( Tsai et al., 2010), as well as the rs363224 marker, with the low-expression AA genotype appearing to be protective against TD (p = 0.005). We further found the rs363224 marker to interact with the putative functional D2 receptor rs6277 (C957T) polymorphism (p = 0.001), supporting the dopamine hypothesis of TD. Pending further replication, VMAT2 may be considered a therapeutic target for the treatment and/or prevention of TD.