Title: Robotic Gastrointestinal Surgery

Abstract:

Robotic Gastrointestinal Surgery

The field of gastrointestinal surgery has experienced the progression of minimally invasive techniques including the robotic approach, which enables surgeons to perform the most advanced operations with minimal tissue trauma, decreased risk of complications, and improved ergonomics which mimic the human hand movements with enhanced visualization.  The robotic applications in gastrointestinal surgery for benign and malignant disorders has revolutionized the way in which surgery is performed in the United States and other countries.  The sub-specialties of metabolic and bariatric, colorectal, hepatobiliary and pancreatic, and foregut/anti-reflux surgery have witnessed the production of high-quality randomized controlled trials, meta analyses, prospective and retrospective cohort studies which have established, in many instances, superior results to those of laparoscopy and at least non-inferior outcomes.  The following lecture will present an abbreviated yet thorough overview of the current status of robotic gastrointestinal surgery.  It will also illustrate the advances that have been achieved to date as a product of perseverance, determination, and the pursuit of innovation with patient safety as the priority.

Biography:

Rodolfo J. Oviedo, MD, FACS, FASMBS graduated from medical school at The University of Texas at San Antonio in 2007, and from Houston Methodist General Surgery Residency Program in 2013.  He decided to pursue an Advanced Minimally Invasive Gastrointestinal and Bariatric Surgery Fellowship at Baptist Hospital of Miami from 2017 to 2018.  He is a board-certified and fellowship-trained metabolic and bariatric surgeon, robotic advanced gastrointestinal surgeon, and flexible endoscopic surgeon.  He is a Diplomate of the American Board of Surgery, a Fellow of the American College of Surgeons, and a Fellow of the American Society for Metabolic and Bariatric Surgery.

Title: Percutaneous Femoral Shortening Over A Nail Using On-Site Smashing Osteotomy Technique

Abstract:

Introduction Closed femoral-shortening osteotomy over an intramedullary nail for the treatment of leg length discrepancy (LLD) and tall stature is a demanding surgical technique, classically requiring specialized instrumentation (intramedullary saw and chisel). Herein, we describe surgical technique and our experience  with shortening osteotomy over a nail, using a percutaneous multiple drill-hole osteotomy technique to perform the bone section with the osteotomized bone smashed and let on-site. Pre and Post-operative clinical and radiological data are presented.  Shortening was achieved, with a final LLD of < 1 cm in all patients. All patients were satisfied and considered the lengths of the lower limbs to be equal. Our technique did not require special surgical skill or specialized instrumentation. Moreover, we did not record intraoperative and post-operative complications. We concluded that percutaneous femoral-shortening osteotomy over a nail using the on-site smashing osteotomy technique was effective and safe in treating LLD in this initial case series.

Biography:

Rami Jahmani is an orthopaedic surgeon from Jordan University of Science and Technology, Jordan. He is a specialist in Bone lengthening and reconstruction, Dr Jahmani has completed fellowship from Paley Institute, USA and has more than 10 years experience in this field. He has published many papers and book chapters, and developed many surgical techniques

Title: An Evaluation of Morphine Use in Obstetrics During a National Shortage of Diamorphine: A Re-Audit Highlighting Changes in Practice Over Time

Abstract:

An Evaluation of Morphine Use in Obstetrics During a National Shortage of Diamorphine: A Re-Audit Highlighting Changes in Practice Over Time

Introduction: Since the national shortage of diamorphine began in late 2018, preservative-free morphine has been used as an alternative adjunct to local anaesthetics in intrathecal blockade in obstetrics. An initial departmental audit following this enforced change to morphine established a statistically significant increased risk of PONV and reduced patient satisfaction compared with previous diamorphine use. A statistically significant link between intrathecal morphine and reduced post-operative oramorph use was also found. These finding correlate with the different pharmacodynamic profiles of the two drugs. The aim of our re-audit was to evaluate the way in which morphine use changed over time, following our initial audit feedback and with increased familiarity, within our department.

Methods: All obstetric anaesthetic interventions at the Lister Hospital are routinely recorded electronically on the Xentec Epidural Audit System. Data is collected on completion of the procedure and during a post-procedure follow-up 1-3 days later. Data points collected immediately post-procedure include choice of intrathecal opiod and adequacy of block intra-operatively. On follow-up data collected includes overall patient satisfaction, side-effects experienced (including severe PONV and pruritis) and post-operative oramorph requirement. Parturients undergoing intrathecal blockade with morphine (n=104) between 13/07/18 and 20/09/18 had been previously audited. This data set represented the initial use of intrathecal morphine as an alternative to diamorphine: Morphine 1. Upon completion, these audit findings were presented at a local departmental meeting where results were displayed with no protocolised changes suggested or enforced. Post-presentation and following a period of time, a second data set was taken analysing parturients undergoing intrathecal blockade with morphine between 05/09/19 and 01/03/20 (n=374): Morphine 2. Data from these two audit sets were then analysed for comparison.

Results: Statistical analysis was carried out using Chi-Squared tests and results deemed significant if p < 0.05. There was a statistically significant increase in overall patient satisfaction and regional adequacy in the Morphine 2 group versus Morphine 1, with p values of 0.0006 and 0.0051 respectively.  However, no statistically significant change was seen in incidence of severe PONV and pruritis or in post-operative oramorph requirements between  the two groups.

Conclusions: The results above show an overall improvement in patient satisfaction and intra-operative adequacy of intrathecal blockade with morphine use over time. This most likely represents an increased familiarity with intrathecal morphine use as well as changes in practice following presentation of the initial audit results. Practitioners have reported modifications in terms of morphine dosing and/or addition of a second intrathecal adjust, fentanyl. The later agent has the benefit of augmenting the regional blockade more rapidly than morphine whilst not significantly contributing to side-effects experienced. Furthermore, this may account for the lack of change in post-operative oramorph requirement despite a statistically significant improvement in intrathecal block adequacy. Future audits should focus on comparing specific doses of intrathecal morphine and use of a second opiod adjunct.

Biography:

Dr. Hana Damirji is an anaesthetics and intensive care trainee currently working at the Lister Hospital in Stevenage, UK. She completed her medical training in London, graduating from University College London in 2015 with distinction and also obtaining first class honors in Neuroscience iBSc. Previous publications include the initiation of a debriefing session for intensive care trainees, which NHS Improvement listed as one of the top 10 quality improvement measures of 2017. ​

Title: Neutrophil / Lymphocyte Ratio (NLR) – Trombocyte / Lymphocyte Ratio (TLR): A Predictor of Axillary Lymph Node Metastasis in Breast Cancer Patients?

Abstract:

Neutrophil / Lymphocyte Ratio (NLR) – Trombocyte / Lymphocyte Ratio (TLR): A Predictor of Axillary Lymph Node Metastasis in Breast Cancer Patients?

Background: This study evaluated the relationship between preoperative neutrophil / lymphocyte ratio - platelet / lymphocyte ratio, clinicopathological, radiological factors, and axillary lymph node metastasis in stage I-III breast cancer to determine if axillary surgery can be safely omitted in selected patients.

Methods: The study included 158 Stage I-III breast cancer patients operated on at Baskent University Zubeyde Hanim Research Center between 2011 and 2018. The incidence of axillary lymph node metastasis was correlated with clinical, radiological, pathological, and laboratory (neutrophil count to lymphocyte count, platelet count to lymphocyte count) findings by univariate and multivariate analyses. Sensitivity and specificity calculations, positive predictive value, negative predictive value, positive and negative Likelihood Ratio (accuracy ratio), and exact accuracy were calculated for neutrophil/lymphocyte ratio cut-off values of 3.5 and 1.

Results: Neutrophil and platelet values were significantly higher in patients with lymph node metastasis. Neutrophil / lymphocyte ratio - platelet / lymphocyte ratio values were higher in patients with axillary lymph node metastasis, but this was not statistically significant. Axillary lymph node metastasis was not associated with age, lymphocyte, monocyte count, estrogen receptor, progesterone receptor, or c-erb B2 status. The incidence of axillary lymph node metastasis was statistically significantly higher in the presence of lymphovascular invasion. Sensitivity, specificity, positive predictive value, and negative predictive value were 93.85%, 16.67%, 44.9%, and 78.9% respectively for axillary lymph node metastasis while the neutrophil / lymphocyte ratio was ≥ 3.5. Specificity, sensitivity, positive predictive value, and negative predictive value were 97.78%, 9.23%, 75.0%, and 59.9% respectively for axillary lymph node metastasis while the neutrophil / lymphocyte ratio < 1.

Conclusions: For axillary lymph node metastasis, neutrophil, platelet counts, lymphovascular invasion status, radiological and pathological mass size, and presence of radiological axillary lymphadenopathy are the statistically significant independent variables. They provide information that can help surgeons decide on the treatment of breast cancer patients with certain neutrophil / lymphocyte ratio values (neutrophil / lymphocyte ratio < 1 and neutrophil / lymphocyte ratio ≥ 3.5).

Biography:

Tuğba Han Öner works as a General Surgery specialist in İzmir Başkent University Zübeyde Hanım Application and Research Center in İzmir Karşıyaka district.