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When discussing imaging of the paediatric urogenital (UG) system, the basic rational of any imaging should be reconsidered and remembered: imaging should only be used if it has an impact on diagnosis, treatment, further management and/or patient outcome. Particularly, in paediatrics the imaging modality should be selected considering the specifi c paediatric needs and diseases: imaging should try to avoid ionising radiation whenever possible, the least invasive procedure applicable for the individual query should be selected (e.g., try to avoid catheterism if possible, reduce examinations that need sedation, etc.), and any imaging that does not impact management should be avoided. Furthermore, the recommended imaging method should be easily accessible and available. Another basic comment on imaging in children: children are not small adults, therefore state-of-the-art imaging of infants and children requires dedicated techniques (equipment, transducer, fi ltering...) as well as age-adapted investigation protocols (ultrasound, CT, MR, etc.). This means that everyone who deals with children needs to have not only the adequate equipment available, but also has undergone dedicated training in paediatric imaging.

The aim of this analysis was to determine whether optimal outcomes have increased in recent years. Hepatic surgery is high risk, but regionalization and minimally invasive approaches have evolved. Best practices also have been defined with the goal of improving outcomes.The American College of Surgeons National Surgical Quality Improvement Program database was queried. Analyses were performed separately for partial (≤2 segments), major (≥3 segments), and all hepatectomies. Optimal hepatic surgery was defined as the absence of mortality, serious morbidity, need for a postoperative invasive procedure or reoperation, prolonged length of stay (75th percentile) or readmission. Tests of trend, χFrom 2014 to 2018, 17,082 hepatectomies, including 11,862 partial hepatectomies and 5,220 major hepatectomies, were analyzed. Minimally invasive approaches increased from 25.6% in 2014 to 29.6% in 2018 (P.01) and were performed more frequently for partial hepatectomies (34.2%) than major hepatectomies (14.4%) (P.01). Operative time decreased from 220 minutes in 2014 to 208 minutes in 2018 (P.05) and was lower in partial hepatectomies (189 vs 258 minutes for major hepatectomies) (P.01). Mortality (0.7%) and length of stay (4 days) were lower for partial hepatectomies compared with major hepatectomies (1.9%; 6 days), and length of stay decreased for both partial hepatectomies (5 days in 2014 to 4 days in 2018) and major hepatectomies (6 days in 2014 to 6 days in 2018) (all P.01). Postoperative sepsis (2.9% in 2014 and 2.4% in 2018), bile leaks (6% in 2014 and 4.8% in 2018), and liver failure (3.7% in 2014 and 3.3% in 2018) decreased for all patients (.05). On multivariable analyses, overall morbidity decreased for major hepatectomies (OR 0.95, 95% CI 0.91-0.99) and all hepatectomies (OR 0.97, 95% CI 0.94-0.99, both P.01), and optimal hepatic surgery increased over time for partial hepatectomies (OR 1.05, 95% CI 1.02-1.09) and all hepatectomies (OR 1.04, 95% CI 1.02-1.07, both P.01).Over a 5-year period in North America, minimally invasive hepatectomies have increased, while operative time, postoperative sepsis, bile leaks, liver failure, and prolonged length of stay have decreased. Optimal hepatic surgery has increased for partial and all hepatectomies and is achieved more often in partial than in major resections.

Positive pressure ventilation with Ambu bag and face masks or T-piece resuscitation in preterm babies have proved their worth in acute neonatal airway management. However, failure rates are high and endotracheal intubation is the final life-saving procedure. However, intubation is an invasive procedure and requires good expertise, especially for handling acute emergency situations. Expertise of trainees as well as consultants is coming down rapidly due to various reasons. In these situations, supraglottic airways (laryngeal mask airway or LMA) seem to be ideal. Here, we are reviewing the application and utility of LMA in acute neonatal airway management.

Anticoagulation therapy is prescribed for the prevention of recurrence in patients with venous thromboembolism, which could be temporarily interrupted during invasive procedures. The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic VTE in Japan between January 2010 and August 2014. We identified patients who underwent invasive procedures during the entire follow-up period and evaluated periprocedural managements and clinical outcomes at 30 days after invasive procedures. During a median follow-up period of 1213 (IQR: 847–1764) days, 518 patients underwent invasive procedures with the cumulative incidences of 5.8% at 3 months, 11.1% at 1 year, and 24.0% at 5 years. Among 382 patients in high bleeding-risk category of invasive procedures, anticoagulation therapy had been discontinued already in 62 patients (16%) and interrupted temporarily in 288 patients (75%) during the invasive procedures with bridging anticoagulation therapy with heparin in 214 patients (56%). Among 80 patients in low bleeding-risk category, anticoagulation therapy had been already discontinued in 15 patients (19%) and interrupted temporarily in 31 patients (39%) during invasive procedure with bridging anticoagulation therapy with heparin in 17 patients (21%). At 30 days after the invasive procedures, 14 patients (2.7%) experienced recurrent VTE, while 28 patients (5.4%) had major bleeding. This study elucidated the real-world features of peri-procedural management and prognosis in patients with VTE who underwent invasive procedures during follow-up in the large multicenter VTE registry. The 30-day incidence rates of recurrent VTE and major bleeding events were 2.7% and 5.4%.

Patients with cirrhosis have coagulopathy often necessitating correction with blood products, such as plasma products (fresh frozen plasma and plasma frozen within 24 h) prior to certain invasive procedures. However, plasma administration has the potential for substantial negative adverse effects such as volume overload, transfusion-related lung injury and allergic/anaphylactic reactions. In addition, its effectiveness in preventing bleeding is similarly unclear. The purpose of this study was to determine the safety and efficacy of plasma administration in cirrhotic patients undergoing minimally invasive procedures, specifically vascular access placement, transjugular liver biopsies, renal biopsies and thoracenteses. In this retrospective cohort study, we identified patients receiving plasma products in preparation for an invasive procedure, with the primary outcomes of volume overload and bleeding. Of the 145 transfusion events that met the criteria from 2015 to 2018, the median INR decreased from 2.7 to 2.2 pre and post plasma administration and 13.8% of recipients had complications of volume overload. The cost of acquisition of plasma administered below clinically impactful doses accumulates to an estimated 19 000 dollars over this time period, not including nursing preparation or production costs. Plasma products minimally, if at all, improved laboratory values of coagulation and in some patients led to adverse effects.

Histopathological examination is the gold standard for the diagnosis of nonmelanoma and melanoma skin cancer, but it is an invasive procedure that consumes time and requires large costs. The average cure rate for skin cancer is high with early detection and appropriate treatment. This is an article review that was made through findings from several scientific articles. There are several noninvasive imaging modality choices that can be used for screening at low cost, high quality, and faster result, which includes dermoscopy, optical coherence tomography, reflectance confocal microscopy, electrical impedance spectroscopy, multispectral imaging, and SIAscopy ® . These imaging modalities can assist in the detection of skin cancer using a combination of high-quality computer science, mathematics, and optics. This can improve the efficiency of diagnosis and management, reduce treatment costs , and increase patient satisfaction while utilizing teledermatology. Keywords : noninvasive, imaging modality, teledermatology, skin cancer

Background: t he infusion procedure is an invasive procedure that is often performed when treating children in the hospital, this action is done by inserting a needle into the child's vein which can cause pain. Cold compress using ice gel is one way to stimulate the skin so that it is therapeutic before infusion procedure. Purpos e: to find out whether there is an effect of cold compresses using ice gel on the pain intensity during infusion procedure of school age children. Methods: this type of research is a quasi experiment two group posttest only design method. The population in this study were 32 children aged 6-12 years and the reaseach was taken at RSUD KRMT Wongsonegoro Semarang. The instruments were used ice gel compress, and were measured using pain intensity (OUCHER). The hypothesis test used the Wilcoxon test and Man-Whitney test. Results: data from 32 respondents obtained the results of the pain scale using the cold compress application. Ice gel against pain intensity of school-age children during infusion with p -value - 0,000> 0.05. Thus, if p - 0.000> 0.05 then Ho is accepted and Ha is rejected, which means that there is a significant difference in the pain scale between giving compresses (ice gel) to school-age children who are subjected to infusion. Conclusion: the application of cold compresses using ice gel can reduce the pain intensity of school-age children during the infusion procedure. That is recomended as the intervension during infusion procedure.

Interest in endomyocardial biopsy (EMB) has progressively grown during the past decade. Still, its use remains limited to highly specialized centers, mostly because it is considered an invasive procedure with poor diagnostic yield and inherent complications. Indeed, the diagnostic performance of EMB is strictly linked to the sample of myocardium we can obtain. If we can precisely localize areas of diseased myocardium, sampling error or inadequate withdrawals are minimized. In this state-of-the-art review, we provide guidance on how to technically and practically perform EMB guided by electroanatomic voltage mapping and intracardiac echocardiography, and review the evidence supporting this combined approach.

Closed reduction and fixation using a cephalomedullary nail represents the accepted management of unstable intertrochanteric fractures. Cut-through has been described as a complication associated with the treatment. Although a hip arthroplasty may be the most predictable revision method, a non-prosthetic option can lead to similar results. The objective is to describe a non-prosthetic revision procedure in cases of cut-through.We performed a retrospective analysis of our Institutional Registry for Hip Fractures in elderly patients (RIAFC) from January 2010 to June 2018 searching for cut-through as a failure after unstable intertrochanteric fracture treatment. REVISION PROCEDURE: (A) Helical blade removal, introduction of structural bone graft (autologous or allograft) as a plug to obliterate the communication to the joint and a new blade insertion. (B) Same as in A but augmenting the blade/head purchase with poly(methyl methacrylate) (PMMA). Before the cement insertion, a radio-opaque solution was instilled to assure lack of joint leakage.We evaluated 1616 patients. Sixteen of them presented a cut-through complication (1%). Ten of them were females with an average age for all of 84 years. One patient denied an implant revision and opted for a total joint replacement. In four of the patients, the procedure A was done, 2 of them had a new failure, and an joint arthroplasty was performed. In the B group, only one patient needed a revision to a total hip. The other 10 patients healed uneventfully and did not need any further intervention.Cut-through revision after fixation of unstable intertrochanteric fractures treated with cephalomedullary nail by blocking of the joint communication and augmenting the head blade purchase with PMMA is a safe and minimal invasive procedure, generates low blood loss and rate of complications and allows bone healing preserving the native joint.Nil.

Objective: This study aimed to analyze the indications and outcomes of prenatal invasive diagnostic procedures performed in a single tertiary center. Materials and Methods: The invasive procedure indications and karyotype results of 1666 pregnant women who underwent prenatal invasive procedures between March 2016 and November 2018 were retrospectively analyzed. The indications and results of prenatal invasive diagnostic procedures were recorded. Results: Amniocentesis (AS) was performed to 1060 (63.6%) patients, corion villus sampling (CVS) to 299 (17.9%), and cordocentesis (CS) to 307 (18.4%) patients. Among the prenatal invasive procedure indications, the most frequent indication was abnormal ultrasound (US) findings, with a rate of 48.3% (n= 805). A normal karyotype was detected in 85% (n= 1416) of the cases, and chromosomal abnormality was detected in 12.2% (n= 204) of the cases. Abnormal karyotype results were found in 111 (10.5%) of 1060 patients who underwent AS, 87 (29.1%) of 299 patients who underwent CVS, and 52 (16.9%) of 307 patients who underwent CS. Among the numerical chromosomal abnormalities, trisomy 21 was the most common abnormality with a rate of 46% (94/204), while inversions were the most common abnormality of structural chromosomal abnormalities at 8.8% (18/204). Conclusion: The results of the current study show that AS is the most common prenatal diagnostic invasive procedure. We obtained the highest fetal chromosomal anomaly rate in patients who experienced CVS. Abnormal US findings were the most common prenatal invasive diagnostic procedure indication in our study. Choosing the most appropriate invasive procedure is related to the obstetricians' experience, medical history of the patient, the gestational week at admission, maternal prenatal serum screening test results, and abnormal US findings.

Immature fetal lung is associated with many adverse outcomes including respiratory distress syndrome and transient tachypnoea of the newborn. Several methods/tools have been used over several decades to assess fetal lung maturity prior to delivery. Some of the methods that have been used to assess fetal lung maturity include amniocentesis for the biochemical markers, lecithin and sphingomyelin, lamellar body counts, gray scale ultrasound scan and magnetic resonance imaging. Amniocentesis an invasive procedure which carries a small risk of miscarriage has almost become obsolete. Magnetic resonance imaging on the other hand is expensive and not very practical. Quantitative ultrasound fetal lung maturity (quantusFLM) assessment is a new technique aimed at assessing fetal lung texture using ultrasound. The technique depends on visualization of fetal lungs at the level of the 4- chamber view. Images obtained are then uploaded via a web page application and these are analyzed remotely and results generated in minutes. The analysis depends on studying changes in the texture of lung images that depend on changes at histological level especially of collagen, fat and water. These changes are undetectable to the human eye. Randomized clinical trials have shown this technique to be accurate, reproducible, and completely non - invasive. The aim of this review was to take a historic look at methods/tools for assessing fetal lug maturity and discuss further advances and a potential non-invasive tool/method especially the non-invasive assessment that combines ultrasound scan and machine learning to accurately assess lung maturity.

La definición de síndrome coronario crónico de alto riesgo varía según la prueba no invasiva empleada para evidenciar isquemia, lo que se consigue a través de un aumento del trabajo miocárdico y la demanda de oxígeno, generados con el uso de fármacos o el ejercicio. El abordaje inicial nos sumerge en la discusión de contextualizar en qué casos priorizar la terapia médica óptima inicial, frente al manejo invasivo inicial con el objetivo de lograr la revascularización miocárdica. Este aspecto central será desarrollado en esta revisión, tomando en cuenta diversos estudios realizados hasta la fecha, en los que el manejo invasivo inicial no ha demostrado ser superior a la terapia médica óptima inicial en resultados clínicos relevantes como muerte o eventos adversos cardiovasculares mayores.

Background:Tactile stimulation has a great effect on decreasing neonatal stress during invasive procedures in neonatal intensive care units. Aim of the study: The study aimed to assess the effect of tactile stimulation on neonatal stress during invasive procedures at neonatal intensive care units. Design and setting: A quasi-experimental research design was used in this study, which was implemented in neonatal intensive care units Port Said, Port-Fouad and El-Nasr General Hospitals in Port Said. Sample: A sample of 130 neonates were used in the study. Tools: Data were collected by using three tools the first for neonatal characteristics, the second for assessment of neonatal blood sample (invasive procedure) and the third for stress physiological, behavioral & motor measurements. Results: There were high statistically significant differences in physiological, behavioral & motor measurements between two methods (with & without tactile stimulation) and the degree of neonatal stress control during invasive procedures in NICUs. Moreover, there was high statistically significant differences between two methods (with & without tactile stimulation) regarding total stress score and the degree of neonatal stress control during invasive procedures in NICUs, p value

Newborns in intensive unit receives a number of invasive procedures that would causeschanges in sensitizationof pain and possible long-term effects on child’s subsequentdevelopmental period. This encourages the need for pain measurement that could reflectthe actual pain responses especially in blood sampling.The purpose of this review is tooverview pain responses in newborns receiving procedures invasive of blood samplingusing advance pain measurement. Literature search was conducted through threeonline database, namely EBSCO (CINAHL and MEDLINE), Scopus, and Wiley, withinrelated keyword applied are invasive procedure, neonate, newborn, pain assessment andpain intensity. Twelve articles were identified for critical review. This literature studyprovides an overview of responses to blood collection procedures through measurementsof behavioral and skin conductance activities in neonates. Pain response with behavioralmeasurement shows the range of mild-moderate pain in the procedure of blood samplingthrough peripheral veins, the range of moderate-severe pain in heel pricking, and therange of severe pain in arterial blood sampling. Skin conductance measurement reflectsympathetic activity to pain stimulus through sweat gland activity in the superficiallayer of the skin, and is expected to be an objective method of pain measurement forneonates in clinical practice.

Pendahuluan: Amniosentesis adalah suatu prosedur invasif pengambilan cairan amnion untuk mendapatkan sel-sel janin dalam rangka pemeriksaan kromosom, salah satu teknik dan prosedur diagnosis prenatal yang diperkenalkan selama 10 tahun terakhir. Hal ini penting diperkenalkan karena besarnya insiden kelainan kromosom pada bayi yaitu 90 kejadian per 10.000 kelahiran.Tujuan: Artikel ini digunakan sebagai bahan pembelajaran untuk meningkatkan wawasan mengenai amniosentesis yang merupakan metode diagnostik prenatal invasif yang paling sering digunakan dengan tingkat keberhasilan yang cukup tinggi serta membantu agar dapat melakukan pencegahan dan deteksi dini penyakit keturunan dan kelainan bawaan pada janin yang belum lahir.Metode: Penulisan artikel ini menggunakan metode tinjauan naratif sebagai bagian dari studi literatureDiskusi: Amniosentesis memiliki tujuan lainnya seperti menilai tingkat pematangan paru janin dan mengetahui apakah terdapat infeksi pada janin. Prosedur amniosentesis biasanya dilakukan pada usia kehamilan 15 – 20 minggu. Jika prosedur amniosentesis dilakukan di bawah usia kehamilan 15 minggu, dapat meningkatkan kejadian keguguran. Analisis fosfolipid cairan amnion dapat menentukan tingkat pematangan paru janin. Cairan amnion juga dapat digunakan untuk analisis biokimia, studi molekuler, dan microarray chromosome analysis (CMA).

Background: Fracture of lower end of radius is common fracture in orthopaedic practice. No age is immune to this fracture but commonly seen in elderly population. Till date there is no consensus in management of this fracture. Variety of treatment is available in literature from casting to plating of this fracture. Minimal invasive technique of percutaneous k-wire fixation and cast is cost-effective with better functional end results.Material and method: In this study, Frykman`s classification system has been used to describe the fracture types. Frykman type II and IV were more common fracture pattern. All patients were treated with percutaneous multiple k wires and cast. Cast and k- wires were removed after six weeks. Results: In this study thirty patients were treated by this technique. results were analysed according to Lindstrom`s criteria for anatomical and functional end results. All patients had good to excellent functional results. Discussion: Though this fracture is described sssince so many years, unsatisfactory results are also common. Percutaneous pinning is attempted to bridge the gap between conservative and more invasive procedures. This fracture is commonly seen in elderly population. Co-morbid medical conditions are highly present in these people. So any invasive procedure is not without any risk. This minimal invasive procedure is gold standard in these age groups. In this study most of the patient had good functional end results. Conclusion: Minimal invasive percutaneous Kirshner wire fixation is superior method of treatment for distal end radius fractures. There is very low incidence of complication and unsatisfactory results.

For many years tissue biopsy has been the primary procedure to establish cancer diagnosis and determine further treatment and prognosis. However, this method has multiple drawbacks, including, to mention some, being an invasive procedure carrying significant risk for fragile patients and allowing only for a “snapshot” of the tumor biology in time. The process of liquid biopsy allows for a minimally invasive procedure that provides molecular information about underlying cancer by analyzing circulating tumor DNA (ctDNA) via next-generation sequencing technology and circulating tumor cells. This paper focuses on describing the basis of ctDNA and its current utilities.

First metatarsophalangeal (MTP) arthrodesis is a common procedure for treating degeneration in the MTP joint. Open arthrodesis is a conventional procedure that provides acceptable results but is more invasive than minimally invasive or arthroscopic arthrodesis. However, little is known about the different outcomes between minimally invasive surgery (MIS) and arthroscopic surgery (AS) for MTP arthrodesis. This study was performed to compare the outcomes of the first MTP joint preparation for arthrodesis regarding the effectiveness of articular surface preparation and safety between MIS and the arthroscopic procedure in cadaveric specimens. Sixteen cadaveric feet were collected in this study from eight cadavers. The potential exclusion criteria were significantly decomposed or deformed joint. All feet were randomly allocated into two groups, eight feet for the MIS (under fluoroscopic control) group and eight feet for the arthroscopic group. One foot in the AS group was excluded because the position of an arthroscopic portal was incorrect. All feet were operated on by four fellowship-trained foot and ankle orthopedic surgeons who also had prior clinical experience with the arthroscopic and minimal invasive procedure. Following a complete procedure in each specimen, all feet were dissected and the areas of joint preparation on the metatarsal and phalangeal sides were recorded via photography and the ImageJ program. Injury to the adjacent structure was noted in each specimen. All data were analyzed via the IBM SPSS program version 22 and GraphPad to compare the outcomes between the two groups. The average age of the cadavers was 68.6 ± 12.3 years. The average areas of joint preparation on the metatarsal and phalangeal sides were 136.97 and 99.08 mm2, respectively. The average areas of joint preparation on the metatarsal sides were 154.26 and 117.21 mm2 in the MIS and arthroscopic groups, respectively (p value = 0.353). The average areas of joint preparation on the phalangeal sides were 82.46 and 118.08 mm2 in the MIS and arthroscopic groups, respectively (p value = 0.151). Regarding the ratio of prepared area/mean estimated fusion contact area, there was no significant difference of a ratio on metatarsal side with p value as 0.285. However, a higher level of ratio on phalangeal side was found in the arthroscopic group with p value as 0.085. For the safety profiles, the rate of adjacent injury was insignificantly higher in the MIS group (37.5%) than the arthroscopic group (0%) (p value = 0.20). All injuries were found at the extensor hallucis longus tendon. There were no significant differences of the effectiveness of articular surface preparation between the MIS and arthroscopic groups. However, the arthroscopic procedure seemed to provide higher rate of prepared surface area on phalangeal side and be safer to the adjacent structures than MIS for this arthrodesis.

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure, which is widely used in the management of pancreas and biliary tract diseases. It may induce complications, such as pancreatitis, bleeding, and perforation. Splenic injury is an extremely rare but life threatening complication. We reviewed the literature, and found that 23 ERCP associated splenic injuries cases had been reported. We discussed the likely mechanism, clinical features, diagnostic modality, and treatment, also shared our experience on a patient who suffered splenic laceration after ERCP and was successfully treated by splenectomy.

Objective: Venipuncture is an invasive procedure, and repeated puncture attempts may be uncomfortable or even traumatic for patients. Vein visibility is one of the most influential variables for the failure of venipuncture; however, the factors affecting vein visibility remain unclear. The present study was conducted to identify the factors influencing vein visibility at the upper limb in healthy young adults. Methods: Twenty-seven healthy volunteers were included. All measurements were performed at the right arm, right cubital fossa, and right forearm. The depth and cross-sectional area of superficial veins were measured by ultrasonography. Skin color was assessed by a spectrophotometer and quantified according to Commission International d’Eclairage L*a*b* values. Results: Invisible superficial veins were significantly deeper and had a larger cross-sectional area than visible superficial veins. Skin color b* of invisible superficial veins was significantly higher than that of visible superficial veins. Vein depth, skin color b*, and gender markedly affected superficial vein visibility at the upper limb. The cutoff for vein depth was 2.3 mm (area under the curve = 0.91). Conclusion: The present results confirmed that vein depth, skin color b*, and gender strongly influenced vein visibility at the upper limb. The cutoff for vein depth was 2.3 mm.

Background: Fistula-in-Ano is common in clinical practice and is notorious for morbidity and recurrence with current treatment options. Minimal invasive procedure is being tried with encouraging results. Materials and Methods: This is a series of 35 patients who underwent video-assisted anal fistula treatment (VAAFT) in our institution from 2015 to 2018. All patients were evaluated both clinically and with magnetic resonance imaging to delineate the details of the fistula. Patients were treated by VAAFT and followed up for 12 months. The data were acquired from the hospital information system. Failure of the procedure, recurrence, and any other adverse events were recorded correlating it with the gender, comorbidity, type of the tract, linearity of the tract, and relation to the levator ani muscle. Chi-square test with continuity correction was used to find the association between recurrence and clinical parameters. Kruskal–Wallis test was used to compare the mean recurrence time among the type of fistula and tract. Results: In the 27 males and 8 females, we found 22 patients had linear fistulous tract, 6 had linear bifurcated, curvilinear tract in 6, and 1 had a blind tract. The median operation time was 58 min. Healing rate was highest (72.7%) in patients who had a linear tract, and recurrence was highest (66.7%) in patients who had a curvilinear tract. Patients with blind tracts or multiple tracts identified at the surgery and those with Crohn's disease had a higher incidence of recurrence. Conclusion: VAAFT can be recommended as an initial minimally, morbid, though expensive procedure in the management of the simple type of fistula-in-ano with an acceptable recurrence rate.

Background This systematic review and meta-analysis searched, retrieved and synthesized the evidence as to whether preoperative esophagogastroduodenoscopy (p-EGD) should be routine before bariatric surgery (BS). Methods Databases searched for retrospective, prospective, and randomized (RCT) or quasi-RCT studies (01 January 2000–30 April 2019) of outcomes of routine p-EGD before BS. STROBE checklist assessed the quality of the studies. P-EGD findings were categorized: Group 0 (no abnormal findings); Group 1 (abnormal findings that do not necessitate changing the surgical approach or postponing surgery); Group 2 (abnormal findings that change the surgical approach or postpone surgery); and Group 3 (findings that signify absolute contraindications to surgery). We assessed data heterogeneity and publication bias. Random effect model was used. Results Twenty-five eligible studies were included (10,685 patients). Studies were heterogeneous, and there was publication bias. Group 0 comprised 5424 patients (56%, 95% CI: 45–67%); Group 1, 2064 patients (26%, 95% CI: 23–50%); Group 2, 1351 patients (16%, 95% CI: 11–21%); and Group 3 included 31 patients (0.4%, 95% CI: 0–1%). Conclusion For 82% of patients, routine p-EGD did not change surgical plan/ postpone surgery. For 16% of patients, p-EGD findings necessitated changing the surgical approach/ postponing surgery, but the proportion of postponements due to medical treatment of H Pylori as opposed to “necessary” substantial change in surgical approach is unclear. For 0.4% patients, p-EGD findings signified absolute contraindication to surgery. These findings invite a revisit to whether p-EGD should be routine before BS, and whether it is judicious to expose many obese patients to an invasive procedure that has potential risk and insufficient evidence of effectiveness. Further justification is required.Other Information Published in: Obesity Surgery License: https://creativecommons.org/licenses/by/4.0See article on publisher's website: http://dx.doi.org/10.1007/s11695-020-04672-4

Background Open repair for chronic DeBakey type IIIb dissecting aortic aneurysm is an invasive procedure involving open proximal anastomosis under hypothermic cardiac arrest, with significant morbidity in high-risk patients. We adopted a two-stage repair strategy using total arch replacement with the elephant trunk technique, which enables aortic crossclamping and avoids open proximal anastomosis at the second-stage graft replacement through a left thoracotomy. Methods From January 2008 to October 2018, we performed DeBakey type IIIb dissecting aortic aneurysm repair in 76 cases, and compared the results of two-stage repair (group 1, 25 cases) and single-stage repair using graft replacement with open proximal anastomosis through a left thoracotomy (group 2, 31 cases). Results In group 1, the elephant trunk technique was successful in all cases. The second intervention included endovascular repair (13 cases) and graft replacement through a left thoracotomy (7 cases). Five cases were followed up conservatively because the false lumen was thrombosed after the elephant trunk technique. Aorta-related adverse events were seen in 5 cases in group 1 (1 re-dissection, 1 rupture, 2 stent-graft-induced new entries, 1 stent-graft migration) and 6 in group 2 (1 additional thoracic endovascular aortic repair, 1 rupture, 4 acute type A aortic dissections). There were no statistical differences between the two groups regarding aorta-related adverse events and death. The postoperative course was acceptable in both groups. Conclusions Single-stage repair with open proximal anastomosis is an option in patients not at high risk for invasive surgery, while two-stage repair is recommended for high-risk patients.

Adrenal venous sampling is the gold standard test to identify surgically curable primary aldosteronism, but it is markedly underused in clinical practice being perceived as a technically challenging and invasive procedure and, moreover, as difficult to interpret. This review provides updated information on current indications to adrenal venous sampling and how to perform and interpret adrenal venous sampling.

Aim LIRA technique (Laparoscopic Intracorporeal Rectus Aponeuroplasty) was described in 2018 in order to reduce the tension in the midline as an alternative to defect closure (CD) in Laparoscopic Ventral Hernia Repair. We present our results in LIRA series in patients over 1-year follow-up. Material and Methods A prospective controlled study was conducted from January 2015 to December 2020 to evaluate an elective new procedure (LIRA) performed on patients with midline ventral hernias w2 (EHS Classification). Data analyzed included patient demographics, operative parameters and complications. A Tomography was performed preoperatively and postoperatively (1 month and 1 year) to evaluate recurrence, distance between rectus and seroma Results 49 patients were included. Mean Age was 58± 10.59 years old and BMI 33.11± 6.61 kg/m2. Mean width of the defect was 6.19± 1.49 cm. Average VAS (24 h) was 5.09 ± 5, 0.38(1 month) and 0 (1 year). Mean preoperative distance between rectus was 5.55± 1.61 cm; postoperative was 2.15 ± 0.79 cm (1 month) and 2.20±0.68 cm (1 year). Radiological seroma at first month was detected in 40%. Seroma after 1 year was 4,08% Mean follow-up was 24 months. Bulging was detected only in 1 case (2.04%) of our series after 1 year follow up. No recurrence is data. Conclusions LIRA technique could be considered as an alternative to CD for w2 defects with a low rate of complication, and could be related to a low rate of postoperative pain with no recurrence and a low rate of bulging compared to CD, being a safe, feasible and reproducible technique.

The coagulopathy of chronic liver disease causes derangement of the results of traditional laboratory tests. As such, there is an expectation that when undergoing invasive procedures patients with cirrhosis are at increased risk of bleeding. Standard practice is to optimise laboratory values with prophylactic transfusions of platelets, plasma and fibrinogen to reduce perceived bleeding risk. There has been a shift in thinking regarding coagulation in patients with chronic liver disease, whereby a rebalancing of haemostasis occurs with reduction in both procoagulants and anticoagulants. Guidelines for the preprocedural management of patients with chronic liver disease are inconsistent and may not account for this new paradigm. The risk of prophylactic transfusion should be measured against the risk of bleeding while considering the rebalancing of haemostasis. Future management may be guided by whole blood viscoelastic tests or use of thrombopoietin receptor agonists to optimise patients in these scenarios.

Catheter ablation is a well-recognized treatment for a number of cardiac arrhythmias. Initially used to treat supraventricular tachycardia, this technique is now also widely used to treat ventricular arrhythmia and atrial fibrillation. This review aims to describe all the possible types of complication related to this invasive procedure. Definitions according to the current guidelines are provided, as are some details on the frequency of complications and how to diagnose and treat them appropriately. Finally, each section of the review provides guidance on how to prevent the complications associated with catheter ablation.

Introduction.There are various osteoplasty methods aimed at managing the challenge of jaw atrophy. When the scope of the osteoplasty is extensive it is not always possible to prepare an appropriate amount of bone tissue without additional surgeries. In some cases there is a lack of intraoral bone tissue sources for this kind of operations. Using extraoral sources of bone tissue is not always justified; it is invasive and patients take longer to recover and return to work. Using alternative sources of bone biomaterials might help establish a less invasive osteoplasty protocol.Goal.To demonstrate the efficiency of alveolar ridge osteoplasty with the application of laminar technique and using various combinations of autograft and allograft tissues.Materials and methods.To achieve the goal set we have examined and treated fourteen patients (N=14) surgically. All patients presented a clinical picture of severe atrophy in dentoalveolar segments 3 and 4, knife-edged ridge, Cawood and Howell class IV–V. Depending on the combination of autograft and allograft biomaterials patients were split into three study groups and one control group.Results and discussion.Positive outcomes for the treatment administered were observed in 13 out of 14 patients. Complications were determined by the lack of soft tissue, exposure of the graft or its suppuration. All the patients in all the groups underwent a control CT which confirmed the bone tissue growth at the area of the augmentation performed.Conclusion.Using the bone biomaterial allograft in combination with autograft bone makes it possible to get good clinical results in all the groups observed. This method may be a method of choice eliminating the additional invasive procedure of bone transplant harvesting; it does, however, require further, more detailed research.

Study Design.A case series of dual time-point 18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) for the diagnosis of spinal cord sarcoidosis.Objective.The aim of this study was to illustrate three cases of spinal sarcoidosis with occult presentation and subsequent identification with the use of dual time-point 18F-FDG PET/CT.Summary of Background Data.Sarcoidosis of the spinal cord is very rare and when it occurs without systemic manifestations of disease can be a challenging diagnostic dilemma frequently resulting in the need for spinal cord biopsy in order to establish a diagnosis.Methods.Case series presentation and report.Results.This manuscript presents a case series experience of dual time-point 18F-FDG PET/CT for the diagnosis of spinal cord sarcoidosis. We review the cases of three patients who presented with myelopathy and underwent 18F-FDG DTPI as part of the evaluation for enhancing spinal cord lesions of unknown etiology for 2 years at a university-based cancer hospital. 18F-FDG DTPI was vital in making the diagnosis of sarcoidosis, and in two of the cases, the patients were able to avoid biopsy, thereby avoiding potential morbidity from an invasive procedure.Conclusion.18F-FDG PET/CT imaging is a noninvasive imaging technique that can be crucial in the diagnosis of sarcoidosis of the spinal cord and help avoid unnecessary procedures.Level of Evidence: 4. © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Surgical site infections (SSIs) are defined as infections of the tissues, organs, or spaces exposed by surgeons during performance of an invasive procedure. Motivation/Background: A lot of expense both with regards to nursing time and dressing material costs is invested in prevention of SSI using occlusive surgical incision site dressing. But to what extent is this beneficial over open wound treatment? In the present study, we have compared the incidence of SSIs in surgical wounds treated with occlusive dressings versus those treated with open wound treatment to find out the same. Method: The study was conducted on 860 patients of General Surgery wards. Patients were categorized under two groups of cases where (1) Dressing was opened after 24 hours and then only open wound treatment by cleaning with Betadine 12 hourly was done till stitch removal and (2) Dressing was opened after 48 hours and then again after every 2 days occlusive dressing was done until stitch removal. Result: A Chi-Square Test was performed to understand if Occlusive dressings have an added advantage over Open Wound Treatment in prevention of SSIs. Conclusion: Occlusive Dressings have no added advantage over Open Wound Treatment in the prevention of SSIs and hence Open wound treatment can be taken as an alternative for occlusive dressings.

Ultrasound-guided central line placement has been shown to decrease the number of needle puncture attempts, complication, and failure rates. In order to obtain successful central access, it is important to have adequate cognitive knowledge, workflow understanding, and manual dexterity to safely execute this invasive procedure. The operator should also be familiar with the anatomical variations, equipment operations, and potential complications and their prevention. In this article, we present a detailed review of ultrasound-guided central venous access. It includes a description of anatomy, operative technique, equipment operation, and techniques for specific situations. We describe the use of ultrasound guidance to avoid and identify various complications associated with this procedure. We have also reviewed recent recommendations and guidelines for the use of ultrasound for central venous access and the current evidence pertaining to the recommendations for the expected level of training, methodology, and metrics for establishing competency.

Objectives: The objective of the study is to determine the incidence, clinical and ultrasound characteristics of choroid plexus cyst diagnosed during the 18 -23 weeks anomaly scan and the genetic outcome in 6 pregnancies that underwent molecular diagnosis. Methods: The information obtained from the clinical records of pregnancies with ultrasound diagnosis of choroid plexus cyst Data are analyzed and presented in simple frequency tables. Results: Choroid plexus cyst was diagnosed in 8 (0.9%) pregnancies. The majority of the cysts were solitary (75.0%), unilateral in location (62.5%) and with no associated aneuploidy marker (75.0%). Echogenic bowel and ventricular septal defect was found in 1 fetus each (25%). Six (75.0%) out of the 8 fetuses with chorionic plexus cyst had molecular diagnosis. Two (25%) were trisomy 21 and 1 was trisomy 18. Maternal age > 35 years, multiple cysts and bilateral cyst location was reported in 2 (66.7%) of the 3 fetuses with aneuploidy. Conclusions: Trisomy 21 was the more frequent aneuploidy in fetuses with choroid plexus cyst. Maternal age > 35 years, bilateral location, multiple cysts and presence of soft aneuploidy marker are suggested as indications for molecular diagnosis in CPC.

Management of impacted mandibular third molars with surgical removal is a very common procedure in day-today- practicein whichever Wards or Modified Wards the incisions are performed. In some cases Envelope Flap and other such types of flaps are commonly performed. Incision, reflection of flap, osteotomy, suturing are the normal protocols which give more tissue handling, more trauma to tissue and discomfort to the patient. It also causes swelling and pain. This surgical procedure is needed in deeply seated impacted mandibular third molar tooth. But we observed in some cases of impaction, which werenot deeply seated, half or more than half the crown was clinically visible in the oral cavity. In such cases, we can modify the technique and remove this third molar with minimum invasive conservative approach. From this observation, we modified the technique for surgical removal of partially erupted third molar and inset to avoid incision and bone cutting. This paper suggests management of partially erupted mandibular third molar tooth with minimum invasive technique or conservative approach. We observed, minimum invasive procedures were causing less post-operative complications and it definitely reduces the time to perform the procedure. The prevention of incision with conservative approach is discussed in thirty patients. The purpose of this article is to present the cases that led to this observation, and present the technique modification in design and execution that we have used.[1-5]

Soft tissue reconstruction of a complex wound in the lower leg still presents a challenge to reconstructive surgeons, especially in the foot and ankle with exposed bones. We report the preliminary results of soft tissue complex defect treatment and coverage with our new lipogluing technique plus full-thickness skin graft. From September 2015, five patients with complex soft tissue defects on the lower leg underwent the coverage procedure with our new lipogluing technique plus full-thickness skin graft. At the first surgical step after standard debridement, we fix by fibrin glue the graft of fat cells withdrawn using the standard Coleman technique. Lipoglued fat cells enhance the soft tissue cover and better supplement the final skin thickness and pliability. This allows us to achieve the ultimate goal of reconstructive procedures: the recreation of all anatomical cutaneous and subcutaneous layers. Based on this preliminary personal experience, reliable information can be given about the safety, effectiveness, and usefulness of the lipogluing technique plus skin graft. All patients were able to wear normal footwear and to return to their usual activities thanks to the good results obtained and, when necessary, to thin coverage. To date, the coverage appears durable on all patients and they do not show any secondary problems of skin ulceration or breakdown. The lipogluing technique represents an evolution of the reconstructive process that aims to augment the autologous soft tissue under the skin graft avoiding more invasive procedure, in order to obtain a skin cover that feels natural. Level of Evidence: Level V, therapeutic study.

Haemorrhoid is a common anorectal disorder which usually requires surgical intervention. Conventional haemorrhoidectomy had been practiced for long time but in 1993 Longo introduced a newer minimally invasive procedure for haemorrhoids. In this study we have compared the post-operative results of MIPH with conventional open haemorrhoidectomy. To analyze and compare various Pre and post-operative factors such as duration of surgery, post-operative pain and analgesia, duration of hospital stay, post- operative complications, recurrence and early return to work in the patients suffering from Grade III and IV Haemorrhoids undergoing Open Miligan-Morgan’s haemorrhoidectomy and Minimal Invasive Procedure for Haemorrhoids(MIPH). In this prospective study a total of sixty patients underwent surgery for grade III and IV haemorrhoids at Santosh Medical College and Hospital, Ghaziabad from April 2017 to October 2018. Thirty patients in group A underwent Milligan Morgan technique of open haemorrhoidectomy and thirty patients in group Bunderwent Longo’s technique of MIPH (Minimal Invasive Procedure for Haemorrhoids). The average duration of surgery was significantly less in MIPH group as compared to open haemorrhoidectomy group. Only 6.6% of MIPH developed early post-operative complications whereas atleast 25% of open haemorrhoidectomy developed early complications such as pain, bleeding per rectum and wound infection. Early return to work was significantly better in MIPH group. MIPH is safe with a low recurrence rate and complications. It is a nobel technique and has emerged as an alternative to open haemorrhoidectomy. Only limitation is the cost of the MIPH stapler device. Keywords: Haemorrhoids; MIPH, Open Haemorrhoidectomy; Stapled Haemorrhoidopexy.

Arterial blood pressure monitoring is a major part of the decision-making process for every anesthetic. It is important to recognize the advantages, disadvantages, and limitations of available measurement modalities as well as have some understanding of the engineering principles on which these measurements are based. Oscillometry is by far the most common modality used but is limited by its intermittent nature and inaccuracy during hypotension and hypertension. Arterial catheterization is the gold standard for measuring blood pressure but is an invasive procedure that is expensive and not without risk of harm to the patient. Volume clamp and tonometric technologies are relatively new and allow for continuous noninvasive monitoring of the blood arterial waveform, but their accuracy when compared with oscillometry is not well described, and they have not been widely incorporated into standard practice. Additional research is needed to determine whether continuous noninvasive blood pressure monitors can improve outcomes.

Supporting clearance of a toxic substance by an extracorporeal removal technique is one of the advanced treatment methods applied in poisoned patient management. General indications stem from toxicokinetics of the poison while individual indications are determined by poisoning severity. The first part of this review deals in detail with particular options of extracorporeal treatment in toxicology and also with its specific application when treating lithium and salicylates poisoning or dabigatran overdose. The aim of this review is to facilitate the clinicians and nephrologists decision making whether to indicate this invasive procedure, to communicate and summarize the existing recommendations and to highlight the most important ways of how to treat poisoning by specific toxic substances.

The aim of this study is to evaluate the surgical outcomes of single-port laparoscopic percutaneous extraperitoneal closure of inguinal hernia using “two-hooked” core needle apparatus in children. This study was conducted at Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine between January 2016 and June 2018. Five hundred and eighteen patients under the age of 12 years with inguinal hernias were subjected to single-port laparoscopic percutaneous extraperitoneal closure (SPLPEC) using non-absorbable suture by “two-hooked” core needle apparatus. Description of the technique is as follows: Under general anesthesia, a 0.5–0.8 cm trans-umbilical skin incision was done for insertion of a 0.5 cm port. A “two-hooked” core needle apparatus was used for insertion of a non-absorbable suture around internal ring. The suture knot was tied extracorporeally. Among 518 child patients with inguinal hernias, there were 406 males and 112 females with a mean age of 4.6 ± 3.5 years. One hundred and six cases were subjected to bilateral surgery including 91 cases of contralateral patent processus vaginalis (PPV). Three cases converted to open surgery and additional 0.5 cm port was done in five cases. The mean operative time was 13.2 ± 3.5 min for unilateral hernia repair and 16.9 ± 4.6 min for bilateral cases. All patients achieved full recovery without complications such as surgical site infection (SSI), testicular atrophy, or iatrogenic ascent of the testis. At the mean follow-up time of 18.72 ± 5.27 months, two cases had recurrences (0.39%) and one case had postoperative hydrocele (0.19%). SPLPEC of inguinal hernia using “two-hooked” core needle apparatus in children is a feasible and reliable minimal invasive procedure. It has the advantages of short operating time, low complication rate, low recurrence rate and better cosmetic result.

Primary avalvular varicose anomaly (PAVA) is a new medical concept defined as primary varicose veins resembling neovascularized tissue on ultrasound examination. PAVAs could be misdiagnosed as recurrence at the saphenofemoral or saphenopopliteal junction, but no studies have yet examined their role before and after venous invasive procedure. In this report, we describe a case of PAVA in a 39-year-old man with symptomatic varicose veins and great saphenous vein truncal incompetence. Six months after radiofrequency ablation of the great saphenous vein, duplex ultrasound revealed complete occlusion of great saphenous vein and partial thrombosis of the still incompetent PAVA.

Introduction: Pelvic exenteration is a highly invasive procedure, with a reported rate of 20%–80% for serious complications. Thus, the prevention of postoperative complications is a major issue. Many previous reports have emphasized the importance of filling the dead space to prevent postoperative complications. In addition to filling the dead space, we believe that achieving sufficient drainage is extremely important. In this paper, we present a new combined method of the extended rectus abdominis myocutaneous flap and vacuum drainage with multiple drains, which achieved a lower frequency of complications. Case Presentation: The subjects were 6 patients who underwent reconstruction following pelvic exenteration during a 7-year period between April 2005 and September 2013. We retrospectively measured the volume of the pelvic cavity and that of the rectus abdominis flap on lateral computed tomography (CT) scans to calculate the percentage of the dead space that was filled by the flap. There were no problems with flap engraftment in any of the patients. There were no serious complications, and no patient required additional surgery. The percentage of the dead space filled ranged from 25% to 46% (mean: 32%). Conclusion: The rectus flap + vacuum drainage method, which uses an extended rectus abdominis myocutaneous flap to decrease the pelvic dead space and multiple vacuum suction drains, was associated with the prevention of serious complications.

Injectable biomaterials have attracted more and more interest owing to their advantages over traditional open surgeries: minimal invasive procedure and ease of handling. Commonly used synthetic injectable polymers exhibited low drug loading and poor biodegradability. In this work, we describe a novel series of degradable copolymers comprising salicylic acid–based poly(anhydride-esters) and poly(ethylene glycol) subunits suitable for injectable drug releasing applications. By tuning the rheology properties, these salicylic acid–based poly(anhydride-esters) and poly(ethylene glycol) copolymers may function as injectable drug delivery vehicles that deliver salicylic acid at the injury site. These copolymers were designed to have glass transition temperatures (Tg) below 0ºC, resulting in extrudable polymers that behave like viscous fluids at room temperature. Salicylic acid–based poly(anhydride-esters) and poly(ethylene glycol) copolymers of different ratios (2:1, 1:1, and 1:2 salicylic acid–based poly(anhydride-esters) and poly(ethylene glycol)) were synthesized and characterized by nuclear magnetic resonance and Fourier-transform infrared spectroscopies. Their shear viscosities were determined both at room and physiological temperatures. The in vitro drug release profiles, cytotoxicity, and anti-inflammatory activities were assessed. The shear viscosities were found to compare favorably with current injectable barrier materials on the market.

Background: Approximately 10–15% of patients on DOACs have to interrupt their anticoagulant before an invasive procedure every year. The perioperative management and monitoring of DOACs have proved to be challenging, as differences in patients’ status and in the invasiveness of each procedure develop different situations that need a tailored therapeutic approach to each patient’s needs. Methods: This review aims to summarize current evidence on the perioperative management of DOACs in patients undergoing a vascular surgical procedure focusing with a practical approach on three key clinical questions: (i) can we stop DOAC therapy before the vascular procedure? (ii) is bridging therapy necessary? and (iii) which is the best perioperative strategy for interruption and resumption of the anticoagulant therapy? Results: No specific data exist for the perioperative management of vascular surgery patients on DOACs, as most studies include low number of such patients. Therapeutic strategy on how to handle DOACs perioperatively must be based on their half-life, the bleeding risk of the invasive procedures, and on the thromboembolic risk of the patient. Renal function plays a crucial role in such situations, increasing thromboembolic and bleeding risk. In general, DOACs should be stopped 2 days for high bleed risk, 1 day for low risk and should be resumed 48-72 hrs after high risk, 24 hrs after low-risk procedure. Bridging is almost never needed. Conclusion: Further perioperative research studies on patients undergoing vascular surgery are needed to confirm whether currently accepted therapeutic perioperative strategy is appropriate for these patients.

Inadequate nurse’s knowledge and poor skills associated with negative outcome. EBP help CCNs to apply invasive procedure safely at ICU through simulated education. Aim: To evaluate the impact of simulated education on nurses’ knowledge and performance about invasive procedure at Intensive Care Units : evidence based practice. Subject and method: quasi-experimental design, purposive sample of all ICUs nurses, number were 65 nurses whom assigned to work at ICUs of Minia University Hospitals in Minia City, Egypt. Results: More than half of them (61.5%) were female and (38.5 %) male. The majority of them were new graduated less than 5 years of experience (81.6%). (100 %) of CCNs had unsatisfactory knowledge about EBP and ideal performance of invasive procedures before education, after it their knowledge improved to (87.7%) and (84.6) at post and follow up program. After educational program the majority of CCNs apply invasive procedure using EBP satisfactory at the post program and follow up program phase. There were a statistically significant improvement of CCNs mean score in all dimensions related to general performance post program and follow up program. Conclusion: There were a positive correlation between EBP knowledge, procedural intervention and general performance after the simulated education program.

To evaluate different techniques for reducing hemorrhagic complications in coagulopathic patients with elevated international normalized ratio having an image-guided percutaneous invasive procedure; techniques included systemic transfusion of fresh frozen plasma (FFP), local injection of FFP, percutaneous injection of gelatin sponge, and percutaneous placements of angiographic coils.Retrospective review of 232 consecutive patients with known coagulopathy undergoing image-guided minimally invasive procedures were selected. Ninety-one patients had local FFP injected, 40 patients underwent local synthetic gelatin injection, 16 patients had percutaneous coil embolization, and 85 patients received systemic FFP. The number of bleeds, complications related to bleeds, and systemic complications were recorded. A 30 cc threshold was used to delineate significant bleeding.No patients experienced clinically significant or insignificant bleeding with local FFP injection (P value.05). Other local hemostatic methods (Gelfoam, systemic FFP, and coil embolization) were associated with higher levels of bleeding (12.5%, 17.1%, 37.5%, respectively) and complications (7.5%, 31.4%, 37.5%, respectively). Systemic FFP infusion was associated with respiratory, infectious, and mortal complications.Local injection of blood products provides a safe and efficacious hemostatic agent to reduce the incidence of postprocedural bleeding. The technique is associated with lower rates of bleeding and systemic complications when compared to other local and systemic techniques. Further randomized prospective studies with a larger patient cohort need to be performed to corroborate these initial findings.

The aim of this retrospective cohort study was to review rate of miscarriage following antenatal invasive diagnostic procedures from a unit where relatively low annual numbers of procedures are undertaken. Data were analysed for 201 chorionic villous samplings (CVSs) performed between January 2007 and June 2019 and 511 amniocenteses performed between January 2008 and June 2019, in singleton pregnancies. The miscarriage rates after CVS was 0% at 48 hours, 0.6% at 2 weeks and 2.5% up to 24 weeks of gestation. All four miscarriages following CVS had significant inherent high-risk features, therefore, it would be inappropriate to attribute these losses solely to the procedure itself. None of the women who had an amniocentesis had a miscarriage during the study period. We did not find a causal association between number of invasive procedures performed by an operator and miscarriage rate in our setting even with low annual numbers of invasive procedures.Impact StatementWhat is already known on this subject? Royal College of Obstetricians and Gynaecologists (RCOG) of UK recommends a minimum of at least 30 CVSs or amniocenteses procedures per year for a practitioner in order to maintain skills. A centre performing more fetal invasive procedures has lower miscarriage rates due to more experience of practitioners.What the results of this study add? This study is the first long-term audit data from a smaller fetal medicine unit with relatively low annual case load, suggesting that miscarriage risk may actually be lower than the current understanding. No additional risk of miscarriage or pregnancy loss following fetal invasive procedures even with relatively low annual numbers than that recommended by the RCOG.What the implications are of these findings for clinical practice and/or further research? The findings of this study are important in the era of non-invasive prenatal testing which will see the overall number of fetal invasive procedures decline with time. Competence in safely undertaking antenatal invasive procedure can possibly be maintained with lower annual procedure numbers. Units undertaking low number of antenatal invasive procedure must continuously audit their practice to ensure satisfactory standards and outcomes. More research is needed from smaller units to corroborate or refute the findings of this study.

Introduction: Large vessels are often encountered during endobronchial ultrasound (EBUS). Safety of traversing the vessels weighed against a more invasive procedure can be a dilemma. Material and methods: We describe a case series of 8 patients who underwent transvascular needle aspiration during EBUS, to access a lesion in the absence of an alternate safe window. A 21 gauge EBUS needle was used to traverse either the main or a major branch of the pulmonary artery. Results: Malignancy was suspected at ROSE in five cases. Granuloma and necrosis noted in 2 cases were confirmed as tubercu-losis on culture. Diagnostic yield of EBUS-TVNA was 87.5% (7/8). No complications were noted in the immediate post-operative period as well as during 6 months of follow up. Conclusion: EBUS-TVNA in carefully selected patients is a feasible alternative to more invasive procedures with excellent yield. Appropriate intraoperative, perioperative and postoperative monitoring and care must be available in the case of fatal bleeds.

Background and importance Surgical smoke is composed of chemical substances, viable cells and viral particles (HBV, HPV, HIV) of unproven contagiousness for the operating theatre staff. In the context of the COVID-19 health crisis, several learned societies (SFCO, SCGP, SAGES) recommended the use of systems that filter the surgical plume during an invasive procedure, the presence of this virus in the pneumoperitoneum not being excluded. Aim and objectives The objective was to perform a comparative study of existing medical devices (MD) on the market with enough filtration capacity to trap SARS-CoV-2. Material and methods We performed a literature review, contacted providers susceptible to market this type of MD, drew a summary table comparing the different characteristics and costs, and finally, analysed the responses in collaboration with the surgical team, hygiene and the biomedical engineer. Results We identified two categories of MD. The first can be used in laparotomy: tubing or scalpel connected to a suction terminal or a smoke aspirator. The second are intended for laparoscopy. Some of them provide passive filtration. They are filters connected to the trocar valve. Others perform active filtration. This is done by means of a tube that is connected on one side to the trocar valve. On the other side, it is connected either to the wall vacuum or to a smoke aspirator or a generator with a dual function: insufflation and aspiration. All of these systems use ULPA quality filters with variable porosity and classification depending on the supplier. Finally, there is a generator using electrostatic precipitation. It electrically charges the particles, which then precipitate against the walls of the peritoneal cavity throughout their formation. The price of the consumables varies from 8 to 182€, excluding taxes. Conclusion and relevance A panel of MDs for surgical smoke filtration was available. To ensure the safety of operating theatre personnel while controlling costs, we established a strategy based on the patient‘s viral status: if the patient was COVID-19 positive, a filtration device with insufflation and aspiration was preferred, while if the patient was only suspected of having COVID-19, passive filtration was preferred to minimise costs. This is subject to change according to the state of scientific knowledge. References and/or acknowledgements Conflict of interest No conflict of interest

Lenvatinib is a multi-tyrosine kinase inhibitor that inhibits angiogenesis and is currently in use for the treatment of refractory thyroid cancer. Therapy using this agent can be prolonged in patients, although serious complications may ensue among those who require surgical procedures. To the best of our knowledge, the safety of invasive surgical procedures in patients undergoing treatment with lenvatinib has not been fully evaluated. A total of 94 patients were treated with lenvatinib for thyroid cancer between June 2015 and August 2019 at the Kanagawa Cancer Center. Of this cohort, 14 invasive procedures were performed on 11 patients. A total of 8 of these procedures were performed under local anesthesia and 6 under general anesthesia; 3 belonging to the latter group were emergency procedures. No primary wound complications were observed among the patients in the cohort; however, one case of delayed healing secondary to placement of a thoracic drain for acute pneumothorax was reported in the present study. Lenvatinib was initially discontinued in this patient, but it was reintroduced 17 days later due to hypoxemia that may have been related to lung metastases. Hypoxemia improved, although wound healing spanned 14 weeks. Therapy was discontinued prior to percutaneous endoscopic gastrostomy in a patient with local progression; while no wound complications were observed, the patient ultimately died from exacerbation of neoplastic disease. In the current study, which focused on surgical interventions performed on patients undergoing lenvatinib treatment, 1 in 14 wound complications improved conservatively. However, it is critical to recognize that disease progression may occur if drugs are withdrawn prior to performing invasive procedures.