6^th International Conference and Exhibition on Surgery September 07-09, 2017 London, UK

Giovanna Occhipinti was born in 1978, performed her medical school in Catania from 1997 to 2003 and finished her specialization school in Belgium at ERASME Hospital having Daniel De Backer as Coauthor of her final thesis: “Effect of fluids challenge on microcirculation” in 2007. Since than she worked as Intensivist at Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy, as clinician and preclinical researcher. Currently she is senior attending in critical care medicine at IsMeTT, involved in ECMO (extra corporeal membrane ossigenation) assistance for end stage heart and lung failure and extra hospital transfer on ECMO support by ambulance and helicopter. In IsMeTT, she is involved also in clinical study about protective mechanical ventilation during ARDS and different type of anticoagulation used during extracorporeal assistance. She was also involved as local investigator in the Lung Safe Study.

Extracorporeal Membrane Oxygenation (ECMO) has been shown to be very effective in treating ARDS patients during the 2009 H1N1 pandemic 1 and, since then, its use as salvage therapy in case of severe ARDS not responsive to conventional therapy has become more and more common, overwhelming many of the limitations once considered as insurmountable. Successful use of ECMO in immunocompromised patients has been reported but it remains controversial because of the high mortality rate linked to the compromised immune response. ARDS occurrence in HIV infected patients is burden by an extremely high mortality rate, especially before Highly Active Antiretroviral Therapy (HAART) introduction. HAART has profoundly changed the course of HIV infection significantly reducing the rate of opportunistic infections; nevertheless the need of ICU care among HIV patients remained almost unchanged (4-12%) and respiratory impairment is the most common indication.2,3 Recent studies cite that clinical outcomes for HIV-1-infected patients admitted to the ICU are comparable with that for critically ill HIV-uninfected patients and HIV-1 infection was not associated with increased mortality in patients with ARDS. Up to now HIV seropositivity has been considered a contraindication to ECMO and only anecdotic cases have been reported with variable outcomes. We report two cases of Pnumocystis jiorvecii pneumonia as AIDS exordium opportunistic infection. Both evolved to severe ARDS and were successfully treated with VV ECMO support.

Shun Huang has her expertise in evaluation and passion in improving the Chinese medicine especially acupuncture. Her open and contextual evaluation model based on responsive constructivists creates new pathways for improving perioperative analgesia. She has built this model after years of experience in research, evaluation, teaching and administration both in hospital and education institutions. The investigation is based on transcutaneous electric acupoint stimulation which is a methodology that utilizes the acupoints effects to patients for improving the recovery of them.

Objective: To investigate the specific effects of different frequencies of transcutaneous electrical acupoints stimulation (TEAS) on perioperative anesthetic dosage, recovery, complications, and prognosis in patients who underwent video-assisted thoracic surgical (VATS) lobectomy. Methods: 80 patients with no previous experience of TEAS or acupuncture undergoing VATS lobectomy were randomly assigned into four groups: control, 2/100Hz, 2Hz and 100Hz groups. The experimental group received TEAS for 30 minutes right before induction, during the entire intraoperative period, for another 30 minutes at 24 and 48 hours after surgery respectively. TEAS were given over acupoints Neiguan(PC6), Hegu(LI4), Lieque(LU7) and Quchi (LI11) sick-laterally. The control group received zero frequency of TEAS, while the 2/100Hz, 2Hz and 100Hz groups used 2/100Hz, 2Hz and 100Hz stimuli frequency respectively. Anesthetic dosage, blood gas analysis results, lung function indexes such as FEV1 and FVC, post anesthesia care unit (PACU) status, postoperative complications, and quality of life scores were collected and analyzed statistically. Results: Intraoperative opioid consumption was significantly decreased in 2/100Hz group (vs Con p≤0.001, vs 2Hz p≤0.001, vs 100Hz p=0.026). During one-lung ventilation arterial oxygen partial pressure (PaO2) showed slower decreasing pattern in 2/100Hz group (vs Con p=0.042). Moreover, 2/100Hz group showed shorter extubation time (vs Con p=0.038), lower VAS score (vs Con p=0.047) and shorter PACU stay time (vs Con p=0.043) right after surgery. Meanwhile 100Hz group revealed a reduced incidence of postoperative nausea and vomiting (PONV) (vs Con p=0.044). Conclusions: TEAS are a safe and non-invasive adjunctive intervention in the anesthesia management for patients undergoing VATS lobectomy. TEAS at 2/100Hz is more potent in decreasing intraoperative opioid dosage and slowing down PaO2 decrease during one-lung ventilation. It can also effectively decrease the pain score and extubation and PACU stay time right after surgery. 100Hz TEAS can decrease the morbidity of PONV.

Laura Meney is a medical student at University of Dundee undertaking her intercalated BMSc degree in Clinical Research with a strong interest in anesthetics, critical care and pre-hospital medicine. She has taken a year out of her studies to explore the world of human factors through the eyes of the surgical team of Ninewells Hospital, Dundee. She has spent the year combining two well established, complimentary models as described above to create the beginnings of a new, adapted model for a more thorough analysis of qualitative, human factors-related data.

Statement of the problem: Current neuromuscular junction monitoring is notoriously subjective and inaccurate so anaesthetists in Ninewells Hospital, Dundee are trialling TOFcuff technology, a quantitative NMJ monitor, to improve the accuracy of monitoring with the intention to maintain a deep neuromuscular block and facilitate lower intra-abdominal pressure laparoscopic colorectal surgery. Introducing new technology to a complex sociotechnical system brings its challenges and there will be a range of willingness to adopt this change from the users. This pilot study takes a human factors approach, capitalizing on the Systems Engineering Initiative for Patient Safety model and Thematic Hierarchical Network Model of Consequences, looking at the process of introducing TOFcuff to laparoscopic colorectal surgery by identifying the relevant system factors that act as barriers or facilitators to this introduction. Methodology: A mixed methods design was used, including observations of practice (as well as routine patient outcome data), semi-structured interviews with 2 anaesthetists and questionnaires with 2 surgeons before and after TOFcuff implementation. A deductive thematic analysis was performed. Findings: TOFcuff provided an easy to use, accurate way of monitoring neuromuscular block. Pain scores were not often recorded and therefore assessing whether lower intra-abdominal pressures reduce post-operative pain are not feasible until a reliable recordingmethod was in place. Anaesthetists reported that the benefits outweighed the drawbacks of TOFcuff, both of which will be discussed. Surgeons found having an accurate indicator of the patient’s level of paralysis reassuring and were able to operate at lower laparoscopic pressures without it impairing their field of view. Conclusions: Incorporating TOFcuff into routine practice would improve confidence in anaesthetists’ decisions regarding the reversal of neuromuscular block, allow them to adhere to AAGBI guidelines and improve laparoscopic surgical performance. Following this pilot study, a bigger sample size will be targeted to assess wider TOFcuff.

Theadora Forster-Anderson is a surgical registrar practicing in a service role at Fiona Stanley Hospital in Perth, WA. She is interested in the field of general surgery including the evaluation and management of trauma cases. With a background of unaccredited time spent in otolaryngology she has a particular familiarity with facial trauma. Dr Tamalee Henson is a junior medical officer practicing at the same hospital with an interest in orthopaedic surgery.

Introduction: Pneumomediastinum with facial trauma is rare and only intermittently described through case reports. Usually it is a complication related to thoracoabdominal trauma as air travels upwards within the fascial planes – see Figure 1 [1,2,3]. When this occurs in the reverse direction, it is often in patients with facial subcutaneous oedema blowing their nose or having pressure ventilation, as this dissects the fascial plane downwards [4]. Most are self-limiting [5]. Case: A 53 year-old man presented with facial trauma of a large open fracture to the right mandible (Figure 2). Routine trauma CXR found pneumomediastinum (Figure 3). The patient was promptly transferred to a tertiary centre. He was monitored in ICU and after cardiothoracic consultation, treated with intravenous antibiotics for potential mediastinitis (cephazolin/ metronidazole). The following day he underwent surgical repair of his facial injuries. Due to contraindication of bag-mask ventilation in pneumomediastinum, it was decided awake fibreoptic intubation would be utilized. Intra- operatively he was found to have full thickness soft palate laceration, tongue laceration, and a deep injury to the posterior pharyngeal wall to prevertebral fascia. Simple closure was performed. This deep wound is the most likely source of pneumomediastinum. Non-viable bone and tissue was debrided from the jaw and reconstructed with plates and screws (Figure 4). The patient wasmonitored in ICU a further 24 hours. CXR on Day 4 showed resolution of pneumomediastinum (Figure 5) and the patient was discharged. He was followed up with Maxillofacial Surgery however has not required further Cardiothoracic input. Conclusion: This case highlights the importance of assessing thoracic injuy in patients with significant orofacial trauma. While reverse pneumomediastinum aetiology is occasionally related to trauma patients blowing their nose, there is also the consideration of direct trauma at a higher level to be considered. All aetiologies must therefore be explored.

Ko-Woon Kim completed his Graduation at Kyunghee University, Department of Genetic Engineering, Chungbuk National University Medical School, and is working at St. Vincent’s Hospital of the Catholic University of Korea.

Aim: Smoking is a major risk factor for diabetes mellitus, mainly due to decreased insulin secretion and increased insulin resistance. However, there has been little research on the effects of smoking cessation period on changes in insulin resistance. In this study, we investigated the relationships between the length of time since smoking cessation period and insulin resistance in asymptomatic Korean male ex-smokers. Methods: A total of 851 male adults were included in this study. We considered several factors that can affect insulin resistance and, through multiple linear regression analysis, we assessed the effect of the length of time since smoking cessation on insulin resistance in ex-smokers. Insulin resistance was represented as the insulin resistance index estimated by homeostasis model assessment (HOMA-IR). Results: HOMA-IR values showed a statistically significant negative correlation with the length of time since smoking cessation (p=0.009) and high-density lipoprotein cholesterol (p=0.003). After performing multiple linear regression analysis using factors that could potentially influence insulin resistance, we found that waist circumference (p=0.026) and the length of time since smoking cessation (p=0.039) were independent predictors of HOMA-IR. Conclusion: The longer the smoking cessation period, the more the insulin resistance tended to decreasein asymptomatic Korean male ex-smokers.

Na-Rae Kim is a graduate of Chung-Ang University Medical School, and is working as a major in Family Medicine at St. Vincent's Hospital of the Catholic University of Korea.

Mental health problems are a major public health issue worldwide, and zinc may be associated with psychiatric symptoms, but such associations have not been investigated extensively. This study was conducted to evaluate the relationship between serum zinc levels and mental health problems in Korean adults. We used data from the Korean National Health and Nutrition Examination Survey V-1, a cross-sectional survey of Korean civilians. Data from 1748 subjects were analyzed. Serum zinc levels did not differ significantly according to psychiatric symptoms including sleep duration, stress, depressed mood, suicidal ideation, and whether respondents sought psychiatric consultation. The frequencies and odds ratios of psychiatric symptoms according to serum zinc tertiles were not significantly associated after adjusting for age, smoking, alcohol consumption, physical activity, body mass index, total body fat, and renal function and for daily fat, carbohydrate, and protein intake. Serum zinc levels may not be associated with psychiatric symptoms in Korean adults without psychiatric disorders.

Shun-Yu Chi graduated from the School of Medicine, Kaohsiung Medical University during the academic year 1990-1997. During 1999-2004, he worked as a Resident in Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan. Then, during the years 2004-2008, he was an Attending Physician in Department of Emergency and Traumatic Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan. In 2006 and 2007, he was a Fellow in Department of Surgery, Lukas Hospital, Germany. During 2008-2013, he was an Attending Physician in Department of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan and in 2013, he was an Assistant Professor in Department of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan. He is also a member of Taiwan Surgical Association, Taiwan Surgical Society of Gastroenterology, and Taiwan Association of Endocrine Surgeon.

Background: To find out if it is necessary to do bilateral cervical thymectomy (BCT) during total parathyroidectomy plus autotransplantation (TPXT+AT) for symptomatic secondary hyperparathyroidism (SSHP). Methods: 147 patients (group A) with SSHP were operated on with TPXT+AT and BCT; 153 patients (group B) were with TPXT+AT and selective thymectomy at the side of a missing gland. The serum intact parathyroid hormone level less than 60 pg/ml in one week was defined as successful surgery. Patient’s characteristics, operative findings and operative results were compared between the two groups and all removed thymuses were examined, localization studies were applied for 20 of 54 patients with the primary surgical failure. Results: There was no significant difference between the two groups regarding patient’s characteristics, operative findings, the primary successful rates and successful rates after reoperations. In group A patients, the successful rates after primary surgery between, patients who had 4 or more glands and those had 3 glands being removed were significant (p=0.003) and so were group B patients (p=0.001). After localization procedures, 12 parathyroid glands were found in the neck, 7 in mediastinum, one failed to be localized and none in thymic tongue. 13 parathyroid glands were found and removed in reoperations, 9 were in the neck and 4 in mediastinum (via thoracoscope). Histological examinations of 327 thymuses showed parathyroid glands in 14 among which 13 could be found during surgery and one had microscopic parathyroid tissue. Conclusion: If four or more glands are found, thymectomy is optional and not necessary.

Theadora Forster-Anderson is a Surgical Registrar practicing in a service role at Fiona Stanley Hospital in Perth. She was recently posted at Gosford Hospital in New South Wales (NSW), where this case was encountered. She is interested in the field of General Surgery including the evaluation and management of trauma cases. She is a Consultant General Surgeon practicing on the Central Coast in NSW.

Introduction: Atraumatic splenic and peri-splenic haemorrhage accounts for 1/5 splenic bleed. Those without intra-capsular haemorrhage are less common and not widely documented. When bleeds occur without trauma, it tends to be in the presence of portal hypertension from liver cirrhosis, haematological malignancy, infection, primary hepatoma, pancreatitis, pregnancy or amyloidosis. Case: A 72-year-old presented with acute epigastric pain, tachycardia, hypotension, fever and a tender abdomen. History included prostate cancer, deep vein thrombosis and pulmonary embolism (DVT/PE) (on warfarin), essential thrombocytosis, portal vein thrombosis, and heparin induced thrombosis--thrombocytopenia syndrome (HITTS). Haemoglobin was stable and INR 2.3. CT revealed bleeding from a small region of peri-splenic veins. The patient was stabilized and INR reversed using prothrombinex. Clotting disorders were screened and indicated JAK-2 genetic disorder. Haematology recommended Fondaparinux, fresh frozen plasma, platelets, and tranexamic acid. On day 3 in ICU, blood pressure dropped, CT was repeated (Images 1, 2), and the patient was taken to theatre where he was found to have frank hemoperitoneum. Medtronic stapler was fired along bleeding vessels with successful hemostasis. Due to bleeding extent and risk of further injury, the decision was made to complete the operation. He then developed lower limb DVT where his access line was placed. ICU, hematology, general surgical and vascular teams all concluded it would be unsafe to anti-coagulate due to bleeding. DVT progressed to venous infarction and limb ischaemia. The patient was palliated and passed away from multiple organ failure. Conclusion: In this patient, raised venous pressures lead to variceal dilation and splenomegaly. Dilated, friable veins are prone to spontaneous rupture. Bleeding was exacerbated by warfarin and having a pre-existing clotting disorder. Ultimately the balance between managing his clotting issues and preventing further bleeding was too delicate to be maintained. Despite prompt diagnosis, this case was not traumatic, making management decisions difficult. This case aims to add to the database of this rare but fatal condition.