Application of different CO2 pneumoperitoneum pressure in laparoscopic pyeloplasty for infants with ureteropelvic junction obstruction.

Background: Laparoscopic pyeloplasty is a minimally invasive approach for the therapy of infant ureteropelvic junction obstruction (UPJO), reliant on CO2 pneumoperitoneum insufflation. While the impact of CO2 insufflation on adult and older pediatric populations has been studied, its effects on infants remain less explored. Methods: This prospective randomized controlled trial included infants with UPJO undergoing laparoscopic pyeloplasty. Patients were allocated to low pneumoperitoneum pressure (LPP, 5 mmHg) or high pneumoperitoneum pressure (HPP, 8 mmHg) groups. Surgical parameters, postoperative complications, acid-base balance, stress markers, inflammatory cytokines, and oxidative stress markers were evaluated and compared. Results: A total of 116 infants were analyzed. Preoperative characteristics were comparable between LPP and HPP groups. No significant differences in blood loss, operation time, or hospitalization time were observed. Postoperative complications were similar between groups. Acid-base balance analysis revealed a decrease in pH after pneumoperitoneum in both groups, with greater reductions in actual base excess and standard base excess in the HPP group. Stress markers, cytokines, and oxidative stress markers increased postoperatively in both groups, with higher levels in the HPP group. Conclusion: HPP leads to more pronounced physiological responses, including acid-base alterations, stress reactions, and inflammatory cytokine elevations.

Cadaveric Study on the Safety of High-Flow Nasal Oxygen in Laser Microlaryngeal Surgery.

INTRODUCTION: High-flow nasal oxygen (HFNO), or transnasal humidified rapid-insufflation ventilatory exchange (THRIVE), is a technique providing apneic oxygenation and a degree of ventilation during microlaryngeal surgery. Its use with laser has been questioned due to concern for airway fire. For fire to occur, a triad of ignition source, oxidizer, and fuel source must be present. By using HFNO and eliminating an endotracheal tube (fuel source), it is hypothesized that airway fire risk is minimal. We tested this theory with human cadavers using HFNO with increasing levels of FiO2 while performing microlaryngeal laser surgery. METHODS: HFNO was placed on two cadavers, and oxygen was administered at incrementally increasing fraction of inspired oxygen (FiO2) concentrations (30%-100%). Laryngeal microsurgery was conducted with CO2 and KTP lasers applied for 30 s. Oxygen readings were taken at several anatomic locations along the body assessing oxygen concentrations in correlation with increasing FiO2 administration. RESULTS: The use of CO2 and KTP laser on cadaveric vocal folds produced char but no spark or airway fire at any of the tested oxygen concentrations. Apart from the mouth, there was minimal increase in oxygen levels at the surrounding anatomic sites despite elevating FiO2 levels. CONCLUSION: HFNO may be safe to use during microlaryngeal laser surgery. By eliminating the endotracheal tube as a fuel source, risk of airway fire may be negligible. Our study safely applied CO2 and KTP lasers for an uninterrupted 30 s with HFNO at 70 L/min and 100% FiO2 producing no spark or fire. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.

Does the Uterine Ozone Therapy Alter the Transcript Profile of Anti- and Proinflammatory Genes in Mares With Endometritis?

This study aimed to evaluate the localised effects of intrauterine ozone therapy on endometrial recovery in mares with endometritis. Our investigation assessed changes in gene expression profiles of anti-inflammatory (IL-1RA and IL-10), proinflammatory (IL-R1B3i and TNFα) and pleiotropic (IL-6) cytokines, along with detailed histological measurements of epithelial and endometrial thickness and the glandular area ratio. Twenty mares were assigned to a 2 × 2 factorial design based on endometritis diagnosis and treatment (control or 42 µg/mL ozone insufflation), resulting in four groups: NC (negative for endometritis/control), NO (negative/ozone), PC (positive/control) and PO (positive/ozone). Oestrus was induced with 2 mg of oestradiol benzoate on Days -1, 1 and 3, plus 1 mg on Day 5. Day 0 marked the initial uterine treatment, followed by insufflations on Days 1 and 2 with O3 (ozone) or O2 (control). Uterine biopsies were taken before treatment on Day 0 and Day 6 for histological analysis and gene expression assessment. Data were analysed using a statistical model that included endometritis status, treatment type, biopsy times (D0 and D6) and their interactions, analysed with Proc Glimmix. Regardless of treatment or endometritis status, significant biopsy effects (p < 0.01) indicated increased epithelial height and endometrial thickness in Day 6 samples. Analysis of IL-1 and TNFα revealed a significant interaction (p < 0.05) among endometritis, treatment and biopsy, with higher IL-1B3i expression on Day 6 in the PC group. The treatment effect (p < 0.04) showed a higher frequency (p < 0.01) of animals with positive modulation in the PC group (66.7%) versus the PO group (0.0%). An interaction effect (p = 0.08) between endometritis and treatment resulted from higher IL-1RA expression on Day 6 in the PC group compared to the PO group. Biopsy effect was significant for IL-10 (p < 0.01), indicating higher values in the second sample associated with tissue repair. In the short-term evaluation, ozone therapy did not influence endometrial morphology and may modulate cytokine expression, specifically the reduction in IL-1 and TNFα levels. Therefore, this therapy appears to be a safe and potentially effective treatment for modulating the inflammatory response in mares with endometritis.

End-Tidal CO2 During Enhanced-View Totally Extraperitoneal Hernia Repair: A Comparison of Retrorectus and Intraperitoneal Insufflation.

INTRODUCTION: Although the enhanced-view totally extraperitoneal (eTEP) approach has demonstrated safety, efficacy, and durability for small- to medium-sized hernia repairs, the relationships between retrorectus insufflation, intraoperative respiratory stability, and end-tidal CO2 (ETCO2) levels has not been appraised. METHODS: We conducted a retrospective chart review of patients undergoing elective robotic-assisted ventral hernia repairs at our quaternary academic center from July 2018 through December 2021. Patients were grouped by repair technique, either eTEP or robotic transversus abdominis release (r-TAR). Baseline demographics, intraoperative anesthesia records, and perioperative outcomes were reviewed. Anesthesia data were collected at intubation and 30-min time intervals thereafter. Operative time, length of stay, patient-controlled anesthesia use, and perioperative complications were compared. RESULTS: In total, 205 patients underwent an eTEP repair and 97 patients underwent an r-TAR repair. Intraoperatively, eTEP repairs had significantly higher ETCO2 at the beginning of the case (times 1-4, P < 0.05), and a higher peak ETCO2 (P < 0.05) when compared to r-TAR repairs. This difference in ETCO2 desisted as the case progressed, with a subsequent increase in respiratory rate (times 2-6, P < 0.05) in the eTEP procedures. The eTEP group demonstrated significantly shorter operative times, decreased patient-controlled anesthesia use, and a shorter length of stay. There was no significant difference in postoperative intensive care unit admission or respiratory distress. CONCLUSIONS: This study demonstrates that retrorectus insufflation during eTEP hernia repairs correlated with higher levels of ETCO2 compared to r-TAR repairs yet was not associated with any meaningful difference in perioperative outcomes. Communication of these respiratory differences with anesthesia is needed for proper ventilation adjustments.

Upper Airway and Translaryngeal Resistance During Mechanical Insufflation-Exsufflation.

BACKGROUND: Mechanical insufflation-exsufflation (MI-E) uses positive and negative pressures to assist weak cough and to help clear airway secretions. Laryngeal visualization during MI-E has revealed that inappropriate upper airway responses can impede its efficacy. However, the dynamics of pressure transmission in the upper airways during MI-E are unclear, as are the relationships among anatomic structure, pressure, and airflow. RESEARCH QUESTION: Can airflow resistance through the upper airway and the larynx feasibly be calculated during MI-E, and if so, how are the pressures transmitted to the trachea? STUDY DESIGN AND METHODS: Cross-sectional study of 10 healthy adults with and without active cough to whom MI-E was provided, using pressure settings +20/-40 cm H2O and ± 40 cm H2O. Airflow and pressure at the level of the facemask were measured using a pneumotachograph, whereas pressure transducers (positioned via transnasal fiber-optic laryngoscopy) recorded pressures above the larynx and within the trachea. Upper airway resistance (Ruaw) and translaryngeal resistance (Rtl) were calculated (in centimeters of water per liter per second) and were compared with direct observations via laryngoscopy. RESULTS: Positive pressures reached the trachea effectively, whereas negative tracheal pressures during exsufflation were approximately half of the intended settings. Insufflation pressure increased slightly when passing through the larynx. Participant effort influenced tracheal pressures and the resistances, with findings consistent with laryngoscopic observations. During MI-E, resistance seems to be dynamic, with Ruaw exceeding Rtl. Inappropriate laryngeal closure increased Rtl during both positive and negative pressures. INTERPRETATION: Ruaw and Rtl can be calculated feasibly during MI-E. The findings indicate different transmission dynamics for positive and negative pressures and that resistances are influenced by participant effort. The findings support using lower insufflation pressures and higher negative pressures in clinical practice.

Long-Term Outcomes of Carbon Dioxide Insufflation in Thoracoscopic Esophagectomy After Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma: A Retrospective Cohort Study.

BACKGROUND: Thoracoscopic esophagectomy (TE) with carbon dioxide (CO2) insufflation is increasingly performed for esophageal cancer; however, there is limited evidence of the long-term outcomes of CO2 insufflation on postoperative survival. OBJECTIVES: We investigated the long-term outcomes of TE with or without CO2 insufflation. METHODS: We enrolled 182 patients who underwent TE for esophageal cancer between January 2003 and October 2013 and categorized them into two groups: with and without CO2 insufflation. The primary endpoint was five-year overall survival (5y-OS). Secondary endpoints included long-term outcomes, such as five-year relapse-free survival (5y-RFS) and five-year cancer-specific survival (5y-CSS), and short-term outcomes, such as surgical and non-surgical complications and reoperation within 30 days. RESULTS: Follow-up until death or the five-year postoperative period was 98.9% (median follow-up duration was six years in survivors). After adjusting for age, sex, and yield pathologic tumor, node, and metastasis (TNM) stage, we found no significant differences in 5y-OS (HR 1.12, 95% CI 0.66-1.91), 5y-RFS (HR 1.12, 95% CI 0.67-1.83), or 5y-CSS rates (HR 1.00, 95% CI 0.57-1.75). For short-term outcomes, significant intergroup differences in operation time (p=0.02), blood loss (p<0.001), postoperative length of stay (p<0.001), and incidence of atelectasis (p=0.004) were observed. The results of the sensitivity analysis were similar to the main results. CONCLUSIONS: In thoracoscopic procedures, CO2 insufflation significantly improved short-term outcomes, and it appears that the recurrence risk of esophageal cancer may not impact the long-term prognosis. While the influence of CO2 insufflation in thoracoscopic esophageal surgery remains unclear, our study suggests that the long-term prognosis is not compromised in other thoracic surgeries.

Exploring the Parental Perspectives and Experiences With the Use of a Home Mechanical Insufflation-Exsufflation Device.

BACKGROUND: A mechanical insufflation-exsufflation (MI-E) device is a commonly used tool for airway clearance in children with an ineffective cough. Whereas the device has been shown to have multiple benefits, limited evidence exists regarding parents' experiences with its home use in the Canadian context. This study's objective was to explore the perspectives and experiences of parents who receive service through the IWK Health Centre and use an MI-E device at home with their child. METHODS: The study used an interpretive description design. Semi-structured interviews, conducted with 9 participants, were audio recorded and transcribed verbatim. Transcripts were analyzed using a reflective thematic process. RESULTS: Seven mothers and 2 fathers were interviewed. Following analysis, 3 themes were identified: (1) Learning about the MI-E device described participants' journey from becoming aware of the device to acquiring knowledge and skills about its use; (2) using the device detailed the integral role the MI-E device played in their lives, including decisions around use, and parental role; and (3) changing lives outlined the physical, emotional, and social benefits the device provided to the child and their family. CONCLUSIONS: Participants provided detailed descriptions of their journey from learning to integrating the MI-E device into their child's daily routine and family life. Its multiple associated benefits improved the child's and their family's quality of life. However, better education on its use was highlighted as a need for both parents and the health care professionals who work with them.

Addition of nitrous oxide and oxygen to carbon dioxide pneumoperitoneum during laparoscopic surgery for pain reduction: A double-blinded randomized controlled trial.

OBJECTIVE: To examine if peritoneal conditioning with an altered insufflation gas mixture is associated with reduced postoperative pain intensity compared to the standard insufflation gas (i.e., 100% CO2). DESIGN: A prospective, single-centre, randomized, double-blind, superiority trial was performed. SETTING: This study was conducted between 4 April 2019 and 10 February 2022 at the Jessa Hospital, Hasselt, Belgium. POPULATION: Patients scheduled for elective gynaecologic laparoscopic surgery. METHODS: Seventy-four patients scheduled for elective gynaecologic laparoscopic surgery were randomised to receive either the standard insufflation gas with 100 CO2 (n = 37; control group) or the altered gas mixture of 86% CO2, 10% N2O and 4% O2 (n = 37; experimental group). MAIN OUTCOME MEASURES: Postoperative pain was assessed at 4, 8 and 24 hours after surgery and on postoperative day (POD) 7 by an 11-point Numeric Rating Scale, with 0 indicating no pain and 10 indicating worst imaginable pain. RESULTS: No significant differences were found between the control and experimental groups regarding postoperative pain at 4, 8 and 24 h after surgery, as well as on POD7. In addition, the median (25% and 75%) total amount of IV piritramide consumption during the first 24 h after surgery was not significantly different between groups (control group: 18.0 [10.0, 27.0] mg vs. experimental group: 17.0 [10.0, 34.0] mg, p = 0.62). CONCLUSION: The alternative insufflation gas mixture comprising 86% CO2, 10% N2O and 4% O2 used for the pneumoperitoneum during gynaecologic laparoscopic surgery does not appear to reduce postoperative pain compared to the standard insufflation gas of 100% CO2.

Airway Clearance in Neuromuscular Disease.

High-quality respiratory care and airway clearance is essential for people with neuromuscular disease (pwNMD) as respiratory tract infections are a major cause of morbidity and mortality. This review expands on published guidelines by highlighting the role of cough peak flow along with other options for cough evaluation, and discusses recent key research findings which have influenced the practice of respiratory therapy for pwNMD.

[Proposals from a French expert panel for respiratory care in ALS patients]. / Propositions formulées par un groupe d'experts français concernant la prise en charge respiratoire chez les patients atteints de sclérose latérale amyotrophique.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by progressive diaphragm weakness and deteriorating lung function. Bulbar involvement and cough weakness contribute to respiratory morbidity and mortality. ALS-related respiratory failure significantly affects quality of life and is the leading cause of death. Non-invasive ventilation (NIV), which is the main recognized treatment for alleviating the symptoms of respiratory failure, prolongs survival and improves quality of life. However, the optimal timing for the initiation of NIV is still a matter of debate. NIV is a complex intervention. Multiple factors influence the efficacy of NIV and patient adherence. The aim of this work was to develop practical evidence-based advices to standardize the respiratory care of ALS patients in French tertiary care centres. METHODS: For each proposal, a French expert panel systematically searched an indexed bibliography and prepared a written literature review that was then shared and discussed. A combined draft was prepared by the chairman for further discussion. All of the proposals were unanimously approved by the expert panel. RESULTS: The French expert panel updated the criteria for initiating NIV in ALS patients. The most recent criteria were established in 2005. Practical advice for NIV initiation were included and the value of each tool available for NIV monitoring was reviewed. A strategy to optimize NIV parameters was suggested. Revisions were also suggested for the use of mechanically assisted cough devices in ALS patients. CONCLUSION: Our French expert panel proposes an evidence-based review to update the respiratory care recommendations for ALS patients in daily practice.

Combination of transbronchoscopic oxygen insufflation and a digital chest drainage system in endobronchial occlusion: a hybrid technique for localization of fistula in intractable pneumothorax.

BACKGROUND: The management of intractable secondary pneumothorax poses a considerable challenge as it is often not indicated for surgery owing to the presence of underlying disease and poor general condition. While endobronchial occlusion has been employed as a non-surgical treatment for intractable secondary pneumothorax, its effectiveness is limited by the difficulty of locating the bronchus leading to the fistula using conventional techniques. This report details a case treated with endobronchial occlusion where the combined use of transbronchoscopic oxygen insufflation and a digital chest drainage system enabled location of the bronchus responsible for a prolonged air leak, leading to the successful treatment of intractable secondary pneumothorax. CASE PRESENTATION: An 83-year-old male, previously diagnosed with chronic hypersensitivity pneumonitis and treated with long-term oxygen therapy and oral corticosteroid, was admitted due to a pneumothorax emergency. Owing to a prolonged air leak after thoracic drainage, the patient was deemed at risk of developing an intractable secondary pneumothorax. Due to his poor respiratory condition, endobronchial occlusion with silicone spigots was performed instead of surgery. The location of the bronchus leading to the fistula was unclear on CT imaging. When the bronchoscope was wedged into each subsegmental bronchus and low-flow oxygen was insufflated, a digital chest drainage system detected a significant increase of the air leak only in B5a and B5b, thus identifying the specific location of the bronchus leading to the fistula. With the occlusion of those bronchi using silicone spigots, the air leakage decreased from 200 mL/min to 20 mL/min, and the addition of an autologous blood patch enabled successful removal of the drainage tube. CONCLUSION: The combination of transbronchoscopic oxygen insufflation with a digital chest drainage system can enhance the therapeutic efficacy of endobronchial occlusion by addressing the problems encountered in conventional techniques, where the ability to identify the leaking bronchus is dependent on factors such as the amount of escaping air and the location of the fistula.

Comparison of AirSeal versus conventional insufflation system for robot-assisted partial nephrectomy: a meta-analysis and systematic review.

A systematic review and meta-analysis were performed to investigate the efficacy of the AirSeal Valveless Trocar Needle Insufflation System in robot-assisted partial nephrectomy (RAPN). The study compared the differences in perioperative outcomes between the AirSeal insufflation group (AIS) and the conventional insufflation group (CIS). A systematic search of databases such as PubMed, Embase, Cochrane library, and Web of science was performed to identify studies reporting perioperative outcomes between the AirSeal insufflation group (AIS) and the conventional insufflation group (CIS) in RAPN. The study protocol is registered with PROSPERO (CRD42024524335). The primary outcome was to compare the incidence of subcutaneous emphysema (SCE) and postoperative pain scores between the two approaches. The review included four studies with 379 patients, 194 in the AIS group and 185 in the CIS group. Baseline characteristics of the two groups were similar in all outcomes. SCE was significantly lower in the AIS group than in the CIS group [(OR) 0.30 (0.16, 0.54), p < 0.001]. Postoperative 12-h pain scores were also significantly lower in the AIS group compared to the CIS group [(WMD) - 0.93 (- 1.67, - 1.09), p = 0.014]. Both groups showed a significant reduction in length of hospitalization [(WMD) - 0.12 (- 0.84, 0.60), p = 0.746], thermal ischemia time [(WMD) 4.72 (- 5.71, 15.15), p = 0.375], amount of lost hemoglobin [(WMD) - 0.19 (- 0.53, 0.15), p = 0.284], pneumothorax [(OR) 0.13 (0.02,1.10), p = 0.062], mediastinal emphysema [(OR) 0.55 (0.20, 1.46), p = 0.230], and 4-h pain score [(WMD) - 0.25 (- 1.16, 0.65), p = 0.584]; no significant differences were observed. The incidence of subcutaneous emphysema SCE and 12-h pain scores were significantly lower in the AIS group compared to the CIS group. The AirSeal system demonstrated similar efficacy and a higher safety profile than the conventional insufflation system in robotic-assisted partial nephrectomy; however, due to the lack of a randomized study on the topic, further data are needed.

Transumbilical laparoscopy for pneumoperitoneum establishment: a comprehensive multicentre evaluation affirming safety, feasibility, and a range of clinical benefits.

Introduction: Transumbilical laparoscopy (TUL) has emerged as a promising technique for establishing pneumoperitoneum in laparoscopic cholecystectomy, offering potential safety, feasibility, and clinical benefits. This retrospective multicentre study aims to evaluate the efficacy and outcomes of TUL in the management of gallbladder diseases. Methods: A retrospective analysis was conducted on a cohort of 2,543 patients who underwent TUL between 2011 and 2021 across various medical institutions in Italy. Data collection included demographic, clinical, intraoperative, and postoperative parameters. Standardized protocols were followed for preoperative and postoperative management. The TUL technique involved precise anatomical incision and trocar placement. Results: The study demonstrated favorable outcomes associated with TUL, including a low conversion rate to open surgery (0.55%), minimal intraoperative complications (0.16%), and short hospital stays (average 2.4 days). The incidence of incisional hernias was notably low (0.4%). Comparison with existing literature revealed consistent findings and provided unique insights into the advantages of TUL. Discussion: Despite limitations, such as the absence of a control group and the retrospective nature of the study, the findings contribute valuable insights to the literature. They inform surgical decision-making and advance patient care in laparoscopic cholecystectomy for gallbladder diseases. Conclusion: Transumbilical laparoscopy shows promise as a safe and feasible technique for establishing pneumoperitoneum in laparoscopic cholecystectomy. The study's findings support its clinical benefits, including low conversion rates, minimal complications, and short hospital stays. Further research, including prospective studies with control groups, is warranted to validate these results and optimize patient outcomes.

Use of THRIVE for Apneic Oxygenation in Transoral Laser Microlaryngeal Surgery: A Scoping Review.

OBJECTIVES: Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) has demonstrated utility in extending the apneic window in the perioperative setting. Its benefits in facilitating tubeless anesthesia are recognized during elective laryngotracheal surgeries. The use of THRIVE and administering higher fractional inspired oxygen concentrations in laser laryngeal surgery (LLS) remains controversial due to the theoretical risk of airway fires. A scoping review of the literature describing institutional experiences with THRIVE during LLS was conducted. DATA SOURCES AND REVIEW METHODS: A systematic scoping review of the literature was performed including PubMed, Medline, Embase, Scopus, JBI EBP Database, and Cochrane Library from inception to April 2023. RESULTS: From the 472 articles identified in our review, nine articles were included representing 271 cases. THRIVE was used for preoxygenation and to maintain apneic oxygenation during LLS. Different institutional practices related to THRIVE parameters and intraoperative modifications during lasing were described in the literature, including cessation of THRIVE, reduction of FiO2 to 30%, and continuous 100% FiO2 oxygenation. One study described a brief ignition of the coating of a KTP laser fiber without injury to the patient. No adverse patient outcomes have been documented in the literature with THRIVE during LLS. CONCLUSION: THRIVE is a safe and effective form of tubeless anesthesia and apneic oxygenation during LLS, with no adverse patient safety events reported in the literature. Key determinants to maintain safety include optimal patient and team selection, effective surgeon-anesthetist cooperation, and institutional protocols that govern intraoperative practice. Laryngoscope, 2024.

Successful Application of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange in a Case of Subglottic Stenosis.

We widely employ microlaryngeal surgery to treat diverse oropharyngeal and laryngeal conditions, but it presents challenges to shared airway management. This case report addresses the limitations of conventional techniques, such as tracheal intubation and jet ventilation, and explores the emerging interest in transnasal humidified rapid insufflation ventilatory exchange (THRIVE). While THRIVE offers advantages such as enhanced visualization and reduced airway trauma, its application is limited by the duration of apnea, with the literature referring to a maximum of 30 minutes of apnea. We present the successful application of THRIVE as the primary airway management technique in a patient undergoing a 55-minute dilation procedure for subglottic stenosis. Successful oxygenation was achieved, creating a tubeless field and improving visibility. The patient maintained oxygen saturation above 98%, demonstrating the effectiveness of THRIVE in managing prolonged apnea. Remarkably, intentional ventilation via a face mask at specific moments allowed extended apneic oxygenation without harmful carbon dioxide levels. This report complies with the growing evidence supporting the efficacy of THRIVE in providing extended apnea for tubeless surgery. The success demonstrated in our case highlights the feasibility and effectiveness of THRIVE in situations demanding prolonged apnea and complex airway management.

Stroke Secondary to Air Embolism Following Laparoscopic Nissen Fundoplication.

An air embolism is characterized by the entry of gas bubbles into the circulatory system, which can lead to the possible occlusion of blood vessels, posing a potentially life-threatening risk. While commonly associated with lung trauma or decompression sickness, it can also result from medical procedures such as central venous catheter insertion or, in our case, gas insufflation for laparoscopic surgery. We present the case of a 65-year-old female who suffered from a stroke secondary to an air embolism after undergoing a laparoscopic Nissen fundoplication in which carbon dioxide insufflation of the abdominal cavity was utilized. We also will discuss the elusive etiology of this complication as well as diagnosis, treatment, and proposed preventative measures.  A 65-year-old female with gastroesophageal reflux disease and a hiatal hernia elected to undergo a laparoscopic Nissen fundoplication for hernia repair. After a successful surgery, the patient was found with significant neurological deficits, including left-sided hemiplegia, numbness in the left hand, hemianopsia, dysarthria, and a National Institutes of Health Stroke Scale score of 20. CT head imaging revealed several low-density foci in the right frontal lobe, while CT neck and chest imaging revealed subcutaneous emphysema and pneumomediastinum. Subsequent labs were significant for an elevated lactate at 7.6 mmol/L. MRI of the brain depicted evidence of an acute infarct in the right frontal lobe with diffusion-weighted imaging (DWI) sequences. The imaging results were correlated with the patient's clinical presentation to establish the diagnosis of a nondominant hemisphere stroke, localized to an anterior branch of the right middle cerebral artery (MCA). After intubation and supportive treatment for three days, the patient was extubated and able to follow commands but had left facial weakness and diminished strength in the left upper and lower extremities. At the two-month follow-up visit, the patient no longer had any focal neurological deficits. Air emboli, though very rare, can occur as a complication in laparoscopic surgeries that utilize CO2 for body cavity insufflation. Patients may be asymptomatic with small, self-limiting emboli, while others may exhibit pulmonary symptoms, cardiac arrest, or focal neurologic changes, depending on the emoji's size and location. Given the wide range of patient presentations, the elevated mortality of laparoscopic procedures complicated by air emboli, and the rare occurrence of focal neurological symptoms as depicted in this case, rapid diagnosis and close postoperative observation and treatment are vital for both short-term and long-term patient outcomes.

Narrative Review and Consensus Recommendations for the Use of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange in Modified Electroconvulsive Therapy.

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is a safe, effective, and novel technique that is currently being used in electroconvulsive therapy (ECT). This study aimed to summarize the clinical practices of THRIVE use in ECT to aid physicians and institutions in implementing the best practice guidelines for ECT. Thus, we reviewed the current literature and presented our consensus on the application of THRIVE in ECT in daily clinical practice. This consensus provides information regarding THRIVE use in ECT, including its safety, effectiveness, procedures, precautions, special case management, and application in special populations. Moreover, it guides the standardized use of THRIVE in ECT.

Appendicitis after colonoscopy-a case report, literature review, and synopsis of the pitfalls in diagnosis.

A case is described in which appendicitis presented in a 73-year-old woman the day after a colonoscopy. Possible mechanisms for appendicitis aggravated by colonoscopy include barotrauma, irritation by residual glutaraldehyde type solution used for cleaning the endoscope, fecalith, and/or appendicolith being pushed into the orifice of the appendix by insufflation during the colonoscopy. This rare complication is likely most often unavoidable due to the pressure required to properly visualize the colon (which typically ranges from 9 to 57 mmHg) and the manipulation required to visualize and cannulate the ileocecal valve. Physicians should consider possibility of acute appendicitis after colonoscopy when evaluating abdominal pain after a recent colonoscopy.