Search results for: facial surgery

Authors: Yohtahe Woldegerima Berhe, Tadesse Belayneh Melkie, Girmay Fitiwi Lema, Marye Getnet, Wubie Birlie Chekol

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Introduction: Anxiety was repeatedly reported as the worst aspect of the perioperative time. The objective of this study was to assess the prevalence of preoperative anxiety among adult surgical patients at the University of Gondar Comprehensive Specialized Hospital (UoGCSH), Northwest Ethiopia. Methodology: Hospital-based cross-sectional study was conducted among surgical patients at the university hospital. After obtaining ethical approval, 407 surgical patients were approached during the preoperative period. Preoperative anxiety was assessed by the State-Trait Anxiety Inventory. The association between variables was determined by using binary logistic regression analysis. The strength of association was described in adjusted odds ratio (AOR) and a p-value < 0.05 at a 95% confidence interval which was considered statistically significant. Results: A total of 400 patients were included in this study, with a 98.3% response rate. Preoperative anxiety was observed among 237 (59.3%) patients, and the median (IQR) STAI score was 50 (40 – 56.7). age ≥ 60 years (AOR: 5.7, CI: 1.6 – 20.4, P: 0.007), emergency surgery (AOR: 2.5, CI: 1.3 – 4.7, P: 0.005), preoperative pain (AOR: 2.6, CI: 1.2 – 5.4, P: 0.005), and rural residency (AOR: 1.8, CI: 1.1 – 2.9, P: 0.031) were found significantly associated with preoperative anxiety. Conclusions: The prevalence of preoperative anxiety among surgical patients was high. Older age (≥ 60 years), emergency surgery, preoperative pain, and rural residency were found to be significantly associated with preoperative anxiety. Assessment for preoperative anxiety should be a routine component of preoperative assessment of both elective and emergency surgical patients. Preoperative pain should be appropriately managed as it can help to reduce preoperative anxiety. Optimal anxiety reduction methods should be investigated and implemented in the hospital.

Keywords: preoperative anxiety, anxiety, anxiety of anesthesia and surgery, state-trait anxiety inventory, preoperative care

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Authors: John Joseph S. Martis, Rohanchandra R. Gatty, Aaron Jose Fernandes, Rahul P. Nambiar

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Introduction: Surgery for breast cancer is either mastectomy or breast conservation surgery. The most commonly used incision for modified radical mastectomy is the transverse Stewart incision. But this incision may have the disadvantage of causing disparity between the closure lines of superior and inferior skin flaps in mastectomy and can cause overhanging of soft tissue below and behind the axilla. The curvizigzag incision, on principle, may help in this regard and can prevent scar migration beyond the anterior axillary line. This study aims to compare the two incisions in this regard. Methods: 100 patients with cancer of breast were included in the study after satisfying inclusion and exclusion criteria. They underwent surgery at Father Muller Medical College, Mangalore, India, between November 2019 to September 2021. The patients were divided into two groups. Group A patients were subjected to modified radical mastectomy with curvizigzag incision and group B patients with transverse Stewart incision. Results: Seroma on postoperative day1, day 2 was 0% in both the groups. Seroma on postoperative day 30 was present in 14% of patients in group B. 60% of patients in group B had sag of soft tissue below and behind the axilla, and none of the patients in group A had this problem. In 64% of the patients in group B, the incision crossed the anterior axillary fold, 64% of the patients in group B had tension in the incision site while approximation of the skin flaps. Conclusion: Curvizigzag incision is statistically better with lesser complications when compared to the transverse Stewart incision for modified radical mastectomy for carcinoma breast.

Keywords: breast cancer, curvizigzag incision, transverse Stewart incision, seroma, modified radical mastectomy

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Authors: Lingyu Ding, Hongxia Hua, Hanfei Zhu, Jinling Lu, Qin Xu

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Background: Postoperative pain is a prevalent problem leading to many adverse outcomes in surgical patients. Virtual reality (VR) is an emerging non-pharmacological method of postoperative pain relief, but the effects of it are not clear. This review aimed to explore the effects of VR on relieving postoperative pain. Methods: We searched PubMed, Embase, Web of Science, and other databases from inception to November 2019 to get the eligible studies. Meta-analyses were conducted to compare VR and usual care for relieving postoperative pain. Subgroup analyses and sensitivity analyses were performed to explain the heterogeneity. Results: Overall, 8 randomized control trials (RCTs) enrolling 723 participants were included. Our results demonstrated that the patients receiving the VR intervention had lower postoperative pain scores than those receiving the usual care. One subgroup analysis revealed that VR could relieve postoperative pain both in minor surgery and major surgery. Another subgroup analysis demonstrated a significant reduction in postoperative pain among patients receiving VR during the intraoperative and the postoperative periods. However, there was no significant postoperative pain relief when receiving VR during the preoperative period. Additionally, significant improvements in postoperative satisfaction were reported in two studies. However, another two studies included found that VR could not affect physiological parameters related to pain. Conclusion: Applying VR can relieve postoperative pain effectively. The type of surgery and timing of using VR are the main sources of heterogeneity. More rigorous studies about the relationship between VR and postoperative pain relief will be needed.

Keywords: meta-analysis, postoperative pain, systematic review, virtual reality

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Authors: Jenee Gooden, Kevin Vasquez-monterroso, Lady Paula Dejesus, Sandra Wainwright, Daniel Kim, Mackenzie Walker

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Introduction: Pyoderma gangrenosum (PG) is a rare, rapidly progressive, neutrophilic ulcerative colitis condition with an incidence of 3 to 10 cases per year ¹ ². Due to the similar appearance, PG is often misdiagnosed as a diabetic ulcer in diabetic patients. Though they may clinically appear similar in appearance, the treatment protocol and diagnostic criteria differ. Also, end-stage renal disease (ESRD) is often a condition seen in diabetic patients, which can have a significant impact on wound healing due to the wide range of uremic toxins³. This case study demonstrates a multidisciplinary team and multimodal treatment approach by podiatric surgery, general surgery, rheumatology, infectious disease, interventional cardiology, wound care and hyperbaric medicine for an uncontrolled diabetic with pyoderma gangrenosum of a significant circumferential wound, covering almost the entire right lower extremity. Methods:56 y.o male presents with multiple PG ulcerations, including the chest, right posterior lower extremity and sacrum. All ulcerations were previously managed by the same wound care specialist. His chief complaint was worsening PG ulcerations accompanied by a fever of 103 °F . This case study focuses on the wound to his RLE. Past medical history significant for diabetes mellitus type 2 with hemoglobin A1c of 10% and end stage renal disease (ESRD) on hemodialysis. A multidisciplinary team approach by podiatric surgery, general surgery, rheumatology, infectious disease, interventional cardiology, wound care and hyperbaric medicine was successfully used to perform right lower extremity limb salvage. The patient was managed by rheumatology for the continuation of prior medication, as well as the mutual agreement with wound care for the addition of dapsone. A coronary CT angiogram was performed by interventional cardiology, but no significant disease was noted, and no further vascular workup was necessary. Multiple surgical sharp wide excisional debridements with application of allografts and split thickness skin grafts for the circumferential ulceration that encompassed almost the entire right lower extremity were performed by both podiatric surgery and general surgery. Wound cultures and soft tissue biopsies were performed, and infectious disease managed antibiotic therapy. Hyperbaric oxygen therapy and wound vac therapy by wound care were also completed as adjunct management. Results: Prevention of leg amputation by limb salvage of the RLE was accomplished by a multidisciplinary team approach, with the wound size decreasing over a total of 29 weeks from 600 cm² to 12.0 x 3.5 x 0.2 cm. Our multidisciplinary team included podiatric surgery, general surgery, rheumatology, infectious disease, interventional cardiology, wound care and hyperbaric medicine. Discussion: Wound healing, in general, can have its challenges, and those challenges are only magnified when accompanied by multiple systemic illnesses. Though the negative impact of diabetes on wound healing is well known, the compound impact of being a diabetic with ESRD and having pyoderma gangrenosum is not. This case demonstrates the necessity for a multidisciplinary team approach with a wide array of treatment modalities to optimize wound healing and perform limb salvage with prevention of lower extremity amputation.

Keywords: diabetes, podiatry, pyoderma gangrenosum, end stage renal disease

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Authors: Sitti Rahmawati

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Payment system of cataract surgery implemented by professional attendant of doctor and nurse has been increasing, through health insurance program and this has become one of the factors that affects a lot of government in the budget establishment. This system has been implemented in purpose of quality and expenditure control, i.e., controlling health overpayment to obtain benefit (moral hazard) by the user of insurance or health service provider. The increasing health cost becomes the main issue that hampers the society to receive required health service in cash payment-system. One of the efforts that should be taken by the government in health payment is by securing health insurance through society's health insurance. The objective of the study is to learn the capability of a patient to pay cataract eye operation for the elders. Method of study sample population in this study was patients who obtain health insurance board card for the society that was started in the first of tri-semester (January-March) 2015 and claimed in Indonesian software-Case Based Group as a purposive sampling of 40 patients. Results of the study show that total unit cost analysis of surgery service unit was obtained $75 for unit cost without AFC and salary of nurse and doctor. The operation tariff that has been implemented today at Anutapura hospitals in eye department is tariff without AFC and the salary of the employee is $80. The operation tariff of the unit cost calculation with double distribution model at $65. Conclusion, the calculation result of actual unit cost that is much greater causes incentive distribution system provided to an ophthalmologist at $37 and nurse at $20 for one operation. The surgery service tariff is still low; consequently, the hospital receives low revenue and the quality of health insurance in eye operation department is relatively low. In purpose of increasing the service quality, it requires adequately high cost to equip medical equipment and increase the number of professional health attendant in serving patients in cataract eye operation at hospital.

Keywords: economic evaluation, cataract operation, health attendant, health insurance system

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Authors: Jitendra Jain, Cassandra Hidajat, Hansraj Riteesh Bookun

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Graft patency underpins long-term prognosis after coronary artery bypass grafting surgery (CABG). The benefits of the combined use of only the left internal mammary artery and radial artery, referred to as total arterial revascularisation (TAR), on long-term clinical outcomes and quality of life are relatively unknown. The aim of this study was to identify whether there were differences in long term clinical outcomes between recipients of TAR compared to a cohort of mostly arterial revascularization involving the left internal mammary, at least one radial artery and at least one saphenous vein graft. A retrospective analysis was performed on all patients who underwent TAR or were re-vascularized with supplementary saphenous vein graft from February 1996 to December 2004. Telephone surveys were conducted to obtain clinical outcome parameters including major adverse cardiac and cerebrovascular events (MACCE) and Short Form (SF-36v2) Health Survey responses. A total of 176 patients were successfully contacted to obtain postop follow up results. The mean follow-up length from time of surgery in our study was TAR 12.4±1.8 years and conventional 12.6±2.1. PCS score was TAR 45.9±8.8 vs LIMA/Rad/ SVG 44.9±9.2 (p=0.468) and MCS score was TAR 52.0±8.9 vs LIMA/Rad/SVG 52.5±9.3 (p=0.723). There were no significant differences between groups for NYHA class 3+ TAR 9.4% vs. LIMA/Rad/SVG 6.6%; or CCS 3+ TAR 2.35% vs. LIMA/Rad/SVG 0%.

Keywords: CABG; MACCEs; quality of life; total arterial revascularisation

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Authors: Sandipika Gupta

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Objective: Due to admirably low 30-day mortality rates for paediatric cardiac surgery, it is now pertinent to turn towards more intermediate-length outcomes such as morbidities closely associated with these surgeries. One such morbidity, major adverse events (MAE) comprises a group of adverse outcomes associated with paediatric cardiac surgery (e.g. cardiac arrest, major haemorrhage). Methods: This is a retrospective study that analysed the incidence and impact of MAE which was the primary outcome in the UK population. The data was collected in 5 centres between October 2015 and June 2017, amassing 3090 surgical episodes. The incidence and risk factors for MAE, were assessed through descriptive statistical analyses and multivariate logistic regression. The secondary outcomes of life status at 6 months and the length of hospital stay were also evaluated to understand the impact of MAE on patients. Results: Out of 3090 episodes, 134 (4.3%) had a postoperative MAE. The majority of the episodes were in: neonates (47%, P<0.001), high-risk cardiac diagnosis groups (20.1%, P<0.001), episodes with longer 5mes on the bypass (72.4%, P<0.001) and urgent surgeries (57.9%, P<0.001). Episodes reporting MAE also reported longer lengths of stay in hospital (29 days vs 9 days, P<0.001). Furthermore, patients experiencing MAE were at a higher risk of mortality at the 6-month life status check (mortality rates: 29.2% vs 2%, P<0.001).Conclusions: Key risk factors were identified. An important negative impact of MAE was found for patients. The identified risk factors could be used to profile and flag at-risk patients. Monitoring of MAE rates and closer investigation into the care pathway before and after individual MAEs in children’s heart units may lead to a reduction in these terrible events.

Keywords:

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Authors: Munirah Ismail, Joon Hock Yeo

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Babies born with Tetralogy of Fallot, a congenital heart defect, are required to undergo reconstruction surgery to create a valved conduit. As the child matures, the partially reconstructed pulmonary conduit increases in diameter, while the size of the reconstructed valve remains the same. As a result, follow up surgery is required to replace the undersized valve. Thus, in this project, we evaluated the in-vitro performance of a bi-leaflet valve design in terms of percentage regurgitation with increasing artery (conduit) diameters. Results revealed percentage regurgitations ranging from 13% to 34% for conduits tested. It was observed that percentage of regurgitation increased exponentially with increasing diameters. While the amount of regurgitation may seem severe, it is deemed acceptable, and this valve could potentially reduce the frequency of re-operation in the lifetime of pediatric patients.

Keywords: pulmonary heart valve, tetralogy of fallot, expanded polytetrafluoroethylene valve, pediatric heart valve replacement

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Authors: Ahmed Yousef A. Al Sultan

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Introduction: The aim of this review is based on clinical research that studies the changes in middle cerebral artery velocity using Transcranial Doppler (TCD) and cerebral oxygen saturation using cerebral oximetry in patients undergoing carotid endarterectomy (CEA) surgery under local anesthesia (LA). Patients with or without neurological symptoms during the surgery are taking a role in this study using triplet method of cerebral oximetry, transcranial doppler and awake test in detecting any cerebral ischemic symptoms. Methods: about one hundred patients took part during their CEA surgeries under local anesthesia, using triple assessment mentioned method, Patients requiring general anesthesia be excluded from analysis. All data were recorded at eight surgery stages separately to serve this study. Results: In total regional cerebral oxygen saturation (rSO2), middle cerebral artery (MCA) velocity, and pulsatility index were significantly decreased during carotid artery clamping step in CEA procedures on the targeted carotid side. With most observed changes in MCA velocity during the study. Discussion: Cerebral oxygen saturation and middle cerebral artery velocity were significantly decreased during clamping step of the procedures on the targeted side. The team with neurological symptoms during the procedures showed higher changes of rSO2 and MCA velocity than the team without neurological symptoms. Cerebral rSO2 and MCA velocity significantly increased directly after de-clamping of the internal carotid artery on the affected side.

Keywords: awake testing, carotid endarterectomy, cerebral oximetry, Tanscranial Doppler

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Authors: Badriah Khaleel

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Language acquisition is one of the most striking aspects of human development. It is a startling feat, which has engrossed the attention of linguists for generations. The present study will explore the hidden identities and attributes of nonverbal gestures. The current research will reflect the significant role of body language as not mere body gestures or facial expressions but as the first language of humanity.

Keywords: a startling feat, a new horizon for linguists to rethink, explore the hidden identities and attributes of non-verbal gestures, English as a third language, the first language of humanity

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Authors: Ryan Goh, Nicholas Beech

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Introduction: Le Fort I Osteotomies, although are common procedures in Oral and Maxillofacial Surgery, carry a degree of risk of unfavourable propagation of the down-fracture of the maxilla. This may be the first reported case in the literature for meningoencephalitis to occur following a Le Fort I Osteotomy. Case: A 32-year-old female was brought into the Emergency Department four days after a Le Fort I Osteotomy, with a Glasgow Coma Scale (GCS) of 8 (E3V1M4). A Computed Tomography (CT) Head showed a skull base fracture at the right sphenoid sinus. Lumbar puncture was completed, and Klebsiella oxytoca was found in the Cerebrospinal Fluid (CSF). She was treated with Meropenem, and rapidly improved thereafter. CSF rhinorrhoea was identified when she was extubated, which was successfully managed via a continuous lumbar drain. She was discharged on day 14 without any neurological deficits. Conclusion: The most likely aspect of the Le Fort I Osteotomy to obtain a skull base fracture is during the pterygomaxillary disjunction. Care should always be taken to avoid significant risks of skull base fractures, CSF rhinorrhoea, meningitis and encephalitis.

Keywords: meningitis, orthognathic surgery, post-operative complication, skull base, rhinorrhea

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Authors: Sizhu Wang, Cuisong Tang, Lin Zhang, Guangyu Tang

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Objective: We aimed to detect the composition of bone marrow fatty acids early after ovariectomized (OVX) surgery and explore the potential mechanism. Methods: Thirty-two female Sprague-Dawley (SD) rats (12 weeks) were randomly divided into OVX group and Sham group (N=16/group), and received ovariectomy or sham surgery respectively. After 3 and 28 days, eight rats in each group were sacrificed to detect the composition of bone marrow fatty acids by gas chromatography–mass spectrometry (GC–MS) and evaluate the trabecular bone microarchitecture by micro-CT. Significant different fatty acids in the early stage of post-menopausal osteoporosis were selected by OPLS-DA and t test. Then selected fatty acids were further studied in the process of osteogenic differentiation through RT-PCR and Alizarin Red S staining. Results: An apparent sample clustering and group separation were observed between OVX group and sham group three days after surgery, which suggested the role of bone marrow fatty acids in the early stage of postmenopausal osteoporosis. Specifically, myristate, palmitoleate and arachidonate were found to play an important role in classification between OVX group and sham group. We further investigated the effect of palmitoleate and arachidonate on osteogenic differentiation and found that palmitoleate promoted the osteogenic differentiation of MC3T3-E1 cells while arachidonate inhibited this process. Conclusion: Profound bone marrow fatty acids changes have taken place in the early stage of post-menopausal osteoporosis. Bone marrow fatty acids may begin to affect osteogenic differentiation shortly after deficiency of estrogen.

Keywords: bone marrow fatty acids, GC-MS, osteoblast, osteoporosis, post-menopausal

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Authors: Marcelo Lopes Dias Kolling, Felipe Ferreira Laranjeira, Guilherme Augusto Hettwer, Pedro Salomão Piccinini, Marwan Masri, Carlos Oscar Uebel

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Introduction: Injectable fillers are among the most common nonsurgical cosmetic procedures, with significant growth yearly. Knowledge of rheological and mechanical characteristics of fillers, facial anatomy, and injection technique is essential for safety. Concepts such as the use of cannula versus needle, aspiration before injection, and facial danger zones have been well discussed. In case of an accidental intravascular puncture, the pressure inside the vessel may not be sufficient to push blood into the syringe due to the characteristics of the filler product; this is especially true for calcium hydroxyapatite (CaHA) or hyaluronic acid (HA) fillers with high G’. Since viscoelastic properties of normal saline are much lower than those of fillers, aspiration with saline prior to filler injection may decrease the risk of a false negative aspiration and subsequent catastrophic effects. We discuss a technique to add an additional safety step to the procedure with saline aspiration prior to injection, a ‘’reverse Seldinger’’ technique for intravascular access, which we term SANIT: Saline Aspiration Negative Intravascular Test. Objectives: To demonstrate the author’s (PSP) technique which adds an additional safety step to the process of filler injection, with both CaHA and HA, in order to decrease the risk of intravascular injection. Materials and Methods: Normal skin cleansing and topical anesthesia with prilocaine/lidocaine cream are performed; the facial subunits to be treated are marked. A 3mL Luer lock syringe is filled with 2mL of 0.9% normal saline and a 27G needle, which is turned one half rotation. When a cannula is to be used, the Luer lock syringe is attached to a 27G 4cm single hole disposable cannula. After skin puncture, the 3mL syringe is advanced with the plunger pulled back (negative pressure). Progress is made to the desired depth, all the while aspirating. Once the desired location of filler injection is reached, the syringe is exchanged for the syringe containing a filler, securely grabbing the hub of the needle and taking care to not dislodge the needle tip. Prior to this, we remove 0.1mL of filler to allow for space inside the syringe for aspiration. We again aspirate and inject retrograde. SANIT is especially useful for CaHA, since the G’ is much higher than HA, and thus reflux of blood into the syringe is less likely to occur. Results: The technique has been used safely for the past two years with no adverse events; the increase in cost is negligible (only the cost of 2mL of normal saline). Over 100 patients (over 300 syringes) have been treated with this technique. The risk of accidental intravascular puncture has been calculated to be between 1:6410 to 1:40882 syringes among expert injectors; however, the consequences of intravascular injection can be catastrophic even with board-certified physicians. Conclusions: While the risk of intravascular filler injection is low, the consequences can be disastrous. We believe that adding the SANIT technique can help further mitigate risk with no significant untoward effects and could be considered by all performing injectable fillers. Further follow-up is ongoing.

Keywords: injectable fillers, safety, saline aspiration, injectable filler complications, hyaluronic acid, calcium hydroxyapatite

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Authors: Fikri Turk, Sahika Pinar Akyer, Mevci Ozdemir, Mehmet Bulent Ozdemir, Ilgaz Akdogan

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The complications such as bleeding, thrombosis and air embolism depend on injuries emissary veins is often encountered in surgery. Detailed descriptions of the mastoid foramen, occipital foramen, parietal foramen, posterior condylar canal and foramen vesalius are lacking in the literature. For this reason, the purpose of our study was to explore and represent the morphology and morphometry of these emissary foramina in order to prevent complications and to guide for surgeons. The present study was made on 60 dry human skull in the laboratories of Pamukkale University, Faculty of Medicine Department of Anatomy. After taken photograph of emissary foramens by Canon 650D professional camera, the evaluation and measurement’s these foramens made with Matlab program by computer. The overall prevalence of mastoid foramen was 90.52%, occipital foramen was 72.52%, parietal foramen was 42.85%, posterior condylar canal was 91.25% and foramen vesalius was 78.26%. The mean diameter of the mastoid foramen was 1.81±0.76 mm, occipital foramen was 1.20±0.25 mm, parietal foramen was 1.49±0.46 mm, posterior condylar canal was 2.83±1.33 mm and foramen vesalius was 1.74±0.60 mm. Distances between emissary foramina and fixed bony landmarks were measured. Emissary veins are important in clinic practice and surgical procedures because they act a route of spread of exracranial infection to the intracranial structures and these veins may be a significant bleeding during surgery of the skull and they can be source of thrombosis and air embolism. The detailed anatomical knowledge of these veins and foraminas may help to prevent complications and to guide for surgeons.

Keywords: emissary foramina, mastoid foramen, occipital foramen, parietal foramen, posterior condylar canal, foramen vesalius, morphology, morphometry

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Authors: Yang Zhao, Feng Zhang, Xuanchu Duan

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Trans-differentiation of human Tenon fibroblasts (HTFs) to myo-fibroblasts and fibrosis of episcleral tissue are the most common reasons for the failure of glaucoma filtration surgery, with limited treatment options like antimetabolites which always have side-effects such as leakage of filter bulb, infection, hypotony, and endophthalmitis. Rosiglitazone, a specific thiazolidinedione is a synthetic high-affinity ligand for PPAR-r, which has been used in the treatment of type2 diabetes, and found to have pleiotropic functions against inflammatory response, cell proliferation and tissue fibrosis and to benefit to a variety of diseases in animal myocardium models, steatohepatitis models, etc. Here, in vitro we cultured primary HTFs and stimulated with TGF- β to induced myofibrogenic, then treated cells with Rosiglitazone to assess for fibrogenic response. In vivo, we used rabbit glaucoma model to establish the formation of post- trabeculectomy scarring. Then we administered subconjunctival injection with Rosiglitazone beside the filtering bleb, later protein, mRNA and immunofluorescence of fibrogenic markers are checked, and filtering bleb condition was measured. In vitro, we found Rosiglitazone could suppressed proliferation and migration of fibroblasts through macroautophagy via TGF- β /Smad signaling pathway. In vivo, on postoperative day 28, the mean number of fibroblasts in Rosiglitazone injection group was significantly the lowest and had the least collagen content and connective tissue growth factor. Rosiglitazone effectively controlled human and rabbit fibroblasts in vivo and in vitro. Its subconjunctiiva application may represent an effective, new avenue for the prevention of scarring after glaucoma surgery.

Keywords: fibrosis, glaucoma, macroautophagy, rosiglitazone

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Authors: Joshua Chew, Vesa Cheng, David Thomson

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Background: Hereditary angioedema (HAE) or C1 esterase deficiency is a relatively rare entity that has a potential for significant anesthetic complications. Methods: A literature review was performed of published cases of surgery in patients with HAE. Results were limited to English language only and cases were examined for management strategies and successful prevention of acute attacks. Results: The literature revealed the successful use of C1 esterase inhibitors as the most common agent in surgical prophylaxis therapy. Other therapeutic targets described included kallikrein inhibitors and bradykinin B2 receptor antagonists. Conclusions: Therapeutic targets that exist for the management of acute attacks in HAE have been successfully employed in the setting of surgery. The data is currently limited and could not be used as a firm evidence base, but the limited outcomes seen are positive and reassuring for the prospective anesthetic management of this potentially fatal condition.

Keywords: anesthesia, C1 esterase deficiency, hereditary angioedema, surgical prophylaxis

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Authors: Albert Suryaprawira

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The Nasion-Sella Line (NSL) has been used for several years as a reference line in longitudinal growth study. Therefore this line is considered to be stable not only to evaluate treatment outcome and to predict relapse possibility but also to manage prognosis. This is a radiographic superimposition of an adult male aged 19 years who complained of difficulty in aesthetic, talking and chewing. Patient has a midface hypoplasia profile (concave). He was diagnosed to have a severe Skeletal Class III with Class III malocclusion, increased lower vertical height, and an anterior open bite. A pre-treatment cephalometric radiograph was taken to analyse the skeletal problem and to measure the amount of bone movement and the prediction soft tissue response. A panoramic radiograph was also taken to analyse bone quality, bone abnormality, third molar impaction, etc. Before the surgery, a pre-surgical cephalometric radiograph was taken to re-evaluate the plan and to settle the final amount of bone cut. After the surgery, a post-surgical cephalometric radiograph was taken to confirm the result with the plan. The superimposition using NSL as a reference line between those radiographs was performed to analyse the outcome. It is important to describe the amount of hard and soft tissue movement and to predict the possibility of relapse after the surgery. The patient also needs to understand all the surgical plan, outcome and relapse prevention. The surgical management included maxillary impaction and advancement of Le Fort I osteotomy. The evaluation using NSL as a reference was a very useful method in determining the outcome and prognosis.

Keywords: Nasion-Sella Line, midface hypoplasia, Le Fort 1, maxillary advancement

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Authors: Esra Yuce, Isil D. S. Yamaner, Murude Yazan

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Aims and objective: Antiresorptive agents including bisphosphonates and denosumab as strong suppressors of osteoclasts are the most commonly used antiresorptive medications for the treatment of osteoporosis which counteract the negative quantitative alteration of trabecular and cortical bone by inhibition of bone turnover. Oral bisphosphonate therapy for the treatment of osteopenia, osteoporosis or Paget's disease is associated with the low-grade risk of osteonecrosis of the jaw, while higher-grade risk is associated with receiving intravenous bisphosphonates therapy in the treatment of multiple myeloma and bone metastases. On the other hand, there has been a remarkable increase in incidences of antiresorptive related osteonecrosis of the jaw (ARONJ) in oral bisphosphonate users. This clinical presentation will evaluate the healing outcomes via piezoelectric bone surgery under the irrigation of PVP-I solution irrigation in patients received bisphosphonate therapy. Material-Method: The study involved 8 female and 5 male patients that have been treated for ARONJ. Among 13 necrotic sites, 9 were in the mandible and 4 were in the maxilla. All of these 13 patients treated with surgical debridement via piezoelectric bone surgery under irrigation by solution with 3% PVP-I concentration in combination with long-term antibiotic therapy and 5 also underwent removal of mobile segments of bony sequestrum. All removable prosthesis in 8 patients were relined with soft liners during the healing periods in order to eliminate chronic minor traumas. Results: All patients were on oral bisphosphonate therapy for at least 2 years and 5 of which had received intravenous bisphosphonates up to 1 year before therapy with oral bisphosphonates was started. According to the AAOMS staging system, four cases were stage II, eight cases were stage I, and one case was stage III. The majority of lesions were identified at sites of dental prostheses (38%) and dental extractions (62%). All patients diagnosed with ARONJ stage I had used unadjusted removable prostheses. No recurrence of the symptoms was observed during the present follow-up (9–37 months). Conclusion: Despite their confirmed effectiveness, the prevention and treatment of osteonecrosis of the jaw secondary to oral bisphosphonate therapy remain major medical challenges. Treatment with piezoelectric bone surgery with irrigation of povidone-iodine solution was effective for management of bisphosphonate-related osteonecrosis of the jaw. Taking precautions for patients treated with oral bisphosphonates, especially also denture users, may allow for a reduction in the rate of developing osteonecrosis of the maxillofacial region.

Keywords: antiresorptive drug related osteonecrosis, bisphosphonate therapy, piezoelectric bone surgery, povidone iodine

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Authors: Nicolas Galazis, Nikolina Docheva, Constantinos Simillis, Kypros Nicolaides

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Background: Obese women are at increased risk for many pregnancy complications, and bariatric surgery (BS) before pregnancy has shown to improve some of these. Objectives: To review the current literature and quantitatively assess the obstetric and neonatal outcomes in pregnant women who have undergone BS. Search Strategy: MEDLINE, EMBASE and Cochrane databases were searched using relevant keywords to identify studies that reported on pregnancy outcomes after BS. Selection Criteria: Pregnancy outcome in firstly, women after BS compared to obese or BMI-matched women with no BS and secondly, women after BS compared to the same or different women before BS. Only observational studies were included. Data Collection and Analysis: Two investigators independently collected data on study characteristics and outcome measures of interest. These were analysed using the random effects model. Heterogeneity was assessed and sensitivity analysis was performed to account for publication bias. Main Results: The entry criteria were fulfilled by 17 non-randomised cohort or case-control studies, including seven with high methodological quality scores. In the BS group, compared to controls, there was a lower incidence of preeclampsia (OR, 0.45, 95% CI, 0.25-0.80; p=0.007), GDM (OR, 0.47, 95% CI, 0.40-0.56; P<0.001) and large neonates (OR 0.46, 95% CI 0.34-0.62; p<0.001) and a higher incidence of small neonates (OR 1.93, 95% CI 1.52-2.44; p<0.001), preterm birth (OR 1.31, 95% CI 1.08-1.58; p=0.006), admission for neonatal intensive care (OR 1.33, 95% CI 1.02-1.72; p=0.03) and maternal anaemia (OR 3.41, 95% CI 1.56-7.44, p=0.002). Conclusions: BS as a whole improves some pregnancy outcomes. Laparoscopic adjustable gastric banding does not appear to increase the rate of small neonates that was seen with other BS procedures. Obese women of childbearing age undergoing BS need to be aware of these outcomes.

Keywords: bariatric surgery, pregnancy, preeclampsia, gestational diabetes, birth weight

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Authors: Joana Gato, Ahmed Abotabekh, Panayoti Bachkangi

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Introduction: Oestrogen is an essential gonadal hormone that plays a vital role in the reproductive system of women1. The average age of menopause in the UK is 512. Women who go through premature menopause should be offered Hormone replacement therapy (HRT). Similarly, women who undergo surgical menopause should be offered HRT, unless contraindicated, depending on the indication of their surgery2,3. Aim: To assess if the patients in our department are counselled regarding HRT after surgical treatment and if HRT was prescribed. Methodology: A retrospective audit in a busy district hospital, examining all the patients who had a hysterectomy. The audit examined if HRT was discussed pre-operatively, prescribed on discharge and if a follow up was arranged. For women with contraindication to HRT, the audit assessed if the reasons were discussed pre-operatively and communicated to the Inclusion criteria: woman having a total or subtotal hysterectomy, with or without bilateral salpingo-ophorectomy (BSO), between April and September 2022. Exclusion criteria: woman having a vaginal hysterectomy. Results: 40 patients in total had hysterectomy; 27 (68%) were under the age of 51. 15 out of 27 patients bad BSO. 9 women were prescribed HRT, but 8 were offered HRT immediately, and 1 of them were offered a follow up. Of women who underwent surgical menopause, 7 were not given any HRT. The HRT choice was diverse, however, the majority was prescribed oral HRT. 40% of women undergoing surgical menopause did not have a discussion about HRT prior to their surgery. In postmenopausal women (n=13; 33%), still two were given HRT for preexisting menopausal symptoms. Discussion: Only 59% of the pre-menopausal patients had oophorectomy, therefore undergoing surgical menopause. Of these, 44% were not given any HRT, and 40% had no discussion about HRT prior to surgery. Interestingly, the majority of these women have no obvious contraindication to HRT. The choice of HRT was diverse, but the majority was commenced on oral HRT. Our unit is still working towards meeting all the NICE guidance standards of offering HRT and information prior to surgery to women planning to undergo surgical menopause. Conclusion: Starting HRT at the onset of menopause has been shown to improve quality of life and reduce the risk of cardiovascular disease and osteoporotic fractures4. Our unit still has scope for improvement to comply with the current NICE guidance. All pre-menopausal women undergoing surgical menopause should have a discussion regarding HRT prior to surgery and be offered it if there are no contraindications. This discussion should be clearly documented in the notes. At the time of this report, some of the patients have not yet had a follow up, which we recognize as a limitation to our audit.

Keywords: hormone replacement therapy, menopause, premature ovarian insufficiency, surgical management

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Authors: Silvia Santano Guillén, Luigi Lo Iacono, Christian Meder

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One of the main aims of current social robotic research is to improve the robots’ abilities to interact with humans. In order to achieve an interaction similar to that among humans, robots should be able to communicate in an intuitive and natural way and appropriately interpret human affects during social interactions. Similarly to how humans are able to recognize emotions in other humans, machines are capable of extracting information from the various ways humans convey emotions—including facial expression, speech, gesture or text—and using this information for improved human computer interaction. This can be described as Affective Computing, an interdisciplinary field that expands into otherwise unrelated fields like psychology and cognitive science and involves the research and development of systems that can recognize and interpret human affects. To leverage these emotional capabilities by embedding them in humanoid robots is the foundation of the concept Affective Robots, which has the objective of making robots capable of sensing the user’s current mood and personality traits and adapt their behavior in the most appropriate manner based on that. In this paper, the emotion recognition capabilities of the humanoid robot Pepper are experimentally explored, based on the facial expressions for the so-called basic emotions, as well as how it performs in contrast to other state-of-the-art approaches with both expression databases compiled in academic environments and real subjects showing posed expressions as well as spontaneous emotional reactions. The experiments’ results show that the detection accuracy amongst the evaluated approaches differs substantially. The introduced experiments offer a general structure and approach for conducting such experimental evaluations. The paper further suggests that the most meaningful results are obtained by conducting experiments with real subjects expressing the emotions as spontaneous reactions.

Keywords: affective computing, emotion recognition, humanoid robot, human-robot-interaction (HRI), social robots

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Authors: Luna Sequier, Florian Forelli, Maude Traulle, Amaury Vandebrouck, Pascal Duffiet, Louis Ratte, Jean Mazeas

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The study's objective is to compare the muscular activity of the flexor knee muscle in patients who underwent an anterior cruciate ligament reconstruction with hamstring autograft and the individuals who have not undergone surgery. Methods: The participants were divided into two groups: a healthy group and an experimental group who had undergone an anterior cruciate ligament reconstruction with a hamstring graft. All participants had to perform a knee flexion strength test on an isokinetic dynamometer. The medial Gastrocnemius, lateral Gastrocnemius, Biceps femoris, and medial Hamstring muscle activity were measured during this test. Each group’s mean muscle activity was tested with statistical analysis, and a muscle activity ratio of gastrocnemius and hamstring muscles was calculated Results: The results showed a significant difference in activity of the medial gastrocnemius (p = 0,004901), the biceps femoris (p = 5,394.10-6), and the semitendinosus muscles (p = 1,822.10-6), with a higher Biceps femoris and Semitendinosus activity for the experimental group. It is however noticeable that inter-subject differences were important. Conclusion: This study has shown a difference in the gastrocnemius and hamstring muscle activity between patients who underwent an anterior cruciate ligament reconstruction surgery and healthy participants. With further results, this could show a modification of muscle activity patterns after surgery which could lead to compensatory behaviors at a return to sport and eventually explain a higher injury risk for our patients.

Keywords: anterior cruciate ligament, electromyography, muscle activity, physiotherapy

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Authors: Soudeh Tabashi, Mohammadreza Moshari, Parisa Sezari

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Introduction: Postoperative analgesia in Orthotopic Liver Transplantation (OLT) surgery is challenging for anesthesiologists. Although OLT is one of the most extensive abdominal operations, it seems that patients don’t suffer from severe post operative pain. On the other hands drug metabolism is unpredictable due to unknown graft function. The aim of this study was to compare intraoperative infusion of remifentanil versus fentanyl in postoperative opioid demand in patients with OLT and evaluating the complications in two groups. Method: In this double-blind clinical trial 34 patients who had OLT were included. They divided randomly in two groups of Remifentanil (R) and Fentanyl (F). Patients in group R and F received infusion of Remifentanil 0.3-1 µg/Kg/min and Fentanyl 0.3-1 µg/Kg/min during maintenance of anesthesia. Post operative pain were measured in 6, 12, 18, 24 hours and second and third days after surgery with Numeric Rate Scale (NRS). Patients had received intravenous acetaminophen as rescue therapy with NRS of 3 or more. In addition to demographic information, post operative opioid consumption were recorded as the primary outcome. Intraoperative blood transfusion, intraoperative inotropic drugs consumption, weaning time and intensive care unit stay were also evaluated. Results: Total dose of acetaminophen consumption in first 3 days after surgery did not have significant difference between two groups (Pvalue=0.716). intraoperative inotrope consumption, blood transfusion and post operative weaning time and ICU stay were also similar in both groups. Conclusion: This study demonstrates that intraoperative infusion of remifentanil in OLT have the same effect on post operative pain management as fentanyl. Despite the complications of operation were not increased by remifentanil.

Keywords: liver transplantation, postoperative pain, remifentanil, fentanyl

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Authors: Christolyn Raj, Lewis Levitz

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Introduction: Two cases of late presentation ( > five years ) of bilateral pseudophakic macula edema related to oral tyrosine kinase inhibitors are described. These cases are the first of their type in the published literature. A review of ocular inflammatory complications of tyrosine kinase inhibitors in the current literature is explored. Case Presentations(s): Case 1 is an 83-year-old female who has been stable on Ibrutinib (Imbruvica ®) for chronic lymphocytic leukemia (CLL). She presented with bilateral blurred vision from severe cystoid macula edema seven years following routine cataract surgery. She was treated with intravitreal steroids with complete resolution without relapse. Case 2 is a 76-year-old female who was on therapy for polycythemia vera with Ruxolitinib (Jakafi®). She presented with bilateral blurred vision from mild cystoid macula edema six years following routine cataract surgery. She responded well to topical steroids without relapse. In both cases, oral tyrosine kinase inhibitor agents were presumed to be the underlying cause and were ceased. Over the last five years, there have been increasing reports in the literature of the inflammatory effects of tyrosine kinase inhibitors on the retina, uvea and optic nerve. Conclusion: Late presentation of pseudophakic macula edema following routine cataract surgery is rare. Such presentations should prompt investigation of the chronic use of systemic medications, especially oral kinase inhibitors. Patients who must remain on these agents require ongoing ophthalmologic assessment in view of their long-term inflammatory side effects.

Keywords: macula edema, oral kinase inhibitors, retinal toxicity, pseudo-phakia

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Authors: Sabrina S. W. Chan, Emily Schwartzman, Nicholas O. Rule

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Past literature showed mixed findings on how smiling affects a person’s chance of getting hired. On one hand, smiling suggests enthusiasm, cooperativeness, and enthusiasm, which can elicit positive impressions. On the other hand, smiling can suggest weaker professionalism or a filler to hide nervousness, which can lower a candidate’s perceived competence. Emotion expressions can also be perceived differently depending on the person’s gender and can activate certain gender stereotypes. Women especially face a double bind with respect to hiring decisions and smiling. Because women are socially expected to smile more, those who do not smile will be considered stereotype incongruent. This becomes a noisy signal to employers and may lower their chance of being hired. However, women’s smiling as a formality may also be an obstacle. They are more likely to put on fake smiles; but if they do, they are also likely to be perceived as inauthentic and over-expressive. This paper sought to investigate how smiling affects hiring decisions, and whether this relationship is moderated by gender. In Study 1, participants were shown a series of smiling and emotionally neutral face images, incorporated into fabricated LinkedIn profiles. Participants were asked to rate how hireable they thought that candidate was. Results showed that participants rated smiling candidates as more hireable than nonsmiling candidates, and that there was no difference in gender. Moreover, individuals who did not study business were more biased in their perceptions than those who did. Since results showed a trending favoritism over female targets, in suspect of desirability bias, a second study was conducted to collect implicit measures behind the decision-making process. In Study 2, a mouse-tracking design was adopted to explore whether participants’ implicit attitudes were different from their explicit responses on hiring. Participants asked to respond whether they would offer an interview to a candidate. Findings from Study 1 was replicated in that smiling candidates received more offers than neutral-faced candidates. Results also showed that female candidates received significantly more offers than male candidates but was associated with higher attractiveness ratings. There were no significant findings in reaction time or change of decisions. However, stronger hesitation was detected for responses made towards neutral targets when participants perceived the given position as masculine, implying a conscious attempt of making situational judgments (e.g., considering candidate’s personality and job fit) to override automatic processing (evaluations based on attractiveness). Future studies would look at how these findings differ for positions which are stereotypically masculine (e.g., surgeons) and stereotypically feminine (e.g., kindergarten teachers). Current findings have strong implications for developing bias-free hiring policies in workplace, especially for organizations who maintain online/hybrid working arrangements in the post-pandemic era. This also bridges the literature gap between face perception and gender discrimination, highlighting how engendered facial cues can affect individual’s career development and organization’s success in diversity and inclusion.

Keywords: engendered facial cues, face perception, gender stereotypes, hiring decisions, smiling, workplace discrimination

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Authors: Giovanna Borges Bottino, Luis Felipe Freitas do Nascimento Alves Teixeira

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This article aims to present a case study of the National Civil Aviation Agency (ANAC) in Brazil, ANAC-id. ANAC-id is the artificial intelligence algorithm developed for image analysis that recognizes standard images of unobstructed and uprighted face without sunglasses, allowing to identify potential inconsistencies. It combines YOLO architecture and 3 libraries in python - face recognition, face comparison, and deep face, providing robust analysis with high level of accuracy.

Keywords: artificial intelligence, deepface, face compare, face recognition, YOLO, computer vision

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Authors: Lakmali Anthony, Madeline Gillies

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Background Breast cancer (BC) is usually managed with surgical resection. Many outcomes traditionally used to define successful operative management, such as resection margin, do not adequately reflect patients’ experience. Patient-reported outcomes (PRO) such as Health-Related Quality of life (HRQoL) provide a means by which the impact of surgery for cancer can be reported in a patient-centered way. This exploratory cross-sectional study aims to; (1) describe postoperative HRQoL in patients who underwent primary resection in a regional Australian hospital; (2) describe the prevalence of anxiety, depression and clinically significant fear of cancer recurrence (FCR) in this population; and (3) identify demographic, psychosocial, disease and treatment factors associated with poorer self-reported HRQoL. Methods Patients who had resection of BC in a regional Australian hospital between 2015 and 2022 were eligible. Participants were asked to complete a survey designed to assess HRQoL, as well as validated instruments that assess several other psychosocial PROs hypothesized to be associated with HRQoL; emotional distress, fear of cancer recurrence, social support, dispositional optimism, body image and spirituality. Results Forty-six patients completed the survey. Clinically significant levels of FCR and emotional distress were present in this group. Many domains of HRQoL were significantly worse than an Australian reference population for BC. Demographic and disease factors associated with poor HRQoL included smoking and ongoing adjuvant systemic therapy. The primary operation was not associated with HRQoL for breast cancer. All psychosocial factors measured were associated with HRQoL. Conclusion HRQoL is an important outcome in surgery for both research and clinical practice. This study provides an overview of the quality of life in a regional Australian population of postoperative breast cancer patients and the factors that affect it. Understanding HRQoL and awareness of patients particularly vulnerable to poor outcomes should be used to aid the informed consent and shared decision-making process between surgeon and patient.

Keywords: breast cancer, surgery, quality of life, regional population

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Authors: Manee Hasap, Mongkolchai Hasap, Tasanee Nasae

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The purpose of this study was to evaluate the primary caregivers’ knowledge and capabilities for providing quality care to be hospitalized post-hip fracture surgery elderly patients. The theoretical framework of the study was derived from the concepts of dependent care agency in Orem’s Self-Care theory, and family care provision for the elderly and chronically ill patients. 59 subjects were purposively selected. The subjects were primary caregivers of post-operated hip fracture elderly patients who had been admitted to the Orthopaedic Ward of Songklanagarind Hospital. Demographic data of the caregivers and patients were collected by non-participant observation using the evaluation and recording forms. The reliability of caregivers’ knowledge measurement (0.86) was obtained by KR-20 and that of caregivers’ capabilities for post-operative care evaluation form (0.97) obtained from 2 observers by interrater reliability. The data were analyzed using descriptive statistic, which were frequency, percentage, mean, and standard deviation. The result of this study indicated that elderly patients with post-hip fracture surgery had many pre-discharge self care limitations. Approximately, 75% of the caregivers had knowledge to respond to patient’s essential needs at a high level, while the rest (25%) had this knowledge a moderate level. For observation, 57.63% of the subjects had capabilities in care practice at a moderate level; 28.81% had capabilities in care practice at a high level, while 13.56% had at a low level. The result of this study can be used as basic information for patients and caregivers capabilities developing plan especially, providing patients’ activities, accident surveillance and complications prevention for a good life quality of elderly patients after hip surgery both hospitalization and rehabilitation at home.

Keywords: care givers’ knowledge, care givers’ capabilities, elderly hip fracture patients, patients

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Authors: Nickolas A. Stewart, Donald C. Hefelfinger, Garrett V. Brittain, Timothy C. Frommeyer, Adrienne Stolfi

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Orthopedic surgery is currently considered one of the most competitive specialties that medical students can apply to for residency training. As evidenced by increasing United States Medical Licensing Examination (USMLE) scores, overall grades, and publication, presentation, and abstract numbers, this specialty is getting increasingly competitive. The recent change of USMLE Step 1 scores to pass/fail has resulted in additional challenges for medical students planning to apply for orthopedic residency. Until now, these scores have been a tool used by residency programs to screen applicants as an initial factor to determine the strength of their application. With USMLE STEP 1 converting to a pass/fail grading criterion, the question remains as to what will take its place on the ERAS application. The primary objective of this study is to determine the trends in the number of research projects, abstracts, presentations, and publications among orthopedic residency applicants. Secondly, this study seeks to determine if there is a relationship between the number of research projects, abstracts, presentations, and publications, and match rates. The researchers utilized the National Resident Matching Program's Charting Outcomes in the Match between 2007 and 2022 to identify mean publications and research project numbers by allopathic and osteopathic US orthopedic surgery senior applicants. A paired t test was performed between the mean number of publications and research projects by matched and unmatched applicants. Additionally, simple linear regressions within matched and unmatched applicants were used to determine the association between year and number of abstracts, presentations, and publications, and a number of research projects. For determining whether the increase in the number of abstracts, presentations, and publications, and a number of research projects is significantly different between matched and unmatched applicants, an analysis of covariance is used with an interaction term added to the model, which represents the test for the difference between the slopes of each group. The data shows that from 2007 to 2022, the average number of research publications increased from 3 to 16.5 for matched orthopedic surgery applicants. The paired t-test had a significant p-value of 0.006 for the number of research publications between matched and unmatched applicants. In conclusion, the average number of publications for orthopedic surgery applicants has significantly increased for matched and unmatched applicants from 2007 to 2022. Moreover, this increase has accelerated in recent years, as evidenced by an increase of only 1.5 publications from 2007 to 2001 versus 5.0 publications from 2018 to 2022. The number of abstracts, presentations, and publications is a significant factor regarding an applicant's likelihood to successfully match into an orthopedic residency program. With USMLE Step 1 being converted to pass/fail, the researchers expect students and program directors will place increased importance on additional factors that can help them stand out. This study demonstrates that research will be a primary component in stratifying future orthopedic surgery applicants. In addition, this suggests the average number of research publications will continue to accelerate. Further study is required to determine whether this growth is sustainable.

Keywords: publications, orthopedic surgery, research, residency applications

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Authors: Andriana Purnama, Reno Rudiman, Kezia Christy

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Anal stenosis which develops due to anoderm scarring usually caused by secondary to surgical trauma, has become common, causing significant decrease patient’s quality of life. Even though mild anal stenosis was treated with non-surgical treatment, but surgical reconstruction in unavoidable for moderate to severe anal stenosis that cause distressing, severe anal pain and inability to defecate. In our study, we intend to share our result with the use of diamond flap in treatment of anal stenosis. This case report illustrates a 57-year-old male patient who presented with difficulty and discomfort in defecation caused by anal stenosis after 2 years of open hemorrhoidectomy surgery. At physical examination, there was requirement of forceful dilatation when the index finger was inserted or precisely 6mm as measured by hegar dilator (moderate anal stenosis). Blood test result was within normal limits. The patient underwent anal repair and diamond flap where the scar tissue at 6 and 9 o’clock directions was excised and diamond graft was incised carefully while paying attention to the vascular supply. Finally, the graft was fixated without any tension to the anal canal, resulting in diameter of 2 cm after operation. After 2 days post operation, the patient was in stable condition, without any complication, and discharged. There was no abnormality concerning the stool. Ten days after the operation, diamond flap was in normal condition and without any complication. He was scheduled for futher follow up at the Digestive Surgery Department. Anal stenosis due to overzealous hemorrhoidectomy is a complication that is preventable when performed in experienced hands. Diamond flap was one of the options for the anal stenosis treatment with less complication.

Keywords: anal stenosis, diamond flap, post hemorrhoidectomy, anal repair

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