The coronavirus disease-2019 (COVID-19) pandemic has raised many concerns regarding the safety of patients and healthcare workers. Anaesthetic implications and the impact of this pandemic on anaesthesiologists have been discussed widely in the recent past. Operating theatres are high-risk areas where anaesthesiologists perform various aerosolgenerating procedures (AGPs).Prolong patient contact predisposes them to the risk of exposure. Scarcity of resources and limitations in testing pose an additional risk to the anesthesiologist. Although guidance from various professional bodies is in abundance, there is a general lack of consensus. This review summarises current evidence and guidelines related to anaesthesiology during the COVID-19 pandemic. Ensuring the provision of unhindered care, ensuring patient safety and protecting oneself with optimum utilization of available resources remain a challenge to the anesthesiologist.

Pre-operative assessment of a patient for routine redo thyroidectomy requires a detailed airway assessment, clear documentation and formulation of an appropriate airway management plan by the anesthetist. Failure to identify problems related to oxygenation and ventilation during surgery will cause grave consequences to the patient and an unpleasant experience to the anesthetist and the surgeon. Redo thyroid surgery can be challenging. There is a possibility of preoperative vocal cord palsy due to previous surgical insult and infiltration by tumour recurrence, that can lead to difficulty in ventilation following induction of anesthesia. Therefore, it is mandatory to perform a detailed assessment of the airway using conventional as well as the advanced techniques. We report the lessons learnt from a 42-year-old, ASA I, male patient scheduled for a redo thyroidectomy who could not be intubated nor ventilated, following a “missed difficult airway,” despite a clean history and the available past records. An emergency airway was declared and managed according to Difficult Airway Society (DAS) guidelines which finally resulted in a successful outcome. Subsequent evaluation by the ENT team revealed an absent glottic opening due to bilateral vocal cord palsy which resulted in a “can’t intubate, can’t oxygenate” state in this patient. Citation: Jayaweer DA, Abayadeera A, Dassanayake V. ‘Can’t intubate, can’t oxygenate’ during an elective redo thyroid surgery; A successful rescue and the lesson learnt. Anaesth. pain intensive care 2022;26(5):727-729. DOI: 10.35975/apic.v26i5.1984

Background: Leaks from the pancreatojejunostomy (PJ) after a pancreaticoduodenectomy (PD) occur in 20%-40% patients. Clinically significant grade B & C leaks occurring in 12.3%-16.5% result in morbidity and mortality. This study looks at the outcomes of patients who had a PJ in a low volume HPB surgical unit. Methods: Retrospective analysis of a HPB patient database and records from 2011-2021 was done. Patient demography, clinico-pathological details, pancreatic leak rates (ISGPF classification) and survival was recorded. PJs were done using a duct to mucosa technique with 3-0 and 5-0 polypropylene with a stent in-situ. Results: Of the 59 patients, mean age was 55.1 years with a M:F ratio of 1.1:1. 93.2% (n = 55) of the PJs were done as part of a PD, 3.4% (n = 2) after central pancreatectomy and 3.4% (n = 2) after longitudinal PJs. Histologically, 78% (n = 46) were malignant and 81.4% had a R0 resection margin (n = 35/43) while 18.6% (n = 8) were R1 resections. Grade B and C leaks occurred in 6.8% (n = 4). One grade B and both grade C fistulae were after PD. The other grade B fistula followed a central pancreatectomy. One grade C leak led to death on postoperative day 18 despite reopening. Among those that developed Grade B or C fistulae, the pancreas was soft in 50% (2/4) and firm in 25% (1/4), whereas 75% (3/4) had a PD diameter ≤ 3 mm. The median postoperative ICU and hospital stay were 2 (IQR = 3, n = 24) and 11 days (IQR = 8, n = 31), respectively. Conclusions: Clinically significant PJ leaks were comparatively low in this group. However, grade B & C fistulae resulted in significant morbidity and in one case mortality. Even in low volume centres, adhering to standard practice can result in good outcomes.

Background: Laparoscopic cholecystectomy (LC), the gold standard for treatment of symptomatic cholelithiasis, is one of the most commonly performed minimal-access surgical procedures. Despite this, morbidity due to bile duct injuries (BDI) remains a concern globally and nationally. This study describes the practice and outcomes of LCs performed by or under the supervision of a single surgeon. Methods: A retrospective analysis of prospectively collected data of patients who underwent LC from 2015-20 was done. A standardised surgical technique with demonstration of the critical view of safety (CVS) was followed by the surgeon and trainees under supervision. The image of the CVS was printed in the discharge summary. Results: LCs were performed in 180 patients. The mean age was 46.62 years (13-85) with a male: female ratio of 1:1.85. Indications for surgery were symptomatic gallstones/biliary colics (42.52%), gallstone pancreatitis (21.83%,), acute cholecystitis (14.94%), chronic cholecystitis (9.19%) and choledocholithiasis (4.59%). LCs were completed in 96.1% (173/180) while conversion to open cholecystectomy was required in 3.9% (7/180). Apart from one (0.55%) Strasberg type D BDI identified intraoperatively and one (0.55%) delayed port site hernia, no significant morbidity was reported. The mean hospital stay was 1.19 days (SD 1.02). Conclusions: Adherence to standardised, safe surgical practice and appropriate supervision when performing LCs favour good outcomes even in low volume settings. Conversion to open surgery in challenging circumstances and early identification of BDIs minimise morbidity. Printing the image of the CVS in the discharge summary contributes to quality assurance.

Background: Venous reconstruction after portal (PVR) and superior mesenteric vein resections (SMVR) facilitate curative (R0) resections in hilar cholangiocarcinoma resections (HCR) and pancreatico-duodenectomies (PD). They are also used in iatrogenic vascular injuries. This study examines pathological and early postoperative outcomes of patients who underwent venous reconstruction during major pancreatico-biliary resections. Methods: Retrospective analysis of a prospective HPB database of venous reconstructions during pancreaticoduodenectomy and perihilar cholangio resections during 2021-2022 was done. Vascular resection was planned based on preoperative CT images and intra-operative findings. Results: Six patients of mean age 55.17 years (46-69) with a M:F ratio of 2:1 were included. There were three pancreaticoduodenectomies and three extended right hepatectomies. The median duration of hospital stay was 12 days (10-47). PVR and end-to-end reconstruction was performed in 3 patients. Two underwent SMV venous patch repair and one underwent SMA vein patch repair. The median duration of hospital stay was 12 days (10-47). Histopathology revealed hilar cholangiocarcinoma (n = 2), ampullary adenocarcinoma (n = 1), combined hepatocellular cholangiocarcinoma (n = 1), pancreatic neuroendocrine tumour (n = 1) and chronic pancreatitis. R1 resection was revealed in two patients (PV margin, hepatic resection margin). There was one mortality due to post hepatectomy liver failure and ventilator associated pneumonia. There was one mortality during follow-up (day 35) due to massive upper gastrointestinal bleeding secondary to pseudoaneurysm. Rest had transient hepatic dysfunction (n = 2) and pneumonia (n = 1) among the complications. The mean follow-up duration was 186 days (26-477). Conclusions: Venous reconstructions enable R0 resections in selected patients with borderline pancreatico-biliary tumours, but have attendant morbidity and mortality.