This document discusses anastomotic leak following low anterior resection for rectal cancer. It covers the definition, risk factors, diagnosis, and management of anastomotic leaks. Some key points:
- Anastomotic leak is a serious complication with increased morbidity, mortality, and decreased survival. Risk factors include patient comorbidities, technical factors, and disease factors.
- Leaks are classified based on their severity from Grade A (managed non-operatively) to Grade C (requiring reoperation). Diagnosis can be difficult as leaks often present after discharge. Imaging and biochemical markers like CRP can help in diagnosis.
- Management depends on the severity of the leak and patient stability. Options include medical
Colorectal anastomosis leaks are most difficult to manage for a surgeon carrying morbidity and mortality. Discussion on risk factors as well as management of anastomotic leak.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
This document discusses the management of pancreatic fistulas. It defines pancreatic fistulas as leakage of pancreatic fluid resulting from pancreatic duct obstruction, which can be iatrogenic such as from surgery or ERCP, or non-iatrogenic due to conditions like pancreatitis. Initial management involves controlling pancreatic secretions with drain placement or TPN, correcting electrolyte imbalances, and evaluating the pancreatic duct with imaging. Most fistulas close spontaneously with drainage alone. For persistent fistulas, octreotide can help while ERCP with stenting has closure rates over 80%. Surgery is reserved for failures of other methods and involves duct decompression or resection. Risk factors for postoperative fistulas include duct size, texture, jaundice, and
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
This document discusses surgical considerations for rectal cancer, including:
1. The total mesorectal excision (TME) technique aims to remove the mesorectum containing all lymph nodes, leading to low local recurrence rates of 3-4% after 5-10 years.
2. Pre-operative chemoradiotherapy can downstage tumours and improve survival, especially for T3/T4 tumours.
3. A modified TME removing the mesorectum at least 5cm below the tumour is acceptable for high and mid rectal cancers, as distal spread beyond this is rare.
4. Good surgical outcomes depend on meticulous technique, surgeon experience operating in the pelvis, and multidis
Bile duct injuries are a complex complication seen more frequently with laparoscopic cholecystectomies due to aberrant anatomy and increased procedures. They can involve the cystic duct, gallbladder bed, or major bile ducts. Various classification systems exist to describe the level and extent of injury. Injuries may be detected intraoperatively by cholangiogram abnormalities, bile drainage from unusual locations, or anomalous anatomy. Prevention strategies include proper case selection, opening retroperitoneal folds, dissecting close to the gallbladder, achieving the critical view of safety, and using intraoperative cholangiography.
Extra Levator Abdomino Perineal Resection Dr Harsh Shah
This document discusses extralevator abdominoperineal excision (ELAPE) for rectal cancer. It describes how ELAPE aims to improve on conventional abdominoperineal resection (APR) by removing a larger volume of tissue, including the levator muscles, to obtain clear margins. Meta-analyses have found ELAPE results in lower rates of circumferential resection margin involvement, local recurrence, and involved nodes compared to APR. However, ELAPE also increases morbidity risks and requires perineal wound reconstruction. While ELAPE shows potential oncological benefits, more high-quality studies are still needed to prove its superiority over selective approaches.
Extended totally extraperitoneal repair (eTEP) is a novel technique that was first introduced by Jorge Daes in 2012 to address difficult inguinal hernias.
Open right hemicolectomy is performed to treat malignant tumors, polyps, and other conditions in the ileocecal region, ascending colon, and hepatic flexure. The procedure involves mobilizing the right colon, ligating blood vessels, resecting the involved bowel segments, and creating an ileocolic or ileotransverse anastomosis. Key steps include careful dissection to avoid injury to nearby structures like the duodenum and ureter, and ensuring a well-vascularized, tension-free anastomosis to minimize risks of leakage. Post-operative care focuses on early ambulation and advancing diet based on progress.
Colorectal anastomosis leaks are most difficult to manage for a surgeon carrying morbidity and mortality. Discussion on risk factors as well as management of anastomotic leak.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
This document discusses the management of pancreatic fistulas. It defines pancreatic fistulas as leakage of pancreatic fluid resulting from pancreatic duct obstruction, which can be iatrogenic such as from surgery or ERCP, or non-iatrogenic due to conditions like pancreatitis. Initial management involves controlling pancreatic secretions with drain placement or TPN, correcting electrolyte imbalances, and evaluating the pancreatic duct with imaging. Most fistulas close spontaneously with drainage alone. For persistent fistulas, octreotide can help while ERCP with stenting has closure rates over 80%. Surgery is reserved for failures of other methods and involves duct decompression or resection. Risk factors for postoperative fistulas include duct size, texture, jaundice, and
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
This document discusses surgical considerations for rectal cancer, including:
1. The total mesorectal excision (TME) technique aims to remove the mesorectum containing all lymph nodes, leading to low local recurrence rates of 3-4% after 5-10 years.
2. Pre-operative chemoradiotherapy can downstage tumours and improve survival, especially for T3/T4 tumours.
3. A modified TME removing the mesorectum at least 5cm below the tumour is acceptable for high and mid rectal cancers, as distal spread beyond this is rare.
4. Good surgical outcomes depend on meticulous technique, surgeon experience operating in the pelvis, and multidis
Bile duct injuries are a complex complication seen more frequently with laparoscopic cholecystectomies due to aberrant anatomy and increased procedures. They can involve the cystic duct, gallbladder bed, or major bile ducts. Various classification systems exist to describe the level and extent of injury. Injuries may be detected intraoperatively by cholangiogram abnormalities, bile drainage from unusual locations, or anomalous anatomy. Prevention strategies include proper case selection, opening retroperitoneal folds, dissecting close to the gallbladder, achieving the critical view of safety, and using intraoperative cholangiography.
Extra Levator Abdomino Perineal Resection Dr Harsh Shah
This document discusses extralevator abdominoperineal excision (ELAPE) for rectal cancer. It describes how ELAPE aims to improve on conventional abdominoperineal resection (APR) by removing a larger volume of tissue, including the levator muscles, to obtain clear margins. Meta-analyses have found ELAPE results in lower rates of circumferential resection margin involvement, local recurrence, and involved nodes compared to APR. However, ELAPE also increases morbidity risks and requires perineal wound reconstruction. While ELAPE shows potential oncological benefits, more high-quality studies are still needed to prove its superiority over selective approaches.
Extended totally extraperitoneal repair (eTEP) is a novel technique that was first introduced by Jorge Daes in 2012 to address difficult inguinal hernias.
Open right hemicolectomy is performed to treat malignant tumors, polyps, and other conditions in the ileocecal region, ascending colon, and hepatic flexure. The procedure involves mobilizing the right colon, ligating blood vessels, resecting the involved bowel segments, and creating an ileocolic or ileotransverse anastomosis. Key steps include careful dissection to avoid injury to nearby structures like the duodenum and ureter, and ensuring a well-vascularized, tension-free anastomosis to minimize risks of leakage. Post-operative care focuses on early ambulation and advancing diet based on progress.
This document discusses principles of bowel anastomosis, including types of anastomoses, indications for anastomoses, pre-operative preparation, intra-operative techniques, post-operative care, complications, and controversies. It covers topics such as hand-sewn versus stapled anastomoses, single versus double layer closure, inversion versus eversion of tissue, and use of abdominal drains and NG tubes. The goal of bowel anastomosis is to successfully rejoin bowel segments through meticulous surgical technique and postoperative management in order to restore intestinal continuity.
Laparoscopic colectomy was slow to gain acceptance compared to laparoscopic cholecystectomy due to concerns over its steep learning curve, costs, operating time, and whether it could achieve the same oncological outcomes as open surgery. While short-term benefits like less blood loss, faster recovery, and lower morbidity have been shown, long-term oncological data is still lacking and conversion rates are high, particularly for rectal resections. Randomized trials show no differences in short-term outcomes or quality of life, but higher positive circumferential resection margin rates for laparoscopic anterior resection.
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
The document discusses pancreatic trauma, including relevant anatomy, epidemiology, etiology, presentation, workup, staging, and treatment. Some key points:
- The pancreas is protected by surrounding structures but can be injured by penetrating trauma or direct blunt force.
- Injury is staged based on severity from grade I (minor) to grade V (massive disruption). Treatment depends on grade and location of injury.
- Workup may include labs, CT, MRCP, ERCP. Surgical treatment ranges from observation for minor injuries to distal pancreatectomy or pancreaticoduodenectomy for more severe injuries.
- Complications include pancreatic fistula, abscess, and pseudocyst.
This document discusses intestinal anastomosis, which involves creating a connection between intestinal loops or ends. Intestinal anastomosis is commonly performed for elective and emergency cases involving conditions like cancer, infections, or obstructions. The key factors for a successful anastomosis are minimal contamination, good blood supply, and tension-free apposition of the intestinal ends. The document compares hand-sewn and stapled techniques, noting that while staplers are faster, studies have found no difference in outcomes between the two methods. Proper patient factors and surgical technique are more important than the specific method used.
Liver resection indications & methodsDr Harsh Shah
This document provides information on liver resection techniques and methods. It discusses the history and indications for liver resection, preoperative assessment including future liver remnant assessment, portal vein embolization to augment the liver volume, and surgical techniques for vascular control and parenchymal transection including the Pringle maneuver, water jet dissection, CUSA, and radiofrequency devices. The key steps in liver resection are preoperative planning, intraoperative assessment, inflow and outflow control, low central venous pressure, and parenchymal transection using various techniques and instruments.
This document discusses chronic pancreatitis, including its definition, causes, symptoms, diagnostic tests, and surgical treatment options. It notes that chronic pancreatitis is characterized by irreversible morphological changes and permanent loss of pancreatic function. The main indications for surgery are intractable pain and complications. Surgical options include drainage procedures like longitudinal pancreaticojejunostomy or cyst-enterostomies, as well as resections like Whipple procedure or distal pancreatectomy. The goals of surgery are pain relief, control of complications, and improved quality of life. While surgery provides sustained pain relief in over 85% of patients, outcomes may be complicated by associated issues like portal hypertension.
Biliary stricture is an abnormal narrowing of the bile duct. The most common cause is injury during cholecystectomy, accounting for 80% of non-malignant strictures. Bile duct injury can cause inflammation, fibrosis, scarring, and cirrhosis. Surgical treatment depends on when the injury is recognized, with immediate repair during surgery or delayed repair weeks later being options. Roux-en-Y hepaticojejunostomy is a common repair method that involves a mucosa-to-mucosa anastomosis of the bile duct to the jejunum. Factors like multiple prior repairs, proximal strictures, and surgeon inexperience can lead to poor outcomes.
Lt hemicolectomy - Surgical Approach, Complications.Vikas V
This is a detailed Presentation of the surgical procedure - Left Hemicolectomy. It deals with the Surgical anatomy, Indications, Surgical Steps, Complications of the Procedure
This document discusses bile duct injuries during cholecystectomy. It notes that the incidence of bile duct injuries is higher in laparoscopic compared to open cholecystectomy. Anatomical variations contribute to injuries, and dissection errors where the bile duct is mistaken for the cystic duct are common. Intraoperative cholangiography and fluorescence imaging can help identify ducts but may not prevent injuries. Several classification systems for bile duct injuries are described. Management depends on the type and severity of injury, ranging from repair to hepaticojejunostomy. Preventing medicolegal issues requires thorough informed consent, documentation, transparency if complications occur, and promptly involving specialists.
1) Duodenal injuries are uncommon and difficult to diagnose and repair due to the duodenum's retroperitoneal location. The mortality rate for duodenal injuries is high.
2) Diagnosis of duodenal injuries requires a high index of suspicion as there is no single, fully accurate diagnostic test. CT scans, upper GI studies, and exploratory laparotomy can help diagnose duodenal injuries.
3) Treatment depends on the grade of the duodenal injury. Lower grade injuries may be treated with primary closure, tube duodenostomies, or jejunal patching. Higher grade injuries involving complete wall disruption may require duodenal resection or diversion procedures like duodenal divertic
Brief description of hepatectomy with indications, procedure, pre operative, intra operative and post operative management of the patient. Also describes the various techniques and instrument available for liver resection.
1. Surgery for rectal cancer aims to remove the tumor and surrounding tissue while preserving nerve function to maintain bowel and bladder control.
2. The gold standard surgery is total mesorectal excision (TME), which provides a low local recurrence rate below 10% due to complete removal of surrounding tissue.
3. TME requires meticulous technique by an experienced colorectal surgeon to dissect the rectum from the surrounding tissue while preserving nerves.
This document provides an overview of renal trauma, including epidemiology, modes of injury, classification systems, diagnostic evaluation, disease management, and complications. It discusses the American Association for the Surgery of Trauma renal injury grading scale and recommendations for initial patient evaluation, laboratory tests, and imaging modalities like CT, US, and IVP. Treatment options include conservative management with observation, angioembolization for bleeding injuries, and surgical exploration for hemodynamic instability or high-grade injuries. The goal is to control hemorrhage while salvaging the kidney through reconstruction when possible.
This document discusses Mirizzi syndrome, which refers to common hepatic duct obstruction caused by an impacted gallstone. It can occur in 0.1-2.5% of gallstone cases. Large stones can impact in the cystic duct or gallbladder neck, causing mechanical obstruction or inflammation of the common hepatic duct. Patients often present with jaundice, abdominal pain, or cholangitis. Diagnosis is difficult but can be aided by imaging like MRCP or ERCP. Surgical treatment depends on the classification and may involve cholecystectomy with possible bile duct repair or bypass. Complications can include bile duct injury, bleeding, or stricture.
This document discusses the management of common bile duct (CBD) stones. It begins by describing the causes, symptoms, signs, and diagnosis of CBD stones. CBD stones can be primary (formed in the duct) or secondary (passed from the gallbladder). Diagnosis involves blood tests, ultrasound, MRCP, and ERCP. Treatment depends on whether stones are detected before, during, or after cholecystectomy. Options include ERCP sphincterotomy and stone extraction, laparoscopic CBD exploration, open CBD exploration, and surgery like choledochoduodenostomy. For retained stones, additional options are extracting through a T-tube or dissolving chemically. The goal is to remove stones using the least
This document provides an overview of bowel anastomosis, including definitions, types, factors affecting healing, and complications. It defines anastomosis as the surgical connection of separate hollow viscus to form a continuous channel. It describes different types of anastomosis by orientation (side-to-side, end-to-end, end-to-side), technique (hand sewn, stapled), layer (single, double), and anatomy. It discusses factors affecting healing such as patient health, technical execution, blood supply, and tension. Complications include bleeding, leak, intra-abdominal sepsis, and late issues like stricture and obstruction. The conclusion emphasizes knowledge, optimization, technique, postoperative care, and evidence
This document discusses intestinal anastomosis, beginning with definitions of resection and anastomosis. It then covers the history, indications, types based on orientation and technique, principles of safe anastomosis, healing process, techniques including hand sewn and stapling methods, as well as complications and their management. The ideal goals and factors for a safe anastomosis are presented.
This journal club presentation summarizes a randomized controlled trial comparing high tie ligation of the inferior mesenteric artery (HT) to low tie ligation (LT) during laparoscopic rectal cancer surgery. The study found no significant differences in anastomotic leakage rates, number of lymph nodes retrieved, or 5-year survival rates between the two techniques. However, the incidence of postoperative bowel obstruction was significantly higher with HT. The presentation concludes that LT and HT have equal oncological outcomes, but LT may better preserve gastrointestinal function.
This document outlines a study examining the role of subcutaneous negative suction drainage in reducing surgical site infections and its relation to subcutaneous fat thickness in exploratory laparotomies. The study will involve 80 patients undergoing exploratory laparotomy split into two groups - one with a subcutaneous negative suction drain placed and one without. Subcutaneous fat thickness will be measured and patients will be monitored postoperatively for 30 days to check for any surgical site infections according to CDC criteria. The results will be analyzed to determine if negative suction drainage and subcutaneous fat thickness impact the rate of surgical site infections.
This document discusses principles of bowel anastomosis, including types of anastomoses, indications for anastomoses, pre-operative preparation, intra-operative techniques, post-operative care, complications, and controversies. It covers topics such as hand-sewn versus stapled anastomoses, single versus double layer closure, inversion versus eversion of tissue, and use of abdominal drains and NG tubes. The goal of bowel anastomosis is to successfully rejoin bowel segments through meticulous surgical technique and postoperative management in order to restore intestinal continuity.
Laparoscopic colectomy was slow to gain acceptance compared to laparoscopic cholecystectomy due to concerns over its steep learning curve, costs, operating time, and whether it could achieve the same oncological outcomes as open surgery. While short-term benefits like less blood loss, faster recovery, and lower morbidity have been shown, long-term oncological data is still lacking and conversion rates are high, particularly for rectal resections. Randomized trials show no differences in short-term outcomes or quality of life, but higher positive circumferential resection margin rates for laparoscopic anterior resection.
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
The document discusses pancreatic trauma, including relevant anatomy, epidemiology, etiology, presentation, workup, staging, and treatment. Some key points:
- The pancreas is protected by surrounding structures but can be injured by penetrating trauma or direct blunt force.
- Injury is staged based on severity from grade I (minor) to grade V (massive disruption). Treatment depends on grade and location of injury.
- Workup may include labs, CT, MRCP, ERCP. Surgical treatment ranges from observation for minor injuries to distal pancreatectomy or pancreaticoduodenectomy for more severe injuries.
- Complications include pancreatic fistula, abscess, and pseudocyst.
This document discusses intestinal anastomosis, which involves creating a connection between intestinal loops or ends. Intestinal anastomosis is commonly performed for elective and emergency cases involving conditions like cancer, infections, or obstructions. The key factors for a successful anastomosis are minimal contamination, good blood supply, and tension-free apposition of the intestinal ends. The document compares hand-sewn and stapled techniques, noting that while staplers are faster, studies have found no difference in outcomes between the two methods. Proper patient factors and surgical technique are more important than the specific method used.
Liver resection indications & methodsDr Harsh Shah
This document provides information on liver resection techniques and methods. It discusses the history and indications for liver resection, preoperative assessment including future liver remnant assessment, portal vein embolization to augment the liver volume, and surgical techniques for vascular control and parenchymal transection including the Pringle maneuver, water jet dissection, CUSA, and radiofrequency devices. The key steps in liver resection are preoperative planning, intraoperative assessment, inflow and outflow control, low central venous pressure, and parenchymal transection using various techniques and instruments.
This document discusses chronic pancreatitis, including its definition, causes, symptoms, diagnostic tests, and surgical treatment options. It notes that chronic pancreatitis is characterized by irreversible morphological changes and permanent loss of pancreatic function. The main indications for surgery are intractable pain and complications. Surgical options include drainage procedures like longitudinal pancreaticojejunostomy or cyst-enterostomies, as well as resections like Whipple procedure or distal pancreatectomy. The goals of surgery are pain relief, control of complications, and improved quality of life. While surgery provides sustained pain relief in over 85% of patients, outcomes may be complicated by associated issues like portal hypertension.
Biliary stricture is an abnormal narrowing of the bile duct. The most common cause is injury during cholecystectomy, accounting for 80% of non-malignant strictures. Bile duct injury can cause inflammation, fibrosis, scarring, and cirrhosis. Surgical treatment depends on when the injury is recognized, with immediate repair during surgery or delayed repair weeks later being options. Roux-en-Y hepaticojejunostomy is a common repair method that involves a mucosa-to-mucosa anastomosis of the bile duct to the jejunum. Factors like multiple prior repairs, proximal strictures, and surgeon inexperience can lead to poor outcomes.
Lt hemicolectomy - Surgical Approach, Complications.Vikas V
This is a detailed Presentation of the surgical procedure - Left Hemicolectomy. It deals with the Surgical anatomy, Indications, Surgical Steps, Complications of the Procedure
This document discusses bile duct injuries during cholecystectomy. It notes that the incidence of bile duct injuries is higher in laparoscopic compared to open cholecystectomy. Anatomical variations contribute to injuries, and dissection errors where the bile duct is mistaken for the cystic duct are common. Intraoperative cholangiography and fluorescence imaging can help identify ducts but may not prevent injuries. Several classification systems for bile duct injuries are described. Management depends on the type and severity of injury, ranging from repair to hepaticojejunostomy. Preventing medicolegal issues requires thorough informed consent, documentation, transparency if complications occur, and promptly involving specialists.
1) Duodenal injuries are uncommon and difficult to diagnose and repair due to the duodenum's retroperitoneal location. The mortality rate for duodenal injuries is high.
2) Diagnosis of duodenal injuries requires a high index of suspicion as there is no single, fully accurate diagnostic test. CT scans, upper GI studies, and exploratory laparotomy can help diagnose duodenal injuries.
3) Treatment depends on the grade of the duodenal injury. Lower grade injuries may be treated with primary closure, tube duodenostomies, or jejunal patching. Higher grade injuries involving complete wall disruption may require duodenal resection or diversion procedures like duodenal divertic
Brief description of hepatectomy with indications, procedure, pre operative, intra operative and post operative management of the patient. Also describes the various techniques and instrument available for liver resection.
1. Surgery for rectal cancer aims to remove the tumor and surrounding tissue while preserving nerve function to maintain bowel and bladder control.
2. The gold standard surgery is total mesorectal excision (TME), which provides a low local recurrence rate below 10% due to complete removal of surrounding tissue.
3. TME requires meticulous technique by an experienced colorectal surgeon to dissect the rectum from the surrounding tissue while preserving nerves.
This document provides an overview of renal trauma, including epidemiology, modes of injury, classification systems, diagnostic evaluation, disease management, and complications. It discusses the American Association for the Surgery of Trauma renal injury grading scale and recommendations for initial patient evaluation, laboratory tests, and imaging modalities like CT, US, and IVP. Treatment options include conservative management with observation, angioembolization for bleeding injuries, and surgical exploration for hemodynamic instability or high-grade injuries. The goal is to control hemorrhage while salvaging the kidney through reconstruction when possible.
This document discusses Mirizzi syndrome, which refers to common hepatic duct obstruction caused by an impacted gallstone. It can occur in 0.1-2.5% of gallstone cases. Large stones can impact in the cystic duct or gallbladder neck, causing mechanical obstruction or inflammation of the common hepatic duct. Patients often present with jaundice, abdominal pain, or cholangitis. Diagnosis is difficult but can be aided by imaging like MRCP or ERCP. Surgical treatment depends on the classification and may involve cholecystectomy with possible bile duct repair or bypass. Complications can include bile duct injury, bleeding, or stricture.
This document discusses the management of common bile duct (CBD) stones. It begins by describing the causes, symptoms, signs, and diagnosis of CBD stones. CBD stones can be primary (formed in the duct) or secondary (passed from the gallbladder). Diagnosis involves blood tests, ultrasound, MRCP, and ERCP. Treatment depends on whether stones are detected before, during, or after cholecystectomy. Options include ERCP sphincterotomy and stone extraction, laparoscopic CBD exploration, open CBD exploration, and surgery like choledochoduodenostomy. For retained stones, additional options are extracting through a T-tube or dissolving chemically. The goal is to remove stones using the least
This document provides an overview of bowel anastomosis, including definitions, types, factors affecting healing, and complications. It defines anastomosis as the surgical connection of separate hollow viscus to form a continuous channel. It describes different types of anastomosis by orientation (side-to-side, end-to-end, end-to-side), technique (hand sewn, stapled), layer (single, double), and anatomy. It discusses factors affecting healing such as patient health, technical execution, blood supply, and tension. Complications include bleeding, leak, intra-abdominal sepsis, and late issues like stricture and obstruction. The conclusion emphasizes knowledge, optimization, technique, postoperative care, and evidence
This document discusses intestinal anastomosis, beginning with definitions of resection and anastomosis. It then covers the history, indications, types based on orientation and technique, principles of safe anastomosis, healing process, techniques including hand sewn and stapling methods, as well as complications and their management. The ideal goals and factors for a safe anastomosis are presented.
This journal club presentation summarizes a randomized controlled trial comparing high tie ligation of the inferior mesenteric artery (HT) to low tie ligation (LT) during laparoscopic rectal cancer surgery. The study found no significant differences in anastomotic leakage rates, number of lymph nodes retrieved, or 5-year survival rates between the two techniques. However, the incidence of postoperative bowel obstruction was significantly higher with HT. The presentation concludes that LT and HT have equal oncological outcomes, but LT may better preserve gastrointestinal function.
This document outlines a study examining the role of subcutaneous negative suction drainage in reducing surgical site infections and its relation to subcutaneous fat thickness in exploratory laparotomies. The study will involve 80 patients undergoing exploratory laparotomy split into two groups - one with a subcutaneous negative suction drain placed and one without. Subcutaneous fat thickness will be measured and patients will be monitored postoperatively for 30 days to check for any surgical site infections according to CDC criteria. The results will be analyzed to determine if negative suction drainage and subcutaneous fat thickness impact the rate of surgical site infections.
This document discusses catheterization, including appropriate indications, insertion techniques, complications, and prevention of catheter-associated urinary tract infections (CAUTIs). The key points are:
1) Catheters should only be used for approved indications and removed as soon as possible to prevent CAUTIs.
2) CAUTIs are the most common healthcare-associated infection and have significant costs and patient impacts.
3) Biofilm formation on catheters is a major mechanism of CAUTI development. Strict aseptic insertion and maintenance techniques can reduce risk.
This proposal outlines a study on the experience of laparoscopic cholecystectomy (gallbladder removal surgery) at St. Paul's Hospital Millennium Medical College in Addis Ababa, Ethiopia. The study will retrospectively review medical records from 2015-2020 to evaluate postoperative complications, conversion rates from laparoscopic to open surgery, and factors associated with complications. The objectives are to assess complication patterns, determine factors linked to complications, and calculate conversion rates and reasons. The proposal describes the background, literature review, methods, work plan, and budget for the study.
This randomized controlled trial compared duct-to-mucosa pancreaticojejunostomy (PJ) to invagination PJ for patients undergoing pancreatoduodenectomy (PD). The study found that invagination PJ resulted in significantly fewer postoperative pancreatic fistulas (POPFs) compared to duct-to-mucosa PJ for patients with soft pancreas tissue. Additionally, invagination PJ was associated with shorter drain duration, shorter hospital stays, and lower costs compared to duct-to-mucosa PJ, especially for patients who developed clinically significant POPFs. Therefore, the authors concluded that invagination PJ may be superior to duct-to-mucosa
This study analyzed data from patients in the Netherlands who underwent preoperative endoscopic biliary drainage (EBD) followed by pancreatoduodenectomy for pancreatic or periampullary cancers between 2017-2018. The study found that over 50% of patients received plastic stents for EBD despite guidelines recommending self-expanding metal stents (SEMS). Patients who received SEMS had fewer episodes of cholangitis but similar overall complication rates. Additionally, SEMS were associated with shorter time to surgery, less postoperative pancreatic fistula, and shorter hospital stay. The results suggest greater implementation of SEMS is needed in accordance with guidelines.
The document discusses the management of bladder cancer, including treatment options for non-muscle invasive bladder cancer like transurethral resection of bladder tumor and intravesical immunotherapy or chemotherapy, as well as options for muscle invasive bladder cancer such as radical cystectomy or bladder preservation protocols using radiation and chemotherapy. It provides details on staging, risk stratification, surgical procedures, radiation therapy techniques, and chemotherapy regimens used in treating non-muscle invasive and muscle invasive bladder cancer.
Past present future - laparoscopic colorectal surgerypiyushpatwa
Laparoscopic colorectal surgery has become widely adopted, with up to 60% of elective colectomies performed laparoscopically. While technically demanding, laparoscopic surgery has been shown to be associated with lesser pain, earlier recovery, and shorter hospital stays compared to open surgery. For colorectal cancer, large randomized controlled trials found no differences in oncologic outcomes between laparoscopic and open surgery. New technologies like single-incision laparoscopy, robotics, and natural orifice translumenal endoscopic surgery continue to expand the applicability of minimally invasive approaches for complex colorectal procedures.
This document summarizes a study assessing pre-operative outcomes and their correlation with intra-operative findings for laparoscopic cholecystectomies. It introduces cholelithiasis and laparoscopic cholecystectomy as the gold standard treatment. The study aims to evaluate factors that make laparoscopic cholecystectomy difficult. It employs a pre-operative scoring system based on patient history, exam, and ultrasound findings, and compares it to intra-operative scoring of difficulty. The results show a 91.5% correlation between pre-operative and intra-operative scores. Most pre-operative risk factors were significantly correlated with difficulty. The scoring system was found to reliably predict difficulty of laparoscopic cholecyst
A retrospective study of outcome of intraoperative gallbladder perforation du...Kundan Singh
Intraoperative gallbladder perforation occurs in around 5% of laparoscopic cholecystectomy cases. This retrospective study analyzed 310 patients who underwent laparoscopic cholecystectomy, of which 16 patients (5.17%) experienced gallbladder perforation. Perforation most commonly occurred during dissection from the liver bed. Patients with perforation had a longer average surgery time of 65 minutes compared to 50 minutes for non-perforated cases. They also had a longer average hospital stay of 56 hours compared to 22 hours. However, intraoperative gallbladder perforation did not result in any other adverse complications and did not require conversion to open surgery in any cases.
This document provides details regarding a thesis presentation on comparing outcomes of laparoscopic appendicectomy using single versus double endoloop knots at the base of the appendix. The study aims to evaluate operation duration, post-operative complications, and hospital stay for the two techniques. A literature review found no consensus on whether single or double knots are superior. The study plans to enroll 90 patients undergoing laparoscopic appendicectomy and randomly assign them to single or double knot groups. Patient details, operative findings, and outcomes will be collected and statistically analyzed to compare the techniques.
Systematic lymphadenectomy did not improve overall survival compared to no lymphadenectomy in patients with optimally resected, lymph node-negative advanced ovarian cancer. Both groups had a median overall survival of approximately 67 months. While lymphadenectomy prolonged progression-free survival slightly from 25.5 to 25.5 months, this difference was not statistically significant. Lymphadenectomy removed significantly more lymph nodes than no lymphadenectomy, took an additional hour on average, and resulted in more blood loss, but quality of life outcomes were similar between the groups.
- Anastomotic leakage is a dangerous surgical complication that increases mortality and morbidity. It occurs when there is a defect in the intestinal wall at the site of bowel reconnection that allows internal and external bowel contents to mix.
- Risk factors include patient characteristics like age and comorbidities, neoadjuvant treatments, surgical factors like emergency surgery or surgeon experience, and technical aspects of the anastomosis.
- Preventive measures include temporary stomas, but leakage risk can't be eliminated. Early detection through close postoperative monitoring and imaging is important, as early treatment improves outcomes. Treatment depends on the severity but may include drainage, resection and reanastomosis or stoma formation.
Colon cancer is one of the most common reasons for colonic obstruction. This presentation focusing on benign as well as malignant diseases with its management.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Outcome of abscess treatment in Crohn's diseasedrnkhokhar
This document discusses the outcomes of surgical and medical treatment of abscesses in Crohn's disease. It notes that 10-30% of Crohn's patients will develop spontaneous abscesses in their lifetime. Percutaneous abscess drainage (PAD) is the first choice of treatment when the patient is clinically stable, as it allows for delayed surgery and improved nutrition with antibiotics. Success rates for PAD are 50-95%, but multiple or multilocular abscesses and associated fistulae often require surgery. The timing of surgery after PAD is controversial, but many patients wait 6-8 weeks to allow for nutritional improvement first. A multidisciplinary team is needed to manage these complex cases.
Journal club-Determination of surgical priorities in appendicitisYouttam Laudari
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2. Introduction
• Most common cause of death after colorectal surgery
• Most feared complication
• Reported incidence - 1% to 30%
Isbister WH. Anastomotic leak in colorectal surgery: A single surgeon's experience. ANZ J Surg 2001
Matthiessen P et al. Risk factors for anastomotic leakage after anterior resection of the rectum. Colorectal Dis 2004
Tsai YY, Chen WT. Management of anastomotic leakage after rectal surgery: a review article. J Gastrointest Oncol 2019
3. Consequences- Early
• Increased perioperative morbidity and mortality
• Prolonged length of stay
• Higher readmission rates
• Potential need for further operative interventions/ stoma
Turrentine FE et al. Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks. J Am Coll Surg 2015
Tsai YY, Chen WT. Management of anastomotic leakage after rectal surgery: a review article. J Gastrointest Oncol 2019
4. Late consequences
• Higher local recurrence rate (OR- 2.05)
• Delay in starting chemotherapy
• Worsen survival (5YOSR- 35% VS 53%)
• Decreased quality of life
McArdle CS, McMillan DC, Hole DJ. Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer. Br
J Surg 2005
Lu ZR et al. Anastomotic leaks after restorative resections for rectal cancer compromise cancer outcomes and survival. Dis Colon Rectum 2016
Mirnezami A et al. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-
analysis. Ann Surg 2011.
5. What constitutes an anastomotic leak?
• Extravasation of contrast
• Perirectal abscess
• Faecal output from drain
• Sepsis – need for laparotomy
• Enterocutaneous fistula
6. Definition
International Study Group of Rectal Cancer (2010)
• Defect at anastomotic site leading to communication between intraluminal
and extraluminal compartments
• Also perirectal abscess
Rahbari, N.N. et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: A proposal by the
International Study Group of Rectal Cancer. Surgery 2010
7. Grading of anastomotic leak
• Grade A
-those managed without an invasive intervention
• Grade B
- those managed with invasive intervention other than repeat surgery
(percutaneous drainage)
• Grade C
- those requiring repeat surgical intervention and often diversion
- Life threatening
8. Risk Factors
• Preoperative and intraoperative
• Modifiable and non-modifiable
• Patient factors, technical factor, disease factor, surgeon factor
Midura EF et al. Risk factors and consequences of anastomotic leak after colectomy: a national analysis. Dis Colon Rectum 2015
Trencheva K, Morrissey KP, Wells M, et al. Identifying important predictors for anastomotic leak after colon and rectal resection: prospective
study on 616 patients. Ann Surg 2013
Sparreboom CL et al. Different Risk Factors for Early and Late Colorectal Anastomotic Leakage in a Nationwide Audit. Dis Colon Rectum 2018
9. McDermott, F. et al. Prevention, Diagnosis and Management of Colorectal Anastomotic Leakage; Issues in Professional Practice; Association of
Surgeons of Great Britain and Ireland, Lincoln’s Inn Fields: London, UK, 2016
10. McDermott, F. et al. Prevention, Diagnosis and Management of Colorectal Anastomotic Leakage; Issues in Professional Practice; Association of
Surgeons of Great Britain and Ireland, Lincoln’s Inn Fields: London, UK, 2016
11. Doubtful factors Factors definitely helpul
Type of anastomosis Proper technique (no tension, vascularity)
Reinforcements Proximal diversion
Prophylactic drainage Surgery in high volume centres
Open/laparoscopic MBP with antibiotics
Goal directed fluid therapy
McDermott, F. et al. Prevention, Diagnosis and Management of Colorectal Anastomotic Leakage; Issues in Professional Practice;
Association of Surgeons of Great Britain and Ireland, Lincoln’s Inn Fields: London, UK, 2016
12. • Role of microbiota
• Macrophages
• MMPs
• NSAIDS
• Simultaneous liver resection- no increased risk (iCral study group
2021)
van Praagh JB et al. Intestinal microbiota and anastomotic leakage of stapled colorectal anastomoses: a pilot study. Surg Endosc 2016
Gaines S, Shao C, Hyman N, et al. Gut microbiome influences on anastomotic leak and recurrence rates following colorectal cancer surgery. Br J
Surg 2018
Shogan BD, Belogortseva N, Luong PM, et al. Collagen degradation and MMP9 activation by Enterococcus faecalis contribute to intestinal
anastomotic leak. Sci Transl Med 2015
14. Laser Fluorescence Angiography
Indocyanine green dye (ICG-FA) - to assess tissue perfusion
• Indocyanine green intravenously near-infrared imaging system
• Subjective assessment
• Variable evidence
• Good screening tool
• PILLAR III trial- multicentre, no difference in leak rates (9 vs 9.8%)
Intraoperative ICG fluorescence angiography to prevent anastomotic leak after LAR : a meta- analysis. Shen et al.ANZ J Surg 2020
Jafari et al. Perfusion assessment in left sided/LAR (PILLAR III): A randomized, multicentre study assessing perfusion outcomes with PINPOINT near
infra-red flouroscence imaging. Dis Col Rectum 2021
15.
16. Air leak test
• Filling pelvis with warm saline - distention of anastomosis with air
• Objective assessment
• Not effective
Wu, Z. et al. Is the intraoperative air leak test effective in the prevention of colorectal anastomotic leakage? A systematic review and
meta-analysis. Int. J. Color. Dis. 2016
17.
18. • Dye Test
- Easier detection and localization of leaks than air leak testing
20. Prophylactic drain
• Extensively debated
• Pelvic drains after low anterior resection - greater utility
• Do not reduce postoperative anastomotic complications
• Many leaks do not present through surgical drain
• Removed early
Tsujinaka S, Konishi F. Drain vs No Drain After Colorectal Surgery. Indian J Surg Oncol 2011
21. Diverting Stoma
Benefits of Diversion Complications of Diversion Decision to Divert
Reduced risk of clinically
symptomatic leaks
Impaired quality of life High risk of leak versus stomal
complications
Reduced need for urgent
reoperation
Stoma-related complications Individualised
Reduced severe septic
complications
Increased readmission rates
Shiomi, A. et al. Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer:A propensity score
matching analysis. J. Am. Coll. Surg. 2015
Lightner, A.L.; Pemberton, J.H. The role of temporary fecal diversion. Clin. Colon Rectal Surg. 2017
22. Not to anastomose
• Haemodynamic instability
• Peritonitis
• Ischaemia
• Disseminated malignancy
• Immunosuppressed
• When in doubt
23. Mechanical bowel preparation and oral antibiotics
• Growing evidence - significantly decrease incidence of infectious complications
including anastomotic leak (2.8 vs 5.7%)
• Not antibiotics alone
• ? Increased Clostridium difficile infections
Scarborough JE et al. Combined mechanical and oral antibiotic bowel preparation reduces incisional SSI and anastomotic leak rates after elective colorectal resection:
an analysis of colectomy- targeted ACS-NSQIP. Ann Surg. 2015
Argyrios et al. Current evidence of combination of oral antibiotics and mechanical bowel preparation in elective colorectal surgery and their impact on anastomotic
leak. Surgical Innovation 2020
ASCRS clinical practice guidelines for use of bowel preparation in elective colon and rectal surgery. Dis Colon Rectum 2019
24. Transanal decompression devices
• Large-diameter soft rubber tubes placed above anastomosis for 5 to 7
days - decrease intraluminal pressure
• No definite benefit seen in RCTs
25. Diagnosis
• Early diagnosis –difficult
• Classic presentations
• Positive predictive value of abnormal vital signs - 4% to 11%
• Drains - ? early clues
• Small, contained leaks - present late, D/D- postoperative abscesses
Erb L, Hyman NH, Osler T. Abnormal vital signs are common after bowel resection and do not predict anastomotic leak. J Am Coll Surg
2014
26. • Majority - diagnosed between 7th - 12th postoperative days
• Upto 42% diagnosed after discharge
• Upto 12% occur beyond postoperative day 30
Hyman N et al. Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg 2007
27. Early and late anastomotic leaks
• Early - Within postoperative day 6, due to technical failure of anastomosis
• Late - After postoperative day 6, due to frailty of patients and tissues, poor
healing process
• Different pathophysiology
Sparreboom CL et al. Different Risk Factors for Early and Late Colorectal Anastomotic Leakage in a Nationwide Audit. Dis Colon Rectum 2018
28. Biochemical markers
CRP-
• Most extensively studied
• Negative predictive value - 89–97% for AL
• Postoperative days 3 and 5
• Cutoff levels - variable (range- 100 to 172 mg/L)
Singh PP et al. Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after
colorectal surgery. Br J Surg 2014
29. Procalcitonin (PCT) –
• More specific marker of bacterial infection than CRP
• Low PCT levels on POD 3 and 5 - high negative predictive values, reliably excludes
• Serial values - more potential
• Decrease in PCT levels from admission through hospital days 3 to 5 - predict survival in patients
with sepsis and septic shock
Hyponatraemia (water retention)
Cousin F et al. Diagnostic Accuracy of Procalcitonin and C-reactive Protein for the Early Diagnosis of Intra-abdominal Infection After Elective Colorectal
Surgery: A Metaanalysis. Ann Surg 2016
30. Imaging
CT-
• Most employed test
• Specificity >84% , sensitivity - 68–71%
• Contrast extravasation -most reliable sign (present in 15% - 17%)
• Perianastomotic air/fluid levels
• Fluid and inflammatory stranding- D/D early postoperative changes
• Use of rectal contrast
Kornmann VN et al. Systematic review on the value of CT scanning in the diagnosis of anastomotic leakage after colorectal surgery. Int J
Colorectal Dis 2013
32. Management
Goals Decisive factors
Early recognition Site of leak
Resuscitation Patient stability
Prevention of contamination/ source control Interval
Free/ contained leak
Degree of dehiscence
33. Available options
• Medical management
• Drainage- percutaneous, transanal
• Endoscopic- stents, clips, vaccum assisted closure
• Operative management
34. Medical management
Antibiotics
• Broad-spectrum
• Combination therapy (≥2 different classes of antibiotics)
• Antifungal agents – Indicated in severe sepsis, septic shock, postoperative
intraabdominal infection
• Abscesses <3 cm- only antibiotics if patient stable
• Abscesses >3 cm- percutaneous drains
Montravers P, Dupont H, Leone M, et al. Guidelines for management of intra-abdominal infections. Anaesth Crit Care Pain Med 2015
35. Nonoperative interventions
Percutaneous drainage – indicated if
-Haemodynamically stable
-No signs of diffuse peritonitis
Result in chronic sinus tract - requiring permanent stoma
Transanal drainage
- Malecot catheter
-Follow-up radiographic surveillance by instillation of contrast through drain
Khurrum Baig M et al. Percutaneous postoperative intra-abdominal abscess drainage after elective colorectal surgery. Tech Coloproctol 2002
Thomas MS, Margolin DA. Management of Colorectal Anastomotic Leak. Clin Colon Rectal Surg 2016
Sirois-Giguère E et al. Transanal drainage to treat anastomotic leaks after low anterior resection for rectal cancer: a valuable option. Dis Colon
Rectum 2013
36. Endoscopic options- Stent
• For end-to-end anastomosis
• Distal end of stent >5 cm above anal verge
• Stent migration - major issue
• Current covered stents - not large enough diameter to minimize stent
migration
• Use of endoclips to secure - not effective
Lamazza A et al. Endoscopic placement of self-expanding stents in patients with symptomatic anastomotic leakage after colorectal
resection for cancer: long-term results. Endoscopy 2015
Lamazza A et al. Treatment of anastomotic stenosis and leakage after colorectal resection for cancer with self-expandable metal
stents. Am J Surg 2014
37. Endoscopic options
• Endoscopic transanal vacuum-assisted rectal drainage (E-vac)
Impressive closure rates (85.7%) and low permanent stoma rates (18.9%)
In stable patients, without peritonitis, early cases
Time and resource intensive
• Endoscopic clip application- limited data, for small leaks
Weidenhagen R et al.Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg Endosc 2008
Arezzo A, Verra M, Passera R, et al. Long-term efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. Dig Liver Dis 2015
Shalaby et al.Systematic review of endoluminal vaccum assisted therapy as salvage treatment for rectal anastomotic leakage. BJS 2018
39. Operative management
• Challenging- gross contamination, severe inflammation
• Need- sepsis, peritonitis, failure of non-operative management
• Goal- source control with washout and faecal diversion
• Faecal diversion by-
Takedown of anastomosis and creating end colostomy
Proximal diversion loop ileostomy
Repair or revision of leaking anastomosis with proximal diversion
40. Anastomotic salvage versus takedown
• Takedown of anastomosis with creation of an endostomy - most
frequent approach
• Reduced quality of life - ostomy-associated complications
• Anastomotic salvage with loop diversion - statistically fewer
complications than anastomotic takedown
• ASCRS advocates- anastomosis be taken down if more than a third of
its circumference has broken down
41. • Traditionally- Exteriorization, resection with creation of end stoma
and Hartmann pouch or mucus fistula
• Many end stomas may never be reversed
• Resection of anastomosis- not always feasible, may be deleterious
• Drainage and proximal diversion- more desirable
42. Minimally invasive techniques
• ASCRS recommends- laparoscopic management be considered if
surgeon has sufficient laparoscopic skills and experience
• Active area of study, limited evidence
• Feasible, safe (early leak)
• Possibly reduce postoperative morbidity
Joh YG, Kim SH, Hahn KY, et al. Anastomotic leakage after laparoscopic protectomy can be managed by a minimally invasive approach. Dis Colon
Rectum 2009
Chen WT, Bansal S, Ke TW, et al. Combined repeat laparoscopy and transanal endolumenal repair (hybrid approach) in the early management of
postoperative colorectal anastomotic leaks: technique and outcomes. Surg Endosc 2018
Tsai YY, Chen WT. Management of anastomotic leakage after rectal surgery: a review article. J Gastrointest Oncol 2019
44. Emerging techniques
• Fibrin glue
Inconclusive evidence
Effectiveness - largely dependent on site and size
• Reinforcing staple line
Bovine pericardium strips
Safe
? decrease AL
Cliord et al. Early anastomotic complications in colorectal surgery: A systematic review of techniques for endoscopic salvage. Surg.
Endosc. 2019
Senagore A et al. Bioabsorbable staple line reinforcement in restorative proctectomy and anterior resection. Dis. Colon Rectum 2014
45. • Buttresses- provide additional support and apposition
• Polyphosphate Therapy (Ppi-6) –
To suppress bacterium that cause leak (collagenase production) such as Serratia
marcescens and Pseudomonas aeruginosa
Non-invasive method
• Marine-Inspired Immunogenic Hydrogel Adhesive
Hydrogel adheres to wet tissue surfaces, improving bursting pressure
Mery, C.M. et al. Profiling surgical staplers: Effect of staple height, buttress, and overlap on staple line failure. Surg. Obes. Relat. Dis. 2008
Hyoju, S.K. et al. Oral Polyphosphate Suppresses Bacterial Collagenase Production and Prevents Anastomotic Leak. Ann. Surg. 2018
Huang, J. et al. Marine-inspired molecular mimicry generates a drug-free, but immunogenic hydrogel adhesive protecting surgical anastomosis.
Bioact. Mater.2021
46. Need of future research
• Comparing anastomotic healing to cutaneous healing
• Using surrogate markers- bursting pressure, measuring
hydroxyproline
• Ignoring role of microbiota- potential driver of leak
• Role of macrophages- active participants in healing
47. Take home message
• Serious complication
• Multitude of factors
• Early diagnosis and individualised management
• Future research