This presentation contains details on normal anatomy on female pelvis and fetal head, process of normal labour, abnormal labour, induction of labour and malpresentations.
The document discusses various uterus sparing techniques for prolapse surgery in young women who desire to preserve fertility and menstrual function. It describes Shirodkar's sling operation, which has been shown to have high rates of normal vaginal delivery and low recurrence rates of prolapse. Laparoscopic sacrohysteropexy is indicated for young women with prolapse as it has better efficacy than vaginal sacrospinous fixation and results in fewer mesh complications compared to sacral colpopexy with hysterectomy. While sacral colpopexy has high success rates, it also carries risks of serious mesh-related complications requiring reoperation years later.
A mother gave birth vaginally to a baby girl. During labor and delivery, she experienced preeclampsia and gestational hypertension. She received magnesium to lower her blood pressure. An epidural and oxytocin were administered and she underwent shoulder dystocia maneuvers and an episiotomy. The birth was successful but the baby had a bruised posterior skull. To address impaired parent-infant bonding and the baby's risk of nutritional imbalance, the baby was breastfed and given skin-to-skin contact with the mother. Evaluations found the newborn successfully breastfed and bonded with the mother, and had good APGAR scores and nutritional prognosis.
This pilot study examines myomectomy as an alternative to hysterectomy for women who have completed childbearing. The study found that myomectomy is a feasible option that resulted in significant relief of symptoms for most patients, with average blood loss comparable to hysterectomy when using appropriate techniques. The conclusions suggest that a randomized study directly comparing hysterectomy to myomectomy in this patient population is warranted to further evaluate myomectomy as a conservative treatment alternative to hysterectomy.
The document discusses various methods for managing pain relief during labor and delivery. It describes both non-pharmacological methods like hydrotherapy, TENS, acupuncture, massage and pharmacological methods like systemic opioids, pethidine, fentanyl, butorphanol and tramadol. It also discusses various nerve blocks for pain relief like pudendal, paracervical and neuraxial blocks like spinal and epidural analgesia. The goal is to provide effective pain management options to help make the delivery experience as comfortable as possible for the mother.
This document discusses tuboplasty, a procedure to recanalize fallopian tubes after sterilization. It presents a study evaluating the success of tuboplasty performed through a mini-laparotomy incision. 38 patients underwent the procedure between 2010-2014. On follow up, 30 patients (79%) showed bilateral spillage on hydrotubation, and 8 (21%) showed unilateral spillage. On HSG after 3 months, 28 patients (78%) showed bilateral tubal patency and 8 (22%) showed unilateral patency. The mini-laparotomy approach offers advantages over conventional and laparoscopic tuboplasty such as less tissue injury, fewer adhesions, and faster recovery.
This document provides information about the WHO partograph, including:
- The partograph is a graphical record used to monitor labor progress and the condition of the mother and fetus. It was developed by the WHO.
- The history of the partograph is described, from Friedman's original version in 1954 to later refinements by Philpott and Castle in 1972 who introduced alert and action lines.
- The components of the modern partograph are outlined, including sections to monitor fetal condition, labor progress, and maternal condition. Key indicators like cervical dilation, fetal position, and uterine contractions are plotted over time.
- Guidelines for interpreting labor progress using the partograph and determining appropriate actions are provided, such as transferring or
This presentation contains details on normal anatomy on female pelvis and fetal head, process of normal labour, abnormal labour, induction of labour and malpresentations.
The document discusses various uterus sparing techniques for prolapse surgery in young women who desire to preserve fertility and menstrual function. It describes Shirodkar's sling operation, which has been shown to have high rates of normal vaginal delivery and low recurrence rates of prolapse. Laparoscopic sacrohysteropexy is indicated for young women with prolapse as it has better efficacy than vaginal sacrospinous fixation and results in fewer mesh complications compared to sacral colpopexy with hysterectomy. While sacral colpopexy has high success rates, it also carries risks of serious mesh-related complications requiring reoperation years later.
A mother gave birth vaginally to a baby girl. During labor and delivery, she experienced preeclampsia and gestational hypertension. She received magnesium to lower her blood pressure. An epidural and oxytocin were administered and she underwent shoulder dystocia maneuvers and an episiotomy. The birth was successful but the baby had a bruised posterior skull. To address impaired parent-infant bonding and the baby's risk of nutritional imbalance, the baby was breastfed and given skin-to-skin contact with the mother. Evaluations found the newborn successfully breastfed and bonded with the mother, and had good APGAR scores and nutritional prognosis.
This pilot study examines myomectomy as an alternative to hysterectomy for women who have completed childbearing. The study found that myomectomy is a feasible option that resulted in significant relief of symptoms for most patients, with average blood loss comparable to hysterectomy when using appropriate techniques. The conclusions suggest that a randomized study directly comparing hysterectomy to myomectomy in this patient population is warranted to further evaluate myomectomy as a conservative treatment alternative to hysterectomy.
The document discusses various methods for managing pain relief during labor and delivery. It describes both non-pharmacological methods like hydrotherapy, TENS, acupuncture, massage and pharmacological methods like systemic opioids, pethidine, fentanyl, butorphanol and tramadol. It also discusses various nerve blocks for pain relief like pudendal, paracervical and neuraxial blocks like spinal and epidural analgesia. The goal is to provide effective pain management options to help make the delivery experience as comfortable as possible for the mother.
This document discusses tuboplasty, a procedure to recanalize fallopian tubes after sterilization. It presents a study evaluating the success of tuboplasty performed through a mini-laparotomy incision. 38 patients underwent the procedure between 2010-2014. On follow up, 30 patients (79%) showed bilateral spillage on hydrotubation, and 8 (21%) showed unilateral spillage. On HSG after 3 months, 28 patients (78%) showed bilateral tubal patency and 8 (22%) showed unilateral patency. The mini-laparotomy approach offers advantages over conventional and laparoscopic tuboplasty such as less tissue injury, fewer adhesions, and faster recovery.
This document provides information about the WHO partograph, including:
- The partograph is a graphical record used to monitor labor progress and the condition of the mother and fetus. It was developed by the WHO.
- The history of the partograph is described, from Friedman's original version in 1954 to later refinements by Philpott and Castle in 1972 who introduced alert and action lines.
- The components of the modern partograph are outlined, including sections to monitor fetal condition, labor progress, and maternal condition. Key indicators like cervical dilation, fetal position, and uterine contractions are plotted over time.
- Guidelines for interpreting labor progress using the partograph and determining appropriate actions are provided, such as transferring or
O documento discute os tipos de panelas mais saudáveis para cozinhar, destacando os materiais de vidro, silicone e aço inoxidável como as melhores opções. A cerâmica e o ferro também são boas opções se tomados os devidos cuidados. O alumínio, cobre, barro e teflon devem ser usados com moderação devido aos riscos à saúde que podem apresentar.
This document discusses cardiotocography (CTG), which monitors fetal heart rate and uterine contractions during pregnancy. CTG is performed in the third trimester using external transducers on the abdomen or internal monitors during labor. Recordings are interpreted using the DR C BRAVADO method: defining risk, assessing contractions, baseline rate, variability, accelerations, decelerations, and the overall impression. Abnormal findings like late decelerations or a sinusoidal pattern indicate fetal distress requiring emergency measures.
Classification & conservative surgeries for prolapseIndraneel Jadhav
This document discusses various classifications and conservative surgical treatments for pelvic organ prolapse. It begins by describing the normal anatomical supports that prevent prolapse, including the bony scaffolding, endopelvic fascia, and pelvic musculature. It then covers several classification systems for prolapse, including the Baden-Walker and POP-Q systems. Conservative surgeries discussed include abdominal sling operations, various sling procedures, anterior and posterior colporrhaphies, paravaginal defect repairs, and perineorrhaphies. Newer procedures like vaginal sacrospinous cervico-colpopexy and posterior intravaginal slingplasty are also mentioned. The document emphasizes that hyster
Intrapartum sonography can be used to more accurately assess fetal head position, station, descent, and rotation during labor compared to digital examination alone. It also helps predict success of induction of labor and instrumental delivery. The document outlines the basic technique, objectives, and various clinical applications of intrapartum sonography during different stages of labor.
This document discusses pelvic organ prolapse (POP). It defines POP as the herniation of pelvic organs into or beyond the vaginal walls. POP can occur in the anterior, posterior, apical, or total compartments. Risk factors include vaginal childbirth, advancing age, obesity, and connective tissue disorders. Clinically, POP presents with a feeling of pressure or fullness in the pelvis. Examination involves quantifying the degree of prolapse. Conservative management includes pelvic floor exercises while surgical options depend on the compartment involved. The document provides details on POP etiology, clinical assessment, differential diagnosis, and treatment approaches.
For more notes: Join Us on Telegram: https://t.me/OBGYN_Note_Book Or Facebook: https://www.facebook.com/obgyn.books
Slideshare: https://www.slideshare.net/bjlomsecond
This document discusses female sterilization procedures including timing, guidelines, surgical approaches, counseling requirements, and complications. It describes minilaparotomy, laparoscopic sterilization, and vaginal tubal ligation methods. Timing options include postpartum, interval, or postabortal sterilization. Counseling must cover permanence, risks, and potential for failure or reversal. Surgical risks include infection, bleeding, and injury to nearby organs. Laparoscopy is preferred for interval sterilization due to lower risk of complications compared to minilaparotomy.
This document discusses abnormal uterine bleeding (AUB). It begins by defining normal menstrual cycles and explaining the hormonal regulation of menstruation. It then describes different types of abnormal bleeding patterns seen in AUB, including menorrhagia, metrorrhagia, and oligomenorrhoea. Organic and functional causes of AUB are outlined. The document focuses on the pathophysiology, endometrial changes, and management of anovulatory and ovulatory dysfunctional uterine bleeding. Diagnostic tests for AUB and differential diagnoses for adolescents and reproductive-aged women are also reviewed. Treatment options for AUB include medical therapies like hormones and lifestyle modifications, as well as surgical interventions.
This document describes the Fifth Leopold or Zangemeister maneuver, which is used to determine if a woman's pelvis is contracted during labor. The maneuver involves placing one hand on the woman's pubic bone and the other on the baby's head. There are three potential findings: 1) the head is lower than the pubic bone, indicating no pelvic contraction, 2) the head and pubic bone are at the same level, indicating moderate pelvic contraction, or 3) the head is higher than the pubic bone, indicating significant or extreme pelvic contraction. Significant pelvic contraction means the baby's head is unlikely to fit through the pelvis during a vaginal delivery.
This document discusses the prevention and management of uterine prolapse. Key points include:
1. Prevention focuses on limiting pelvic floor injury during childbirth through measures like avoiding prolonged labor and encouraging postnatal exercises.
2. Treatment is usually only when prolapse causes symptoms that interfere with daily activity.
3. Management options include conservative measures like pelvic floor exercises and pessaries, as well as surgical procedures like vaginal hysterectomy with pelvic floor repair to correct defects.
4. Surgical repair aims to tighten the anterior, middle/apical, and posterior compartments using techniques such as anterior and posterior colporrhaphy.
Pregnancy and COVID-19:
- Pregnancy does not increase the risk of contracting COVID-19 but can cause more severe symptoms due to an altered immune system.
- Most cases in pregnant women are mild, but a small portion can experience severe disease requiring intensive care.
- Vertical transmission from mother to fetus/newborn appears rare based on limited data, though a few possible cases have been reported.
- Routine antenatal care should focus on telehealth and limiting in-person visits when possible to reduce infection risk. Testing criteria include symptoms or exposure risk.
- Management of COVID-19 in pregnancy focuses on supportive care, with delivery timing based on gestational age and maternal condition.
This document discusses discrepancies in uterine size where the size does not correspond to the expected gestation. It may indicate an underlying problem related to the mother, fetus, or placenta. It is important to first confirm the pregnancy dates are correct and consider implications such as whether the fetus is at risk. Key points to consider include investigating potential causes of the discrepancy and determining appropriate management and delivery timing based on the underlying issue.
The document describes the Pelvic Organ Prolapse Quantification (POP-Q) system for evaluating and documenting pelvic organ prolapse. The POP-Q system uses specific anatomical points of reference to measure the degree of prolapse in centimeters in relationship to the hymen. It is the standard system used internationally for quantifying and comparing prolapse. The POP-Q allows for objective assessment of prolapse, comparison of surgical outcomes, and consistency in medical documentation and research.
The document provides guidelines for using a Foley catheter to induce cervical ripening. A Foley catheter can apply mechanical pressure to the cervix to induce ripening. Its use is restricted to patients with intact membranes and an unfavorable cervix who are 35 weeks gestation or more, after consulting with a pediatrician. The document outlines the steps for proper placement and monitoring of the catheter.
This document discusses the physiology of labor and anesthesia during labor. It begins by defining labor as the process by which regular uterine contractions cause cervical dilation, usually resulting in fetus delivery after 22 weeks of pregnancy. Labor involves extensive physiological changes in the mother to allow fetus delivery through the birth canal. The document then covers classifications of labor, theories of labor onset, signs that precede labor, methods for assessing cervical readiness, characteristics of uterine contractions and labor stages. It discusses pain management techniques during labor, including non-medical and medical methods. The document provides details on various anesthesia techniques for labor like local infiltration and epidural anesthesia.
This document provides information about fetal cardiotocography (CTG), including:
1. CTG can be performed from 28 weeks of gestation as that is when the fetal autonomic nervous system is mature.
2. Normal CTG findings include a baseline heart rate between 110-160 bpm, variability between 5-25 bpm, and an absence of or early decelerations with at least 2 accelerations in 20 minutes.
3. Abnormal findings include bradycardia (<110 bpm), tachycardia (>160 bpm), decreased variability (<5 bpm), and late or variable decelerations which can indicate fetal hypoxia or distress.
O documento discute os tipos de panelas mais saudáveis para cozinhar, destacando os materiais de vidro, silicone e aço inoxidável como as melhores opções. A cerâmica e o ferro também são boas opções se tomados os devidos cuidados. O alumínio, cobre, barro e teflon devem ser usados com moderação devido aos riscos à saúde que podem apresentar.
This document discusses cardiotocography (CTG), which monitors fetal heart rate and uterine contractions during pregnancy. CTG is performed in the third trimester using external transducers on the abdomen or internal monitors during labor. Recordings are interpreted using the DR C BRAVADO method: defining risk, assessing contractions, baseline rate, variability, accelerations, decelerations, and the overall impression. Abnormal findings like late decelerations or a sinusoidal pattern indicate fetal distress requiring emergency measures.
Classification & conservative surgeries for prolapseIndraneel Jadhav
This document discusses various classifications and conservative surgical treatments for pelvic organ prolapse. It begins by describing the normal anatomical supports that prevent prolapse, including the bony scaffolding, endopelvic fascia, and pelvic musculature. It then covers several classification systems for prolapse, including the Baden-Walker and POP-Q systems. Conservative surgeries discussed include abdominal sling operations, various sling procedures, anterior and posterior colporrhaphies, paravaginal defect repairs, and perineorrhaphies. Newer procedures like vaginal sacrospinous cervico-colpopexy and posterior intravaginal slingplasty are also mentioned. The document emphasizes that hyster
Intrapartum sonography can be used to more accurately assess fetal head position, station, descent, and rotation during labor compared to digital examination alone. It also helps predict success of induction of labor and instrumental delivery. The document outlines the basic technique, objectives, and various clinical applications of intrapartum sonography during different stages of labor.
This document discusses pelvic organ prolapse (POP). It defines POP as the herniation of pelvic organs into or beyond the vaginal walls. POP can occur in the anterior, posterior, apical, or total compartments. Risk factors include vaginal childbirth, advancing age, obesity, and connective tissue disorders. Clinically, POP presents with a feeling of pressure or fullness in the pelvis. Examination involves quantifying the degree of prolapse. Conservative management includes pelvic floor exercises while surgical options depend on the compartment involved. The document provides details on POP etiology, clinical assessment, differential diagnosis, and treatment approaches.
For more notes: Join Us on Telegram: https://t.me/OBGYN_Note_Book Or Facebook: https://www.facebook.com/obgyn.books
Slideshare: https://www.slideshare.net/bjlomsecond
This document discusses female sterilization procedures including timing, guidelines, surgical approaches, counseling requirements, and complications. It describes minilaparotomy, laparoscopic sterilization, and vaginal tubal ligation methods. Timing options include postpartum, interval, or postabortal sterilization. Counseling must cover permanence, risks, and potential for failure or reversal. Surgical risks include infection, bleeding, and injury to nearby organs. Laparoscopy is preferred for interval sterilization due to lower risk of complications compared to minilaparotomy.
This document discusses abnormal uterine bleeding (AUB). It begins by defining normal menstrual cycles and explaining the hormonal regulation of menstruation. It then describes different types of abnormal bleeding patterns seen in AUB, including menorrhagia, metrorrhagia, and oligomenorrhoea. Organic and functional causes of AUB are outlined. The document focuses on the pathophysiology, endometrial changes, and management of anovulatory and ovulatory dysfunctional uterine bleeding. Diagnostic tests for AUB and differential diagnoses for adolescents and reproductive-aged women are also reviewed. Treatment options for AUB include medical therapies like hormones and lifestyle modifications, as well as surgical interventions.
This document describes the Fifth Leopold or Zangemeister maneuver, which is used to determine if a woman's pelvis is contracted during labor. The maneuver involves placing one hand on the woman's pubic bone and the other on the baby's head. There are three potential findings: 1) the head is lower than the pubic bone, indicating no pelvic contraction, 2) the head and pubic bone are at the same level, indicating moderate pelvic contraction, or 3) the head is higher than the pubic bone, indicating significant or extreme pelvic contraction. Significant pelvic contraction means the baby's head is unlikely to fit through the pelvis during a vaginal delivery.
This document discusses the prevention and management of uterine prolapse. Key points include:
1. Prevention focuses on limiting pelvic floor injury during childbirth through measures like avoiding prolonged labor and encouraging postnatal exercises.
2. Treatment is usually only when prolapse causes symptoms that interfere with daily activity.
3. Management options include conservative measures like pelvic floor exercises and pessaries, as well as surgical procedures like vaginal hysterectomy with pelvic floor repair to correct defects.
4. Surgical repair aims to tighten the anterior, middle/apical, and posterior compartments using techniques such as anterior and posterior colporrhaphy.
Pregnancy and COVID-19:
- Pregnancy does not increase the risk of contracting COVID-19 but can cause more severe symptoms due to an altered immune system.
- Most cases in pregnant women are mild, but a small portion can experience severe disease requiring intensive care.
- Vertical transmission from mother to fetus/newborn appears rare based on limited data, though a few possible cases have been reported.
- Routine antenatal care should focus on telehealth and limiting in-person visits when possible to reduce infection risk. Testing criteria include symptoms or exposure risk.
- Management of COVID-19 in pregnancy focuses on supportive care, with delivery timing based on gestational age and maternal condition.
This document discusses discrepancies in uterine size where the size does not correspond to the expected gestation. It may indicate an underlying problem related to the mother, fetus, or placenta. It is important to first confirm the pregnancy dates are correct and consider implications such as whether the fetus is at risk. Key points to consider include investigating potential causes of the discrepancy and determining appropriate management and delivery timing based on the underlying issue.
The document describes the Pelvic Organ Prolapse Quantification (POP-Q) system for evaluating and documenting pelvic organ prolapse. The POP-Q system uses specific anatomical points of reference to measure the degree of prolapse in centimeters in relationship to the hymen. It is the standard system used internationally for quantifying and comparing prolapse. The POP-Q allows for objective assessment of prolapse, comparison of surgical outcomes, and consistency in medical documentation and research.
The document provides guidelines for using a Foley catheter to induce cervical ripening. A Foley catheter can apply mechanical pressure to the cervix to induce ripening. Its use is restricted to patients with intact membranes and an unfavorable cervix who are 35 weeks gestation or more, after consulting with a pediatrician. The document outlines the steps for proper placement and monitoring of the catheter.
This document discusses the physiology of labor and anesthesia during labor. It begins by defining labor as the process by which regular uterine contractions cause cervical dilation, usually resulting in fetus delivery after 22 weeks of pregnancy. Labor involves extensive physiological changes in the mother to allow fetus delivery through the birth canal. The document then covers classifications of labor, theories of labor onset, signs that precede labor, methods for assessing cervical readiness, characteristics of uterine contractions and labor stages. It discusses pain management techniques during labor, including non-medical and medical methods. The document provides details on various anesthesia techniques for labor like local infiltration and epidural anesthesia.
This document provides information about fetal cardiotocography (CTG), including:
1. CTG can be performed from 28 weeks of gestation as that is when the fetal autonomic nervous system is mature.
2. Normal CTG findings include a baseline heart rate between 110-160 bpm, variability between 5-25 bpm, and an absence of or early decelerations with at least 2 accelerations in 20 minutes.
3. Abnormal findings include bradycardia (<110 bpm), tachycardia (>160 bpm), decreased variability (<5 bpm), and late or variable decelerations which can indicate fetal hypoxia or distress.
Indicazione alla chirurgia endoscopica nella patologia flogistica e neoplasti...Domenico Di Maria
XIII Congresso Nazionale AOICO - Cava de’Tirreni (SA)
Relazione tenuta dal dott. Michele Barbara e dal Dott. Alessandro Maselli sulle indicazioni alla terapia delle patologie endonasali.
http://www.aoico.it
XIII Congresso Nazionale AOICO - Cava de’Tirreni (SA)
Relazione tenuta dal dott. Gaetano Criscuoli sulla chururgia endoscopica dell’orecchio medio.
Pomeriggio SEID Campania dedicato alle nuove linee guida ESGE su PEG e PEJ tenutosi su piattaforma ZOOM
2- Tecnica di inserimento e scelta dei materiali- Dott. G. Spinosa
Slide per la gestione del sondino nasogastrico ed orogastrico. Slide approntate da Stefano Bambi per lezioni universitarie nei corsi di laurea triennale in infermieristica e medicina
Ulcere nel palato: caso di perforazione da consumo di cocainaPasquale Longobardi
Presentazione di Pasquale longobardi al IV Raduno Otosub del 28-30 ottobre 2011.
Sessione "L'ossigenoterapia iperbarica nelle patologia otorinolaringoiatrica".
SANDRI G. La Nutrizione Clinica al S.Eugenio. ASMaD 2017Gianfranco Tammaro
DOTT. GIANCARLO SANDRI - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/O7NcSQjnRR4
GASBARRINI A. Nutrizione Clinica e Gastroenterologia. ASMaD 2017Gianfranco Tammaro
PROF. ANTONIO GASBARRINI - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/FYlsQzE8xfk
PALLAGROSI R. Gli Alimenti a fini medici speciali: nuova definizione e normat...Gianfranco Tammaro
DOTT.SSA ROBERTA PALLAGROSI - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/86dXMRSe6hQ
DE SANTIS D. Il Supporto Nutrizionale in Ospedale: ieri, oggi, domani. ASMaD ...Gianfranco Tammaro
CPSI DANIELA DE SANTIS - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/VhUPt78wU4Y
Giorgetti G.M. Il Supporto Nutrizionale in Ospedale: ieri, oggi, domani. ASMa...Gianfranco Tammaro
DOTT. GIAN MARCO GIORGETTI - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/hDOnIcyTagc
Franceschi F. Il Ruolo del Gastroenterologo nel DEA. ASMaD 2016Gianfranco Tammaro
PROF. FRANCESCO FRANCESCHI - 3° Giornata Master ECM in Gastroenterologia 2016 (25/11/2016) - Fondazione Santa Lucia - Sala Congressi - Roma
Sito: www.asmad.net
Canale Youtube: https://youtu.be/NZzctPkJiGI
This document discusses functional constipation. It provides the Rome IV diagnostic criteria for functional constipation which includes symptoms like straining, hard stools, sensation of incomplete evacuation occurring in over 25% of bowel movements. It notes that loose stools are rarely present without laxative use. Therapeutic options for functional constipation are discussed including fiber, PEG, linaclotide, prucalopride, and lubiprostone. A diagnostic and therapeutic algorithm is proposed. Risk factors for anorectal pathology after pregnancy are also discussed.
Gasbarrini A. Microbiota, Antibiotici e Probiotici in Gastroenterologia. ASMa...Gianfranco Tammaro
PROF. ANTONIO GASBARRINI - 3° Giornata Master ECM in Gastroenterologia 2016 (25/11/2016) - Fondazione Santa Lucia - Sala Congressi - Roma
Sito: www.asmad.net
Canale Youtube: https://youtu.be/ouYcXg_ZtJM
Petruzziello L. La Colonscopia di qualità e le Procedure operative. ASMaD 2016Gianfranco Tammaro
1) Colorectal cancer screening through colonoscopy has been shown to reduce CRC incidence and mortality by detecting and removing precancerous polyps.
2) Quality indicators like adequate bowel preparation, adenoma detection rates, and cecal intubation rates are important for colonoscopy effectiveness.
3) New technologies like HD imaging, water jets, and wide-angle endoscopes aim to improve polyp detection rates and make the procedure more comfortable and effective.
2. FISIOPATOLOGIA DELL’OSAS
• SITI DI OSTRUZIONE:
– Ostruzione Nasale
– Palato molle ipertrofico e prolassato
– Retroposizionamento Mandibolare
• Restringimento orofaringeo
– Prolasso ed ipertrofia dei tessuti faringei
– Ipertrofia tonsilla linguale
– Macroglossia
– Epiglottide ipertrofica o “plongeant”
– Retroposizionamento dello ioide
3. TRATTAMENTO CHIRURGICO
• PARAMETRI DI SUCCESSO
– Non necessità di ulteriori terapie mediche e/o
chirurgiche
– Risposta = 50% di riduzione di RDI
– Riduzione di RDI < 20
– Riduzione dei “risvegli” e della sonnolenza
diurna
4. TRATTAMENTO CHIRURGICO
• Chirurgia Nasale
– Efficacia limitata se unica procedura
– Verse et al 2002 hanno dimostrato un tasso di
successo del 15.8% impiegata come unico
trattamento in pazienti con OSA e
congestione nasale diurna con russamento
(RDI<20)
• Adenoidectomia
5. TRATTAMENTO DEL SETTO OSTEOCARTILAGINEO
OCCORRE LIBERARE IL PIU’
POSSIBILE LA LAMINA
QUDRANGOLARE DALLA
“CORNICE” OSSEA POSTERIORE.
SE IL SETTO MANTIENE UNA
QUALCHE MEMORIA DELLA
PRECEDENTE DEVIAZIONE, CON
LA CICATRIZZAZIONE
SUCCESSIVA “RIPORTA” TUTTA
LA PIRAMIDE AD UN
CONDIZIONE DI TORSIONE.
NEI CASI PIU’ COMPLESSI
VIENE CONSIGLIATA LA
CORREZIONE EXTRACORPOREA
DELLA CARTILAGINE
QUADRANGOLARE
ASHLEY 1952, VILAR E GUBISH
1976, REES 1986
7. TRATTAMENTO CHIRURGICO
• Uvulopalatofaringoplastica
– Chirurgia percentualmente più diffusa per OSA
– La gravità della malattia non è linearmente
correlata con il risultato dell’intervento
– Levin e Becker (1994) hanno evidenziato che
da un iniziale 80% di successo si arrivava al
46% dopo 12 mesi
– Friedman et al hanno rilavato una percentuale
di successo dell’80% a 6 mesi in pazienti ben
selezionati
Friedman M, Ibrahim H, Bass L. Clinical staging
for sleep-disordered breathing. Otolaryngol Head
Neck Surg 2002; 127: 13–21.
10. TRATTAMENTO CHIRURGICO
• Cahali, 2003 ha
proposto la
faringoplastica
laterale per pazienti
con significativo
restringimento
laterale
Cahali MB. Lateral pharyngoplasty: a
new treatment for obstructive sleep
apnea hypopnea syndrome.
Laryngoscope. 113(11):1961-8, 2003
Nov.
12. GO
Posterior Airway Space
PAS
Valori di B
riferimento in una popolazione di non apneici
(da Cisneros & Trieger, Orthognatic Surgery)
media DS
Maschio 12.45 mm 9.10
Femmina 11.75 mm 4.05
“… patients were treated sucessfully with UPPP generally had
… a normal airway space at the base of the tongue (PAS>10)
…
in failures PAS was smaller than 6 …”
13.
14. INDICATORI PER CHIRURGIA
DELL’IPOFARINGE E DEL BASE LINGUA:
Indiretti 1. RDI elevato (>40)
2. BMI elevato (>30)
3. Circonferenza del collo >43 cm
4. Deformità scheletriche mass.facciale
(Ph.# & Imaging SNA<79°, SNB<77°)
5. Lievi anomalie orofaringee. (Ph.#)
6. Macroglossia (Ph.# & Endo & Imaging)
Diretti 1. collasso ipofaringeo (Endoscopia)
2. Collasso ipofaringeo (Radiologia)
& altre anomali del PAS
3. Altri indicatori strumentali (reflessometria acustica
manometria)
15. TRATTAMENTO CHIRURGICO
• Procedure sulla base della lingua
– Asportazione Tonsilla linguale
• Utile in pazienti con ipertrofia ma normalmente
associata ad altre procedure
16. Indicazioni
per ch.
ipofaringea
No Si
RFVR Narcosi
proponibile
linguale
narcosi non accettata PHASE
ONE
narcosi ad alto rischio
richiesta di scarso dolore
rispetto della deglutizione
rispetto della fonazione
recupero insuccessi
17. TRATTAMENTO CHIRURGICO
PROCEDURE PER LA
BASE DELLA
LINGUA
– Plastica linguale
• Chabolle, et al 77% di
successo (RDI<20,
riduzione 50%) in 22
pazienti trattati anche
con UPPP
• Incidenza di
complicanze del 25%
- emorragia,
disgeusia,odinofagia,
edema
• Può essere associata
con epiglottectomia
34. TRATTAMENTO CHIRURGICO
• Avanzamanto Maxillo-Mandibolare
– Malattia Severa
– Insuccesso con procedure più conservative
– Massiccio facciale, palato e mandibola
dislocate anteriormente
– Condizionate dalla capacità di stabilizzare i
segmenti ossei e i cambiamenti estetici
39. TRATTAMENTO CHIRURGICO
• Algoritmi
– Efficacia di differenti algoritmi
– La Terapia va indirizzata verso i presunti siti
di ostruzione
• Il risultato, tuttavia, non è garantito
40. TRATTAMENTO CHIRURGICO
• Algoritmi
– Riley et al 1992
• Approccio a 2 fasi per ostruzioni a differenti livelli
(Protocollo di Stanford ):
– Fase 1: Avanzamento Genioglosso , sospensione
ioidea antero-inferiore, UPPP
– Fase 2: Avanzamento Maxillo-Mandibolare dopo 6 mesi
se la fase 1 è inefficace
– Riportato >90% tasso di successo nei pazienti che
hanno completato entrambe le fasi
– Ulteriori studi hanno evidenziato risultati peggiori
– La valutazione si esegue a 6 mesi
44. circa 30 ’ di durata
in degenza ordinaria, in narcosi
facile per l ’ORL (cisti tireoglosso + LOS)
procedura esterna,non limitazioni per scarsa apertura orale
non dolore, rara disfagia, complicanze eccezionali
cicatrice esterna variamente visibile
potenzialmente reversibile
low tech, low cost
buon risultato funzionale, specie con collassi trasversali e bassi e con
valori di BMI inferiori a 30 o 40
ben integrabile in interventi combinati
45.
46. TRATTAMENTO CHIRURGICO
• Incisione dei muscoli
sopra e sottoioidei e
sospensione
– Disloca l’osso ioide
anteriormente ed
inferiormente
– Anteriorizza
l’epiglottide e la
base della lingua
– Da eseguire insieme
ad altre procedure
– Potenziale disfagia
post-operatoria
51. TONGUE BASE
REDUCTION
with
HYOEPIGLOTTOPLASTY
(TBRHE)
52. LE ATTUALI INDICAZIONI CEFALOMETRICHE
PER LA TBRHE DI CHABOLLE ( da Telecefalo standard)
H1
H2
1. Valutazione soggettiva di
macroglossia sul profilo
2. MP-H > 20 mm
H3
3. Altezza Aerea Posteriore
> 47 mm
> 77 mm
53. Indicazioni secondo Chabolle (Laryngoscope 109: agosto 1999):
:
“… pazienti con anomalie iolinguali sono trattati con TBRHE; la proce-
dura è associata ad UPPP quando una ostruzione del palato mollle è
documentata clinicamente…”
Superficie della Area
Orofaringea > 25 cm2
“… anomalie del complesso iolinguale sono definite:
(Chabol-
le & Coll., Ann Otolaryngol 1990; 107,159)
59. ELEMENTI A FAVORE DELLA TRACHEOTOMIA
( da Powell & Riley, 1995)
LSAT<60%
BMI > 40 (morbid obesity)
alterazioni focioscheletriche estreme
aritmie cardiache
cardiopatia ischemica
patologia cerebrovascolare
BPCO
urgenza di intervento
sicurezza di risultato
Il chirurgo non è in grado di eseguire altre procedure (?)
Il paziente non tollera altre opzioni
Il paziente la richiede espressamente (?)
60. Probabilità di tracheostomia in casi di OSAS sindromica
( 251 casi di malformazione facciale severa osservati tra
il1990 ed il 1994, Sculerati & Coll., 1998; Magardino & Tom, 1999)
Crouzon, Pfeiffer, Apert ………………………… 48%
Treacher Collins, Nager ………………………… 41%
Sequenza oculo-auricolo-vertebrale …………. 22%
Paralisi cerebrale ………………………………… 15%*
Craniosinostosi(dismorfismo facciale) ……… 01%
media tra tutti i casi ……………………. 20%
61. 1. OSAS grave
2. OSAS medio Indicazioni
3. OSAS lieve
per ch.
ipofaringea
3. 2. 1.
RDI 30 40 60 BMI<33
SNA>79
SNB>77
collasso
miniinvasività PAS<<10 alterazioni
apertura orale OK trasversale OSAS posturale
dotazione disponibile
ed inferiore Test di protrusione
ioido-linguali
mandibolare +
RDI>20
LSAT<90
Snoring+
EDS+ PHASE
NOSE + PALATE : PHASE ONE TWO
PSG
stabilizzazione sospensione
linguale ioidea
avanzamento
genioglosso TBRHE 6 mesi
62. 1. OSAS severi, assai obesi, mono/biretrusi, a rischio
Indicazioni
2. Mono/biretrusi severi
per ch.
3. Insuccessi Phase One
ipofaringea
4. Pazienti programmaticamente provenienti da fase 1
RDI
BMI RDI>60 BMI>33
SNA SNA<79 SNB<77
SNB
SNA<<79 SNB<<77 LSAT<60%
aritmie cardiache
_ cardiopatia ischemica
patologia cerebrovascolare +
BPCO
4. 2. urgenza
sicurezza 1.
PHASE
3. PHASE
ONE TWO avanzamento
tracheotomia
bimascellare
RDI> 20
PSG LSAT<90 lingualplasty
6 mesi Snoring+
EDS+
63. 1. OSAS severi, assai obesi, mono/biretrusi, a rischio
Indicazioni
2. Mono/biretrusi severi
per ch.
3. Insuccessi Phase One
ipofaringea
4. Pazienti programmaticamente provenienti da fase 1
RDI
BMI RDI>60 BMI>33
SNA SNA<79 SNB<77
SNB
SNA<<79 SNB<<77 LSAT<60%
aritmie cardiache
_ cardiopatia ischemica
patologia cerebrovascolare +
BPCO
4. 2. urgenza
sicurezza 1.
PHASE
3. PHASE
ONE TWO avanzamento
tracheotomia
bimascellare
RDI> 20
PSG LSAT<90 lingualplasty
6 mesi Snoring+
EDS+
64. 1. OSAS severi, assai obesi, mono/biretrusi, a rischio
Indicazioni
2. Mono/biretrusi severi
per ch.
3. Insuccessi Phase One
ipofaringea
4. Pazienti programmaticamente provenienti da fase 1
RDI
BMI RDI>60 BMI>33
SNA SNA<79 SNB<77
SNB
SNA<<79 SNB<<77 LSAT<60%
aritmie cardiache
_ cardiopatia ischemica
patologia cerebrovascolare +
BPCO
4. 2. urgenza
sicurezza 1.
PHASE
3. PHASE
ONE TWO avanzamento
bimascellare tracheotomia
RDI> 20
PSG LSAT<90 lingualplasty
6 mesi Snoring+
EDS+
65. QUESTIONARIO RONCOCHIRURGICO PER INTERVENTI COMBINATI:
analogo visivo del dolore per procedura (naso, velo, iode, lingua)
Key: 0 = nessun dolore; 100 = massimo dolore concepibile
100% massimo dolore concepibile
3
2,5 N = 30
2
1,5
30%
1
0,5
0% 0
nessun dolore
naso velo iode lingua
naso velo ioide
lingua
66. QUESTIONARIO RONCOCHIRURGICO PER INTERVENTI COMBINATI:
opinione dei pazienti sulle scelte di chirurgia combinata vs. isolata
E ’ favorevole alla esecuzione di interventi SI 90%
combinati in un singolo tempo chirurgico?
Secondo la Sua esperienza l ’associazione
di tre interventi allunga e/o peggiora il post NO 65%
operatorio ?
Il risparmio di tempo (tre interventi in uno) SI 90%
giustifica l ’eventuale disagio in piu ?
67. Bruno E., Alessandrini M., Napolitano B., De Padova A., Di Daniele N.,
De Lorenzo A.
Dual energy x-ray absorptiometry analysis of body composition in
patients affected by OSAS
European archives of oto-rhino-laryngology: official journal of the
European Federation of Oto-Rhino-Laryngological Societies (EUFOS)
266(8), 1285, 1290 (2009)
Editor's Notes
La conoscenza approfondita dell’anatomia chirurgica, integrando gli input macroscopici, endoscopici e radiologici, fornisce il substrato necessario per affrontare gli interventi di chirurgia di revisione in sicurezza. TS= turbinato superiore TM= turbinato medio TI= turbinato inferiore SF= seno frontale SS= seno sfenoide