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Background: Better understanding of the pathogenesis of gastroesophageal reflux disease in recent years has not been accompanied by appreciable advances in the design of antireflux operations. In many cases, operations are still being performed just as they were described 30 years ago. It is important now to go beyond the eponymous procedures traditionally associated with antireflux operations and to identify the technical elements that contribute to effective and durable fundoplications. Objectives: To compare antireflux operations and identify the important technical elements. Design and Setting: Retrospective study in a universitybased tertiary care center. RESULTS The operating time for groups A, B, and C was 193 (±45), 150 (±50), and 161 (±47) minutes, respectively. The hospital PAPER

Background The Covid-19 pandemic necessitated the delivery of online higher education. Online learning is a novel experience for medical education in Sri Lanka. A novel approach to undergraduate surgical learning was taken up in an attempt to improve the interest amongst the students in clinical practice while maximizing the limited contact time. Method Online learning activity was designed involving medical students from all stages and multi consultant panel discussions. The discussions were designed to cover each topic from basic sciences to high-level clinical management in an attempt to stimulate the student interest in clinical medicine. Online meeting platform with free to use basic plan and a social media platform were used in combination to communicate with the students. The student feedback was periodically assessed for individual topics as well as for general outcome. Lickert scales and numeric scales were used to acquire student agreement on the desired learning outcomes. Results A total of 1047 student responses for 7 questionnaires were analysed. During a 6-week period, 24 surgical topics were discussed with 51 contact hours. Eighty-seven per cent definitely agreed (highest agreement) with the statement ‘students benefitted from the discussions’. Over 95% have either participated for all or most sessions. A majority of the respondents (83.4%) ‘definitely agreed’ that the discussions helped to improve their clinical sense. Of the total respondents, 79.3% definitely agreed that the discussions helped to build an interest in clinical medicine. Around 90% agreed that both exam-oriented and clinical practice-oriented topics were highly important and relevant. Most widely raised concerns were the poor Internet connectivity and limitation of access to the meeting platform. Conclusion Online teaching with a novel structure is feasible and effective in a resource-limited setting. Students agree that it could improve clinical interest while meeting the expected learning outcomes.

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Partial fundoplication is an excellent treatment for patients with GERD and weak peristalsis, for it corrects the abnormal reflux and avoids postoperative dysphagia.

Pain is a major problem for Intensive Care Unit (ICU) patients. Despite numerous improvements it is estimated that as many as 70% of the patients experience moderate-to-severe postoperative pain during their stay in the ICU. Effective pain management means not only decreasing pain intensity, but also reducing the opioids’ side effects. Minimizing nausea, vomiting, urinary retention, and sedation may indeed facilitate patient recovery and it is likely to shorten the ICU and hospital stay. Adequate postoperative and post-trauma pain management is also crucial for the achievement of effective rehabilitation. Furthermore, recent studies suggest that effective acute pain management may be helpful in reducing the development of chronic pain. When used appropriately, and in combination with other treatment modalities, regional analgesia techniques (neuraxial and peripheral nerve blocks) have the potential to reduce or eliminate the physiological stress response to surgery and trauma, decreasing the possibility of surgical complications and improving the outcomes. Also they may reduce the total amount of opioid analgesics necessary to achieve adequate pain control and the development of potentially dangerous side effects.

Management of pain in critically ill patients can be very difficult. In the attempt to provide comfort with adequate levels of opioids and sedatives, respiratory depression and cardiovascular instability may become difficult to control in patients with labile hemodynamics and poor cardiopulmonary reserve. The use of medications like ketamine, an anesthetic agent that in subanesthetic doses has been reported to be effective in preventing opioidinduced tolerance and to have analgesic properties, may be of help, especially in patients who develop tolerance, leading to rapidly escalating doses of opioids and sedatives. The case report presented here shows how a very low dose of ketamine can be helpful for the management of pain and sedation in critically ill patients, especially when they are ready to be weaned from mechanical ventilation, and very high doses of opiods and sedatives do not permit it.

In the attempt to reduce postoperative complications and costs and improve outcomes, the concept of fast track surgery has been proposed. Improvements in anesthesia techniques and a better understanding of the pathophysiologic events occurring during and after surgery have made it possible. A group of patients undergoing colorectal resections with a fast track approach were investigated; specifically, the effects on postoperative morbidity, resumption of intestinal function, and duration of hospitalization. Fifty patients were managed according to a protocol, which included epidural analgesia, early ambulation, and oral feeding (fast track group); they were compared with 50 patients managed with a different protocol: no epidural analgesia, early ambulation, and early oral diet (control group). Primary outcome end-points reported include morbidity, time to passage of flatus and stool, and length of hospital stay. Fourteen complications occurred in the fast track group and 13 in the control group ( P = not significant (NS)). Resumption of intestinal function occurred after 3 days, and length of hospital stay was 5 days in the fast track group compared with 4 and 7 days respectively in control patients ( P = NS, P < 0.01). Patients undergoing elective colorectal resections can be managed safely with fast track protocols reducing hospital stay.