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BACKGROUND:: Endoscopic sphenopalatine artery ligation (ESPAL) is the intervention of choice for refractory epistaxis in specialist ear, nose and throat (ENT)units and should be within the repertoire of competencies for all ENT trainees. Following its recent incorporation within the United Kingdom competency-based training syllabus as an explicit outcome standard, the ESPAL is not uncommonly being delivered by trainees under appropriate supervision. We assessed the efficacy and outcome of ESPAL in epistaxis management within our teaching hospitals. METHODS:: Retrospective, structured review of all ESPAL procedures performed for epistaxis between December 2005 and December 2013. The techniques of ligation, operator grade, and outcome were studied. RESULTS:: Sixty-five patients (41 male:24 female; average age of 58.2 years) were identified in whom 67 artery ligations were performed (63 unilateral; 2 bilateral). Overall, success rate of ESPAL was 92.3% (60/65), with 5 rebleed cases recorded within 30 days of the primary procedure. Sixteen (24.6%) underwent "clipping," 26 (40.0%) had diathermy ligation, 18 (27.7%) had both clipping and diathermy, and in 5 (7.7%) patients, the ligation technique was not recorded. In 31 (47.7%) of 65 cases, a consultant was the principal surgeon. The remaining 34 (52.3%) of 65 cases were performed by trainees with (24, 70.6%) or without (10, 29.4%) supervision. There was no correlation between rebleed and operators' grade, level of supervision, or ligation technique. CONCLUSION:: With appropriate training, ESPAL can achieve hemostasis in teams of varying grades of operators without significant reduction in outcome. To further enhance the technical learning curve, the utility of simulation-based training could offer continuous and longitudinal development of skills.

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Accurate control and precise positioning of opto-thermocapillary flow-addressed bubble microrobots are necessary for micromanipulation. In addition, micromanipulation using the simultaneous actuation of multiple microrobots requires a robust control system to enable independent motion. This paper demonstrates a hybrid closed-loop vision-assisted control system capable of actuating multiple microrobots simultaneously and positioning them at precise locations relative to micro-objects under manipulation. A vision-assisted grasp-planning application was developed and used to calculate the necessary trajectories of the microrobots to form cages around micro-objects. The location of the microrobots and the micro-objects was detected at the caging locations using a particle-tracking application that used image feedback for precise positioning. The closed-loop image feedback information enabled the position update of the microrobots, allowing them to precisely follow the trajectory and caging locations calculated by the grasp-planning application. Four microrobots were assigned to cage a star-shaped micro-object using the closed-loop control system. Once caged, the micro-object was transported to a location within the workspace and uncaged, demonstrating the micromanipulation task. This microrobotic system is well suited for the micromanipulation of single cells.

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We report a case of unilateral mydriasis following nasal electrocautery presumed to be the result of retrograde flow of adrenaline and/or xylometazoline hydrochloride (Otrivine) through the nasolacrimal duct into the eye. We review the literature and highlight the importance of correct interpretation of finding a dilated pupil post-operatively. To our knowledge. we report the first such case involving xylometazoline hydrochloride and also following nasal electrocautery. Unilateral mydriasis is alarming after nasal surgery but must be interpreted with caution. During minimally invasive procedures it is likely to be due to the effects of topical medication to the nose rather than surgical trauma.

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Although cases of lymphoplasmacytic sclerosing pancreatitis (LSP) associated with idiopathic retroperitoneal fibrosis have been reported, the association is rare. We describe a 74-year-old man who presented with obstructive jaundice and weight loss. Nineteen months earlier, he had been diagnosed with idiopathic retroperitoneal fibrosis and treated with bilateral ureteric stents. Initial investigations were suggestive of a diagnosis of LSP, however, a malignant cause could not be ruled out. He underwent an exploratory laparotomy and frozen sections confirmed the diagnosis of LSP. An internal biliary bypass was performed using a Roux loop of jejunum, and the patient made an uneventful recovery. This case illustrates the difficulty in distinguishing LSP from pancreatic carcinoma preoperatively.