Adjacent Organs Research Articles

The Migration of an Intrauterine Device in the Bladder of an Asymptomatic Woman: A Case Report

Background: The use of intrauterine devices (IUDs) for contraception has increased in many countries. However, their application has some serious complications such as uterine perforation and injury to adjacent organs. The translocated IUD into the bladder is a very rare occurrence. Case Presentation: Our case was a 41-year-old woman whose IUD was accidentally discovered in her bladder during a routine ultrasound. The IUD has migrated from its normal position in the uterus to the bladder. The IUD was successfully removed by cystoscopy without any complications. Conclusion: The mislocation of an IUD in the bladder, while uncommon, is a possibility that should be considered when the IUD string is not visible during examinations.

EGS SO30 - Management of Iatrogenic Oesophageal Perforations in the era of Endo-Vacuum Therapy- Preliminary Results of a Single-Institution Study

Abstract Background Iatrogenic oesophageal perforation (IOP) following diagnostic and therapeutic interventions at the oesophagus or adjacent organs are responsible for nearly half of oesophageal perforations. If not recognised within 24 hours of injury, then they are associated with devastating morbidity and mortality. Available treatment options encompass non-operative for early perforation without sepsis, endoscopic with endoclip/stent and surgical including primary repair, exclusion and diversion or oesophagectomy. Recently, Endoscopic Vacuum Therapy (EVT) has been introduced as safe and effective alternative approach. We sought to assess treatment outcomes in patients with IOPs prior to and during periods where EVT was available as treatment option. Method A single-centre retrospective cohort study incorporating all consecutive patients (N=30) presented or transferred to our tertiary oesophagogastric unit for IOP management between 01/01/2009-31/12/2023 was undertaken. Patients with anastomotic leak post-surgery or spontaneous perforation secondary to malignancy or benign pathology were excluded. Primary study-outcomes were treatment type including non-operative, EVT after 01/01/2018 or other endoscopic therapy, surgical operation including laparotomy, thoracotomy, primary defect repair or over a T-tube, disconnection with oesophagostomy, stenting or other interventional radiology procedures and their rate of success or failure. Secondary outcomes were length of stay, 90-day complications requiring re-intervention or re-admission, 30-, 90-day and 1-year mortality. Results In 2009-2017 pre-EVT period, 11/30 patients were managed a) non-surgically 7/11, b) endoclip 3/11 and stenting 1/11. 30-day and 90-day mortality were 1/11, 90-day morbidity Clavien-Dindo >IIIa 3/11 (27.3%), 90-day reintervention 8/11 (72.7%), median LOS 27 days. In 2018-2023 EVT period, 19/30 patients were treated with a) laparotomy, left thoracotomy, defect repair over t-tube, chest drainage in 5/19, b) non-surgical 7/19, c) IR NJT, stent or PEG in 6/19 d) EVT in 4/19. 30-day mortality was 0/19, 90-day mortality 1/19 (5.2%), 90-day morbidity Clavien-Dindo >IIIa 7/19 (36.8%), 90-day reintervention 9/19 (47.4%), median LOS 61 days. 1-year mortality was 0/19 for both. Conclusion EVT therapy appears to be a feasible additional treatment modality in the management of iatrogenic oesophageal perforations. Careful patient selection, therapeutic endoscopic expertise, knowledge of the technique, multidisciplinary approach and team collaboration are essentials for favourable outcomes. Of note, management of oesophageal perforations in a dedicated UGI centre is directly related to patient outcomes and is a sine qua non.

Abstract 4128599: Facility-level Variation Underlying Low Inferior Vena Cava Filter Retrieval in the United States

Background: Inferior vena cava (IVC) filters are commonly implanted in patients with venous thromboembolism (VTE) who are unable to receive anticoagulation, to protect against clot migration to the heart. With prolonged implantation, IVC filters are associated with complications: device fracture, migration, penetration into adjacent organs and worsened VTE. Two Federal Drug Administration advisories and multi-society guidelines have emphasized the importance of timely retrieval but national retrieval rates remain low (<30%). Aims: To quantify hospital-level variation in IVC filter retrieval , describe time-based retrieval rates and examine factors associated with retrieval. Methods: IVC Filter implantation for all patients >= 18 years was identified in the 2016-2020 inpatient and outpatient 100% limited data set Medicare files using claims codes. Hospital information for the implanting facility was cross-linked from the American Hospital Association and Healthcare Cost Report Information System files, including identifying information, teaching status, census location, operating margin and % uncompensated care. IVC filter retrieval rates and time to retrieval from implantation was calculated. Bayesian hospital profiling methods were used to quantify 1-year retrieval rate for all U.S. facilities, adjusting for patient factors – demographics, diagnostic indications and comorbidities. Results: Among Medicare beneficiaries, there were 140,481 IVC Filter implantations across 2,850 facilities. Excluding patients who died within 90 days of implantation (25.7%), retrieval rates at 3 months, 1 year and anytime were 7.9%, 18.7% and 20.0% respectively. IVC Filter retrieval within 1 year varied significantly at the facility-level, from 0-100% . Focusing on facilities with at least 13 IVC filter implantations each year (top 25%ile volume), 1-year retrieval ranged from 0 to 74.5%. Higher 1-year retrieval was seen among higher implantation volume (12.4% bottom quartile, 20.5% top quartile), teaching (21.1% teaching vs. 16.9% nonteaching) and non-safety net (21.1% low uncompensated care, 15.0% high uncompensated care) hospitals. Retrieval rates did not vary significantly by hospital operating margin or rurality. Conclusion(s): There is low overall IVC filter retrieval in the United States with large underlying facility-level variation. Focused examination of high-performing facilities could yield insights on how to improve device retrieval nationally.

058. A Rare Case: Anterior Wall Rectum Perforation Due to Intrauterine Device Migration

Background: Intrauterine devices (IUDs) are widely used for contraception due to their long-acting, safe, and effective nature in preventing pregnancy. However, common side effects and complications, such as vaginal bleeding, expulsion, displacement, translocation, and perforation necessitate attention, with translocation and perforation being rare but potentially severe, warranting prompt removal according to WHO recommendations. This study aims to document and analyze a rare case of rectal perforation resulting from the migration of an IUD. Case: A report was made from 31-year-old pregnant woman with a history of two cesarean sections presented with 10-day abdominal pain and an IUD inserted 42 days post-surgery, which MRI revealed had translocated into the left anterolateral rectal wall, prompting retroscopy for extraction. Uterine perforation and IUD migration into adjacent organs can result in various complications, including uterine, bladder, and intestinal perforation, with initial symptoms potentially being asymptomatic, emphasizing the need for routine check-ups. Retrieval of migrated IUDs can be achieved through methods such as endoscopy, laparoscopy, or laparotomy, as illustrated in a case involving a patient with abdominal pain and imaging evidence of IUD translocation to the rectum's anterior wall, managed through less invasive rectoscopy. Conclusion: Translocated IUDs may exhibit varying symptoms or none at all, necessitating removal regardless of type or location, with management guided by radiological and endoscopic findings alongside understanding abdominal organ anatomy

Comparative study of the prevalence of organ injury in placenta accreta spectrum disorder between posterior colpotomy and conventional peripartum hysterectomies at a single referral center in southern Thailand.

To compare the prevalence of adjacent organ injury in placenta accreta spectrum disorder (PAS) between the posterior colpotomy approach and conventional peripartum hysterectomy. This retrospective study analyzed the data of pregnant women diagnosed with PAS who underwent peripartum hysterectomy at Songklanagarind Hospital between January 2006 and December 2021. The patients were divided into two groups: posterior colpotomy and conventional approaches. The characteristics and surgical and obstetric outcomes were compared. Univariate and multivariate logistic regression was used to identify factors and risk of organ injury. Among 174 patients, 64 underwent conventional peripartum hysterectomy, and 110 underwent the posterior colpotomy approach. The overall incidence of adjacent organ injury was 17.82%. Organ injury prevalence was lower in the posterior colpotomy group (10%) than in the conventional group (31.25%), with no difference in operative time. Multivariate analysis showed that posterior colpotomy reduced adjacent organ injury (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.06-0.54, P = 0.002). Placenta percreta was associated with increased injury risk (OR 6.83, 95% CI 2.53-18.44, P < 0.002). Subgroup analysis showed that the posterior approach reduced bladder injury in placenta increta (OR 0.14, 95% CI 0.04-0.57, P = 0.003) and percreta (OR 0.19, 95% CI 0.05-0.77, P = 0.017). Compared with conventional peripartum hysterectomy, the posterior colpotomy approach in patients with PAS reduced the risk of adjacent organ injury, particularly for placenta increta and percreta. This technique should be considered in PAS cases, but further investigations with a prospective study design are needed.

052. Surgical Management of a Tumor Adhering to Ileum and Posterior Stomach: A Case Report

Background: Tumors in the transverse colon that invade adjacent organs, such as the ileum and posterior stomach, present complex surgical challenges. Resection and reconstruction are often required to achieve optimal outcomes. We present a case of a large transverse colon tumor adherent to the ileum and posterior gastric wall, managed with extensive surgical resection and reconstruction. Case: A 54-year-old male presented with abdominal pain, bloating, and weight loss. Imaging studies revealed a large mass originating from the transverse colon, adherent to the ileum and posterior gastric wall. Intraoperative findings confirmed the tumor’s adherence to the ileum, approximately 220 cm distal to the ligament of Treitz, as well as its invasion of the posterior gastric wall. The surgical team performed a multi-organ resection. The segment of ileum involved, located 220 cm from the ligament of Treitz, was resected, and an ileo-ileal anastomosis was performed. The primary tumor, located in the middle of the transverse colon, necessitated a total resection of the transverse colon, with subsequent anastomosis between the ascending and descending colon. Additionally, the portion of the posterior stomach adherent to the tumor was removed through subtotal gastrectomy, followed by a Billroth I reconstruction. Postoperatively, the patient recovered well, with no significant complications. Histopathology confirmed the tumor to be a moderately differentiated adenocarcinoma. The patient is currently undergoing adjuvant chemotherapy. Conclusion: This case highlights the complexity of managing tumors with multi-organ involvement. Comprehensive surgical resection, combined with appropriate reconstruction techniques, can result in favorable outcomes. Early detection and aggressive surgical management are essential in cases involving locally advanced tumors with invasion into adjacent structures.

Feasibility of balloon rectal spacer implantation in HDR and LDR brachytherapy for prostate cancer treatment

PurposeThis study evaluates the use of a biodegradable balloon rectal spacer in two prostate cancer patients undergoing Low Dose Radiation (LDR) and salvage High Dose Radiation (HDR) brachytherapy. The spacer aims to reduce radiation dose to adjacent organs, particularly the rectum, in patients previously treated with radiation. MethodsThe balloon spacer was implanted transperineally under transrectal ultrasonography (TRUS) guidance in two patients. For the LDR case (73-year-old, intermediate-risk), the balloon was placed post-implant with 55 iodine-125 seeds delivering 145 Gy. For the HDR case (66-year-old, high-risk), the balloon was placed one week before treatment, which delivered 23 Gy in two weekly fractions using 16 channels. ResultsThe balloon provided a 14-15mm separation between rectum and prostate. In the LDR case, prostate D90 was 149.1Gy (102.83%), V100 was 91.95%, and rectum D30 was 23.93Gy (16.50%). For the HDR case, prostate D90 was 11.63Gy (105.79%), V100 was 93.63%, and rectum D0.5cc was 8.04Gy (73.15%). Both patients tolerated the treatment well, with no observed postoperative complications at 6-month follow-up. ConclusionsThe use of a rectal balloon spacer in both salvage HDR and LDR brachytherapy is feasible and safe, allowing for controlled placement and providing rectal protection from high radiation doses.

A cost-consequence analysis comparing three distinct cardiac ablation strategies for the treatment of paroxysmal atrial fibrillation

Abstract Background Cardiac ablation is a well-established treatment option for preventing atrial fibrillation (AF). While radiofrequency, cryo-energy, and laser energies are commonly employed in catheter ablation, they present the risk of potential damage to adjacent organs such as the oesophagus and phrenic nerve. To address these concerns, new technologies are being explored including pulsed field ablation (PFA), a non-thermal energy approach that employs high-voltage, short-duration pulses to selectively destroy target cells. Purpose The present analysis aims at: i) quantifying the short-term costs related to three ablation strategies for paroxysmal AF (PFA, radiofrequency ablation -RFA-, and cryo-balloon ablation -CRYO-), identify the cost drivers, and assess potential variations in resource consumption for each treatment alternative; ii) comparing the medium-term (1-year) economic implications of adopting the three alternatives, in terms of redo procedures (effectiveness) and complications (safety). Methods A cost-consequence model was developed to compare economic outcomes of the three ablation strategies for paroxysmal AF in the short- (during procedure) and medium-term (1-year). Resource consumption data during the procedure were collected by two European medical centres specialized in cardiac ablation (N=61 patients). For the medium-term analysis, costs were correlated to the effectiveness and safety of the procedures. The clinical data (i.e., redo and complication rates) considered in the model were retrieved from published literature. Costs and tariffs were collected from economic formularies of the respective hospitals. A scenario analysis was conducted to evaluate economic outcomes under various hypothetical difference in the prices of treatment kits. Results A significant difference was registered in terms of pre-procedural (mean±SD: 13.9±4.4 min for PFA, 20.1±7.6 min for CRYO and 20.5±7.7 min for RFA; ANOVA test p=0.003) and procedural time (skin-to-skin), favouring PFA over RFA and CRYO (53.6±26.8 min for PFA, 72.4±28.1 min for CRYO and 149.9±99.9 min for RFA; p&amp;lt;0.0001; Table 1). PFA was associated with lower procedural costs vs CRYO (-€400) and RFA (-€827). A similar economic advantage was observed in the medium-term (Table 2). The scenario analysis showed that PFA would be cost-saving vs CRYO (Δtotal costs ≤ 0) up to a price difference of +€881 (i.e., PFA kit is more expensive than CRYO kit), and similarly, up to a price difference of +€1,306 vs RFA. Above these thresholds, PFA would be considered cost-effective vs CRYO or RFA, due to its efficacy despite being more expensive. Conclusion In summary, PFA emerges as cost-effective or even cost-saving over CRYO and RFA, thanks to its faster execution, lower redo, and complications rate. Moreover, PFA time predictability would facilitate hospital planning. For a complete analysis, these benefits should be evaluated against the difference in acquisition costs among treatments.Procedural time by phase and techniqueCumulative savings per technique

Exploring the Etiology and Clinical Diagnosis and Treatment of Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding refers to bleeding caused by the digestive tract above the flexor ligament, including diseases of the esophagus, stomach, duodenum, pancreas, biliary tract, and lesions after gastrojejunostomy. It is a common and critical condition in internal medicine. In recent years, with the continuous development of medical technology and the improvement of treatment methods, the diagnosis and treatment level of this disease has been greatly improved. However, this disease has the characteristics of fast onset, complex condition, and certain mortality rate. Therefore, exploring and analyzing the etiology, causes, and treatment plans of this disease is of great significance for improving the cure rate and prognosis of patients with this disease. Due to inflammation, mechanical injury, vascular disease, or adjacent organ lesions, the choice of treatment plan varies depending on the cause. Based on the above situation, this article, The etiology and diagnosis and treatment plan of upper gastrointestinal bleeding have been explored, which can provide reference for improving the treatment level of this disease

Prognostic factors for intraductal papillary neoplasm of the bile duct following surgical resection: a systematic review and meta-analysis.

Intraductal papillary neoplasm of the bile duct (IPNB) is a biliary neoplasm characterized by intraductal papillary growth and varying degrees of malignant transformation. This study aimed to identify effective prognostic factors (PFs) for predicting the prognosis of IPNB after surgical resection, addressing the gap in the higher level evidence. We systematically searched databases from their inception to October 10, 2023. Data on 12 predetermined PFs were collected and subjected to a meta-analysis. Forest plots were used to summarize the findings. Fifteen studies with a total of 2311 patients were included. Among the PFs examined, extrahepatic tumor location (HR, 2.97; 95% CI 1.68-5.23), subclassification type 2 (HR, 2.62; 95% CI 1.45-4.76), R1 resection (HR, 2.47; 95% CI 1.73-3.51), elevated CA19-9 level (HR, 3.25; 95% CI 1.91-5.54), tumor multiplicity (HR, 2.65; 95% CI 1.40-5.02), and adjacent organ invasion (HR, 3.17; 95% CI 2.01-5.00) were associated with a poorer prognosis. Additionally, the combined HR values indicated that lymph node metastasis and poor tumor differentiation were linked to a worse prognosis, although both exhibited significant heterogeneity. Our study offers valuable insights for enhancing postoperative prognostication and treatment decision-making for IPNB patients with IPNB. These findings warrant further validation in future prospective studies.

MRI and placenta accreta: Keys for its interpretation in images, regarding a case

Introduction: Placenta accreta spectrum (PAS) refers to the abnormal adherence of the placental trophoblast to the uterine myometrium. Several conditions are associated with its development. Ultrasound is the imaging modality of choice for antenatal diagnosis. In cases of doubt, magnetic resonance (MR) plays a leading role, due to its high performance, and contributes to surgical planning. The final diagnosis is made in the surgery, with subsequent confirmation by pathology. The objective of this article is to present a case of placenta increta, focused on the imaging findings in magnetic resonance imaging (MRI). Case Report: We present a case of a 35-year-old woman with a history of 2 previous cesarean sections and chronic hypertension, who presented a 23-week pregnancy with obstetric ultrasound showing placenta accreta. An MRI was performed, and it showed signs of placenta accreta, with no evidence of transmural extension to adjacent organs. At 34 weeks, a cesarean section and hysterectomy were performed, with no evidence of bladder invasion. Conclusion: The diagnosis of PAS is made antenatal with ultrasound, but MRI has been used in some cases, with some characteristic features that every radiologist should know.

Determining the Optimal Morphometry of Pedicle Screws in Lumbar and Thoracic Spine in the Iranian Population

Background: The improper length and direction of pedicle screw may also cause it to penetrate the adjacent organs. Unknowing the safe zone of dimensions and directions of the pedicles is essential to proper screw placement. Methods: The present study is a cross-sectional morphometric study on patients with spinal trauma referred to the neurosurgical department in 2021. The MARCO PACS software scale measured the CT scan images and included the vertebral left pedicle diameter, pedicle body distance, body aorta distance, pedicle diameter, height, and area. The entry point and direction of the pedicle screw were made with the “free-hand” method. Results: 301 patients were included, consisting of 113 females (37.5%) and 188 males (62.5%). The mean age of the participants was 42.87±12.3 years. “Among all T12 vertebra parameters, just body aorta distance was not significant between genders (p-value=0.311). The pedicle height and body aorta distance were lowest among 18-35 years patients (p-value=0.001) (p-value=0.003), respectively. Post-hoc analysis revealed a significant difference between 18-35 and 51-70 years for body aorta distance in the L1 vertebra (p-value=0.002). Conclusion: The present investigation has shown significant differences between genders for optimal left pedicle screw parameters, which should be considered before surgery.

Current approaches to prenatal imaging of lung malformations: a review

INTRODUCTION: Congenital lung malformations are result of developmental disorders at any stage of organ formation. Manifestations of these changes vary significantly: from minimal in size to large space-occupying lesion of the lung, which can cause fetal death or severe postnatal respiratory disorders. In proper time and accurate prenatal diagnosis of lung development abnormalities is one of the fundamental factors determining management of pregnancy and prognosis.OBJECTIVE: To demonstrate the most typical features of a wide range of congenital lung anomalies by ultrasound and MRI.MATERIALS AND METHODS: The literature search was performed in open Russian and English databases Medline, PubMed, Web of Science, RSCI, eLIBRARY using keywords and phrases: «prenatal diagnosis», «fetal MRI», «ultrasound diagnostics», «сongenital lung malformations».RESULTS: Based on literature data and our own experience in the use of ultrasound and MRI in diagnosis of сongenital lung malformations, the main signs of normal development and the most specific types of lung anomalies are described. Algorithm for diagnostic search for congenital lung malformations is presented.CONCLUSION: Ultrasound is the main method for diagnosing congenital lung anomalies. Fetal MRI is used to clarify the nature and extent of changes, a more detailed assessment of adjacent organs, also to determine Multiple congenital anomalies. Understanding the characteristics of semiotics of lung malformations and the main signs of these anomalies is a fundamental criterion for prenatal counseling, as well as peri- and postnatal management of this category of patients.

Investigation of pelvic floor influence on prostate displacement in image-guided radiotherapy.

The uncertainty of target location during prostate cancer radiotherapy plays an important role in accurate dose delivery and radiation toxicity in adjacent organs. This study analyzed displacement correlations between the prostate and pelvic floor. We retrospectively analyzed registration results from 467 daily cone-beam computed tomography (CT) in 12 patients with prostate cancer who received radiation therapy. We analyzed prostate displacement and the pelvic floor relative to the pelvic bone's anatomy in the translational and rotational directions and identified statistical correlations. The systematic (Σ) and random (σ) displacements of the prostate in the three translational directions, anterior-posterior (AP), superior-inferior (SI), and right-left (RL), were 1.49 ± 1.45, 2.10 ± 1.40, and 0.24 ± 0.53 mm, respectively, and in the rotational directions of the pitch, roll, and yaw were 2.10 ± 2.02°, 0.42 ± 0.74°, and 0.42 ± 0.64°, respectively. The pelvic floor displacements were 2.37 ± 1.96, 2.71 ± 2.28, and 0.47 ± 0.84 mm in the AP, SI, and RL directions, respectively, and 0.93 ± 1.49°, 0.98 ± 1.28 °, and 0.87 ± 0.94° in the pitch, roll, and yaw directions, respectively. Additionally, there were statistically significant correlations between the displacement of the prostate and pelvic floor in the AP and SI directions, with correlation coefficients (r) of 0.74 (p < 0.001) and 0.69 (p < 0.001), respectively. The movement of the pelvic floor may be an important factor that causes prostate displacement, affecting the accuracy of radiotherapy. Therefore, it is necessary to take appropriate measures to ensure that the pelvic floor muscle tension is as consistent as possible in the treatment' CT scan and daily treatment.

Standard or Extended Lymphadenectomy for Muscle-Invasive Bladder Cancer

BackgroundWhether extended lymphadenectomy is associated with improved disease-free and overall survival, as compared with standard lymphadenectomy, among patients with localized muscle-invasive bladder cancer undergoing radical cystectomy is unclear.MethodsWe randomly assigned, in a 1:1 ratio, patients with localized muscle-invasive bladder cancer of clinical stage T2 (confined to muscle) to T4a (invading adjacent organs) with two or fewer positive nodes (N0, N1, or N2) to undergo bilateral standard lymphadenectomy (dissection of lymph nodes on both sides of the pelvis) or extended lymphadenectomy involving removal of common iliac, presciatic, and presacral nodes. Randomization was performed during surgery and stratified according to the receipt and type of neoadjuvant chemotherapy, tumor stage (T2 vs. T3 or T4a), and a Zubrod’s performance-status score (0 or 1 vs. 2; assessed on a 5-point scale, with higher scores indicating greater disability). The primary outcome was disease-free survival. Overall survival and safety were also assessed.ResultsOf 658 patients who were enrolled, 592 eligible patients were randomly assigned to undergo extended lymphadenectomy (292 patients) or standard lymphadenectomy (300). Surgery was performed by 36 surgeons at 27 sites in the United States and Canada. Neoadjuvant chemotherapy had been received by 57% of the patients. At a median follow-up of 6.1 years, recurrence or death had occurred in 130 patients (45%) in the extended-lymphadenectomy group and in 127 (42%) in the standard-lymphadenectomy group, and the estimated 5-year disease-free survival was 56% and 60%, respectively (hazard ratio for recurrence or death, 1.10; 95% confidence interval [CI], 0.86 to 1.40; P=0.45). Overall survival at 5 years was 59% in the extended-lymphadenectomy group and 63% in the standard-lymphadenectomy group (hazard ratio for death, 1.13; 95% CI, 0.88 to 1.45). Adverse events of grade 3 to 5 occurred in 157 patients (54%) in the extended-lymphadenectomy group and in 132 (44%) in the standard-lymphadenectomy group; death within 90 days after surgery occurred in 19 patients (7%) and 7 patients (2%), respectively.ConclusionsAs compared with standard lymphadenectomy, extended lymphadenectomy did not result in improved disease-free or overall survival among patients with muscle-invasive bladder cancer undergoing radical cystectomy and was associated with higher perioperative morbidity and mortality. (Funded by the National Cancer Institute and the Canadian Cancer Society; SWOG S1011 ClinicalTrials.gov number, NCT01224665.)

The impact of economic crisis, COVID-19, and the Beirut Blast on colorectal cancer patients in Lebanon: A trend to operate more late-stage complex cases.

The convergence of the economic crisis, COVID-19 pandemic, and Beirut Blast has precipitated unprecedented challenges for the healthcare system in Lebanon, particularly for cancer patients. Amidst these crises, our study evaluates its contribution to a concerning trend of operating on more late-stage and complex colorectal cancer (CRC) cases. We included 155 patients operated for CRC between 2017 and 2023. Patients age; sex; operation type (emergency or elective); tumor size, grade, and location; tumour, node, metastasis stage; lymphatic, vascular and perineural invasions; American Society of Anesthesiologists (ASA) score, presentation and previous history, and complications were examined. Surgical outcomes remained relatively consistent before and after the crisis. However, there was a notable increase, with patients being 3.59 times more likely to undergo resection of adjacent organs in metastatic disease post-crisis. Patient characteristics also exhibited notable shifts, with a 9.60-fold increase in the likelihood of having an ASA score of at least 2 after the crisis. Additionally, there was a 5.36-fold decrease in the odds of patients undergoing a colonoscopy before their diagnostic one post-crisis. Preoperative carcinoembryonic antigen levels were significantly elevated post-crisis compared to pre-crisis levels. Pathological findings revealed increased odds of perineural, vascular, and lymphatic invasion post-crisis. Additionally, there was a notable increase in the likelihood of hepatic synchronous metastases post-crisis. Furthermore, a trend to operate on complicated diseases was noted with an increased number of colostomies. The economic crisis in Lebanon has profoundly affected early intervention and comprehensive treatment for CRC patients, resulting in a concerning rise in late-stage cases requiring surgical intervention.

Strong associations between fasting lipids and glucose concentrations and ALT levels strengthened with increasing ALT quantiles

BackgroundA persistent redox state and excessive reactive species involved in carbohydrate and lipid metabolism lead to oxidative damage in the liver, however, how fasting plasma concentrations of lipids and glucose are associated with fasting blood levels of alanine transaminase (ALT) and aspartate transaminase (AST) remains to be evaluated in large-scale population.MethodsA cross-sectional study with 182,971 residents aged 18 to 92 years; multidimensional stratified analyses including quantile linear regression analysis and sex stratification were adopted to improve the quality of the evidence.ResultsThe associations between the concentrations of non-HDL-C and triglyceride and ALT levels were positive, stronger in males in each quantile of ALT levels and the coefficients expanded with increasing ALT levels at slopes of 3.610 and 5.678 in males and 2.977 and 5.165 in females, respectively. The associations between the HDL-C concentrations and ALT levels were negative, also stronger in males in each quantile and the coefficients expanded with increasing ALT levels at slopes of -7.839 in females and − 5.797 in males. The associations between glucose concentrations and ALT levels were positive, but stronger in females in each quantile and the coefficients expanded with increasing ALT levels at slopes of 1.736 in males and 2.177 in females, respectively. Similar pattern consist of relatively weaker coefficients and slops were observed between concentrations of non-HDL-C, triglyceride and glucose and AST levels. The associations between albumin concentration and concentrations of blood lipids and glucose were relatively steady across all quantiles.ConclusionsThe dose dependent effect between blood concentrations of lipids and glucose and liver function changes suggests that excessive carbohydrate and lipid metabolism may cause subclinical liver damage. Long term sustained primary and secondary inflammatory factors produced in the liver might be transmitted to adjacent organs, such as the heart, kidneys, and lungs, to cause and/or exacerbate pathological changes in these visceral organs.

FP1.9 - Evaluating outcomes of multi-visceral resections for locally advanced colorectal cancer

Abstract Introduction Multi-visceral resection for colorectal cancer invading into adjacent organs is often difficult and involves serious complications. The aim of this study is to evaluate the short- and long-term outcomes of patients undergoing multi visceral and beyond TME (total mesorectal excision) resections for locally advanced CRC. Methods Patients undergoing elective surgery for advanced or recurrent CRC between October 2018 and October 2023 were identified. Demographic and clinical data were recorded, and outcomes analysed. Primary outcome was R0 resection rate and post-operative complication rate. Results Thirty-three patients (51.5% male, 48.5% female) were included, with a median age of 66.8 years (IQR 38-82) and median BMI was 26.7 kg/m2 (13.8-50). Majority of patients (n = 29, 87.8%) had surgery for primary, locally advanced CRC and most were referred from external Trusts (n=25, 75.7%). Thirteen patients (39.3 %) had robotic resections, one case was completed laparoscopically, and the remaining were open procedures (n= 19, 57.5%). Seventeen individuals had previous abdominal surgeries with no differences between open (8/20 = 40%) and robotic approach (9/13 = 69.2%) (p=0.207). Median LOS in open and robotic groups were 16 and 10 days respectively (p=0.047). There was no post-operative mortality. Proportion of CD I-II complications was 9/33 (27.3%) and CD III-IV 18/33 (54.5%). R0 resections rate was 63.6 % and eight patients (24.2%) developed recurrence during the follow up period (median = 47.6 months). Conclusions An aggressive surgical approach as part of a multimodal strategy affords the best prospect for long-term survival in selected patients. Robotic multi-visceral resection for locally advanced CRC is a safe and feasible, minimally invasive approach in selected cases.

Management of patients with adrenal myelolipoma: experience from a tertiary referral centre.

Adrenal myelolipomas are rare, benign, tumours of the adrenal cortex. This study reports the experience of a tertiary adrenal surgery referral centre's approach to the management of patients with adrenal myelolipoma. A retrospective observational cohort study was conducted on all adult patients (> 18years age) diagnosed with adrenal myelolipoma from January 1, 2014, to December 30, 2022. Demographics, imaging characteristics, histological diagnosis (where applicable) and follow-up data were compared between patients undergoing surgery and those referred to surveillance. Indications for operative intervention were recorded at the time of multidisciplinary team discussion, consisting of surgeons, endocrinology physicians, radiologists, pathologists and specialist nursing representatives. Of the 522 patients with an adrenal lesion discussed in adrenal tumour meeting between 2014 and 2022, n = 15 (2.8%) were diagnosed with adrenal myelolipoma. Of the 15 patients, 4 underwent adrenalectomy at first presentation (27%), while 1 patient underwent adrenalectomy after interval follow-up. Indications for operative intervention were as follows: 'indeterminate lesion' (n = 3), 'abdominal pain and size (> 4cm)' (n = 1) and 'mass effect on adjacent organs' (n = 1). The mean rate of lesion growth in patients referred for surveillance (n = 10) was 0.13cm/year. Histology confirmed adrenal myelolipoma as the diagnosis in all resected tumours. For patients with adrenal myelolipoma, the presence of symptoms and/or indeterminate features on imaging may be more clinically useful indications for operative intervention over size alone. The surveillance of adrenal myelolipomas, even in patients with adrenal lesions > 4cm, is a safe clinical strategy, provided the imaging characteristics are benign and patients remain asymptomatic.

278. PROPOSED REVISION TO THE DESCRIPTION OF T3 FOR ESOPHAGEAL CANCER: REMOVAL OF “ADVENTITIA”

Abstract Background T3 is an important depth for esophageal cancer to target for surgical cure. According to the Union for International Cancer Control (UICC), T3 is defined as tumor invading the adventitia. However, it remains unclear what structures the adventitia refers to. In fact, tumors that do not directly invade adjacent organs have been classified as T3, even if they extend through the adventitia. Furthermore, in tumors arising at the esophagogastric junction (EGJ), it is difficult to determine the border with the subserosa that defines T3 of the stomach. Our aim was to revise the description of T3 in esophageal cancer. Methods The Union for International Cancer Control T-classification was reviewed from a histologic, pathologic, and embryologic perspective. Analysis of endoscopic ultrasound images, review of intraoperative images, and detailed observation of surgical specimens were followed by a review of the literature. Results Histologically, the adventitia is the extramural adipose connective tissue of the digestive tract and serves as a conduit for blood vessels, lymphatics, and nerves. The esophageal adventitia is further surrounded by connective tissue of adjacent organs, such as the tissue around the trachea, the tissue around the descending thoracic aorta, the pulmonary ligament, and the tissue on the diaphragm (Fig. 1a). In the 2022 revision of the Japanese Esophageal Society, resectable borderline cases in which adjacent organ invasion cannot be excluded by preoperative imaging were subclassified as borderline resectable T3 (T3br). From another perspective, this is a clinically reasonable criterion that not only adventitial invasion, but also invasion of connective tissue associated with adjacent organs is classified as T3. Beyond the EGJ, the adventitia is covered by mesothelium in the peritoneal cavity and leads to the subserosa. Endoscopic ultrasound revealed the fatty tissue of the adventitia as a highly echogenic layer on the surface of the muscularis propria, which continues uninterrupted beyond the EGJ into the stomach, indicating that the adventitia is connected to the subserosa. Intraoperative images showed that the descending posterior trunk of the vagus nerve and its associated vessels pass through the adipose tissue surrounding the esophagus in the esophageal hiatus (Fig. 1b). Thus, the ambiguity in the T-classification of esophageal cancer is not resolved as long as T3 is defined by the adventitia. In practice, however, physicians may have classified tumors as T2 if confined to the muscularis propria, T4 if invading adjacent organs, and T3 if neither. Conclusion We suggest that the description of T3 esophageal cancer be revised to read "tumor extends through the muscularis propria" rather than using the term "adventitia". This revision would clarify the depth criteria for determining the indication for surgical treatment not only for esophageal cancer, but also for EGJ carcinoma where the tumor center overlaps the gastric side.