ASA Level Research Articles

No difference in midterm outcomes and complication rate between retroperitoneal and transperitoneal open aortic aneurysm repair in females.

Abdominal Aortic Aneurysms (AAA) in females are less prevalent, have higher expansion rates and experience rupture at smaller diameters than in males. Studies have compared outcomes of the retroperitoneal (RP) and transperitoneal (TP) approach in open aortic aneurysm repair (OAR) with conflicting results. No study to date has compared the two approaches solely in females. In this study we compare midterm outcomes of the RP and TP approach in females undergoing OAR. Single-center, retrospective review of all females undergoing OAR from 2010 to 2021. Patients undergoing elective, symptomatic and ruptured OAR were included. The cohort was stratified by surgical approach RP versus TP and midterm outcomes were compared amongst the groups. Outcomes included mortality, graft related, and non-graft related complications. A total of 244 patients (RP n = 133; TP n = 111) were identified. Follow-up period was 28 ± 30.7months. Baseline perioperative characteristics were similar except that more people in the RP group had ejection fraction ((EF) > 50% (82% vs 68%), p = .037). Patients who underwent RP repair had longer visceral/renal ischemia time (p = .01), larger graft diameter (18 vs 16mm; p = <0.001), were more likely to have a suprarenal clamp placed(70.5 vs 48.2; p < .001), and had decreased autotransfusion volume (611 vs 861mL; p < .01) compared to those who underwent TP repair. Number of deaths was higher in the TP group during study follow-up period (36.4 vs 23.8; p = .035), but the difference of the time to event analysis was not significant. There was no difference in all-cause survival at 36 months between RP and TP (77.8 vs 76.8; p = .045). Overall midterm complications were 9.5% in both groups. Any graft related complication was 1.8% in TP versus 3% RP (p = .69). In a multivariable model, after adjusting for age, urgency, smoking, prior aneurysm repair, and ASA level, the hazard ratio decreases with the RP approach, however this did not reach significance (p = .052). In a 12-year period of OAR in females, TP and RP results were comparable at midterm analysis. The RP approach appeared to be used more often for OAR requiring suprarenal clamping. Although the TP group had increased mortality, the difference of the time to event analysis was not significant. Midterm postoperative complications in both groups were low. This suggests that both approaches are safe in the female population and decision should be driven by anatomy and surgeon's preference.

Tourniquet-free minimally invasive total knee arthroplasty is associated with early aseptic loosening

BackgroundWhile tourniquet-free (T-) total knee arthroplasty (TKA) has gained popularity, tourniquet-use during minimally-invasive (MIS)-TKA has not been adequately studied. Traditional techniques employ knee hyper-flexion, compressing vasculature and reducing impact of bleeding, while MIS-TKA embraces the semi-extended knee position, which does not restrict the effects of bleeding on cementation and visualization. We compared the risk of aseptic loosening between patients undergoing T- MIS-TKA compared to T + MIS-TKA. MethodsThis single-surgeon cohort study included 329 consecutive MIS-TKA (226 T+,103 T-) patients with minimum 3-year follow-up. Aseptic loosening, radiolucent lines (RLL), health related quality of life scores, and complications were recorded. T-test and chi-square test were used to compare continuous and categorical variables, and logistic regression included BMI, age, ASA, patellar-resurfacing, and tourniquet-use. ResultsThere were no differences in baseline demographics. One (0.4 %) aseptic loosening occurred with T+, versus 7 (6.8 %) with T- (p = 0.002). No T + and 3 T- patients (2.9 %, p = 0.01) had revision for aseptic loosening. The incidence of RLLs was 16.8 % in T + and 30.1 % in T- (p = 0.008). Logistic regression revealed T + was significantly associated with decreased aseptic loosening and risk of RLL (odds ratio = 16.4, odds ratio = 2.8). ConclusionIn this consecutive series, T- MIS-TKA was associated with increased rates of revision for aseptic loosening as compared to the T + MIS-TKA, even controlling for BMI, age, ASA level, and patellar resurfacing. Radiolucent lines were increased with T- MIS-TKA compared to T + MIS-TKA. Complications, all-cause revision, ROM, and HRQoL scores were similar between tourniquet-use and tourniquet-free cohorts.

Effects of Fracture Liaison Service on Outcomes of Patients with Hip Fracture in Rural Area of an Asian Country.

Fracture Liaison Services (FLS) has been proven effective in reducing subsequent fractures and related mortality. However, more research is needed on the impact of FLS on the 30-day readmission rate and its effectiveness in rural hospitals. This study aims to assess the impact of FLS on clinical outcomes including readmission rates, subsequent fractures, and fracture-related mortality in rural areas of an Asain country. In a rural hospital in Taiwan, we conducted a two-year prospective cohort study on elderly individuals with fragility hip fractures. The study compared the clinical outcomes between the control group and the FLS-cohort group. Logistic regression analysis was used to identify factors contributing to 1-year mortality after injury. 556 patients were enrolled. (304 in the control group and 252 in the FLS group) The mean age was 79.8years. The findings revealed that the introduction of FLS did not result in significant differences in mortality, readmission, complication, subsequent fractures, or secondary hip fractures. However, there were notable improvements in the length of hospital stay and the proportion of patients receiving surgery within 48h following the implementation of FLS. Subgroup analysis showed that FLS patients who received anti-osteoporotic treatment had lower mortality and 30-day readmission rates. Factors associated with higher 1-year mortality included male, high ASA level, and delayed surgery. This study provides the real-life evidence of the effect of intensive FLS model in a rural hospital in an Asian country. While FLS did not show significant differences in certain clinical outcomes, it led to shorter hospital stays and increased timely surgeries. FLS patients receiving anti-osteoporotic treatment had better mortality and readmission rates. Further research is necessary to gain a comprehensive understanding of the impact of FLS care in rural areas of Asia.

Overexpression of banana GDP-L-galactose phosphorylase (GGP) modulates the biosynthesis of ascorbic acid in Arabidopsis thaliana

l-Ascorbic acid (AsA) is a potent antioxidant and essential micronutrient for the growth and development of plants and animals. AsA is predominantly synthesized by the Smirnoff-Wheeler (SW) pathway in plants where the GDP-L-galactose phosphorylase (GGP) gene encodes the rate-limiting step. In the present study, AsA was estimated in twelve banana cultivars, where Nendran carried the highest (17.2 mg/100 g) amount of AsA in ripe fruit pulp. Five GGP genes were identified from the banana genome database, and they were located at chromosome 6 (4 MaGGPs) and chromosome 10 (1 MaGGP). Based on in-silico analysis, three potential MaGGP genes were isolated from the cultivar Nendran and subsequently overexpressed in Arabidopsis thaliana. Significant enhancement in AsA (1.52 to 2.20 fold) level was noted in the leaves of all three MaGGPs overexpressing lines as compared to non-transformed control plants. Among all, MaGGP2 emerged as a potential candidate for AsA biofortification in plants. Further, the complementation assay of Arabidopsis thaliana vtc-5-1 and vtc-5-2 mutants with MaGGP genes overcome the AsA deficiency that showed improved plant growth as compared to non-transformed control plants. This study lends strong affirmation towards development of AsA biofortified plants, particularly the staples that sustain the personages in developing countries.

Abstract P2-15-04: Surgical outcomes of ambulatory mastectomy with immediate alloplastic reconstruction for breast cancer or risk reduction

Abstract Purpose: Since 2015, mastectomy with immediate implant-based reconstruction at our institution is an ambulatory “day surgery” procedure. Ambulatory criteria for surgery including ASA level, BMI and major comorbidities were used to screen patients. We aim to evaluate surgical outcomes for women who undergo ambulatory mastectomy with immediate alloplastic reconstruction for breast cancer or risk reduction. Our primary objective was to determine the impact of mastectomy type (nipple- or skin-sparing mastectomy) and device location (subpectoral versus prepectoral plane) on complication rates. Methods: We performed a retrospective cohort study of women receiving immediate alloplastic reconstruction following mastectomy for either breast cancer or risk reduction at Women’s College Hospital in Toronto, Ontario, Canada between 2015 and 2021. We collected demographic data on age, ethnicity, smoking status, and menopausal status. Clinical data collected included breast size, ptosis, surgical indications, laterality, location and type of implant, type of mesh used, and overall complication rate. We used a multivariable logistic regression model to determine the impact of mastectomy type and implant location on complication rates, with age, smoking status, breast size, ptosis, surgical indication, and use of mesh as covariates. Statistical analysis was performed using SAS® OnDemand for Academics and P values &amp;lt; 0.05 were considered statistically significant. Results: 284 women underwent mastectomy with immediate alloplastic reconstruction for risk reduction (130, 45.8%) and breast cancer (154, 54.2%). 134 (47%) underwent skin-sparing mastectomy (SSM) and 149 (53%) underwent nipple-sparing mastectomy (NSM). Demographic and clinical data are presented in Table 1. There was an overall complication rate of 19.4%; women having NSM had a higher crude complication rate compared with SSM (25.5% vs 12.6%, P = 0.006). In our multivariable logistic regression model, there was no interaction between mastectomy type and device location on complication rate (P = 0.5). There was also no difference in complication rates associated with SSM compared with NSM (OR 2.9, 95% CI 0.95 – 9.0, P = .06) or implant location (P = 0.1). Younger age (OR 0.93/year increase in age, 95% CI 0.89-0.98, P = 0.005) and having surgery for breast cancer (OR 3.4, 95% CI 1.1 – 10.2, P = 0.03) were associated with an increased likelihood of complications. Conclusion: In women undergoing ambulatory mastectomy with immediate alloplastic reconstruction for breast cancer or risk reduction, there was no impact of mastectomy type (SSM vs NSM) or implant location (subpectoral vs prepectoral) on complication rates. Non-modifiable factors such as age and having surgery for breast cancer predicted having a complication. Our data suggest that with appropriate patient selection, there is no difference in surgical outcomes between mastectomy types and implant location in the ambulatory surgery setting. Table 1.1 Total Cohort Demographic and Clinical Data Table 1.2 Total Cohort Demographic and Clinical Data Citation Format: Simran Sandhu, Tulin D. Cil, Jaime M. Escallon, Mitchell Brown, John Semple, David Lim. Surgical outcomes of ambulatory mastectomy with immediate alloplastic reconstruction for breast cancer or risk reduction. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-15-04.

The Effects of the COVID-19 Pandemic on Mastectomy Outcomes for Breast Cancer

BackgroundSingle center studies have shown that during the Coronavirus Disease 2019 (COVID-19) pandemic, many patients had surgical procedures postponed or modified. We studied how the pandemic affected the clinical outcomes of breast cancer patients who underwent mastectomies in 2020. MethodsUsing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we compared clinical variables of 31,123 and 28,680 breast cancer patients who underwent a mastectomy in 2019 and 2020, respectively. Data from 2019 served as the control, and data from 2020 represented the COVID-19 cohort. ResultsFewer surgeries of all kinds were performed in the COVID-19 year than in the control (902,968 vs. 1,076,411). The proportion of mastectomies performed in the COVID-19 cohort was greater than in the control year (3.18% vs. 2.89%, <0.001). More patients presented with ASA level 3 in the COVID-19 year vs. the control (P < .002). Additionally, the proportion of patients with disseminated cancer was lower during the COVID-19 year (P < .001). Average hospital length of stay (P < .001) and time from operation to discharge were shorter in the COVID vs. control cohort (P < .001). Fewer unplanned readmissions were seen in the COVID year (P < .004). ConclusionThe ongoing surgical services and mastectomies for breast cancer during the pandemic produced similar clinical outcomes to those seen in 2019. Prioritization of resources for sicker patients and the use of alternative interventions produced similar results for breast cancer patients who underwent a mastectomy in 2020.

EGS P14 Can preoperative Neutrophil-lymphocyte ratio predict post-operative complications in appendicectomy?

Abstract Background Complications after appendicectomy remain common. Neutrophil-lymphocyte ratio (NLR) measures inflammation by incorporating the innate and adaptive components of the circulating immune system. We hypothesised that pre-operative NLR could predict post-operative complications after emergency appendicectomy. Methods A multicentre retrospective observational study was performed investigating all adults undergoing emergency appendicectomy across four hospital (2 teaching centres and 2 district general hospitals) between August 2018 and November 2020. Patients were identified through pathology records. Electronic records were studied for patient demographics, pre-operative routine laboratory tests, imaging, operative details, and post-operative complications. Neutrophil-lymphocyte ratio was calculated by dividing the pre-operative neutrophil count value by the lymphocyte value. A threshold of 8 was used based on previous literature. Results There were 1130 patients identified who underwent emergency appendicectomy, with 43.6% female. ASA level was I or II in 93.8% of patients, and 82.3% underwent a laparoscopic approach. Perforated appendicitis was observed in 21.7% of patients and two patients died. Mean NLR was 10.3 (SD 8.2), with 50.9% of patients with an NLR of &amp;gt;8. NLR &amp;gt;8 was associated with deep surgical site infections (SSI) (p &amp;lt; 0.001). NLR &amp;gt; 8 was predictive of deep SSI with an odds ratio of 3.455 (CI 1.840–6.488, p &amp;lt; 0.001). Conclusions The NLR is an easy to calculate parameter which, when higher than 8, predicts deep surgical site infection following emergency appendicectomy and may help guide perioperative decision making such as antibiotic duration.

Early Monitoring of Redox Status Based on Reduced Molecules Using In Vivo DNP-MRI for Cancer Treatment

<h3>Purpose/Objective(s)</h3> Radiation treatment effectiveness is assessed through the observation of morphological changes with CT or MRI images after treatment. The treatment efficacy of radiotherapy depends on redox modulation in tumor tissue, such as hydroxyl radicals and of reactive oxygen species generated by irradiation. Therefore, redox status may be a prognostic factor response to radiotherapy. However, spatiotemporal response of the redox metabolism in tumor tissue post-irradiation remains unknown. The purpose of this study was to detect early changes in the redox status in tumor tissue after irradiation using <i>in vivo</i> dynamic nuclear polarization (DNP)-MRI, to clarify the key molecules that cause these changes, and to compare these changes with early changes in lactate metabolism using hyperpolarized ¹³C magnetic resonance spectroscopy (MRS). <h3>Materials/Methods</h3> To monitor the response of tumor redox status after irradiation, redox imaging using in vivo DNP MRI/ Carbamoyl PROXYL (CmP) as redox sensitive DNP probe was performed after 5 Gy irradiation. To clarify the relationship between redox status alteration and treatment efficacy, in vivo DNP MRI was performed before and after irradiation by 2 and 5 Gy. In addition, tissue GSH and AsA levels on day 1 post irradiation were determined by HPLC. To observe the Warburg effect after radiation treatment, dissolution DNP study using hyperpolarized ¹³C pyruvate was performed before and after irradiation. <h3>Results</h3> The DNP image intensity in the tumor demonstrated a maximum value approximately four minutes after CmP administration, thereafter the image intensity was decreased by the redox reaction. The tumor GSH and AsA level on day 1 post irradiation were decreased compared to the control group. Production of hyperpolarized ¹³C lactate in tumor tissue did not change before and after irradiation. <h3>Conclusion</h3> Our study highlights that redox status in tumor tissue is already significantly decreased on day 1 before the detection of any morphological changes, even after irradiation with a dose as low as 2 Gy. Early changes in this redox status may be related decreases in glutathione and ascorbic acid levels in the tumor tissue after irradiation, which may alter earlier than ¹³C pyruvate hyperpolarized MRS, based on lactate metabolism. Therefore, early assessment of change in decay rate using in vivo DNP-MRI/CmP probing may predict the subsequent radiotherapy effect.

Operative time tracking for umbilical hernia patients.

Army medical treatment facilities (MTFs) use a surgery scheduling system that reviews historical OR times to dictate expected procedural time when posting new cases. At a single military institution there was a noted inflation to umbilical hernia repair (UHR) times that was leading to issues with under-utilized operating rooms. This is a retrospective review determining what variables correlate with longer UHR operative time. Umbilical, ventral, epigastric, and incisional hernia repairs (both open and laparoscopic) were pulled from the local OR scheduling system at Dwight D. Eisenhower Army Medical Centerfrom January 2013 to June 2018. A total of 442 patients were included in the study with a mean age of 45.74years and 54.98% male. Patient ASA level (p 0.045), primary vs. mesh repair (p < 0.001), number of hernias repaired (p 0.05), hernia size (p < 0.001), and absence of student nurse anesthetist (SRNA) (p 0.05) all correlated with longer UHR OR times. For the aggregated open hernia repair data, almost all independent variables of interest were statistically significant including age, PGY level, history of DM, case acuity, presence of SRNA, patient ASA level, patient's BMI, hernia defect size, number of hernias, history of prior repair, and history prior abdominal surgery. Multivariate regression analysis was done on the open hernia repair variables with only age and size of hernia being significant. This data were used to create a new case request option (open UHR without mesh and open UHR with mesh) to more effectively utilize available OR time.

Secondary Infertility: A Neglected Aspect of Buerger's Disease.

During the gathering of demographic data for the biobank on Buerger's Disease (BD), we found that, after the clinical manifestation of BD, the patients usually became infertile, and the age of their last child was compatible with the time of disease diagnosis. The aim of this study was to evaluate the underlying cause of secondary infertility in BD patients. Anti-sperm antibodies (ASA), testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) in the sera of 39 male BD patients were measured and compared with 39 age-matched Caucasian male controls. Six patients declared that they suffered from impotency. The ASA level was positive in 25.6% of the patients and 2.4% of the controls (p= 0.003, CC= 6.96). The mean levels of testosterone in the patients and controls were 393.12±32.9 ng/dl and 354.37±30.9 ng/dl, respectively. The mean levels of LH in the patients and controls were 0.88±0.12 mIU/r and 0.85±0.1 mIU/r, respectively. The mean levels of FSH in the patients and controls were 4.1± 0.35 mIU/r and 3.56±0.33 mIU/r, respectively. No significant difference in the serum levels of testosterone, LH, or FSH was found between the patients and controls (p> 0.05). The spermograms of three ASA-negative patients demonstrated impaired sperm motility. Anti-sperm antibodies, disturbed genital circulation, autonomic dysfunction and sperm motility may be responsible for secondary infertility in Buerger's Disease.

Supraclavicular Brachial Plexus Block with or without Dexamethasone

Aim: To assess the effect of supraclavicular brachial plexus block in patients with or without dexamethasone. Study design: Double blind randomized controlled trial Place and duration of study: Department of Anesthesia and Critical Care, The Indus Hospital a free of cost tertiary care hospital in Karachi from 9th May 2019 to 19th February 2020. Methodology: Sixty patients were enrolled with 30 patients in each intervention group. Patients who came for elective or emergency surgery of the upper limb below shoulder were included in the study. Block performed on patients lying supine at 45 degree. The dexamethasone group received 0.25% plain bupivacaine 18 ml with 2ml dexamethasone (0.4mg/ml) and control group received 0.25% plain bupivacaine 18 ml with 2 ml normal saline. Results: The age of the group B patients was higher than the group A patients such as 43.4±15.7 years vs 38.6±14.2 years. The ASA level presented higher scoring than II in patients from Group B with 63.3% those patients who called for pain. In this study the intra operative vital signs showed an insignificant variance in both groups.However, a significant increase in duration of analgesia was observed in group A. Conclusion: Perineural administration of dexamethasone with clinical bupivacaine concentration can prolong the duration of anesthesia. Keywords: Supraclavicular, Brachial plexus block, Dexamethasone

Prognostic value of disease-free interval in colorectal cancer: Is it time?

BackgroundPrevious studies have outlined that the onset of synchronous colorectal cancer (CRC) metastases is associated with poor overall survival (OS) compared to patients with metachronous disease. The aim of this study was to evaluate the association of disease-free interval with newly diagnosed CRC scheduled for primary tumor resection. MethodsPatients who underwent primary CRC resection over an 18-year period were identified from a prospective database at a tertiary-care hospital. In this observational study, the cohort was stratified for the onset of metastases, i.e. synchronous, early-onset and late-onset metachronous disease. The OS was compared using Kaplan-Meier estimators and stratified Cox hazard regression analysis. ResultsOf 360 patients, 204 (57%) had synchronous, 61 (17%) had early metachronous, and 95 (26%) had late metachronous metastases, respectively. The onset of synchronous metastases was not associated with worse OS compared to early and late metachronous disease. ASA level > II (P = 0.011), right-sided compared to left-sided cancer (P = 0.032) or rectal cancer (P < 0.001), and high-grade tumors (P = 0.022) were identified as independent predictors of poor OS, whereas the only favorable prognostic factor was surgical resection of metastases (P = 0.047). Additionally, ASA level < III (P = 0.003) and low-grade tumors (P = 0.032) were found to predict resection of metastases. ConclusionIndividual patients' and tumor characteristics rather than the timing of metastases are associated with OS in newly diagnosed CRC. These data support curative treatment strategies even in patients with synchronous metastases.

451 Dural Tears in Full-Endoscopic Unilateral Laminotomies for Bilateral Lumbar Decompression

INTRODUCTION: Full-endoscopic unilateral laminotomy for bilateral lumbar decompression (ULBD) for spinal stenosis has proven benefits when compared to microscopic technique. Intraoperative laceration of the dura may be encountered and their optimal technique and effectiveness of full-endoscopic dural repair remains unclear. METHODS: For this analysis, we utilize a prospectively collected database of all patients undergoing ULBD from 2015 to 2021 at our institution. We evaluate whether patient specific factors such as sex, age, body mass index (BMI), smoking status, ASA level, number of levels, or previous index level surgery affects durotomy risk. We then determine whether having an intraoperative durotomy affects length of stay (LOS), revision surgery risk, length of time on postoperative pain medications, or Oswestry Disability Index (ODI) scores. RESULTS: In 174 patients undergoing ULBD, there were 11 patients who sustained intraoperative dural tears (6.3%). Utilizing our novel bimanual technique, there was only one patient who required temporary CSF drainage via a lumbar drain. None required revision surgery for CSF leak repair. Durotomy risk was not significantly affected by any patient specific risk factors. Sustaining a durotomy did increase LOS (p=0.033). Intraoperative durotomies did not affect revision surgery risk, or length of time on postoperative pain medications. Utilizing MCID of 12.8 increase in ODI, 70.8% of non-durotomy patients achieved the MCID goal versus 60.0% of durotomy patients. However this trend did not achieve statistical significance (p = 0.605). CONCLUSION: Our novel method of bimanual repair of CSF leaks in full-endoscopic spine surgery appears to be a safe and feasible. There are no patient specific risk factors affecting durotomy risk. Sustaining a durotomy intraoperatively affects LOS but does not significantly alter any other aspect of the postoperative course for patients undergoing ULBD.

A Cost Comparison of Holmium Laser Enucleation of the Prostate with and without Moses™.

Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the treatment of benign prostatic hyperplasia. HoLEP has been shown to have excellent improvements in prostate symptom scores and maximum flow rates that have been durable for 2 decades. However, the steep learning curve associated with HoLEP has prevented its widespread adoption. New advancements in lasers, specifically the Moses™ pulse-modulation technology, have resulted in improvements in hemostasis and achieving same-day discharges and catheter removals. We aimed to perform a cost-comparison to analyze if Moses-augmented HoLEP (m-HoLEP) resulted in cost-savings. A retrospective review was performed of a single expert surgeon's experience from May 2018 to November 2020, comparing m-HoLEP with HoLEP. Perioperative and postoperative variables were abstracted from the medical record. Univariate and multivariate analyses were performed using SAS® 9.4. Two-sided significance was set at p <0.05. A total of 312 men underwent HoLEP during the study period (192 in m-HoLEP group and 120 in HoLEP group). The m-HoLEP group had more same-day discharges (p <0.001) and emergency department visits (6.3% vs 1.7%, p=0.0071). m-HoLEP resulted in hospital cost savings of $840 for the initial surgical episode (p=0.0297). When factoring in emergency department visits/readmissions, the cost savings decreased to $747 per case (p=0.0574). m-HoLEP was associated with same-day discharge and hospital cost savings of $840 for the initial surgical episode. Further study in other institutions with surgeons of varying experience levels will need to be performed to see if these findings can be replicated.

Intraoperative hypothermia in patients undergoing Total knee arthroplasty: a cross-sectional study from a developing country

BackgroundIntraoperative hypothermia is associated with various risk factors, morbidity, and mortality in patients undergoing total knee arthroplasty (TKA), increasing the emotional and financial burden on patients. This study aimed to identify risk factors of intraoperative hypothermia in patients undergoing TKA.Materials and methodsAll adult patients (⩾18 years) who underwent TKA from January 2016 to December 2017 at a tertiary-care hospital in Pakistan were included in this retrospective, cross-sectional study. Temperature < 36 °C was defined as hypothermia.ResultsThe study included 286 patients (77.6% female) with a mean age of 61.4 ± 10.4 years. The overall proportion of intraoperative hypothermia was 26.6%. Of the total patients, 66.1% underwent bilateral TKA whereas 33.9% underwent unilateral TKA. 73.8% of the patients were ASA Level 2. Only 13.3% of patients had postoperative hypothermia.ConclusionIntraoperative hypothermia was significantly associated with age, bilateral procedure, ASA level and postoperative hypothermia in patients undergoing TKA. The surgeon and the operative team should be aware of the risk factors and the adverse outcomes associated with intraoperative hypothermia, especially in resource constrained settings to plan preventive strategies.Trial registrationThis study was retrospectively registered on ClinicalTrials.gov on 3rd October 2020. The registration ID is NCT04575246.

Can Antisperm Antibodies affect Male Fertility after Subinguinal Varicocelectomy ? A Local Study

Background: Antisperm Antibodies researches emerged in 1899 in a report referring to the ability of spermsto be antigenic in case of injection into a foreign species. In 1900, researchers showed that sperms are alsoantigenic in case of injection into similar species. Moreover, Wilson (1954) identified ASAB in the partnersof infertile male and then observed the association of ASAB with male infertility. In addition, a correlationwas found between ASAB and sperm proteomics, and thus researchers specified those ASABs decreasingmale fertilities via inhibition of the sperm functions crucial for fertilization.Objectives: The study aimed at evaluating the effect(s) of varicocelectomy on the anti-sperm antibody incases who suffer from varicocele.Methods: In the present prospective, controlled, clinical research which has been performed during theperiod from april 2015 to may 2020. Therefore, the blood samples have been randomly provided from190 males with mean age 33 years (ranging from 20-45 years) ,with the clinical varicocele who have beenindicated for varicocelectomy. Then, participants have been randomly selected from the urology outpatientclinic of Al-Yarmouk Teaching Hospital in Baghdad,Iraq,and Al-Ramadi Teaching Hospital and privateclinic.Results: In our study, ASA level (27.2%) with the positive serum ASA prior to with those (43.2%) followingthe operation demonstrated a significant difference statistically (p = 0.033). However, such a result has beennot confirmed in the patients (27.4%) with positive semen ASA prior to with those (31.3%) following thesurgical operation (p = 0.881).Conclusion: According to the results, varicocelectomy did not have any impact on the semen ASA,despite,but serum antibody enhanced following varicocelectomy and sperm motility improved. Therefore,varicocelectomy usefully affected the semen parameters in the infertile men suffering from varicocele.

Outcomes of robotic and laparoscopic cholecystectomy for benign gallbladder disease in Veteran patients.

The robotic platform for cholecystectomy has been extensively studied in comparison to its laparoscopic counterpart with acceptable outcomes. However, wide acceptance of a robotic approach to cholecystectomy has been limited by increased operative room (OR) times and substantially higher cost. This is a single-institution retrospective review of Veteran patients presenting for elective laparoscopic (LC) and robotic (RC) cholecystectomies for benign biliary disease at the Dallas VA Medical Center. The primary goal was to interrogate 30-day morbidity as well as operative room times, estimated blood loss (EBL), hospital length of stay (LOS), and conversion rates. The entire cohort included 612 patients (age = 55.1 ± 12.9years, men = 77.9%, BMI = 31.2 ± 6.3kg/m2) undergoing elective cholecystectomy (LC = 441 and RC = 171) for benign biliary disease (biliary colic = 78.8%, history of biliary pancreatitis = 7.8%, history of cholecystitis = 5.7%). Univariate analysis comparing LC and RC showed the two groups to be of similar age (55.4 ± 12.4 vs. 54.4 ± 14.2years; p = 0.4), male gender (79.4% vs. 74.3%, p = 0.2), and BMI (31.1 ± 6.4 vs. 31.5 ± 6.3kg/m2; p = 0.5). Except for dyslipidemia (LC = 48.3% vs. RC = 36.8%; p = 0.01), both groups had the same rate of co-morbid conditions. ASA level III and IV (LC = 60.1 vs. RC = 69.0%, p = 0.04) was higher in the RC group. Both groups underwent surgical intervention for similar indications (biliary colic LC = 80.5% vs. RC = 74.3; p = 0.1). Hospital LOS (1.7 ± 3.2 vs. 0.3 ± 0.9days, p < 0.001), EBL (32.3 ± 52.3 vs. 17.0 ± 43.1; p = 0.001), and conversion to open (6.6% vs. 0.6%, p = 0.001) were all superior with the robotic platform. Thirty-day overall morbidity (9.8% vs. 12.3%, p = 0.4), skin-to-skin OR time (84.5 ± 33.5 vs. 88.0 ± 35.3min, p = 0.2), and total OR time (129.2 ± 36.8 vs. 129.7 ± 39.7, p = 0.9) were similar between the LC and RC groups. Despite being older and having more comorbidities, Veteran patients undergoing robotic cholecystectomy experienced equivalent OR time and a moderate improvement in conversion rate, EBL, and hospital LOS compared to those undergoing conventional laparoscopy, therein demonstrating the safety and efficacy of the robotic platform for this patient population.

S0323 Precancerous Polyp and Colorectal Cancer Detection Rates and Safety of Surveillance Colonoscopy in Individuals Aged 75 Years and Above

INTRODUCTION: The risk of development of colorectal cancer (CRC) increases with age and history of colonic adenomas. Currently, there is limited data and lack of consensus about the age to discontinue surveillance colonoscopy in patients aged 75 and above who have had polyps in the past. Most guidelines recommend this decision to be considered individually. We aim to determine the precancerous polyp detection rate during surveillance colonoscopies and safety for individuals above age 75. METHODS: We conducted a retrospective chart review to identify patients who underwent a colonoscopy between the years of 2012 to 2019 and were over age 75. We collected data on patient characteristics, colonoscopy findings and histology of polyps. Exclusion criteria were patients with a history of CRC, polyposis syndromes, or Inflammatory Bowel Disease were excluded. Inclusion criteria included all colonoscopies being performed due to a history of colon polyps. Statistical analyses were conducted in SPSS version 26 to compute means and frequencies of patient characteristics and colonoscopy outcomes. RESULTS: A total of 591 colonoscopies were analyzed and 173 met the inclusion criteria. Median age was 78. A majority of the patients were female (55.5%) and Caucasian (92.5%). Good bowel preparation and high cecal intubation rates were consistent in all groups (Table 1). The majority of patients took aspirin (56.1%), had an ASA level 2 or less (71.7%) while a significant proportion had metabolic syndrome (43.3%), obesity (34.1%), alcohol abuse history (35.3%) and were ex-smokers (38.7%). Precancerous polyps were found in 15/173 (8.7%) colonoscopies. Most of the precancerous polyps were small, located in the proximal colon, and tubular or tubulovillous adenomas on histology (Table 2). The proportion of distal precancerous polyps increased with age. CRC was detected in the distal colon in one patient (0.57 %). No patients developed complications during or after their colonoscopy. CONCLUSION: In contrast to prior studies in the elderly which show a higher preponderance of polyps and/or cancer in the proximal colon, our limited data shows a higher rate of distal colon polyps and one distal CRC in the subgroup who are over age 85 (8% prevalence). There were no complications observed and the majority of the patients were healthy (ASA 1 or 2). Larger studies should be performed to further validate our findings while decision regarding surveillance colonoscopy should continue to be individualized.Table 1.: Demographics, colon cancer risk factors and quality features of surveillance colonoscopyTable 2.: Polyp and Colon cancer outcomes of surveillance colonoscopy

Measuring river planform changes from remotely sensed data – a Monte Carlo approach to assessing the impact of spatially variable error

Abstract. Remotely sensed data from fluvial systems are extensively used to document historical planform changes. However, geometric and delineation errors inherently associated with these data can result in poor or even misleading interpretation of measured changes, especially rates of channel lateral migration. It is thus imperative to take into account a spatially variable (SV) error affecting the remotely sensed data. In the wake of recent key studies using this SV error as a level of detection, we introduce a new framework to evaluate the significance of measured channel migration. Going beyond linear metrics (i.e. migration vectors between diachronic river centrelines), we assess significance through a channel polygon method yielding a surficial metric (i.e. quantification of eroded, deposited, or eroded-then-deposited surfaces). Our study area is a mid-sized active wandering river: the lower Bruche, a ∼20 m wide tributary of the Rhine in eastern France. Within our four test sub-reaches, the active channel is digitised using diachronic orthophotos (1950 and 1964), and the SV error affecting the data is interpolated with an inverse-distance weighting (IDW) technique. The novelty of our approach arises from then running Monte Carlo (MC) simulations to randomly translate active channels and propagate geometric and delineation errors according to the SV error. This eventually leads to the computation of percentage of uncertainties associated with each of the measured planform changes, which allows us to evaluate the significance of the planform changes. In the lower Bruche, the uncertainty associated with the documented changes ranges from 15.8 % to 52.9 %. Our results show that (i) orthophotos are affected by a significant SV error; (ii) the latter strongly affects the uncertainty of measured changes; and (iii) the significance of changes is dependent on both the magnitude and the shape of the surficial changes. Taking the SV error into account is strongly recommended even in orthorectified aerial photos, especially in the case of mid-sized rivers (&lt;30 m width) and/or low-amplitude river planform changes (&lt;1 m2m-1yr-1). In addition to allowing detection of low-magnitude planform changes, our approach is also transferable as we use well-established tools (IDW and MC): this opens new perspectives in the fluvial context (e.g. multi-thread river channels) for robustly assessing surficial channel changes.

The gallbladder that nobody wants: A prediction tool to assess the difficulty of cholecystectomy

Presenter: Maria Baimas-George MD, MPH | Carolinas HealthCare System Background: Cholecystectomy is a common procedure yet can have significantly varied outcomes based on patient physiology and comorbidities. As providers move towards fee-for-value models, it is important to risk stratify patients for appropriate referral and cost prediction. We analyzed differences in comorbidities, outcomes, and cost associated with cholecystectomy by acute care (ACS) versus hepatobiliary (HPB) surgical practices to create a predictive tool for difficult gallbladders. Methods: Patients were retrospectively identified through procedure codes from 2008 through 2015. Exclusion criteria included: (1) cholecystectomy performed at time of or as part of another procedure; (2) abdominal trauma requiring cholecystectomy; (3) ICU admission or preoperative vasopressor requirement. Cholecystectomies referred to HPB were identified and matched to general surgery cholecystectomies by demographics including sex, age, and surgery date. A regression model was created and trained to create a scoring system of independent risk factors. Results: There were 1160 cholecystectomies performed of which 736 were subjectively referred to HPB surgeons from general surgeons. Of these, 122 HPB cholecystectomies met inclusion criteria and were case matched to 126 general surgery cholecystectomies. In the HPB subset, there was higher burden of comorbid disease, different indications for surgery, and a significantly lower projected 10-year survival (87.4 % ACS vs. 68.5% HPB, p < .0001). Median surgical and hospital lengths of stay were longer in HPB patients (1 vs. 4 days, p < .0001; 2 vs. 5 days, p < .0001) as were 30-day and 90-day readmission rates (5.6% vs. 13.1%, p = .040; 7.9% vs. 20.5%, p = .005 respectively). Median cost was higher in the HPB population including operative supply cost (969.42 vs. 1920.66, p < .0001) and total cost of care (7340.66 vs. 19338.05, p < .0001). A predictive scoring system for a difficult gallbladder was constructed using five factors including history of liver disease, ASA, and alkaline phosphatase level. A score of ≥ 5 was determined to be the best cut-off value for the high-risk difficult gallbladder group and a phone application was created to assist providers in quick identification of such cases. Conclusion: Although often regarded as a simple procedure, a cholecystectomy in a complicated patient can become anything but, leading to a difficult operation, significantly longer hospital stays, and higher costs. The hybrid use of an objective scoring system along with a subjective clinical impression can help providers appropriately plan for high-risk patients with management of pre-operative patient expectations and consideration of an HPB consultation or transfer. This predictive tool highlights a population that should have a different reimbursement tool as the use of procedure codes to appropriately explain disparities in outcomes and costs is insufficient. The incorporation of comorbid disease and risk factors with such clinical metrics needs to be addressed for operative planning as well as categorization and reimbursement of surgical practices.