CD Grade Research Articles

EP624 - Clavien Dindo system in general surgical patients at a district hospital in NHS

Abstract Aims To try and use the Clavien-Dindo system of grading of surgical complications to General Surgical patients at NMGH. To understand the predictors of grades of surgical complications. Propose the use of the CD system in regular mortality and morbidity meetings. Methods Retrospective cohort study. Total patients studied were 104. List of all elective and emergency general surgical patients at NMGH from 1st Feb to 2nd March 2023 collected from HIVE. Data collected included MRN, age, sex, BMI, ASA category, surgical time, blood loss, type of surgery, complication and CD grade. CD grade was calculated from the patient notes. Statistical analysis was performed on StatsDirect3 from MFT. Results 26.9 % (n = 28) of the patients developed CD grades complications overall. Mild complications (grade 1 and 2) were 18.2 %. Serious complications (grade 3 and 4) were 7.7 %. CD 5 was 0.96 % 51 % of emergency cases develop complications (Mild 29%, serious 20%, death 2 %) 11 % of elective cases develop mild complications and no serious complications. Age and ASA grade have no statistically significant relationship in the present study. Higher BMI is associated with lower grades of complications in this study. Conclusion Female patients in an emergency setting with a blood loss of greater than 100 ml and a surgical time of 150 minutes or greater developing grade 2 complications. Emergency cases carry 4.6 times more complication rates than elective cases. Blood loss of 50 ml or greater would give rise to CD 1 or greater. Surgical time of lesser than 125 minutes gives CD 1. Surgical time 125 to 200 minutes gives CD 2.

EP625 - Perioperative complications in general surgical patients at a district hospital in NHS

Abstract Aims To try and use the Clavien-Dindo system of grading of surgical complications to General Surgical patients at NMGH. To understand the predictors of grades of surgical complications. Propose the use of the CD system in regular mortality and morbidity meetings. Methods Retrospective cohort study. Total patients studied were 104. List of all elective and emergency general surgical patients at NMGH from 1st Feb to 2nd March 2023 collected from HIVE. Data collected included MRN, age, sex, BMI, ASA category, surgical time, blood loss, type of surgery, complication and CD grade. CD grade was calculated from the patient notes. Statistical analysis was performed on StatsDirect3 from MFT. Results 26.9 % (n = 28) of the patients developed CD grades complications overall. Mild complications (grade 1 and 2) were 18.2 %. Serious complications (grade 3 and 4) were 7.7 %. CD 5 was 0.96 %. 51 % of emergency cases develop complications (Mild 29%, serious 20%, death 2 %). 11 % of elective cases develop mild complications and no serious complications. Age and ASA grade have no statistically significant relationship in the present study. Higher BMI is associated with lower grades of complications in this study. Conclusion Female patients in an emergency setting with a blood loss of greater than 100 ml and a surgical time of 150 minutes or greater developing grade 2 complications. Emergency cases carry 4.6 times more complication rates than elective cases. Blood loss of 50 ml or greater would give rise to CD 1 or greater. Surgical time of lesser than 125 minutes gives CD 1. Surgical time 125 to 200 minutes gives CD 2.

572. TECHNICAL DETAIL AND SHORT-TERM OUTCOMES OF ROBOT-ASSISTED CERVICAL ESOPHAGECTOMY (RACE) WITH BILATERAL CERVICAL APPROACH FOR ESOPHAGEAL CANCER

Abstract Background The transcervical mediastinoscopic esophagectomy is a relative new technique that has gradually demonstrated because of its ease of dissection along the organ sheath and its less invasive nature. However, the conventional cervical approach to mediastinoscopy has been reported to have a relatively high rate of recurrent nerve palsy due to interference in the mediastinum caused by the straight forceps. The robot-assisted transcervical esophagectomy (RACE) approach is novel procedure expected to reduce these interferences and improve maneuverability around the recurrent nerve. In this report, we describe a surgical technique and short-term outcome of RACE. Methods In this study, we included 26 RACE cases performed between Feb 2023 to Feb 2024. Principally, our hospital performs transcervical esophagectomy mainly on patients who are difficult to approach by transthoracic approach due to history of thoracic diseases, etc. In our department, transcervical esophagectomy is usually performed via a bilateral cervical approach, starting from the right neck and continuing to the left neck, and RACE is performed using the da Vinci Xi via a bilateral cervical approach as well. Recently, we have been shortening the operation time by performing simultaneous cervical and abdominal operations without muscle relaxation using NIM. Results Patient background: mean age 74.5, male to female ratio 22:4, cStage I/II/III/IV: 13/3/9/1, NAC: 46.1%, more than 80% had some history of pulmonary disease/systemic history. All patients underwent RACE via bilateral cervical approach, and no intraoperative complications or thoracoscopic conversion were observed. Postoperative complications (CD Grade≥1) included recurrent nerve palsy in 15.6% and respiratory complications in 7.6%. In addition, the recent operation with simultaneous cervical/abdominal NIM and no muscle relaxant has significantly shortened the average total operative time to 4 hours and 40 minutes. Conclusion Robot-assisted Cervical Esophagectomy (RACE) is a relatively safe procedure that offers a natural anatomic approach, fewer respiratory complications, and a significant reduction in operative time due to simultaneous neck and abdominal manipulation. With the advancement of robotics and devices, RACE is expected to become more effective and more widely used in the future.

412. COMPARISON BETWEEN PREOPERATIVE MALNUTRITION, AND SARCOPENIA AND POSTOPERATIVE COMPLICATIONS IN ESOPHAGEAL CANCER PATIENTS

Abstract Background Typical indicators of malnutrition in cancer patients include BMI, CONUT, PNI, and prealbumin, while SMI and PMI are often used as indicators of skeletal muscle mass loss (sarcopenia). Although these indicators have been reported to be associated with surgical outcomes, their combination may be useful in determining the effectiveness of perioperative management because these are closely related during the perioperative period. Methods A total of 132 esophageal cancer patients who underwent esophagectomy between January 2021 and May 2023 were included in this study. Preoperative BMI, CONUT, PNI, prealbumin, SMI (measured by BIA), and PMI (measured by CT imaging) were extracted from clinical record. We also selected BMI and SMI as a new indicator for combined malnutrition and loss of skeletal muscle. Then, we investigated the association between these indicator and postoperative complications (pneumonia, suture failure, total CD Grade ≥II, total CD ≥IIIa), and length of hospital stay. Results The mean age of patients was 67.3 years, 107 were male and 25 were female. Preoperative chemotherapy was administered to 58 patients. Although associations with each single index were found for postoperative pneumonia and low BMI, low SMI, and low PMI, there was no significant association with anastomotic leakage or overall complications. On the other hand, low BMI+SMI was strongly correlated with postoperative pneumonia, overall Grade≥II, and Grade≥IIIa complications. In postoperative hospital stay, low BMI, low PNI, and low SMI as single indicators showed a significant increase in hospital stay, while low BMI+SMI showed further statistically significant increase. Conclusion In patients who underwent esophagectomy, single index for malnutrition and low skeletal muscle mass may be predictors of postoperative complications respectively. However, because perioperative management is inseparable from nutritional therapy and exercise therapy, composite index of BMI and SMI may be better predictor of therapeutic efficacy of perioperative nutrition and exercise therapy.

The Role of Secondary Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy in Recurrent Ovarian Peritoneal Carcinomatosis.

Ovarian cancer maintains the highest mortality rate among gynecological malignancies. Unfortunately, two-thirds of cases are diagnosed at an advanced stage with the presence of peritoneal carcinomatosis. In this study, we aimed to present the 7-year results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in cases where peritoneal carcinomatosis developed during the medical oncological treatment and follow-up after primary high-grade serous ovarian cancer debulking surgeries. Data from 63 patients collected prospectively in our clinic were retrospectively evaluated. Postoperative Clavien-Dindo grade 3-4 complications occurred in 12 cases (19%) and 14 cases (22.2%), respectively. CD grade 3a complications developed in four cases (6.3%), which were treated with percutaneous drainage catheters, while CD grade 3b complications occurred in eight cases (12.7%), and these cases underwent reoperation. Five cases (7.9%) experienced mortality within the first 30 days. The mean survival time was determined as 44.99 months (36.33-53.65), while the median survival time was 56 months. In selected patients requiring redo surgery due to recurrent ovarian cancer, secondary cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are associated with longer overall survival and should be considered in the treatment of advanced-stage disease. Further large-scale randomized controlled trials are needed in this regard.

Endoscopic resection in subepithelial lesions of the upper gastrointestinal tract: Experience at a tertiary referral hospital in The Netherlands.

Background and study aims Histological confirmation of subepithelial lesions (SELs) in the upper gastrointestinal tract remains challenging. Endoscopic resection of SELs is increasingly used for its excellent diagnostic yield and opportunity to do away with continued surveillance. In this study, we aimed to evaluate the indications, success rates and complications of different endoscopic resection techniques for SELs at a large, tertiary referral hospital in Rotterdam, The Netherlands. Patients and methods Data between October 2013 and December 2021 were retrospectively collected and analyzed. Main outcomes were R0-resection rate, en bloc resection rate, recurrence rate, and procedure-related adverse events (AEs) (Clavien-Dindo). Secondary outcomes were procedure time, need for surgical intervention, and clinical impact on patient management. Results A total of 58 patients were referred for endoscopic resection of upper gastrointestinal SELs. The median diameter of lesions was 20 mm (range 7-100 mm). Median follow-up time was 5 months (range 0.4-75.7). Forty-eight procedures (83%) were completed successfully leading to en bloc resection in 85% and R0-resection in 63%. Procedure-related AEs occurred in six patients (13%). Severe complications (CD grade 3a) were seen in three patients. The local recurrence rate for (pre)malignant diagnosis was 2%. Additional surgical intervention was needed in seven patients (15%). A total of 32 patients (67%) could be discharged from further surveillance after endoscopic resection. Conclusions Endoscopic resection is a safe and effective treatment for SELs and offers valuable information about undetermined SELs for which repeated sampling attempts have failed to provide adequate tissue for diagnosis.

Integration of a machine learning model-generated surgical risk score into the EHR and preoperative workflow.

11163 Background: We previously developed a machine learning model (MLM) that accurately predicts postoperative complications (POC) for cancer inpatients. As laborious manual entry of patient data is a barrier for risk calculator use, and risk constantly changes depending on clinical status, we sought to integrate our MLM into the electronic health record (EHR) and preoperative workflow as a readily available surgical risk score (SRS) that is generated using real-time data. Here, we report on the integration process and survey results regarding its functionality and impact on patient care. Methods: A MLM that predicts severe POC (CD Grade ≥3) for cancer inpatients undergoing same-hospitalization operations was previously developed using EHR data. To integrate our MLM into the Epic EHR, we developed a real-time infrastructure (RTI) using the cloud-based platform Azure. EHR data is inputted to RTI and processed in real-time to generate model outputs. These outputs are then sent back to the EHR through the Epic Cognitive Computing Platform to generate each patient’s specific SRS. The SRS is dichotomized as “high” or “low” risk based upon a previously determined threshold and is displayed as a “Best Practice Advisory (BPA)” when a surgical case request is entered. In addition to the automated BPA, the SRS is sent to the primary surgeon as an InBasket Case Message. To elicit feedback of our EHR-integrated SRS, a survey was distributed to surgical providers at our institution. Results: After integration of our MLM into the EHR preoperative workflow, 185 surgeries were completed between November 16, 2021 to July 31, 2023. The 30-day severe POC rate was 27.6%, and our MLM had precision of 44.7% and recall of 74.5%, resulting in AUROC of 0.78 and AUPRC of 0.53. 35 surgical providers (40% primary surgeons, 34% surgical fellows, 26% advanced practice providers) from the divisions of surgical oncology, colorectal surgery, and gynecologic oncology completed our survey in July 2022 and July 2023. 28 (80%) of providers stated that they have interacted with the SRS through either BPA or InBasket Case Messages. Of these providers, 21 (75%) strongly agreed or agreed that the SRS was visible at appropriate times, and 18 (64%) strongly agreed or agreed that the SRS contains relevant information to assess surgical risk. 8 (29%) strongly agreed or agreed that the SRS was used to facilitate preoperative discussion. The 2023 survey additionally asked whether the SRS impacted the decision to operate; among providers who had interacted with the SRS, 4 (36%) strongly agreed or agreed with this statement. Conclusions: Integration of a real-time, MLM-generated SRS into the EHR and preoperative workflow can be successfully performed. While our integrated SRS is visible to surgeons and contains risk assessment felt relevant to the operation, the impact of the SRS on clinical care and decision making remains unclear.

Risk factors for abdominal surgical infectious complications after distal gastrectomy for gastric cancer: A post-hoc analysis of a randomized controlled trial (JCOG0912)

BackgroundAbdominal surgical infectious complications (ASIC) after gastrectomy for gastric cancer impair patients' survival and quality of life. JCOG0912 was conducted to compare laparoscopy-assisted distal gastrectomy with open distal gastrectomy for clinical stage IA or IB gastric cancer. The present study aimed to identify risk factors for ASIC using prospectively collected data. MethodsWe performed a post-hoc analysis of the risk factors for ASIC using the dataset from JCOG0912. All complications were evaluated according to the Clavien–Dindo classification (CD). ASIC was defined as CD grade I or higher anastomotic leakage, pancreatic fistula, abdominal abscess, and wound infection. Analyses were performed using the logistic regression model for univariable and multivariable analyses. ResultsA total of 910 patients were included (median age, 63 years; male sex, 61 %). Among them, ASIC occurred in 5.8 % of patients. In the univariable analysis, male sex (odds ratio [OR] 2.855, P = 0.003), diabetes (OR 2.565, P = 0.029), and Roux-en-Y (R–Y) reconstruction (vs. Billroth Ⅰ, OR 2.707, P = 0.002) were significant risk factors for ASIC. In the multivariable analysis, male sex (OR 2.364, P = 0.028) and R–Y reconstruction (vs. Billroth Ⅰ, OR 2.310, P = 0.015) were independent risk factors for ASIC. ConclusionsMale sex and R–Y reconstruction were risk factors for ASIC after distal gastrectomy. Therefore, when performing surgery on male patients or when R–Y reconstruction is selected after gastrectomy for gastric cancer, surgeons should pay special attention to prevent ASIC.

Clinical Outcomes of Preserving Bronchial Arteries During Radical Esophagectomy: A Propensity-Score Matched Analysis.

Postoperative pneumonia is a common and major cause of mortality after radical esophagectomy. Intraoperative preservation of the bronchial arteries is often aimed at avoiding tracheobronchial ischemia; however, it is unknown whether this contributes to a reduction in postoperative pneumonia. We enrolled 348 consecutive patients who underwent radical esophagectomy for esophageal cancer at Toranomon Hospital from January 2011 to July 2018. We classified patients into a bronchial artery-resected (BA-R) group (n = 93) and a bronchial artery-preserved (BA-P) group (n = 255) and compared the incidence of postoperative pneumonia between the two groups. A propensity score-matching analysis for bronchial artery preservation versus resection was performed. Overall, 182 patients were matched. Univariate analysis of the propensity score-matched groups showed that Brinkman index ≥ 400, vital capacity (%VC) < 80%, and bronchial artery resection were associated with the development of postoperative pneumonia. Multivariate analysis revealed three significant factors associated with postoperative pneumonia: Brinkman index ≥ 400 [p = 0.006, odds ratio (HR) 3.302, 95% confidence interval (95% CI) 1.399-7.790], %VC < 80% (p = 0.034, HR 6.365, 95% CI 1.151-35.205), and bronchial artery resection (p = 0.034, HR 2.131, 95% CI 1.060-4.282). The incidence of postoperative complications (CD grade III) was higher in the BA-R group (BA-R 42.8% versus BA-P 27.5%, p = 0.030). There was no significant difference in overall survival between the two groups at 5 years (BA-R 63.1% versus BA-P 72.1%, p = 0.130). Preserving the bronchial artery is associated with a decreased incidence of postoperative pneumonia.

Robotic esophagectomy with outermost layer-oriented dissection for esophageal cancer: technical aspects and a retrospective review of a single-institution database.

Systematic lymph node dissection in patients with gastric cancer could be sufficiently and reproducibly achieved along the outermost layer of the autonomic nerves and similar concept has been extensively used for robotic esophagectomy (RE) since 2018. This study aimed to determine the surgical and oncological safety of RE using the outermost layer-oriented approach for esophageal cancer (EC). Sixty-six patients who underwent RE with total mediastinal lymphadenectomy for primary EC between April 2018 and December 2021 were retrospectively reviewed. All underwent the outermost layer-oriented approach with intraoperative nerve monitoring (IONM). Postoperative complications within 30 days were analyzed. Among the patients, 51 (77.3%) were male. The median age was 64 years, and the body mass index was 21.8 kg/m2. Furthermore, 58 (87.9%) patients had squamous cell carcinoma and eight (12.1%) patients had adenocarcinoma. Clinical stages I, II, and III were seen in 23 (34.8%), 23 (34.8%), and 16 (24.2%) patients, respectively. Thirty-four (51.5%) patients received preoperative treatment. No patient shifted to conventional thoracoscopic or open procedure intraoperatively. The median operative time was 716 min with 119 mL of blood loss. Additionally, 64 (97%) patients underwent R0 resection. The morbidity rates based on Clavien-Dindo grades ≥ II and ≥ IIIa were 30.3% and 10.6%, respectively, within 30 postoperative days. None died within 90 days postoperatively. Three (4.5%) patients exhibited recurrent laryngeal nerve (RLN) palsy (CD grade ≥ II). The sensitivity and specificity of IONM for RLN palsy were 50% and 98.3% at the right RLN and 33.3% and 98.0% at the left RLN, respectively. RE with the outermost layer-oriented approach can provide safe short-term outcomes.

405. SHORT-TERM OUTCOMES OF ROBOT-ASSISTED ESOPHAGECTOMY

Abstract Background Robot-assisted minimally invasive esophagectomy (RAMIE) has become widely performed in Japan, and the technique and short-term results have been accumulated. In our institute, we started with daVinci S in 2013, switched to Xi in 2018, and have experienced 110 cases so far. Method; Technique and Devices: Semi-prone position with the left upper extremity placed under the body, 4 ports +1 assist port (Air Seal), double bipolar system—is the basic approach. The right upper extremity is placed so that it is attached to the head to provide axillary working space, and orthoglass to avoid direct compression of the right upper arm and robotic 4th arm. The range of motion of the 4th arm in the lower mediastinum is limited by the patient’s physique, so assistant forceps are used to assist as needed. Be willing to invert the camera to view the back of the operative field. Intraoperative recurrent nerve monitoring (NIM) was used in all cases. Results Five surgeons have performed RAMIE procedures. There have been no cases of conversion to thoracoscopic or open thoracotomy. The thoracic procedure time was significantly longer in RAMIE (299 min:274 min) than in thoracoscopic MIE. Blood loss tended to be less (17.1 mL: 44.0 mL). The incidence of recurrent nerve palsy (CD grade I or higher) was 44%:37%, that of pneumonia (CD grade II or higher) was 19%:18% and perioperative complications were similar between the two groups. Comparing the first half of the period when RAMIE was initiated with the second half, there was a significant decrease in the amount of bleeding, surgery time, and incidence of pneumonia, indicating an improvement in technique due to the number of experienced cases. Conclusion RAMIE can be performed safely, although no clear advantages can be demonstrated compared to thoracoscopic MIE at this time. RAMIE has clear advantages in terms of visual magnification of the dissected layer and stability of the surgical field, therefore, it is expected to reduce complications due to improved technique.

Robotic-assisted Posterior Urethroplasty: Outcomes From 105 Men in a Single-center Experience

To determine surgical outcomes in a large of cohort men undergoing robotic-assisted posterior urethroplasty (RPU), which has been described in small series as a viable option. We performed a retrospective review of all 105 men who underwent RPU from October 2014 to August 2022 at a single institution. We evaluated postoperative outcomes, including complications; surgical success defined as no need for reintervention; and incontinence requiring artificial urinary sphincter placement. We performed descriptive statistics and chi-square testing to determine if outcomes were associated with certain posterior urethral disease etiologies. Mean follow-up time was 18.7months. Over half of patients (57.1%) received prior pelvic radiation. The most common reconstructive techniques were excision and primary anastomosis (n = 45, 30.0%), resitting of the bladder neck (n = 26, 24.8%), Y-V plasty (n = 21, 20.0%), and buccal mucosal graft urethroplasty (n = 14, 13.3%). Forty-one patients (39.0%) required a combined abdominoperineal approach. Seven patients (6.7%) had ≥CD grade 3 complications within 30days. Thirty patients (28.6%) developed incontinence with subsequent artificial urinary sphincter placement. One-quarter (24.8%) of patients required at least one subsequent surgical reintervention. In the largest RPU cohort to date, surgical success rates were similar and continence rates were improved compared to open surgery and align with existing robotic series, adding to the growing body of evidence demonstrating advantages of RPU.

MP73-15 COMPARISON OF POSTOPERATIVE COMPLICATIONS BETWEEN FOCAL ABLATION AND RADICAL PROSTATECTOMY FOR INTERMEDIATE-RISK PROSTATE CANCER: THE FARP RANDOMIZED CONTROL TRIAL

You have accessJournal of UrologyCME1 Apr 2023MP73-15 COMPARISON OF POSTOPERATIVE COMPLICATIONS BETWEEN FOCAL ABLATION AND RADICAL PROSTATECTOMY FOR INTERMEDIATE-RISK PROSTATE CANCER: THE FARP RANDOMIZED CONTROL TRIAL Eduard Baco, Tigist Alemu, and Erik Rud Eduard BacoEduard Baco More articles by this author , Tigist AlemuTigist Alemu More articles by this author , and Erik RudErik Rud More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003341.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The aim of this study is to report and compare postoperative complications at 1 year, in Clavien-Dindo classification (CD) and Comprehensive Complication Index (CCI), for patients who were treated by Focal Ablation (FA), using high-intensity focused ultrasound (HIFU) or transurethral ultrasound ablation (TULSA), vs. Robot-Assisted Laparoscopic Prostatectomy (RALP) in the FARP Randomized Control Trial. METHODS: 213 men with biopsy-proven unilateral intermediate-risk prostate cancer visible on MRI were randomized 1:1 to FA or RALP with a cross-over rate of 27 % from RALP to FA. 131 patients were treated with FA (108 HIFU, 23 TULSA), and 75 with RALP using a unilateral nerve-sparing technique. Seven patients who were randomized to RALP declined to undergo prostatectomy and remained untreated. All patients were followed for at least 1 year with no drop-out. Complications were prospectively registered in a digital patient journal, entered in the FARP database, and graded according to CD. CCI was calculated as the sum of all complications and weighted for severity. Differences in binary outcomes were assessed with a Chi-square test, while continuous variables were evaluated using an independent sample T-test. RESULTS: Mean age, PSA, index tumor diameter, and prostate volume on MRI for FA vs. RALP were: 64 vs. 66 years, p=0.3; 8.6 vs. 8.5 ng/ml, p=0.9; 14.5 vs. 15.5 mm, p=0.2; and 41.3 vs. 41.7 ml, p=0.9. Grade CD 1 and 2 complications in FA vs. RALP were 17% vs. 25 %, p=0.18. The incidence of serious complications defined as CD≥3 was 2 % vs. 13 %, p<0.001 (Table 1). The mean CCI was 3.9 and 6.9 in FA and RALP, respectively; p=0.08. CONCLUSIONS: FA of prostate was associated with significantly better safety outcomes as compared to RALP considering the frequency and severity of CD grade≥3 complications and across the entire CCI scale. Source of Funding: No © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1041 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eduard Baco More articles by this author Tigist Alemu More articles by this author Erik Rud More articles by this author Expand All Advertisement PDF downloadLoading ...

Early and Long-term Complications of Robotic Assisted Laparoscopy in Infants and Children

BackgroundRobotic-assisted laparoscopy still lacks wide acceptance in infants and children. We developed the service and report the largest single institution experience of complications over a period of 11 years. MethodsBetween March 2006 and May 2017, consecutive infants and children who underwent robotic assisted laparoscopy under the care of two laparoscopic surgeons were studied. Data for patients, surgeons, year of surgery, operation, and timing, nature, grades of complications were assessed. ResultsA total of 601 robotic procedures (45 different types) were carried out in 539 patients. Of these 31 (5.8%) were converted, none for operative complications. These and another 4 with complicated co-morbidity were excluded, leaving 504 patients for further analysis. There were 60 (11.9%) complications in 57 (11.3%) patients. Mean (SD) age was 7.7 years −/+5.1 with the youngest being 4 weeks. Concomitant or bilateral robotic and non-robotic procedures took place in 8.1% and 13.3% of patients respectively. Significant medical co-morbidity and abdominal scarring were present in 29% and 14.9% of patients respectively. Complications occurred in theatre 1.6%, hospital 5.6%, 28 days 1.2%, and late 3.6%. Mean follow up was 7.6 years −/+ 3.1 SD. Over-all postoperative complication rate was 10.3%: CD grade I 6.5% (33), II 0.6% (3), and IIIa/b 3.2% (16) which included 1.4% (7) re-do surgery. Most (11/16) grade III occurred late. There were no bleeding, grade IV or V complications, surgical mortality, or technology related complications. ConclusionsComplications are low even during the learning phase and while developing the new technique. Most complications occurred early and were minor. Most high-grade complications presented late. Levels of Evidence2B

HPB P63 Five-year follow-up after pancreatoduodenectomy performed for malignancy: a nine-year experience

Abstract Background Pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head is a leading cause of cancer-related death in the Western world and its incidence is set to rise across the globe. Unfortunately, the majority of patients present with metastatic disease and prognosis is very poor. Ampullary adenocarcinoma (AA) and cholangiocarcinoma (CC) are less common but their prognoses are only marginally better. Patients with one of these cancers may undergo pancreaticoduodenectomy (PD) providing they present with resectable disease and have an appropriate performance status. Whilst this offers some patients the possibility of a cure, it is a high-risk operation and overall morbidity is often quoted at 50%. Additionally, early recurrence rates are high and few patients achieve long-term survival. This study aimed to describe the experience of a typical tertiary hepatopancreatobiliary (HPB) unit in the United Kingdom. We aimed to a compile a complication profile and investigate the impact of selected preoperative variables on short- and long-term outcomes. We also aimed to compare patient outcomes based on their cancer type. Methods Patients were included if they underwent PD for histologically-confirmed PDAC, AA or CC at our institution between 01/09/2006 and 31/05/2015. The end date of 31/05/2015 was chosen to complete five-year follow-up for all included patients. Information was collected on the following: patient demographics, comorbidities, preoperative imaging and staging, NAT (if given), selected preoperative blood results, procedure and intraoperative findings, postoperative management and complications, histology results, adjuvant treatment (if given), cancer recurrence, palliative treatment (if given), and five-year survival. When comparing patients by their histological diagnosis, medians were compared using the Kruskal-Wallis test and other variables were compared using Fisher's exact test. Fisher's exact test was also used to investigate the association of selected preoperative variables on overall morbidity, major morbidity (Clavien-Dindo grade I and II complications excluded), 90-day mortality and five year survival. The Kaplan-Meier method was used to compare survival between patients with PDAC, AA and CC. The Mantel-Cox method was used to test for statistical significance. Fisher's exact test was used to investigate the impact of selected preoperative variables on five-year survival. A p-value of less than 0.05 was considered statistically significant. Results A total of 271 patients were included; 57.9% had a histological diagnosis of PDAC, 25.8% had AA and 16.2% had CC. Ninety-day mortality was 3.3%, 67.9% of patients experienced at least one complication and 17.3% experienced a complication which was Clavien-Dindo grade III or higher. A total of 401 postoperative complications were recorded; 27.2% were CD grade I, 53.2% were grade II, 12.7% were grade III, 4.4% were grade IV and 1.5% were grade V. Rates of CR-POPF, bile leak, gastrojejunal leak, PPH and DGE were 8.1%, 4.1%, 0.0%, 9.2% and 19.9%, respectively. Patients with a preoperative bilirubin ≤29 µmol/L less often experienced morbidity (p=0.03) or major morbidity (p=0.02) but this did not affect 90-day mortality (p=0.7). Similarly, those with a preoperative neutrophil/lymphocyte ratio (NLR) ≤3.1 had lower rates of morbidity (p=0.04) and major morbidity (p=0.01) but the difference in 90-day mortality was not significant (p=0.3). An ASA grade of III or IV correlated with increased overall morbidity (p=0.002) and major morbidity (p=0.009) but the difference in 90-day mortality was not significant (p=0.2). Overall five-year survival was 22.5%; this was not affected by age, BMI, preoperative comorbidities, ASA grade or preoperative blood tests. Conclusions In our series, most patients experienced at least one complication but less than a fifth experienced major morbidity. Rates of CR-POPF, bile leak, gastrojejunal leak, PPH and DGE were 8.1%, 4.1%, 0.0%, 9.2% and 19.9%, respectively. ASA grade III/IV patients and those with a high preoperative bilirubin and/or NLR more commonly experienced overall and major morbidity. Five-year recurrence and survival rates were 68.3% and 22.5%, respectively. The preoperative variables studied did not affect five-year survival. Surgeons who perform PD should have a sound understanding of the figures above as this will guide patient selection and the consenting process. Future research should focus on identifying patients who are likely to achieve poor long-term outcomes, this sub-group may benefit from neoadjuvant chemotherapy.

PD28-09 SINGLE PERINEAL INCISION IN SIMULTANEOUSLY PLACED PENILE IMPLANT AND ARTIFICIAL SPHINCTER: A COMPARISON OF COMPLICATIONS AND DEVICE LONGEVITY

You have accessJournal of UrologyCME1 May 2022PD28-09 SINGLE PERINEAL INCISION IN SIMULTANEOUSLY PLACED PENILE IMPLANT AND ARTIFICIAL SPHINCTER: A COMPARISON OF COMPLICATIONS AND DEVICE LONGEVITY Kirema Macharia, Kyle Blum, Travis Green, Justin Mehr, Leyla Akhverdiyeva, Alex Leonard, and Run Wang Kirema MachariaKirema Macharia More articles by this author , Kyle BlumKyle Blum More articles by this author , Travis GreenTravis Green More articles by this author , Justin MehrJustin Mehr More articles by this author , Leyla AkhverdiyevaLeyla Akhverdiyeva More articles by this author , Alex LeonardAlex Leonard More articles by this author , and Run WangRun Wang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002576.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) is commonly implanted via a penoscrotal or infrapubic incision. It is known that artificial urinary sphincters (AUS) are more effective when placed through a perineal approach. The most common approach for the synchronous implantation of an IPP and AUS has been through dual incisions (penoscrotal/infrapubic and perineal) or a single penoscrotal approach. We have developed a technique to simultaneously implant an IPP and AUS through a single perineal incision. Presently, no data is available that compares the complications and device longevity of a single perineal approach versus a penoscrotal approach for dual implants. METHODS: We retrospectively identified 45 patients who underwent an AUS/IPP synchronous dual implantation at a large single-institution tertiary referral center between 2011 to 2019. These patients were surveyed regarding their AUS/IPP devices using a series of questions. Out of these patients, a total of 23 patients had responses available for analysis; 13 with penoscrotal incision and 10 via perineal incision. Device malfunction, infection, and Clavien-Dindo classification (CD) for complications were analyzed. Fisher’s exact test for categorical variables was used and p <0.05 was considered to be significant. Follow up ranged from 1.6 to 124.9 months. RESULTS: A difference was observed between the two groups when comparing for total CD Grade 1-2 postoperative complications (p=0.028). Notably, 61.5% (n=8) in the penoscrotal group experienced a CD Grade 1-2 complication in the first 30 days postoperatively vs 10% (n=1) in the perineal group, most commonly surgical site pain. There was no statistically significant difference in CD Grade >3 postoperative complications between the two groups (p=0.617). There was also no significant difference found between the two groups when comparing for infection rates (p=0.603), AUS malfunction (p=1.00), or IPP malfunction (p=1.00). CONCLUSIONS: A single perineal incision for the placement of AUS/IPP synchronous implantation is a viable and effective option with similar device longevity compared to a penoscrotal approach. Low grade complications were found to be significantly improved with the perineal approach. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e502 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kirema Macharia More articles by this author Kyle Blum More articles by this author Travis Green More articles by this author Justin Mehr More articles by this author Leyla Akhverdiyeva More articles by this author Alex Leonard More articles by this author Run Wang More articles by this author Expand All Advertisement PDF DownloadLoading ...

V09-09 ROBOTIC RADICAL CYSTECTOMY WITH INTRACORPOREAL ILEAL CONDUIT: SURGICAL TECHNIQUE, PERIOPERATIVE, FUNCTIONAL AND ONCOLOGIC OUTCOMES

You have accessJournal of UrologyCME1 May 2022V09-09 ROBOTIC RADICAL CYSTECTOMY WITH INTRACORPOREAL ILEAL CONDUIT: SURGICAL TECHNIQUE, PERIOPERATIVE, FUNCTIONAL AND ONCOLOGIC OUTCOMES Leonardo Misuraca, Gabriele Tuderti, Umberto Anceschi, Riccardo Mastroianni, Aldo Brassetti, Mariaconsiglia Ferriero, Alfredo Maria Bove, Salvatore Guaglianone, Michele Gallucci, and Giuseppe Simone Leonardo MisuracaLeonardo Misuraca More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Umberto AnceschiUmberto Anceschi More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Alfredo Maria BoveAlfredo Maria Bove More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Michele GallucciMichele Gallucci More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002617.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A recent comparison between open, semi-robotic and totally robotic cystectomy with ileal conduit (IC), demonstrated that robotic intracorporeal IC is a complex procedure with increased operation time, but lower estimated blood loss, transfusion rates, complications and hospital stays. Moving towards a minimally invasive approach for all kind of urinary diversions, we recently standardized our technique for intracorporeal IC. In this video, we describe our surgical technique, reporting perioperative, functional and oncologic outcomes. METHODS: With patient in steep Trendelenburg position, 6-trocars access was used. Ureters were gently mobilized and isolated, avoiding tractions or manipulations. Distal ureters were clipped with hem-o-lok and a terminal specimen was sent for frozen section. Cystectomy with extended pelvic lymphadenectomy was completed, before transposing left ureter to the right side under the sigmoid mesentery. A 60 mm robotic stapler was used to congure the future IC and to perform a latero-lateral ileal-ileal anastomosis. Ureters were spatulated and, under ICG guidance to check ureters vascularity, a typical Wallace I anastomosis was performed. Two single J stents were positioned through a 5 mm trocar. The proximal end of the IC was opened and the posterior aspect of the uretero-ileal anastomosis was performed with a 3/0 monocryl running suture. The distal end of the IC was exteriorized by a Rampley forceps, together with the two single J stents. The anterior aspect of the uretero-ileal anastomosis was completed and a water tightness test was performed to prove the sealing of the suture. In this phase, camera port and right robotic arm were repositioned, in order to have a better visualization and an improved freedom of movements. Finally, peritoneum defect was closed in order to leave the IC in the retroperitoneum space. RESULTS: Overall, 61 patients with a median of 69 yr were treated. 36 patients had cT3 disease, 11 had evidence of lymphadenopathy and 2 had suspicious metastasis at preoperative imaging. Median operative time was 290 minutes. LOS was 9 days. Only 16.4% of patients required transfusion. 39.3% of patients experienced a perioperative complications of any grade, while severe complications (CD grade ≥3) occurred in only 2 patients. Overall, 50.8% of patients had a pT>2, while PSM were reported in 1.6% of patients. At a median follow up time of 23 months, we registered a median last creatinine of 1.33 mg/dL. Only 5 patients developed a grade 2 or 3 hydronephrosis, which required nephrostomy placement in 3 cases. 3-yr OS, DFS and MFS were 52.9, 43.9 and 47.6%, respectively. CONCLUSIONS: Robotic radical cystectomy with intracorporeal IC is a safe and feasible procedure, with minimized blood loss, improved convalescence and reduced complications rate in tertiary referral centers. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e807 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Leonardo Misuraca More articles by this author Gabriele Tuderti More articles by this author Umberto Anceschi More articles by this author Riccardo Mastroianni More articles by this author Aldo Brassetti More articles by this author Mariaconsiglia Ferriero More articles by this author Alfredo Maria Bove More articles by this author Salvatore Guaglianone More articles by this author Michele Gallucci More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement PDF DownloadLoading ...

Impact of post-operative paralytic ileus on post-operative outcomes after surgery for colorectal cancer: a single-institution, retrospective study.

Post-operative paralytic ileus (POI) occurs after surgery because of gastrointestinal dysfunction caused by surgical invasion. We therefore investigated the frequency of POI after laparoscopic colorectal surgery in patients with colorectal cancer using a strictly defined POI diagnosis and identified associated risk factors. Patients who underwent initial laparoscopic surgery for colorectal cancer between January 2014 and December 2018 were included. The primary end point was the incidence of POI. A multivariate logistic regression analysis revealed the contributing risk factors for POI. Of the 436 patients, 94 (21.6%) had POI. Compared with the non-POI group, the POI group had significantly higher frequencies of infectious complications (p < 0.001), pneumonia (p < 0.001), intra-abdominal abscess (p = 0.012), anastomotic leakage (p = 0.016), and post-operative bleeding (p = 0.001). In the multivariate analysis, the right colon (odds ratio [OR] 2.180, p = 0.005), pre-operative chemotherapy (OR 2.530, p = 0.047), pre-operative antithrombotic drug (OR 2.210, p = 0.032), and post-operative complications of CD grade ≥ 3 (OR 12.90, p < 0.001) were independent risk factors for POI. Post-operative management considering the risk of post-operative bowel palsy may be necessary for patients with right colon, pre-operative chemotherapy, pre-operative antithrombotic drug or severe post-operative complications.

Characterization of tea (Camellia sinensis) granules for quality grading using computer vision system

Tea (Camellia sinensis) has been found as an important medicinal beverage for human which is consumed all over the world. Primarily, the majority of tea is being cultivated in Asia and Africa, however it is commercially produced by more than 60 countries. Though substantial amount is produced, its processing system is still underdeveloped which leads to decrease in export opportunity as well as low monetary value. Moreover, the traditional method of tea grading and sorting is laborious, inefficient, and costly which ultimately produces the low-quality heterogeneous products. Processing and grading of tea granules after drying is very important task for maintaining quality. Computer vision (CV) applications in processing unit especially in grading and sorting of agro-products is very popular and reliable option to improve quality of produce. In this study, an attempt was taken to develop a machine vision system for quality grading of tea granules based on physical parameters of four standard tea grades namely BOP, GBOP, CD and PF. An image acquisition system with suitable illumination arrangement was developed to obtain high resolution image of tea granules. The images were analyzed to extract physical features like projected area, circularity, roundness, ferret diameter, aspect ratio and solidity. Tea granules (BOP, CD, PF and GBOP grade) were found significantly different for the textural features area, perimeter, circularity, roundness and ferret diameter. Projected area, perimeter, and feret diameter treated as a good indicator of the extracted features as the system has been able to significantly (p < 0.01) differentiate among the grade of tea. The developed characterization attributes based on physical features prior to an automatic sorting technology will improve the efficiency and enhance the cost-effectiveness which ultimately led to energize the international export market.

Retrospective Analysis of Complications and Causes of Mortality in Patients Undergoing Esophagectomy for Esophageal Cancer

Background: Esophageal cancer is the eighth most common cancer and the sixth most common cause of death from cancer. Esophagectomy is still the essential treatment for esophageal cancer despite its high morbidity rate. The prediction of complications that are likely to appear after surgery can be the most critical factor in reducing morbidity. Objective: The present study aimed to examine the postoperative complications and causes of mortality in patients undergoing esophagectomy for esophageal cancer. Material and Methods: Data from 34 patients with esophageal adenocarcinoma or squamous cell carcinoma undergoing esophagectomy in the general surgery clinic of Çukurova University Medical School Hospital were collected and analyzed retrospectively between January 1, 2011, and January 1, 2020. Postoperative complications were identified according to the Clavien-Dindo classification (CD). The patients were assigned into two groups (Group 1 and Group 2). Group 1 and Group 2 included patients with CD grade &lt;3 and CD grade , respectively. Results: The mean±SD age of patients (n=34) undergoing resection for esophageal cancer was obtained at 56.38±11.00 years. The ratio of female to male patients was equal. The most common accompanying disease was diabetes mellitus. The number of patients with the American Society of Anesthesiologists score 3 was higher in Group 2 (P=0.034). The tumor was most frequently located in the lower thoracic esophagus of patients in Group 1 and Group 2, and the rate of cervical anastomosis was higher in Group 2. The rate of manual anastomosis was higher in both groups. Respiratory complications were the most frequent complication in both groups; however, a higher rate of respiratory complications was observed in Group 2 (P=0.038). The postoperative 30-days mortality and the reoperation rate were higher in Group 2. Conclusion: Radical surgery for esophageal cancer results in a high rate of complications and death due to the location of the tumor and diagnosis at the advanced stage. Complications and mortality may result from patient-related factors and the surgical technique. The diagnosis and treatment of the correctable causes before surgery can enhance the chance of survival and the quality of life in patients.