Complex Surgical Intervention Research Articles

Aortic Homografts in Surgical Management of Prosthetic Valve Endocarditis: A Case Series from Greece.

BACKGROUND Infective endocarditis (IE) is a severe, life-threatening, and relatively common complication after valve replacement operations, with incidence rates varying between 1.8% and 5.8%, with an in-hospital mortality rate of up to 20%. Common microorganisms are (listed by decreasing incidence) Streptococci, Staphylococcus aureus, Enterococci, bacteria of the HACEK group, and fungi. Treatment of IE is complex, typically involving prolonged courses of antibiotics. However, in cases of aortic prosthetic valve endocarditis, root abscess formation with involvement of the aorto-mitral skeleton is not uncommon and complex surgical intervention is required. One of the notable advancements in surgical management is the use of homografts for aortic root endocarditis. CASE REPORT We report the first case series of 8 patients successfully operated on for prosthetic valve endocarditis with extensive aortic root abscess formation in Greece at Onassis Cardiac Surgery Center with the use of aortic homograft. All cases were redo surgeries and had good outcomes. Interestingly, one of the cases had extensive aortic root involvement with abscess formation extending to the aorto-mitral fibrous skeleton, requiring aortic root replacement with homograft, aorto-mitral skeleton reconstruction with bovine pericardium and mitral valve replacement with a mechanical prosthesis. Two other patients required concomitant coronary bypass grafting of the right coronary artery with reversed saphenous vein grafts. CONCLUSIONS Aortic root replacement with aortic homograft is the preferred choice for prosthetic valve endocarditis with aortic root abscess formation. Despite the technical complexity needed for implantation, this option offers a second chance for survival in patients with this challenging condition.

Double tracheoesophageal fistula after prolonged intubation during COVID-19: surgical treatment by colonic transposition in the retrosternal space

This is a patient with 2 tracheoesophageal fistulas following prolonged intubation due to COVID-19 with severe evolution and indication for surgical treatment due to failure of endoscopic treatment. Patient in a long hospital stay, unable to eat an oral diet, malnourished, chronic cough, developing persistent pneumonia due to recurrent salivary bronchoaspiration. The case was treated by complex surgical intervention consisting of proximal and distal partial esophagectomy with reconstruction of food transit by colonic bypass in the anterior mediastinum, resection and tracheal reanastomosis. The final result was good, with the patient being discharged from the hospital on a restored oral diet and free spontaneous breathing. The resolution of an extremely serious case through a complex and exceptional surgical approach, which imposed enormous challenges in pre-operative preparation and detailed therapeutic planning, with single-stage surgical action by two surgical teams (Digestive System Surgery and Thoracic Surgery).

Comparative assessment of long-term survival of patients after primary and recurrent myocardial infarction: a data from the RIMIS registry

Aim. To compare the long-term prognosis of life of patients after primary and recurrent acute myocardial infarction (MI).Material and methods. The study was based on the RIMIS registry, which included all patients after transmural MI in 2017 in one of the Moscow vascular centers. The prospective part included 191 patients who survived the acute stage of MI, of which 145 suffered a primary acute MI, 46 — a recurrent acute MI. Long-term follow-up data were collected 71 (53;75) months after discharge from the hospital. The primary endpoint was any-cause death.Results. During the follow-up period, 35 (25,2%) patients with a primary MI and 25 (64,1%) patients with a recurrent MI died (p<0,001). It was not possible to establish the fate of 13 (6,81%) patients, of which 7 (4,83%) were people with primary MI and 6 (13,04%) people with recurrent MI. The death risk was significantly higher in patients who had a recurrent MI compared to patients who had a primary MI: hazard ratio (HR)=3,52 (2,09;5,96), p<0,001). An unfavorable prognosis was determined not by the fact of a recurrent MI, but by the complications that resulted from a previous MI, primarily heart failure, as well as age, sex, smoking status, and hospitalizations for cardiovascular diseases in the year before the reference MI, history of angina and following comorbidities: a prior stroke, major bleeding (life-threatening gastrointestinal bleeding requiring complex surgical intervention). Patients who had a recurrent MI were significantly more adherent to follow-up and prescribed therapy.Conclusion. Despite the modern strategy for treating MI both in the acute stage and in the long-term period, the prognosis after recurrent MI remains unfavorable. Signs negatively affecting the prognosis were sex, age, a history of heart failure and angina pectoris, and hospitalizations for cardiovascular diseases one year prior to reference MI.

#1954 Effects of lanosterol synthase (LSS) gene on the development of acute kidney injury after cardiac surgery

Abstract Background and Aims Acute kidney injury (AKI) is a common post-cardiac surgery complication, significantly affecting morbidity and mortality. Recent studies reported that high plasma levels of endogenous ouabain (EO), a stress hormone secreted by the adrenal glands, are associated to worse kidney outcomes after cardiac surgery. Our group demonstrated that EO activity is affected by a missense variant (rs2254524, C -> A, Val642Leu) in Lanosterol Synthase (LSS) gene, an enzyme implicated in EO synthesis. The aim of this work is to analyze the relationship between this LSS polymorphism and the development of AKI after cardiac surgery. Method 1237 patients undergoing elective cardiac surgery were enrolled in the study. Preoperative biological samples were collected (Table 1). LSS genotypes were determined for each patient. The primary outcome was AKI development, according to KDIGO 2012 guidelines. Results 21.4% of patients developed AKI. Different preoperative clinical variables were analyzed, identifying five independent risk factors significantly correlated to AKI development in multivariate logistic regression analysis: age (p < 0.001), FE (p = 0.005), NYHA class (p < 0.001), reoperation (p = 0.002) and complex surgical intervention (p < 0.001), Table 2. No significant differences were observed between preoperative EO plasma levels and allelic variants of LSS gene and patients with the less common A allele were not associated to a more severe preoperative clinical presentation, expressed as EuroScore II value (AA 2.54 ± 3.86 vs AC 2.15 ± 2.52 vs CC 2.04 ± 2.73; p = ns). LSS minor variants turned out significantly associated with the incidence of AKI (AA = 29.3%; AC = 25.3%; CC = 17.2%; X2 p < 0.001—Fig. 1). This evidence remains significant after correction for covariates associated to AKI previously reported (Log regression p = 0.002; RR for AA variant: 2.09 (IC95% 1.15-3.78)) Conclusion Patients with at least one mutated allele of LSS variant have a higher probability of developing AKI after cardiac surgery. We think these results could be of interest to further understand cellular mechanisms underlying AKI development, especially in the cardiac surgery field.

Sternotomic resection of an anterior mediastinal cystic teratoma with pericardial fistula

Background: Mediastinal teratomas are rare tumors and the majority of them are mature teratomas, benign lesions characterized by slow growth and low malignant potential. Signs and symptoms are infrequent; hence the diagnosis is often incidental. Complicated cases are rare and are traditionally treated with elective surgery. Our case report presents a patient with a teratoma complicated by pericardial fistulization requiring emergency surgery: the only case described in the literature. Case presentation: A 36-year-old male with no relevant medical history reported acute thoracic pain. Chest CT scan shows a mediastinal mass (compatible with cystic teratoma) compressing the superior vena cava, the heart, and pericardial involvement. The patient was first subjected to pericardiocentesis and then an en-bloc resection of the mediastinal lesion was performed via sternotomy. Discussion and conclusion: Mediastinal lesions require an accurate differential diagnosis, despite the diagnosis often being incidental in the absence of clinical symptoms. Conversely, if symptomatic, complicated cases can lead to life-threatening situations, where the exeresis of such lesions might require urgent, complex, and multidisciplinary surgical intervention.

Fourteen-Year Experience in Burn Eyelid Reconstruction and Complications Recurrence: A Retrospective Cohort Study.

Loss of vision and other ocular defects are a concern with eyelid burn sequelae. This most commonly progresses from eyelid contracture to cicatricial ectropion and lagophthalmos. When left untreated, these may lead to exposure keratitis, ulceration, infection, perforation, and loss of vision. In the case of full-thickness eyelid burns, release and grafting are required. However, there is a paucity of studies on outcomes in eyelid burn surgery treatment, despite concern for permanent ocular damage or loss of vision. The aim of the study is to describe the complication rates in burn eyelid reconstruction at a single center for 14 years. A retrospective cohort study was performed of all patients who had sustained eyelid burns and required reconstruction between April 2009 and February 2023. Medical records were obtained from patients' charts. Collected data include demographics, medical history, type of injury, indication for surgery, procedure performed, and complications. A total of 14 patients and 25 eyelids underwent eyelid reconstruction of the 901 total patients with burn-related injuries requiring plastic surgery reconstruction. These patients underwent 54 eyelid surgeries with a mean follow-up time of 13.1 ± 17.1 months. Patients were 71% men and 29% women, with a mean age of 45.1 ± 15.6 years. In 53.7% (n = 29) of the cases, the simultaneous reconstruction of both the upper and lower eyelids was necessary. The reconstruction of the upper and lower eyelid alone represented a smaller percentage (25.9% and 20.4%, respectively). On average, the patients received 3.9 ± 3.5 eyelid surgeries. The overall complication rate was 53.7% (n = 29). The most common complication was ectropion (42.6%, n = 23). Other complications included eye injury (25.9%, n = 14), lagophthalmos (24.1%, n = 13), local infection (7.4%, n = 4), and graft loss (5.6%, n = 3). Periorbital burns represent a major challenge that may require complex surgical intervention. Full-thickness skin graft remains the standard of care for patients with eyelid burns. However, there is a high incidence of ectropion that may require reoperation. Further studies examining the conditions of successful eyelid burn procedures may provide guidance on when patients may benefit from eyelid reconstruction during their burn treatment.

O84: A systematic review of pancreaticoduodenectomy for pancreatic cancer in randomised control trials to examine variations in operative technique

Abstract Background Pancreatoduodenectomy (PD) is a complex surgical intervention comprising multiple components which, when delivered differently, can impact outcomes, introduce bias into randomised controlled trials (RCTs) and impair accurate interpretation of results. This study aimed to systematically explore and summarise variation in PD description and standardisation amongst contemporary RCTs in pancreas surgery. Methods Systematic literature searches for RCTs of PD were undertaken from 2020 to 2023. RCTs including robotic PD, or other types of pancreas resection (e.g. total, distal), were excluded. An established methodological framework was used to deconstruct the technical aspects of PD were deconstructed into constituent components (pre-operative considerations, before skin incision, incision, dissection, resection, haemostasis, reconstruction, insertion of adjuncts, closure and after closure). Trial reports and protocols were scrutinised to examine whether the components/steps were described, and whether (and how) adherence was assessed. Results Of 83 screened articles, 29 RCTs were included, reporting on 3440 patients across 16 countries (1 trial compared pre-operative interventions, 18 trials compared intra-operative interventions, and 10 trials compared post-operative interventions). Forty-one PD steps were identified. No studies described all steps and five did not describe any. Fifteen component parts were described in one RCT. Only three RCTs reported that delivery of PD was recorded and assessed, using intra-operative photographs in all cases. Conclusions In a contemporary series of RCTs evaluating PD, descriptions of the procedure were inadequate. Clear descriptions of PD using pre-existing methodological frameworks in future trials are warranted to improve outcomes, decrease bias and facilitate cross-RCT comparisons in systematic reviews.

Radical cystectomy with extraperitoneal location of an artificial bladder

Radical cystectomy remains the “golden standard” for treatment of patients with invasive bladder cancer. The operation is a technically complex surgical intervention after which there are various complications, including gastrointestinal complications such as intestinal obstruction, peritoneal adhesive disease and others. The use of extraperitoneal access for radical cystectomy with an extraperitoneal location of the artificial bladder in carefully selected patients reduces the number of abdominal postoperative complications and improves results in the immediate postoperative period. A literature review is presented which outlines the results of using extraperitoneal approach in comparison with other options for surgical approaches when performing radical cystectomy with intestinal bladder plastic surgery. It is noted that extraperitoneal access during this operation was previously used by Russian urologists.

Update on long-term mental health outcomes in eight face transplant recipients from a single center.

Face transplantation is a groundbreaking and complex surgical intervention offering profound physical and psychological benefits to patients with severe facial disfigurements. This report provides an update on the long-term psychosocial outcome of eight face transplant recipients. All transplant recipients were initially transplanted at Brigham and Women´s Hospital (Boston, USA) between 2011 and 2020 and seen as outpatient patients at Yale New Haven Hospital (New Haven, USA). A mixed-methods approach was used to assess the psychological and social well-being of these patients. The Short-Form 12, Brief-COPE, EQ-VAS and CES-D were administered between October 2022 and October 2023. Older age of face transplant recipients was significantly and positively associated with better mental health and increased use of both emotional and instrumental support (Brief-COPE). The initial enhancement in patients' self-reported quality of life, as assessed by the EQVAS, declined on the EQ-VAS score at the last follow-up. Similarly, an increase in depression score was observed (CES-D score) up through the last follow-up assessment. Both of the latter results, however, did not reach statistical significance. These results underscore the importance of ongoing psychological support throughout the long-term journey of recovery for face transplant recipients. These findings emphasize the need for a comprehensive, patient-centered approach that also addresses the complex psychological dimensions and contributes to our understanding of the mental health dynamics involved in face transplantation, stressing the need for guidelines and continued research in this evolving field.

Correction of proximal femoral deformities in children by a guided growth technique: A review

BACKGROUND: After surgical treatment of proximal femoral deformities in children, secondary deformities can often develop. They can be corrected successfully by epiphysiodesis — a method of working with growth zones.
 AIM: To analyze the literature about the development of epiphysiodesis, a proximal femoral technique, and the results of its use in pediatric patients with hip joint pathologies.
 MATERIALS AND METHODS: The results of using epiphysiodesis for treating secondary deformities in children with hip joint pathologies were analyzed. The literature search was performed in open electronic scientific databases eLibrary and PubMed for the period from 1933 to 2022.
 RESULTS: Most authors reported good and satisfactory results in the correction of secondary proximal femoral deformities in children. They also suggested that the development of these deformities could be prevented by epiphysiodesis in time frames, which should be chosen correctly. However, no consensus has been established on the timing of surgical intervention and methods of its implementation.
 CONCLUSIONS: Proximal femoral deformities in children, such as valgus deformity of the femoral neck and its recurrence, consequences of Kalamchi type II avascular necrosis, and hypertrophy of the greater trochanter, were corrected for a long time by a complex surgical intervention–intertrochanteric osteotomy of the femur. Improvement in examination methods and a deeper understanding of the growth zone functioning of the proximal femur allow orthopedists to introduce into practice less invasive and less traumatic but effective methods for correcting these proximal femoral deformities by controlled blocking of the growth zones.

Conservative treatment of iatrogenic tracheal rupture (clinical case)

The objective was to demonstrate a clinical case of iatrogenic injury of the trachea, which, despite its large size (length 65, width up to 25 mm), wastreated conservatively and, thus, avoided risks for the patient associated with the need for technically complex surgical intervention.Materials and methods. A 65-year-old patient diagnosed with peripheral cancer of the lower lobe of the left lung pT2aN0M0 stage IB, who routinely underwent thoracoscopic left lower lobectomy with mediastinal lymph node dissection. During anesthesia, tracheal intubation with a double-lumen tube of the R. Shaw type was carried out with technical difficulties; during intubation, a defect in the posterior wall of the trachea in its membranous part was formed. The defect was diagnosed on the first postoperative day.Results. Despite the large size of the tracheal defect, the patient had no symptoms of respiratory failure, and there were also no signs of mediastinitis or damage to the esophagus, which almost completely covered the resulting hole in the posterior wall of the trachea. Such circumstances made it possible to avoid a potentially dangerous and complex surgical intervention, carry out conservative therapy and wait for the resulting defect to heal through granulation tissue. Enhanced antimicrobial therapy was carried out; in order to sanitize the tracheobronchial tree and monitor healing, fiber-optic bronchoscopy was performed, which made it possible to clearly demonstrate both the damage itself and the stages of its healing.Conclusions. The described case clearly demonstrates the potential for healing of even very extensive tracheal wall defects with conservative therapy. However, it is important to note that success in this clinical case was the result of a combination of circumstances – only the membranous part of the trachea was damaged; the defect was almost completely covered by the intact esophagus, which reduced the risk of developing mediastinitis and prevented the development of severe pneumomediastinum and subcutaneous emphysema. There were no signs of respiratory failure. The patient was transferred from the intensive care unit on the 13th day of the postoperative period, discharged from the hospital on the 22nd day.

HPB P09 A systematic review of pancreaticoduodenectomy for pancreatic cancer in randomised control trials to examine variations in operative technique

Abstract Background Pancreatoduodenectomy (PD) is a complex surgical intervention comprising multiple components which, when delivered differently, can impact outcomes, introduce bias into randomised controlled trials (RCTs) and impair accurate interpretation of results. This study aimed to systematically explore and summarise variation in PD description and standardisation amongst contemporary RCTs in pancreas surgery. Methods Systematic literature searches for RCTs of PD were undertaken from 2020 to 2023. RCTs including robotic PD, or other types of pancreas resection (e.g. total, distal), were excluded. The technical aspects of PD were deconstructed into constituent components and steps (pre-operative considerations, before skin incision, incision, dissection, resection, haemostasis, reconstruction, insertion of adjuncts, closure and after closure) using a methodological framework. Trial reports and protocols were scrutinised to examine whether the components/steps were described, and whether (and how) adherence was assessed. Results Of 83 screened articles, 29 RCTs were included, reporting on 3440 patients across 16 countries (1 trial compared pre-operative interventions, 18 trials compared intra-operative interventions, and 10 trials compared post-operative interventions). Forty-one PD steps were identified. No studies described all steps and five did not describe any. Fifteen component parts were described in one RCT. Only three RCTs reported that delivery of PD was recorded and assessed, using intra-operative photographs in all cases. Conclusions In a contemporary series of RCTs evaluating PD, descriptions of the procedure were inadequate. Clear descriptions of PD using pre-existing methodological frameworks in future trials are warranted to improve outcomes, decrease bias and facilitate cross-RCT comparisons in systematic reviews.

Anesthesia and postpartum pain management for placenta accreta spectrum: The patient perspective and recommendations for care.

Placenta accreta spectrum (PAS) is a high-risk complication of pregnancy, which often requires complex surgical intervention. There is limited literature on the patient experience during the perioperative period and postpartum pain management for PAS. Therefore, this study aims to explore the patient perspective of anesthesia care. Ethical approval was granted by the hospital ethics committee (EC02.2023). This was a descriptive survey study, including women with a history of pregnancy complicated by PAS who were members of two patient advocacy groups. The survey, consisting of both open and closed questions, was performed over a 6-week period between January and March 2023. Content analysis was performed on qualitative data to identify themes, and recommendations for care are suggested. A total of 347 participants responded to the survey; 76% (n = 252) had a cesarean hysterectomy (n = 252), and general anesthesia was the most common primary mode of anesthesia (39%, n = 130). We identified two overarching themes: experiences of anesthesia and experience of postpartum pain management. Under experiences of anesthesia, three subthemes were identified, namely "communication with the anesthesiologist", "deferring to the expertise of the team", and "consequences of decision around the mode of anesthesia." Under postpartum pain management, two subthemes emerged: "support of specialist PAS team" and "poor pain management following PAS surgery". Women want to be involved in decisions around their care, but do not always understand the consequences of their decision-making, such as missing the birth of their child. An antenatal anesthesiology consultation is important to provide women with information, explore preferences, and develop a plan of care for the birth.

ERECTOR SPINE PLANE BLOCK WITH GENERAL ANAESTHESIA COMPARED WITH GENERAL ANAESTHESIA WITHOUT REGIONAL COMPONENT FOR SPINE SURGERY: PROSPECTIVE RANDOMIZED CONTROLLED TRIAL

Background. Spine surgery is a complex and traumatic surgical intervention that require sufficient anaesthesia supplementation. Erector spine plane block (ESPB) is an effective method of reducing pain intensity, but there is insufficient data on its effect on hemodynamic parameters, blood loss and possible complications.
 Aim. Compare the impact of ESPB as a component of combined anaesthesia with general anaesthesia without regional component on amount of opiates, blood loss and infusion therapy intraoperatively, intensity of pain postoperatively, to study the consequence of the two methods of anaesthesia on hemodynamic parameters, the time of weaning from artificial ventilation and the duration of hospitalization.
 Materials and methods. 151 patients underwent spine surgery. Depending on the method of analgesia, patients were divided into two groups: group 1 – general anaesthesia with ESPB, group 2 – general anaesthesia alone. Primary outcomes: intensity of pain at rest and during movements after surgery 6, 12, 24, 36, 48 hours after surgery, duration of hospitalization, time of weaning from the ventilator. Secondary outcomes: amount of fentanyl used intraoperatively and morphine postoperatively, mean arterial pressure (MAP), heart rate (HR), blood loss, diuresis, and infusion therapy during surgery.
 Results. The intensity of pain at rest and during movement after surgery was significantly lower in group 1. The duration of hospitalization and ventilation was longer in group 2. The amount of opiates intra- and postoperatively was lower in group 1. HR, MBP, blood loss and infusion therapy were higher in group 2. Diuresis did not differ in both groups.
 Conclusion. ESPB as a component of combined anaesthesia reduces the intensity of pain at all stages of observation after surgery, decrease amount of opiates, duration of artificial ventilation and hospitalization. ESPB diminish HR and SBP, minimize blood loss and infusion therapy without affecting diuresis.

Unforeseen consequence: heterotopic ossification following traumatic brain injury and acetabulum fracture-a case report

Heterotopic ossification (HO) is a rare pathological condition characterized by the formation of bone in soft tissues outside the normal skeletal system. HO can result in restricted joint mobility, nerve compression, and pain. We present a case report of a 34-year-old male who developed HO. There is a history of neurological injury and fracture acetabulum (left). Imaging studies revealed extensive HO with complete bony bridging of the hip joint, leading to severe functional impairment and chronic pain. The patient had previously undergone multiple medical treatments with non-steroidal anti-inflammatory drugs, and physiotherapy with limited success. Ultimately, he underwent a complex surgical intervention involving resection of HO, release of joint contractures, resulting in significant improvement in joint mobility and pain control. Here we discuss a rare and debilitating presentation of HO and the treatment options available for such patients. Clinicians should be aware of this challenging condition and manage patients through a multidisciplinary approach.

#4677 EARLY MARKERS OF POSTOPERATIVE ACUTE KIDNEY INJURY

Abstract Background and Aims Acute kidney injury (AKI) is a common clinical condition among patients who undergo cardiac surgery, significantly affecting morbidity and mortality[1]. To date, preoperative biomarkers and solid predictive models for AKI are not yet currently available in clinical practice. Recent studies reported endogenous ouabain (EO), a stress hormone secreted by the adrenal glands, as associated to worse kidney outcomes after cardiac surgery[2]. The aim was to validate the use of EO as biomarker of individual susceptibility for AKI after cardiac surgery and to create a new powerful score for postoperative AKI risk. Method 1174 patients undergoing elective cardiac surgery were enrolled in the study. Preoperative biological samples were collected and analysed. The primary outcome was AKI development, according to KDIGO 2012 guidelines. Results 21.6% of patients developed AKI (9% developed severe AKI, stage≥2). AKI confirmed strong correlation to postoperative death: all patients dead within 90 days for postsurgical complication developed AKI and each AKI stage was associated to a 10 times higher mortality risk (p < 0.001). Different preoperative clinical variables were analyzed, identifying five independent risk factors significantly correlated to AKI and severe AKI: age, FE, NYHA class, reoperation and complex surgical intervention (p < 0.001 for all of them). Preoperative EO levels turned out significantly associated to the incidence of AKI (p < 0.001) and clinical complications. Specifically, patients with higher EO levels had greater incidence of AKI (p < 0.001) and worse cardiac and kidney basal function (p = 0.005 and p = 0.003, respectively). Finally, a simple score was developed on the base of those preoperative clinical values significantly associated to AKI (AUC for severe AKI = 0.79, p <0,001). Adding preoperative EO to the model significantly improved the predictive capability (AUC for severe AKI = 0.82, p < 0.001; Δ-AUC +0.0229, p = 0.026). Conclusion We confirmed in a large population the role of preoperative plasma level of EO as an important early predictor for post-surgical AKI and we built a powerful clinical model for postoperative AKI risk, exclusively using few simple preoperative clinical factors and a single biohumoral marker.

Feasibility and safety of some surgical maneuvers during vena cava thrombectomy in patients with intravenous spread of renal cell carcinoma

The aim of the study is to analyse the feasibility and safety of some complex surgical manoeuvres during vena cava trombectomy.Material and Methods. The study included 78 (62.9%) men and 46 (37.1%) women. The average age of patients was 58.4±10.5 years. There were right-sided tumours in 82 (66.1%) cases and left-sided tumours in 42 (33.9%). Caval thrombi were of levels I, II, II, and IV, respectively, in 35 (28.2%), 36 (29%), 27 (21.8%) and 26 (21%) observations. All operations were performed without the use of artificial circulation. Results of the study. Liver mobilization was technically difficult in 17.8% of observations and was accompanied by 17 (37.8%) intraoperative complications in 13 (28.9%) patients. The most severe complications were injuries to the hepatic parenchyma (11.1%) and the main hepatic veins (11.1%). Access to the supra-diaphragmatic section of the LAA and the right atrium was feasible in all observations with an intraoperative complication rate of 8.8%. No damage to the right diaphragmatic nerve was noted in any of the observations. The right pleural cavity was opened in 2 (5.9%) patients with atrial thrombi. Another patient (2.9%) had damage to the posterior wall of the inferior vena cava at the level of its intrapericardial segment. Thrombus apex palpation and milking maneuver were successful in 83.1% and 90% of patients, respectively.Conclusion. Removal of tumour thrombi from the IVC for renal neoplasms is a complex surgical intervention. It requires the use of a large number of special surgical manoeuvres and techniques, which are difficult to perform in 10% of patients and may be accompanied by severe intraoperative complications.

MP75-16 LONGER SURGICAL WAIT TIMES AFTER VISIT TO UROLOGY CLINIC IS ASSOCIATED WITH DECREASED ODDS OF COMPLEX STONE SURGERY

You have accessJournal of UrologyCME1 Apr 2023MP75-16 LONGER SURGICAL WAIT TIMES AFTER VISIT TO UROLOGY CLINIC IS ASSOCIATED WITH DECREASED ODDS OF COMPLEX STONE SURGERY Sudarshan Srirangapatanam, Cameron Hicks, Thomas Chi, Marshall Stoller, and David Bayne Sudarshan SrirangapatanamSudarshan Srirangapatanam More articles by this author , Cameron HicksCameron Hicks More articles by this author , Thomas ChiThomas Chi More articles by this author , Marshall StollerMarshall Stoller More articles by this author , and David BayneDavid Bayne More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003349.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Kidney stones are known to grow over time and delays between emergency department visits and surgical care are associated with more complex surgical intervention. As such, the objective of this study is to investigate the effect of the wait times from urology clinic visits to surgery on the eventual complexity of kidney stone surgery. METHODS: Urologic visits were identified using The AUA Quality (AQUA) Registry. Subsequently, adults (age ≥18) having a diagnosis of nephrolithiasis and undergoing ≥1 urologic stone procedure were identified. These patients were then followed for at least 365 days after their index surgery to determine the total burden of procedures. Any patients without 365 days of follow-up were excluded. Our outcomes were defined as percutaneous nephrolithotomy (PNL) vs. non-PNL index surgery, undergoing more than 1 urologic procedure within 365 days, and receipt of complex surgery (PNL as index surgery or >1 procedure within 365 days). Each outcome was analyzed using a multivariate logistic model with wait times as predictor controlling for age, gender, race, insurance, social deprivation index, obesity, diabetes, and flomax prescription. RESULTS: A total of 137,477 patients underwent ≥1 urologic stone procedure. Of these, 6,497 (4.7%) patients underwent index PNL and 40,968 (29.8%) patients underwent more than 1 procedure within 365 days. Stratifying patients by index procedure type revealed highers odds of undergoing PNL for any wait time (ref: 0-3 months) but little change was observed as wait times increased (slope=0.0005, p=0.29). Odds of undergoing multiple procedures (slope=-0.0035) and receipt of complex stone surgery (slope=-0.0031) both showed a decreased trend as wait times increased (p<0.001). CONCLUSIONS: Increased surgical wait times is generally expected to lead to worse outcomes due to disease progression in the patients. Paradoxically, we show that an increasing time interval from urologic clinic visits to surgical treatment associates with lower odds of complex surgery. Therefore, time from diagnosis to evaluation by a urologist may be the rate-limiting step in the time course of kidney stone treatment. And reducing this time may reduce previously recognized disparities in the eventual need for complex kidney stone surgery. Source of Funding: K12DK111028 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1086 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sudarshan Srirangapatanam More articles by this author Cameron Hicks More articles by this author Thomas Chi More articles by this author Marshall Stoller More articles by this author David Bayne More articles by this author Expand All Advertisement PDF downloadLoading ...

Unusual surgical treatment option for an uncommon disease: Ureterocutaneostomy in an emphysemateous pyelonephritis patient.

Emphysematous pyelonephritis (EPN) is severe necrotising inflammation of renal parenchyma. Because of the devastating consequences of the pathology aggressive treatment can prevent permanent renal damage. Fifteen-year-old-girl patient without medical follow-up applied to emergency room with fever and vomiting. Computed Tomography (CT) revealed EPN. After diagnostic procedure minimal invasive procedures like double J catheter and nephrostomy tube insertion failed. While taking into account family’s treatment and medical follow-up compliance, also severe dilatation in both ureters made bilateral ureterocutaneostomy (UC) to be considered as a feasible option. UC creation can be thought as a safe and effective alternative surgical procedure. Pediatric neurogenic bladder (NB) population incompatible to treatment and follow-up are candidates for EPN development. We also believe that UC can be beneficial in terms of acute and long-term management of EPN in NB patients who the clinician thinks will not be compatible with complex surgical intervention, follow-up and treatment.

The natural history of postoperative hydrocephalus after pediatric hemispherectomy for medically refractory epilepsy: an institutional experience.

Hemispherectomy is a complex surgical intervention for medically refractory epilepsy, and its surgical sequelae continue to be defined. The incidence, timing, and predictors of postoperative hydrocephalus are not well understood. Correspondingly, the aim of this study was to define the natural history of the development of hydrocephalus after hemispherectomy based on the authors' institutional experience. The authors performed a retrospective review of their departmental database for all relevant cases between 1988 and 2018. Demographic and clinical results were abstracted and analyzed using regression analyses to identify predictors of postoperative hydrocephalus. Of the 114 patients who satisfied selection criteria, there were 53 females (46%) and 61 males (53%) with mean ages of 2.2 and 6.5 years at first seizure and at hemispherectomy, respectively. There were 16 patients (14%) with a history of previous seizure surgery. In terms of surgery, the mean estimated blood loss was 441 ml, with a mean operative time of 7 hours, and 81 patients (71%) required intraoperative transfusions. A planned postoperative external ventricular drain (EVD) was placed in 38 patients (33%). The most common procedural complications were infection and hematoma, occurring in 7 patients (6%) each. Overall, there were 13 patients (11%) with postoperative hydrocephalus requiring permanent CSF diversion, occurring at a median of 1 year (range 0.1-5 years) after surgery. On multivariable analysis, a postoperative EVD (OR 0.12, p < 0.01) was significantly associated with a decreased likelihood of postoperative hydrocephalus, whereas previous surgery history (OR 4.32, p = 0.03) and postoperative infection complication (OR 5.14, p = 0.04) were significantly associated with increased likelihood of postoperative hydrocephalus. Postoperative hydrocephalus mandating permanent CSF diversion following hemispherectomy can be expected in approximately 1 in 10 cases, presenting months after surgery on average. A postoperative EVD appears to reduce this likelihood, whereas postoperative infection and previous history of seizure surgery were shown to statistically increase this likelihood. These parameters should be carefully considered in the management of pediatric hemispherectomy for medically refractory epilepsy.