Incidence Of Leakage Research Articles

Critical Role of Pleural Wrap and Post-operative Neonatal Protocol in Long-gap Oesophageal Atresia: A Team Effort.

The objectives of this study were to bring out the results of application of pleural wrap in primary repair of tracheo - esophageal fistula (TEF) with long-gap oesophageal atresia (LGEA) and also define the role of neonatologists and paediatric intensivists in post-operative management in these patients by laying down standard neonatal management protocol. This was a retrospective descriptive observational study conducted between March 2011 and April 2019 on 23 cases of LGEA with TEF. The study was conducted at two tertiary care paediatric surgery centres in Northern part of India wherein these newborn babies were operated by two paediatric surgeons with variable experience of 8-12 years. It also describes the neonatal management protocol used in post-operative period. Out of 23 patients, 15 were boys and 8 were girls, with a mean age of 32.25 weeks and a mean birth weight of 2.02 kg. The mean hospital stay was 23.5 ± 8 days. Eleven cases had gap between 3 and 3.5 cm, 8 cases between 3.5 and 4 cm and 4 cases had gap more than 4 cm. The incidence of associated anomalies was 52%. Anastomotic leak rate was 8.69%, and 3 (13.04%) patients died in the post-operative period. All the operated patients were managed postoperatively as per strict neonatal management protocol exclusively by the team of neonatologists and neonatal intensivists. Application of pleural wrap over anastomosis following primary repair of LGEA with TEF significantly reduced the incidence of anastomotic leak in our study. Apart from the pleural wrap, the key to successful outcome also is contributed by the little prolonged, controlled ventilation and patience and perseverance in post-operative feeds. This post-operative management protocol that has been followed by us in our study is easily reproducible and can be adopted by paediatric surgeons working alongside neonatologists as a team.

Percutaneous functional spinal unit cementoplasty versus percutaneous kyphoplasty for severe osteoporotic vertebral compression fracture complicated with endplate-disc complex injury: A retrospective case-control study.

Severe osteoporotic vertebral compression fracture (SOVCF) is frequently complicated by endplatedisc complex (EDC) injury. While percutaneous kyphoplasty (PKP) can offer rapid analgesia and facilitate early activity, it does not restore vertebral height and may result in intervertebral leakage and untreated EDC injury. This study aimed to evaluate the clinical outcomes of percutaneous functional spinal unit cementoplasty (PFSUP) for SOVCF complicated by EDC injury and compare its clinical and imaging outcomes with PKP. This was a retrospective case-control study. Patients with SOVCF complicated with EDC injury between January 1, 2018, and December 31, 2019, were recruited and assigned to the PKP group and PFSUP group based on their treatment procedures Back pain was evaluated using the visual analog scale (VAS) and daily life activities were assessed using the Oswestry disability index (ODI). X-rays were employed to observe the presence and location of cement leakage, as well as to measure the sagittal vertical axis (SVA) and local kyphosis angle (LKA). Loss of correction was calculated by subtracting the LKA after surgery from that at the final follow-up visit Subsequent vertebral fracture (SVF) was confirmed using the Genant semi-quantitative method and/or MRI. A total of 64 patients were included in this study. Among them 41 cases were assigned to the PKP group (28 females, 74.8 years on average), while the remaining 23 cases were assigned to the PFSUP group (15 females, 76.3 years on average). All surgical interventions were successfully completed without major complications. Compared to the PKP group, the PFSUP group had longer operation time (70.28 ± 11.44 vs 44.5 ± 10.12, P< 0.001) higher frequencies of radiation exposure (97.6 ± 19.85 vs 38.6 ± 9.53, P< 0.001), and a lower cement leakage rate (26.1% vs. 41.5%, P< 0.001). One day after surgery and at the final follow-up the PFSUP group had lower VAS and ODI scores, as well as lower LKA and Sva values compared with the PKP group (all P< .001). At the final follow-up visit, the PFSUP group demonstrated a lower loss of correction (4.38 ± 2.71 vs. 10.19 ± 3.41 P< 0.001) and a lower SVF rate compared to the PKP group (21.7% vs. 31.7%, P< 0.001). PFSUP outperformed PKP in alleviating pain restoring and maintaining sagittal balance, and lowering the incidence of cement leakage and SVF for SOVCF with EDC injury However, PFSUP was associated with longer operation time and high radiation exposure frequencies.

Fenestrating vs reconstituting laparoscopic subtotal cholecystectomy: a systematic review and meta-analysis.

Laparoscopic cholecystectomy is one of the most frequently performed procedures by general surgeons. Strategies for minimizing bile duct injuries including use of the critical view of safety method, as outlined by the SAGES Safe Cholecystectomy Program, are not always possible. Subtotal cholecystectomy has emerged as a safe "bail-out" maneuver to avoid iatrogenic bile duct injury in these difficult cases. Strasberg and colleagues defined two main types of subtotal cholecystectomies: reconstituting and fenestrating. As there is a paucity of studies comparing the two subtypes of laparoscopic subtotal cholecystectomy (LSC), we performed a systematic review and meta-analysis comparing the reconstituting and fenestrating techniques for managing the difficult gallbladder. A search of PubMed, Embase, and Cochrane databases was conducted to identify prospective and retrospective studies comparing fenestrating and reconstituting LSC. The outcomes of interest were bile leak, reoperation, readmissions, completion cholecystectomy, postoperative ERCP, and retained CBD stones. We screened 2855 studies and included 13 studies with a total population of 985 patients. Among them, 330 patients (33.5%) underwent reconstituting LSC and 655 patients (55.5%) underwent fenestrating LSC. Twelve studies were retrospective, and one was prospective. Notably, reconstituting STC was associated with decreased incidence of bile leak (OR 0.29; CI 95% 0.16-0.55; p = 0.0002; I2 = 36%). We also noted increased rates of postoperative ERCP with fenestrating STC in sensitivity analysis (OR 0.32; CI 95% 0.16-0.64; p = 0.001; I2 = 31%). In addition, there was no difference between the two techniques regarding the rates of completion of cholecystectomy, reoperation, readmission, and retained CBD stones. Fenestrating LSC leads to a higher incidence of postoperative bile leakage. In addition, our sensitivity analysis revealed that the fenestrating technique is associated with a higher incidence of postoperative ERCP. Further randomized trials and studies with longer-term follow-up are still necessary to better understand these techniques in the difficult gallbladder cases.

Dispersion characteristics of large-scale liquid hydrogen spills in a real-world liquid hydrogen refueling station with various releasing and environmental conditions

The global expansion of hydrogen refueling stations (HRS) has heightened interest in the development of liquid hydrogen refueling stations (LHRS). This study presents a model for an LHRS, inspired by the Yilan HRS in Shanghai, to simulate large-scale liquid hydrogen (LH2) leakage scenarios. Utilizing the FLACS-CFD software, comprehensive simulations were performed to assess the impact of various environmental conditions and leakage parameters—such as wind speed, wind direction, spill rate, and spill duration—on critical outcomes including the size of the LH2 pool, evaporation rate, flammable volume of the vaporized hydrogen gas cloud, and maximum downwind distance/height. The findings establish a correlation between these factors and the predicted results, providing real-time guidance for managing LH2 leakage incidents at operational LHRS.

Comparison of Biliary Complications Between Living and Deceased Donor Liver Transplantations: A Systematic Review and Meta-analysis.

To understand if the risk of biliary complications is higher with living donor liver transplantation (LDLT) compared to deceased donor liver transplantation (DDLT), the present meta-analysis was conducted to analyze the differences between these two types of liver transplantations.Three databases were searched from inception to September 2023 for comparative studies reporting biliary complications with LDLT and DDLT. Odds ratios (OR) with 95% confidence intervals were calculated for all the dichotomous outcomes.Twenty-eight studies were included in the final analysis. LDLT was associated with a significantly higher incidence of biliary complications than DDLT (OR 1.96, 95% CI: 1.56-2.47). However, on subgroup analysis, only studies published in or before 2014 reported a higher incidence of biliary complications with LDLT, but not with studies published after 2014. An analysis of individual adverse events showed that LDLT was associated with a higher incidence of both bile leak (OR 3.38, 95% CI: 2.52-4.53) and biliary stricture (OR 1.75, 95% CI: 1.20-2.55).LDLT was associated with a higher incidence of overall biliary complications, including bile leak and biliary stricture. With advances in surgical techniques, there has been a reduction in the risk of biliary complications.

Urine Sample Handling in Laboratory—Process Reengineering is the Need of the Hour

Background and Aims: Monitoring and a continual improvement of turnaround time (TAT) in urine examination and reporting is essential for improved management of laboratory quality as well as ensuring patient satisfaction. TAT can be impacted by multiple factors, some of which appear to be beyond the control of laboratory, especially the preanalytical phase of urine examination such as specimen collection, transportation and sample preparation. The aim of the study was to compare the preanalytical variables like TAT for transportation and incidences of spill between our current urinalysis workflow process and the new urinalysis workflow process using a pneumatic chute-compatible closed urine collection system. Materials and Methods: This observational prospective study was conducted on 4/9/23 from 9 am to 4 pm at the laboratory of Apollo Main Hospital, Chennai. Pneumatic chute compatible closed urine collection cup was given to the patients in Group-A and normal screw cap containers which we are currently using were given to the patients in Group-B. Once the urine samples were collected in the respective containers, they were transported to the laboratory using pneumatic chutes for Group-A samples and manual carry for Group-B samples. Analysis of transportation time using the new collection method (Group-A) when compared with the current method of practice (Group-B) was done. The incidence of spillage was also monitored. Results: A significant improvement was noticed in the transportation process and spill incidence with closed collection devices through the pneumatic chute. Conclusion: To conclude, the implementation of pneumatic chute compatible closed collection tubes for urine improves the transportation and processing time, eliminates the manual carry of urine samples, eliminates the incidences of leakage and spillage, reduces errors and reduces the exposure of urine to healthcare workers, thereby leading to significant improvement in patient care, patient experience and staff satisfaction.

553. CIRCULAR STAPLED CERVICAL ESOPHAGO-GASTROSTOMY, A VALUABLE OPTION AFTER TOTALLY MINIMALLY INVASIVE MCKEOWN ESOPHAGECTOMY?

Abstract Background The optimal choice of anastomotic technique for cervical esophagogastric anastomosis after esophagectomy remains unclear. The incidence of cervical anastomotic leak after esophagectomy can be up to 30%, which is the highest among all types of gastrointestinal anastomosis. Anastomotic stricture is another complication that can decrease the postoperative quality of life with an incidence of 9.1–46.0%. Few studies directly compared circular stapled (CS) and hand sewn (HS) cervical esophago-gastric anastomosis, with mixed results. We aim to compare the two techniques in a pre-post cohort study. Methods Medical record of all patients that underwent minimally invasive subtotal esophagectomy and cervical esophago-gastrostomy in our institution from January 2018 to January 2024 were reviewed from a prospectively collected database. We routinely performed hand sawn anastomoses until February 2022, then switched to circular stapled, with the aim of reducing the incidence of anastomotic leaks. We compared clinical data of patients who received hand sewn cervical anastomosis and circular stapled anastomosis. Primary endpoints were anastomotic leaks and strictures. Results We identified 101 patients who met the inclusion criteria. HS anastomosis was performed in 67 patients, while 34 received CS anastomosis. Anastomotic leak rate was 22.4% in the HS group and 8.8% in the CS group (OR 0.34, p=0.092). Anastomotic stricture rate was 26.9% in the HS group and 14.7% in the CS group (OR 0.47, p=0.17). Median length of stay was 18 (IQR 15-22) days in the HS group and 13.5 (IQR 12-14.5) days in the CS group (p=0.001). Severe complication rate (CD&amp;gt;2) was 16.4% in the HS group and 11.8% in the CS group (OR 0.68, p=0.53). Conclusions In our experience, the introduction of circular stapled cervical esophago-gastrostomy was feasible and safe, and resulted in a lower incidence of anastomotic leak and stricture compared to hand sewn anastomosis, though not statistically significant, possibly because of the small sample size. No difference in other major postoperative outcomes was observed. We found cervical CS anastomosis a reliable, reproducible and technically less demanding procedure, even for very high esophageal cancers. We believe that this anastomotic technique could spread even in Western countries where it has hardly ever been explored.

400. MODIFICATION OF THE LESSER CURVATURE INCISION ENHANCES GASTRIC CONDUIT BLOOD FLOW AND DECREASE ANASTOMOTIC LEAKAGE RISK AFTER ESOPHAGECTOMY

Abstract Background We conducted this study to investigate the effectiveness of a modified incision line on the lesser curvature for gastric conduit formation during esophagectomy in enhancing the perfusion of the gastric conduit, as determined by indocyanine green (ICG) fluorescence imaging, and reducing the incidence of anastomotic leakage. Methods A total of 272 patients who underwent esophagectomy at our institution between June 2014 and August 2022 were enrolled in the study. The patients were divided into two groups in accordance with the type of cutline on the lesser curvature: the Conventional group, consisting of patients operated on until 2018 (Conventional group; n = 141), in which the traditional cutline (5.0 cm from the pylorus in routine) was adopted, and the Current group, consisting of patients operated on from 2019 until date (Current group; n = 131), in which a modified cutline on the lesser curvature was adopted, that allowed preservation of the entire right gastric artery was adopted (hereinafter, modified cutline) was adopted. Gastric conduit perfusion during the surgery was assessed by intraoperative ICG fluorescence imaging, and the clinical outcomes after esophagectomy were also evaluated. Results All patients underwent esophagectomy with regional lymph node dissection and gastric conduit reconstruction via the retrosternal route. The distance from the pylorus to the cutline was significantly longer in the Current group as compared with the Conv group (median: 9.0 cm vs. 5.0 cm, p &amp;lt; 0.001). The blood flow speed in the gastric conduit wall assessed by ICG fluorescence imaging was significantly higher in the Current group than that in the Conventional group (median: 2.81 cm/sec vs. 2.54 cm/sec, p = 0.001). Furthermore, the incidence of anastomotic leakage was significantly lower (p = 0.024) and the hospital stay significantly shorter (p &amp;lt; 0.001) in the Current group as compared with the Conventional group. Logistic regression analysis using the data of the entire cohort identified the blood flow velocity in the gastric conduit wall as the only variable that was significantly (negatively) associated with anastomotic leakage. Conclusions ICG fluorescence imaging is a feasible, reliable method for intraoperative assessment of gastric conduit perfusion. Use of the modified lesser curvature cutline could enhance gastric conduit perfusion, promote blood circulation around the anastomosis and ultimately reduce the risk of anastomotic leakage after esophagectomy.

Delayed Gastric Emptying and Other Adverse Outcomes in Patients Undergoing Classic Whipple Versus Pylorus-Sparing Pancreatoduodenectomy.

Background and objective Pancreatoduodenectomy (PD), or the Whipple procedure, has many variants. There is a lack of data in the literature in terms of comparing various types of this procedure. This study aimed to comparethe classic Whipple procedure with the pylorus-sparing Transverso-Longmire technique, focusing on postoperative complications and delayed gastric emptying (DGE). Methodology We conducted a retrospective observational study including 97 adult patients who underwent either the classic Whipple procedure or the pylorus-sparing technique at Hospital Médica Sur from 2016 to 2021. Data on patient demographics, comorbidities, type of surgery, clinical presentation, and postoperative complications were collected. DGE was defined according to the International Study Group of Pancreatic Surgery(ISGPS) criteria. Results Among the 97 patients, 50.5% were men, and the median age of the cohort was 65 years. Almost all patients underwent surgery for malignancy (96.9%). The classic Whipple group had fewer cases of DGE (9.8% vs. 30.6%, p=0.01), shorter hospital stays (7 vs. 11 days, p=0.001), and lower readmission rates (13.1% vs. 33.3%, p=0.017). The pylorus-sparing PD was associated with a lower incidence of bile leak [odds ratio (OR)=0.62, 95% confidence interval (CI): 0.53-0.73]. However, this technique was associated with a higher incidence of DGE (OR=4, 95% CI: 1.34-12.1), overall hospital admission rates (OR=3.3, 95% CI: 1.2-9.2), and admissions that resulted in a surgical event (OR=1.9, 95% CI: 1.21-2.96). DGE was associated with the need for a second surgery (OR=10.5, 95% CI: 2.8-39.5) and hospital readmission (OR=10, 95% CI: 3.1-32.3). Conclusions While the pylorus-sparing technique is associated with reduced bile leaks, it results in a higher incidence of DGE, prolonged hospital stays, and increased readmissions. Clinicians opting for the pylorus-sparing technique should ensure careful patient selection and rigorous postoperative monitoring.

538. COMPARISON OF EARLY POSTOPERATIVE OUTCOMES OF CERVICAL ANASTOMOSIS TO HIGH INTRATHORACIC ANASTOMOSIS AMONG PATIENTS WITH UPPER THORACIC ESOPHAGEAL CANCER

Abstract Background For upper thoracic esophageal cancer, esophagectomy combined with cervical esophagogastrostomy (cervical anastomosis, CA) and three-field lymph node dissection (3FLND) has been proposed as the standard surgical approach. However, while CA provides sufficient length of proximal resection margins, it is associated with a higher incidence of postoperative complications such as anastomotic leaks, recurrent laryngeal nerve (RLN) injury, and increased mortality. As an alternative, high-intrathoracic esophagogastric anastomosis (high-ITA) with 3FLND has been performed. We aimed to evaluate the benefits and limitations of high-ITA compared to conventional CA in terms of early postoperative outcomes. Methods A total of 232 patients, who underwent curative esophagogastrostomy with 3FLND and either of high-intrathoracic anastomosis (high-ITA) or cervical anastomosis (CA) for upper thoracic esophageal cancer a tertiary hospital from January 2010 to December 2021. Collected data from medical records were analyzed retrospectively regarding morbidity and mortality rates. The primary end point was recurrence. Anastomotic leak, RLN palsy, hospital stay, and 90-day mortality and in-hospital mortality were evaluated using Chi-squared test, Fisher’s exact test, and T-test. The risk of mortality and recurrence were analyzed using Cox-proportional hazard regression with a median follow-up of 39.1(IQR 17.8, 80.2) months. Results Among the fifty patients with high-ITA and 182 patients with CA, the high-ITA group reported fewer anastomotic leaks (6.0% vs. 19.8%, p=0.02) and a shorter hospital stay (median 12days vs. 15 days, p&amp;lt;0.001). No significant difference was observed in RLN palsy (6.0% vs. 13.7%, p=0.22) and the 90-day or in-hospital mortality rate (2.0% vs. 2.2%, p=1.0). The number of lymph nodes dissected (LND) was similar between the groups (47.4(±15.4) vs. 52.7(±18.3), p=0.06), and there was no difference in the risk of mortality and recurrence according to the high-ITA method (HR 0.9, 95% CI 0.6-1.6; HR 1.0, 95% CI 0.6-1.7) after adjustment for age, sex, and stage. Conclusion In the esophagogastrostomy with three-field lymph node dissection, performing high-intrathoracic anastomosis may reduce the incidence of anastomotic leaks and shorten the hospital stay without adversely affecting overall survival.

Robotic, laparoscopic and open surgery for gallbladder cancer: a systematic review and network meta-analysis.

Minimally invasive oncological resections have become increasingly widespread in the surgical management of cancers. However, the role of minimally invasive surgery (MIS) for gallbladder cancer (GBC) remains unclear. We aim to perform a systematic review and network meta-analysis of existing literature to evaluate the safety and feasibility of laparoscopic and robotic surgery in the management of GBC compared to open surgery (OS) by comparing outcomes. A literature search of the PubMed/MEDLINE (2000 to December 2021) and EMBASE (2000 to December 2021) databases was conducted. The primary outcome studied was overall survival, and secondary outcomes studied were postoperative morbidity, severe complications, incidence of bile leak, length of hospital stay, operation time, R0 resection rate, local recurrence and lymph node yield. Thirty-two full-text articles met the eligibility criteria and were included in the final analysis with a total of 5883 patients undergoing either OS or MIS (laparoscopic or robotic) for GBC. 1- and 2-stage meta-analyses did not reveal any significant differences between OS, laparoscopic and robotic surgery in terms of overall survival, R0 resection, lymph node harvest, local recurrence and post-operative complications. Patients who underwent OS had significantly longer hospitalization stay and intra-operative blood loss compared to those who underwent laparoscopic or robotic surgery. Network meta-analysis did not reveal any significant differences between post-operative and survival outcomes of laparoscopic vs robotic surgery groups. This network meta-analysis suggests that both laparoscopic and robotic surgery are safe and effective approaches in the surgical management of GBC, with post-operative and survival outcomes comparable to OS. An MIS approach may also lead to shorter hospitalization stay, less intraoperative blood loss and post-operative complications compared to OS. There was no obvious benefit of either MIS approach (laparoscopic versus robotic) over the other.

389. WILL SYNCHRONOUS ESOPHAGEAL AND LUNG RESECTION INCREASE THE INCIDENCE OF ANASTOMOTIC LEAKS? A MULTICENTER RETROSPECTIVE STUDY

Abstract Background Reports on combined resection for synchronous lung lesions and esophageal cancer (CRLE) cases are rare and mostly individual cases. Furthermore, the feasibility of CRLE has always been a controversial topic. In the current study, we retrospectively analyzed the feasibility of CRLE and established an individualized prediction model for esophageal anastomotic leaks after CRLE by performing a multicenter retrospective study. Methods Patients who underwent esophagectomy between January 2009 and June 2021 were extracted from a 4-centre retrospectively maintained database, and those with CRLE at the same setting were matched in a 1:2 propensity score matched (PSM) ratio to esophagectomy alone (EA) patients. A nomogram was then established based on the variables involved in multivariate logistic regression analysis. Internal validation of the nomogram was conducted utilizing Bootstrap resampling. Decision and clinical impact curve analysis were computed to assess the practical clinical utility of the nomogram. A prognosis analysis for CRLE and EA patients by Kaplan-Meier curves was conducted. Results Of the 7152 esophagectomies, 216 cases of CRLE were eligible, and 1:2 ratio PSM EA patients were matched. The incidence of anastomotic leaks following CRLE increased significantly (P=0.035). The results of the multivariate analysis indicated the leaks varied according to the type of lung resection (anatomic &amp;gt; wedge resection, P=0.016) and site of resected lobe (upper &amp;gt; middle/low lobe; P=0.027), and a nomogram was established to predict the occurrence of leaks accurately (AUC=0.786). Although no statistically significant difference in overall survival (OS) was observed in the CRLE group (P=0.070), a trend toward lower survival rates was noted. Further analysis revealed that combined upper lobe anatomic resection was significantly associated with reduced OS (P=0.027). Conclusion Our study confirms that CRLE is feasible but comes with a significantly increased risk of anastomotic leaks and a concerning trend of reduced survival, particularly when upper lobe anatomic resections are performed. These findings highlight the need for careful patient selection and surgical planning when considering CRLE.

The Use of Synthetic, Nonabsorbable Graft for Middle Fossa Repair in Patients With Spontaneous Cerebrospinal Fluid Leak: A Pilot, Prospective Study.

To evaluate the efficacy of a nonabsorbable, synthetic graft for the reconstruction of spontaneous middle fossa (sMF) cerebrospinal fluid (CSF) leaks. Six adult patients (age ≥16 yr) who had sMF CSF leaks surgically repaired within an 18-month period at a single university hospital using synthetic, nonbiological, nonabsorbable graft (Neuro-Patch) and a retrospective control group of five patients undergoing multilayer MF repair with autologous grafts. MF repair through a combined transmastoid/MF approach using Neuro-Patch or multilayer autologous grafts. The incidence of postoperative leak within 6 months postoperatively was the main outcome measure; we also recorded the need for lumbar drain, additional hearing loss, length of inpatient stay, body mass index, previous meningitis, preoperative increased intracranial pressure, and age. In the Neuro-Patch group, there was no postoperative CSF leak without the need for lumbar drain. We observed no additional hearing loss; patients were monitored for 2 days without any readmissions. Increased intracranial pressure (four of six), previous episodes of meningitis (two of six) or obesity (five of six) did not affect patient outcomes. Demographic and prognostic factors were the same for the control group. However, one patient needed lumbar drain postoperatively because of residual leak; lumbar drain was used in one more case (two of five cases), whereas three of five patients had to stay for longer than 2 days (5 d). Our pilot study suggests the use of Neuro-Patch via combined transmastoid/MF approach as an effective technique with minimum, if any morbidity; it could be of particular benefit for patients with larger MF dura defects. A larger number of patients are required to strengthen the evidence.

646. MCKEOWN VS IVOR-LEWIS ESOPHAGECTOMY FOR PATIENTS WITH A HISTORY OF TOTAL PHARYNGOLARYNGECTOMY: A COMPARISON STUDY

Abstract Background Oncologic esophagectomy in patients with a history of total pharyngolaryngectomy (TPL) is challenging. There are two different esophagectomy procedures: total esophagectomy with cervical anastomosis (McKeown) and subtotal esophagectomy with intrathoracic anastomosis (Ivor-Lewis). Differences in outcomes between McKeown and Ivor-Lewis esophagectomies for patients with this history remain unclear. Patients and Methods We retrospectively reviewed 36 patients with a history of TPL who underwent oncologic esophagectomy and compared the clinical outcomes between the procedures. Results Twelve (33.3%) and 24 (66.7%) patients underwent McKeown and Ivor-Lewis esophagectomies, respectively. McKeown esophagectomy was more frequently performed for the supracarinal tumors (P = 0.002). Other baseline characteristics, including the history of radiation therapy, were comparable between the groups. Postoperatively, the incidences of pneumonia and anastomotic leakage were higher in the McKeown group than in the Ivor-Lewis group (P = 0.029 and P &amp;lt; 0.001, respectively). Neither tracheal necrosis nor remnant esophageal necrosis was observed. The overall and recurrence-free survival rates were comparable between the groups (P = 0.494 and P = 0.813, respectively). Conclusion When performing esophagectomy for patients with a history of TPL, if it is oncologically acceptable and technically available, Ivor-Lewis is preferable over McKeown esophagectomy for avoiding postoperative complications.

440. QUANTIFICATION OF FLUORESCENCE ANGIOGRAPHY FOR ESOPHAGEAL PERFUSION ASSESSMENT: MEASURING AGREEMENT BETWEEN TWO SOFTWARE ALGORITHMS

Abstract Background Indocyanine green fluorescence angiography (ICG-FA) may reduce perfusion related complications after esophagectomy with gastric conduit reconstruction. Software implementations for quantifying ICG-FA are emerging to overcome a subjective interpretation of the technology. Comparison between quantification algorithms is needed to judge its external validity. This study aimed to measure the agreement for esophageal perfusion assessment between two independently developed quantification software implementations. Methods This retrospective cohort analysis included standardized ICG-FA video recordings of patients who underwent esophagectomy with gastric conduit reconstruction between August 2020 until February 2022. Recordings were analysed by two quantification software implementations: AMS and CPH. The quantitative parameter used to measure visceral perfusion was the normalized maximum slope derived from fluorescence time curves. The agreement between AMS and CPH was evaluated in a Bland-Altman analysis. The relation between the intraoperative measurement of perfusion and the incidence of anastomotic leakage was determined for both software implementations. Results Seventy pre-anastomosis ICG-FA recordings were included in the study. The Bland-Altman analysis indicated a mean relative difference of +58.2% in the measurement of the normalized maximum slope when comparing the AMS software to CPH. The agreement between AMS and CPH deteriorated as the magnitude of the measured values increased, revealing a proportional (linear) bias (R2 = 0.512, p &amp;lt; .001). Neither the AMS nor the CPH measurements of the normalized maximum slope held a significant relationship with the occurrence of anastomotic leakage (median of 0.081 versus 0.074, p = 0.32 and 0.041 vs 0.042, p = 0.51, respectively). Divergent approaches in maximum slope determination and raw signal filtering were identified as contributing factors to the differences in outcome. Conclusion This is the first study to demonstrate technical differences in software implementations that can lead to discrepancies in ICG-FA quantification in human clinical cases. The possible variation among software-based quantification methods should be considered when interpreting studies that report quantitative ICG-FA parameters and derived thresholds, as there may be a limited external validity.

604. REAL-WORLD MANAGEMENT AND OUTCOMES OF PATIENTS WITH NON METASTATIC ESOPHAGEAL SQUAMOUS CELL CARCINOMA IN THE FREGAT DATABASE

Abstract Background International guidelines for locally advanced esophageal squamous cell carcinoma (ESCC) recommend both neoadjuvant chemoradiotherapy (nCRT) followed by planned surgery (P-surg) or definitive chemoradiotherapy (dCRT) with salvage surgery (S-surg). However, the optimal treatment remains unknown, and the ongoing pragmatic NEEDS randomized trial is assessing the efficacy of an organ-preserving strategy after dCRT (Nilsson, Front Oncol 2022). Real-world data on the management of non-metastatic ESCC is limited. This study aims to describe the treatment strategies and prognosis of patients with non-metastatic ESCC in a real-world setting. Methods We conducted a retrospective cohort study of patient treated for non-metastatic ESCC between 2014 and 2022. Data were extracted from the FREGAT database. For the entire population, different treatment strategies were described. We compared patients who received nCRT with those who received dCRT under real-life conditions (“Real-life” population) and according to the NEEDS randomized trial criteria (“NEEDS-like” population). Five-year overall survival (OS) and relapse-free survival (RFS) were compared between nCRT and dCRT patients using a Cox proportional hazard model adjusting for major confounders. In operated patients, the impact of surgery on OS and RFS was assessed using a time-dependent Cox proportional hazard model. Postoperative outcomes were compared between P-surg and S-surg using Fisher’s exact test. Results From 971 patients diagnosed with non-metastatic ESCC, 867 (89.3%) received a curative treatment including dCRT (41.0%), nCRT (28.0%), primary esophagectomy (9.8%), neoadjuvant chemotherapy (3.4%), or endoscopic resection (1.0%). Fifty-nine patients (6,1%) received supportive care or chemotherapy alone. Forty-five patients (4.6%) died during or before treatment. In the “real-life” population (n=659), 269 patients received nCRT and 390 patients received dCRT. A total of 229 patients (93.5%) in nCRT group underwent P-surg and S-surg was performed in 44 patients (11.3%) in dCRT group. After adjustment, dCRT was associated with a significantly poorer 5-year OS and RFS (respectively HR=1.83, 95%CI 1.44-2.33; HR=1.98, 95%CI 1.57-2.49). A complete clinical response (cCR) was observed in 21.6% and 29.5% of the nCRT and dCRT groups, respectively. Among cCR undergoing resection, 35.8% had residual disease on pathological specimen. Time between CRT and surgery was 58 days (IQR44-72) vs. 109 days (IQR71-278) for P-surge and S-Surg respectively. The 90-day mortality, major morbidity (Clavien-Dindo III/IV) and pulmonary complication rates were similar in both groups, except for a higher risk of anastomotic leakage after S-surg (p=0.05). In the “NEEDS-like” population (n=598), findings were consistent and comparable to those observed in the “real-life” population. Conclusion Among non-mestastatic ESCC included in the FREGAT database, 10.6% had a non-curative approach or died prematurely. Most patients underwent dCRT, with S-surg rate of only 11.3%. Neoadjuvant CRT followed by P-surg was associated with the best outcome in terms of OS and RFS in both “rela life” and “Needs-like” populations. In operated patients, postoperative outcomes were similar after nCRT and dCRT, except for a higher incidence of anastomotic leakage after S-surg. This study highlighted the therapeutic strategies used and their results in real-life conditions for non-metastatic ESCC inside the FREGAT database. The treatment option of nCRT followed by P-surg appears to remain the optimal curative treatment regimen.

Morbidity and Mortality after Cytoreductive Surgery and HIPEC in a National Reference Center: A Six-Year Experience under Independent Evaluation.

Introduction: Cytoreductive surgery (CRS) coupled with hyperthermic intraperitoneal chemotherapy (HIPEC) is a potentially curative approach to peritoneal disease (PD) and corresponds to the needs of patients with dire survival rates. However, the oncological community remains cautious toward this procedure because of its significant morbidity and mortality rates. This evolving evidence around CRS and HIPEC and its impact suggests a need for more standardized procedures in existing centers. Because of its complexity and potential for high morbidity and mortality, critical observation of our center's complication rates using complication management documentation tools were crucial to further develop our standard operating procedures (SOP) and maximize patient safety. Methods: Our prospectively maintained institutional database was queried to identify all patients who underwent CRS and HIPEC and had a filled-out quality management (QM) and complication management documentation tool at discharge at the surgical department of the Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany, between January 2018 and December 2023. Results: A total of 155 patients had a surgical and/or medical complication recorded. In total, 305 surgeries were surveyed. Some patients had more than one postoperative complication; hence, 344 events in 50 categories were recorded, of which 267 were graded 3a or higher in 92 patients. The most common medical complications were of pulmonary and renal origin. On the surgical side, surgical site infections (SSI) were most common. The incidence of anastomotic leakage (AL) was 5% (n = 8), with no events between 2021 and the present. Patients with longer surgery duration times were at higher risk for developing postoperative complications. Conclusions: Major abdominal surgeries like CRS and HIPEC are associated with significant patient morbidity despite achieving optimal oncological outcomes. Postoperative complications are managed through strict surveillance and transparency, particularly in our large reference centers, to minimize patient risk. Quality management programs in our department have successfully maintained high standards of care without compromising patient safety.

The impact of transanal drainage tube on the incidence of anastomotic leakage and small bowel obstruction in radical surgery (Dixon) for rectal cancer: a retrospective cohort study.

Anastomotic leakage (AL) and small bowel obstruction (SBO) are common complications after rectal cancer radical surgery (Dixon). Although the commonly used defunctioning stoma (DS) can reduce the incidence and harm of AL, it increases the probability of other adverse consequences, including SBO. Therefore, a safe and effective method for preventing the complications related to the radical surgery of rectal cancer is urgently needed. Previous studies have found that transanal drainage tube (TDT) can have a positive impact on the incidence of these two complications by draining gas and feces from the intestinal lumen, without causing other serious consequences. Therefore, this article further explores the clinical benefits that TDT can bring by analyzing the clinical data of postoperative patients with rectal cancer. This study included 221 patients who underwent radical surgery (Dixon) for rectal cancer in Hubei Cancer Hospital from September 2020 to February 2023, determine whether it meets the inclusion criteria of this study based on preoperative examination, intraoperative exploration results, and treatment methods. DS was used in 70 patients and TDT in 88 patients during the surgery; meanwhile, no protective anastomotic measures were applied in 63 patients. Seventy patients subjected to DS were categorized as group 1, 88 patients subjected to TDT as group 2, and 63 patients with no protective measures for anastomosis as group 3. Through postoperative clinical manifestations, imaging examinations, and laboratory tests, a total of 18 cases of AL and 30 cases of SBO were identified in the three groups. The effectiveness of TDT and that of other surgical procedures in preventing complications, accelerating postoperative recovery, and reducing surgical costs were compared through univariate and multivariate analyses. The clinical features of the three groups have baseline comparability. No statistically difference was noted in baseline characteristics between three groups (all P>0.05). The incidence of AL and SBO in group 1 are 7.1% and 27.1%, in group 2 are 3.4% and 4.5%, and in group 3 are 15.9% and 11.1%. Compared to patients in no protective anastomotic measures with TDT and DS, TDT has a lower incidence of postoperative AL (P<0.05) and SBO (P>0.05), and faster postoperative recovery (P<0.05). The cost of inpatient surgery is not significantly different (P>0.05). Although DS can reduce the incidence of AL to a certain extent (P>0.05), it significantly increased the incidence of SBO (P<0.05), delayed postoperative defecation time (P<0.05) and caused higher cost (P<0.001). Compared to DS, the incidence of AL in TDT is not significantly different (P>0.05), but the incidence of SBO is noticeably lower (P<0.001), with faster postoperative recovery and less cost (P<0.05). TDT is a safer, more effective, and more economical surgery for preventing postoperative complications.

Vascular Complications in Patients with ECMO Support after Cardiac Surgery.

Background: This study assessed vascular complications in patients who received extracorporeal membrane support following cardiac surgery. Methods: We included 84 post-cardiotomy patients who underwent extracorporeal membrane oxygenation (ECMO) from July 2018 to May 2022. Only patients connected to VA-ECMO (Veno-Arterial) via peripheral cannulation were included in this study. Vascular complications were compared between those who had ECMO placed using the percutaneous technique (n = 52) and those who had it placed via femoral incision (n = 32). Results: The incidence of vascular thromboembolism was significantly higher in the percutaneous technique group compared with the open technique group (p < 0.05). Hematomas were also more frequent in the percutaneous technique group (p = 0.04). Conversely, bleeding and leakage were significantly more frequent in the open technique group (p = 0.04). There were no significant differences between the two groups in terms of wound infections or revisions in the inguinal area following ECMO removal. The mortality rate associated with vascular ischemia was 81.2%, while the overall in-hospital mortality rate was 60.7%. Conclusions: The open technique for ECMO placement may reduce the risk of thromboembolic events and hematomas compared to the percutaneous technique. However, it may be associated with a higher incidence of bleeding and leakage. Both techniques show similar outcomes in terms of overall mortality and wound infections.

Incidence and Significance of Intraoperative Cerebrospinal Fluid Leak in Endoscopic Pituitary Adenoma Surgery Using Intrathecal Fluorescein

Incidence and Significance of Intraoperative Cerebrospinal Fluid Leak in Endoscopic Pituitary Adenoma Surgery Using Intrathecal Fluorescein