Long-term Recurrence Research Articles

P-087 LAPAROSCOPIC TREATMENT OF TROCAR SITE HERNIA: A SINGLE-CENTER EXPERIENCE

Abstract Introduction Trocar site hernia (TSH) is a complication of minimally invasive surgery that is often underestimated. These lesions cause patient discomfort and require surgery for their correction. Although there are some case reports for laparoscopic repair of TSH, there is data missing in the literature about this specific topic. The aim of this study is to evaluate safety and efficacy of the laparoscopic repair of TSH. Methods We collected data regarding 213 patients submitted to incisional hernia repair in the Department of General Surgery at Humanitas Mater Domini Clinical Institute in Italy since 2011 and 2019. We selected the patients submitted to laparoscopic repair of a TSH with an intraperitoenal mesh. We evaluated the clinical and surgical characteristics of the patients and the following outcomes: post-operative hospitalization, complications and long-term recurrences. Discussion Forty-two out of 213 patients were operated for a TSH. Forty out of 42 patients (95.2%) were treated with a laparoscopic approach. Follow up: 60 months. Study group: females (62.5%), mean BMI 29.1. According to EHS (European Hernia Society) classification, 35 patients had a midline defect. In 77.5% of cases a ePTFE/PP mesh was implanted. Mean hospitalization: 2 nights. The complication rate was low (1 surgical site infection, 1 seroma and 1 hematoma), without re-intervention. We observed 2 cases of recurrence (5%) developed after 5 months and 36 months, respectively. Conclusions Laparoscopic repair of TSH is a safe approach, in absence of specific contraindications. Our experience suggest that a laparoscopic approach could obtain satisfying results.

OC-100 CORRELATION BETWEEN DIASTASIS RECTI AND RECURRENCE AFTER UMBILICAL HERNIA REPAIR

Abstract Aim Evaluate whether diastasis recti is an independent risk factor for recurrence after umbilical hernia repair. Material and Methods Retrospective cohort study based on patients operated on for primary umbilical hernia between 2015–2017. Inclusion criteria were umbilical hernia repair with previous computed tomography scan, without diastasis repair and follow-up of at least two years. Rectus diastasis was defined as a separation >2,5 cm. Different variables were analyzed to assess their influence on hernia recurrence, with diastasis recti being our main factor to evaluate. Demographic characteristics, hernia size, type of hernia repair, postoperative complications and long-term recurrence were recorded. Results 458 patients underwent umbilical hernia repair during the study period, 70 patients (15,28%) met the inclusion criteria and were selected. The mean age was 57.08 years and 42.9% were women. The mean diameter of the hernia defect was 2.26 cm. 67.1% of the sample presented diastasis with a mean size of 3.78 cm. Female sex(p=0.04), diabetes(p=0.16) and diastasis recti(p=0.05) present a statistically significant relationship with the development of recurrence after umbilical hernia repair. We obtained that female sex(p=0,029) and diabetes(p=0,16) significantly increase the recurrence development. Meanwhile, we cannot affirm that diastasis acts as an independently risk factor(p=0,058),since it has been influenced by these variables. Conclusions We obtained that diabetes and female sex independently influence the development of recurrence after umbilical hernia. We have not been able to demonstrate that diastasis is a risk factor by itself for the appearance of recurrence, although we did find a trend towards statistical significance.

Radiofrequency ablation of the great saphenous vein; does the choice of monopolar or bipolar catheters affect outcomes?

Radiofrequency-based procedure is one of the leading methods of endovenous thermal ablation. The most fundamental difference with regards to currently available radiofrequency ablation systems is the way of electric current flow given to the vein wall; bipolar segmental and monopolar ablation. This study aimed to compare the monopolar ablation method with conventional bipolar segmental endovenous radiofrequency ablation method for the management of incompetent saphenous veins. Between November 2019 and November 2021, 121 patients with incompetent varicose veins who were treated either with the F-Care/monopolar (N = 49) or ClosureFast/bipolar (N = 72) were included in the study. A single extremity of each patient with isolated great saphenous vein insufficiency was enrolled. The differences between the two groups in demographic parameters, disease severity, treated veins, peri- and postoperative complications, and treatment efficacy indicators were retrospectively evaluated. There was no statistically significant difference between the groups regarding demographic parameters, disease severity, and treated veins in preoperative period (p > 0,05). The average procedural time was 21.4 ± 4minutes in the monopolar group, while it was 17.1 ± 3minutes in the bipolar group. In both groups, the venous clinical severity scores declined significantly compared with the preoperative period, however; there was no difference between groups (p > 0,05). The occlusion rate of the saphenofemoral junction and proximal saphenous vein after 1year was 94.1% in the bipolar group and 91.8% in the monopolar group (p = 0.4) while there was a significant difference in the occlusion rate of the shaft and distal part of the saphenous vein (93.2% in the bipolar group and 80.4% in the monopolar group, p = 0.04). Postoperative complications (bruising and skin pigmentation) were slightly higher in the bipolar group (p = 0.02, p = 0.01). Both systems are effective in treating the venous insufficiency of the lower extremity. Monopolar system revealed a better early postoperative course with similar occlusion rate of the proximal part of saphenous vein compared with bipolar system, however; the occlusion of the lower half of the saphenous vein was significantly lower which may negatively affect long-term occlusion rates and recurrence of the disease.

Surgical and endovascular treatment of pelvic venous disorder: Results of a multicentre retrospective cohort study

ObjectiveIn the present study, we investigated the clinical outcomes after gonadal vein resection (GVR) and gonadal vein embolization (GVE) with coils in patients with pelvic venous disorder (PeVD). We also assessed the rates of procedural complications and disease recurrence. MethodsOur multicenter retrospective cohort study included 361 female patients with PeVD-related chronic pelvic pain (CPP) and gonadal vein reflux who underwent GVR (n = 184) or GVE with coils (n = 177) from 1999 to 2020. The clinical outcomes (ie, presence and severity of CPP, procedural complications, disease recurrence) were assessed at 1 month and 1, 3, and 5 years after intervention. The pain intensity before and after treatment was assessed using a visual analog scale. All the patients underwent duplex ultrasound after GVR and GVE, and those with persistent CPP and suspected perforation of the gonadal vein by the coils were also evaluated by multiplanar pelvic venography. ResultsGVR and GVE was associated with the reduction or elimination of CPP at 1 month after treatment in 100% and 74% of patients and postprocedural complications in 14% and 37% of patients, respectively (Р < 0.01 for both). The most common complication after either GVR or GVE was pelvic vein thrombosis (11% and 22% patients, respectively; P < .01 between groups). GVE was associated with postembolization syndrome in 20%, coil protrusion in 6%, and coil migration in 1% of patients. The long-term recurrence rate after GVR and GVE was 6% and 16%, respectively (P < .01). ConclusionsBoth GVR and GVE were found to be effective in treating patients with PeVD. However, GVR was associated with better efficacy in the relief of CPP and lower rates of procedural complications and disease recurrence.

Correlation of Atherosclerotic Dyslipidemia with Long-Term Stroke Recurrence in Patients Undergoing Intravenous Thrombolysis for Acute Ischemic Stroke.

Atherosclerotic dyslipidemia (AD) is associated with an increased risk of cardiovascular diseases and stroke events, but the effect of AD among acute ischemic stroke (AIS) patients undergoing intravenous thrombolysis is unclear. This study aimed to investigate the relationship between AD and long-term stroke recurrence in AIS patients undergoing intravenous thrombolysis. This prospective cohort study included 499 AIS patients treated with intravenous thrombolysis. Stroke subtype was classified according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria, patients' clinical characteristics, and results from multiple diagnostic tests. The primary endpoint event was ischemic stroke recurrence; the time to first AIS recurrence was estimated using Kaplan‒Meier analysis and compared using the two-sided Log rank test. Cox univariate and multivariate regression analyses were used to assess the association between AD and long-term stroke recurrence. Of the 499 patients with AIS treated with rt-PA intravenous thrombolysis, 80 (16.0%) had AD, and 60 (12.0%) had a stroke recurrence event. Kaplan‒Meier analysis showed that the stroke recurrence rate was significantly higher in patients with AD than in those without AD (p = 0.035, log rank test) and in the large-artery disease (LAD) subtype (p = 0.006, log rank test). Multivariate Cox regression analysis showed that AD (HR = 2.363, 95% CI: 1.294-4.314, P = 0.005) and atrial fibrillation (HR = 2.325, 95% CI: 1.007-5.366, P = 0.048) were associated with an increased risk of long-term stroke recurrence in AIS patients who underwent intravenous thrombolysis. Furthermore, AD was associated with an increased risk of stroke recurrence in patients undergoing intravenous thrombolysis in the LAD subtype (HR = 3.122, 95% CI: 1.304-7.437, P = 0.011). We found that AD increases the risk of long-term stroke recurrence in AIS patients undergoing intravenous thrombolysis. This association may be stronger in the LAD subtype.

PO-02-164 VALUE OF CARDIONEUROABLATION WITH VAGAL DENERVATION CONFIRMED BY VAGUS NERVE STIMULATION ON PULMONARY VEIN ISOLATION FOR ATRIAL FIBRILLATION CATHETER ABLATION

Despite good results, Atrial fibrillation(AF) ablation shows a relatively high recurrence rate. Therefore, we sought to verify whether endocardial denervation by cardioneuroablation(CNA) can change the AF recurrence post-pulmonary vein isolation(PVI). To compare the long-term AF recurrence post-PVI versus PVI plus vagal denervation (PVI+CNA) by CNA with vagal denervation confirmation by extracardiac vagal stimulation(ECVS). Case-control study of 127 patients, 104(81.9%) males, 53.7±12 years-old, with paroxysmal 71(55.9%) or persistent 56(44.1%) symptomatic AF, refractory to medications without cardiopathy, LA=39.8±6.8, EF=0.66±0.55. Two equivalent groups were established: PVI alone (55 cases) and PVI+CNA (72 cases). The ECVS was performed by intravenous catheter, near the jugular foramen with 50Hz/50microsec/1V/Kg/up to 70V. Endocardial CNA was biatrial over the four main ganglionated plexus and in the AF-Nests regions tagged by fractionation software. The endpoint of CNA was the elimination of the vagal effect induced by ECVS. PVI was achieved in all cases. ECVS effectively induced a vagal reaction in all PVI+CNA patients, and it was possible to eliminate the vagal effect in 88.9% of cases. In 11.1%, there was a slight residual vagal response. Patients were followed up to 45 months (mean FU=21.4±14.2 and 20.4 ± 14.3 months). Recurrences were 17 in the PVI group, and 4 in the PVI+CNA group: Log-Rank p<0.00, HR:5.38(1.78-16.29,p=0.003). No significant complications occurred. The addition of vagal denervation to PVI, with validation of the vagal denervation by ECVS, significantly increased the success rate of the PVI with a marked reduction in AF relapses without increasing complications.

PO-01-041 COMPARISON OF DIFFERENT POWER SETTINGS (40W VS 50W) IN HIGH-POWER SHORT-DURATION RADIOFREQUENCY ABLATION FOR PAROXYSMAL ATRIAL FIBRILLATION: ACUTE AND LONG-TERM CLINICAL OUTCOMES

The REAL-AF registry is a prospective multi-center registry designed to obtain real-world clinical experience of atrial fibrillation (AF) ablations. While pulmonary vein isolation (PVI) can be performed successfully with various power settings, there has been a recent surge of interest in delivering higher power short duration (HPSD) lesions using 40W-50W through the irrigated tip ablation catheters. However, the ideal power setting to deliver HPSD lesions is unknown. Compare the procedural characteristics, safety and long-term all-atrial arrhythmia recurrence between patients undergoing HPSD radiofrequency ablation either using 40W or 50W. We analyzed the data derived from subjects in the Real-AF registry from January 2018 through May 2021. The patients enrolled underwent a first-time catheter ablation for paroxysmal AF with a minimum follow-up of 12 months. The sample of patients was dichotomized in procedures using either HPSD 50 W or HPSD 40 W of power, with a target ablation index (AI) in the anterior wall of 500-550 and posterior wall of 400 for both groups. We used unadjusted bivariate analyses to explore the relationship between power delivery, patient characteristics and procedural and 12-month clinical outcomes. A total of 385 patients were included in the analyses. There were no significant differences in patient characteristics between groups (Table 1). The HPSD 50W group had significantly shorter RF time (18.69 vs. 29.21, p<0.001) and procedural time (77.72 vs. 99.98, p<0.01) when compared to the LPLD group. There were no statistically significant differences between HPSD 50 W and HPSD 40W for first-pass PVI and no clinically significant differences in the target ablation index between the groups. When looking at all -atrial arrhythmia recurrence documented post-blanking period at 12 months, there was no statistically significant relationship (p=0.925) between groups. There was no statistically significant relationship between immediate procedural complications, pericarditis, or complications at 12 months post-ablation (p>0.05). The esophageal temperature measurements were not different between groups. HPSD is a safe and effective way of performing radiofrequency ablation of AF. HPSD using 50W was associated with shorter RF ablation and procedural times when compared to HPSD 40W without increase in complications HPSD 50W and HPSD 40W had similar acute and long-term success rates.

Rehabilitation of Surgically Reconstructed Partially Edentulous Mandible with Iliac Crest Graft After Ameloblastoma Resection with an Implant-Supported “Toronto Prosthesis”

Ameloblastomas are locally invasive and benign odontogenic tumors with a high long-term recurrence rate. These lesions can cause serious anomalies in the facial area and alveolar bones, leading deformity and deterioration of functions. Wide local excision and reconstruction are required for the surgical treatment of these tumors. Aggressive resection effectively eliminates tumors; however, this approach may cause various problems that need reconstruction to restore the oral functions. In the present case report, the rehabilitation of surgically reconstructed partially edentulous mandible with iliac crest graft after ameloblastoma resection with an implant-supported “Toronto Prosthesis” is presented. In the surgical procedure, mandible was partially resected and simultaneous iliac bone graft was applied. Then, four dental implants were inserted into the reconstructed bone and implant-supported Toronto prosthesis was fabricated. The patient was satisfied with the final result of the treatment and recurrence was not observed during the 2-year clinical follow-up.

Late recurrence of atrial fibrillation 5 years after catheter ablation: predictors and outcome.

Atrial fibrillation (AF) is a chronic progressive disease that continuously recurs even after successful AF catheter ablation (AFCA). We explored the mechanism of long-term recurrence by comparing patient characteristics and redo-ablation findings. Among the 4248 patients who underwent a de novo AFCA and protocol-based rhythm follow-up at a single centre, we enrolled 1417 patients [71.7% male, aged 60.0 (52.0-67.0) years, 57.9% paroxysmal AF] who experienced clinical recurrences (CRs), and divided them according to the period of recurrence: within one year (n = 645), 1-2 years (n = 339), 2-5 years (n = 308), and after 5 years (CR>5 yr, n = 125). We also compared the redo-mapping and ablation outcomes of 198 patients. In patients with CR>5 yr, the proportion of paroxysmal AF was higher (P = 0.031); however, the left atrial (LA) volume (quantified by computed tomography, P = 0.003), LA voltage (P = 0.003), frequency of early recurrence (P < 0.001), and use of post-procedure anti-arrhythmic drugs (P < 0.001) were lower. A CR>5 yr was independently associated with a low LA volume [odds ratio (OR) 0.99 (0.98-1.00), P = 0.035], low LA voltage [OR 0.61 (0.38-0.94), P = 0.032], and lower early recurrence [OR 0.40 (0.23-0.67), P < 0.001]. Extra-pulmonary vein triggers during repeat procedures were significantly greater in patients with a CR>5 yr, despite no difference in the de novo protocol (P for trend 0.003). The rhythm outcomes of repeat ablation procedures did not differ according to the timing of the CR (log-rank P = 0.330). Patients with a later CR exhibited a smaller LA volume, lower LA voltage, and higher extra-pulmonary vein triggers during the repeat procedure, suggesting AF progression.

D12. Impact of Breast Reconstruction Modality on Breast Cancer Recurrence Detection

PURPOSE: Post-mastectomy reconstruction is not expected to have different oncologic outcomes than mastectomy alone. However, given the disparate masking of the posterior mastectomy margin by various reconstructive modalities, we evaluate the long-term impact of reconstructive choices on oncologic outcomes, including local recurrence rate, time to detection, and size of recurrence, in a single-institution cohort of breast reconstruction patients. METHODS: A retrospective cohort analysis of patients (n=917) with primary breast cancer who underwent either implant-based (n=502) or autologous (n=415) breast reconstruction was conducted. Kaplan-Meier curve estimated cumulative incidence of local breast cancer recurrence over specific time intervals (<13, 13-18, >18 years). A Cox proportion hazard model stratified by time enabled time to recurrence analysis comparing groups. RESULTS: While unsurprising, 52 patients recurred locally (10.3%) with implant-based reconstruction compared to 66 (15.8%) with autologous reconstruction (p=0.02). Average time to detection was 63.5±47.0 months after implant versus 86.5±61.5 after autologous reconstruction (p=0.02). At the time of recurrence, tumor was larger (p=0.01) and of higher stage (p=0.02) in the autologous cohort. Recurrence free survival was initially similar between groups for the first 13 years. Interestingly, it became significantly higher during years 13-18 for the autologous compared to the implant group (82.7% versus 72.8%, p=0.03), but after 18 years, trended lower than implant reconstruction. CONCLUSION: Our findings highlight an interesting but often neglected consideration when selecting breast reconstructive modality. Implant reconstruction may allow for earlier cancer recurrence detection. While there are significant premiums in autologous reconstruction, those patients may warrant increased long-term recurrence surveillance.

Caplacizumab (Cablivi)

&#x0D; CADTH recommends that Cablivi should not be reimbursed by public drug plans for the treatment of adults with acquired thrombotic thrombocytopenic purpura (aTTP) in combination with plasma exchange (PE) and immunosuppressive therapy.&#x0D; Evidence from clinical trials were unable to demonstrate that Cablivi improved survival and quality of life, minimized organ damage, or prevented long-term aTTP recurrence. Although results showed that Cablivi reduced time to platelet normalization compared with placebo in patients with aTTP who received PE and immunosuppressive therapy, CADTH Canadian Drug Expert Committee was unable to determine how this correlated with the previously mentioned clinical outcomes.&#x0D; Evidence from an integrated analysis of clinical trials and several sources of real-world evidence were unable to clearly demonstrate whether Cablivi provides benefits when added to PE and immunosuppressive therapy due to limitations associated with the methodology.&#x0D; Based on the evidence reviewed, it remains uncertain whether Cablivi meets the needs identified by patients of improving survival and quality of life, preventing disease complications, reducing the need for PE, and preventing disease recurrence.&#x0D;

Laparoscopic deroofing of simple liver cysts: do ancillary techniques, surgical devices, and indocyanine green improve outcomes?

Summary Background Giant liver cysts causing compression symptoms require surgical therapy. Laparoscopy is nowadays considered the first-line approach and has been shown to be non-inferior to open surgery. Ancillary techniques and novel technologies may have the potential to reduce complications rates and improve long-term outcomes. Methods The management of a female patient with a giant and symptomatic liver cyst is reported, as is a literature search in PubMed and Scopus spanning the past two decades, with the aim of assessing current evidence regarding procedural details of laparoscopic deroofing. Results Wide laparoscopic deroofing of a 21-cm liver cyst arising from segment 6 was safely performed under indocyanine green fluorescence imaging using a combination of ultrasonic energy excision and stapling. A contemporary literature review showed that only 22 of the 35 publications included details of the surgical procedure. Ancillary techniques such as omentopexy, argon plasma coagulation, monopolar radiofrequency device ablation, and ethanol sclerotherapy were rarely used (10.8% of patients). Use of energy devices and/or linear staplers was reported in 22 (62.8%) studies. Indocyanine green fluorescence was reported in 4 (11.4%) studies. Conclusion The case report and the literature review show that wide laparoscopic deroofing of giant liver cysts is an effective and relatively simple procedure. Use of emerging technology such as indocyanine green fluorescence imaging can further enhance precision surgery and minimize complications and long-term recurrence rates.

New Developments in Systemic Management for High-Risk Early-Stage Hormone-Receptor-Positive, HER2-Negative Breast Cancer

For high-risk early-stage hormone-receptor-positive, HER2-negative breast cancer (HR + /HER2 - EBC), short- and long-term recurrence risks remain substantial despite local control with surgery and radiation and systemic treatment with chemotherapy and endocrine therapy (ET). Recent trials have provided new strategies for reducing recurrence. The monarchE trial demonstrated that adding 2years of adjuvant abemaciclib to ET improves invasive disease-free survival (iDFS) and distant recurrence-free survival (DRFS). In the OlympiA trial for high-risk disease in patients with germline BRCA1/BRCA2 mutations, adding 1year of olaparib to ET improved iDFS, DRFS, and overall survival (OS). In addition, for premenopausal women with high-risk tumors, long-term follow-up of the SOFT, ASTRRA, TEXT, ABCSG-12, and HOBOE trials supports the role of ovarian function suppression (OFS), in combination with adjuvant tamoxifen or aromatase inhibition (AI). For postmenopausal women with high-risk tumors, extended-duration AI for at least 7years should be used with zoledronic acid. Given the remaining recurrence risk even with these interventions and with the ongoing development of new strategies for HR + disease, patients with high-risk EBC should be encouraged to participate in clinical trials, such as trials of immunotherapy, novel oral estrogen receptor alpha (ERα)-targeting agents, antibody-drug conjugates (ADCs), and trials guided by measurements of minimal residual disease (MRD).

Advances in the Treatment of Implant-Associated Infections of the Pelvis: Eradication Rates, Recurrence of Infection, and Outcome.

Surgical site infections after operative stabilization of pelvic and acetabular fractures are rare but serious complications. The treatment of these infections involves additional surgical procedures, high health care costs, a prolonged stay, and often a worse outcome. In this study, we focused on the impact of the different causing bacteria, negative microbiological results with wound closure, and recurrence rates of patients with implant-associated infections after pelvic surgery. We retrospectively analyzed a study group of 43 patients with microbiologically proven surgical site infections (SSI) after surgery of the pelvic ring or the acetabulum treated in our clinic between 2009 and 2019. Epidemiological data, injury pattern, surgical approach, and microbiological data were analyzed and correlated with long-term follow-up and recurrence of infection. Almost two thirds of the patients presented with polymicrobial infections, with staphylococci being the most common causing agents. An average of 5.7 (±5.4) surgical procedures were performed until definitive wound closure. Negative microbiological swabs at time of wound closure were only achieved in 9 patients (21%). Long-term follow-up revealed a recurrence of infection in only seven patients (16%) with an average interval between revision surgery and recurrence of 4.7 months. There was no significant difference of recurrence rate for the groups of patients with positive/negative microbiology in the last operative revision (71% vs. 78%). A positive trend for a correlation with recurrent infection was only found for patients with a Morel-Lavallée lesion due to run-over injuries (30% vs. 5%). Identified causing bacteria did not influence the outcome and rate of recurrence. Recurrence rates after surgical revision of implant-associated infections of the pelvis and the acetabulum are low and neither the type of causing agent nor the microbiological status at the timepoint of wound closure has a significant impact on the recurrence rate.

29 Molecular markers predict long-term recurrence following resection of clival and spinal chordomas: A multi-center study

OBJECTIVES/GOALS: We aimed to find the histology-specific markers that were predictive of post-operative long-term chordoma recurrence (≤1 year) using trained multiple tree-based machine learning (ML) algorithms. METHODS/STUDY POPULATION: We reviewed the records of patients who had treatment for clival and spinal chordomas between January 2017 and June 2021 across the Mayo Clinic enterprise (Minnesota, Florida, and Arizona). Patients were excluded if they had no histopathology or recurrence as an outcome. Demographics, type of treatment, clinical and radiological follow-up duration, histopathology, and other relevant clinical factors were abstracted from each patient record. Decision tree and random forest classifiers were trained and tested to predict the long-term recurrence based on unseen data using an 80/20 split. The performance of the model was optimized using tenfold cross-validation. RESULTS/ANTICIPATED RESULTS: One hundred fifty-one patients were identified: 58 chordomas from the clivus, 48 chordomas of the mobile spine, and 45 sacrococcygeal. Subtotal Resection followed by radiation therapy, was the most common treatment modality, followed by Gross Total resection, then radiation therapy. The multivariate analysis defines the molecular predictors of recurrence following resection. S100 and pan-cytokeratin is more likely to increase the risk of post-operative recurrence (OR= 3.67; CI= [1.09,12.42], p=0.03). In the decision tree analysis, a clinical follow-up &gt; 1897 days was found in 37 % of encounters and a 90% chance of being classified for recurrence (Accuracy= 77%). Factors predicting long-term recurrence are the patient’s age, type of surgical treatment, location of the tumor, S100, pan-cytokeratin, and EMA. DISCUSSION/SIGNIFICANCE: Our molecular and clinicopathological variables combined with tree-based ML tools successfully demonstrate a high capacity to individually identify the patient’s recurrence pattern with an accuracy of 77%. S100, pan-cytokeratin, and EMA were the histologic drivers of recurrence.

MP78-03 PROPOSAL AND VALIDATION OF A PERIOPERATIVE ALGORITHM TO IMPROVE ANTIMICROBIAL STEWARDSHIP IN URETHROPLASTY PATIENTS

You have accessJournal of UrologyCME1 Apr 2023MP78-03 PROPOSAL AND VALIDATION OF A PERIOPERATIVE ALGORITHM TO IMPROVE ANTIMICROBIAL STEWARDSHIP IN URETHROPLASTY PATIENTS Malte W. Vetterlein, Benedikt Kranzbühler, Omar Nafez, Clemens M. Rosenbaum, Luis A. Kluth, Christian P. Meyer, Lennart Kühnke, Frederik König, Silke Riechardt, Roland Dahlem, Margit Fisch, and Phillip Marks Malte W. VetterleinMalte W. Vetterlein More articles by this author , Benedikt KranzbühlerBenedikt Kranzbühler More articles by this author , Omar NafezOmar Nafez More articles by this author , Clemens M. RosenbaumClemens M. Rosenbaum More articles by this author , Luis A. KluthLuis A. Kluth More articles by this author , Christian P. MeyerChristian P. Meyer More articles by this author , Lennart KühnkeLennart Kühnke More articles by this author , Frederik KönigFrederik König More articles by this author , Silke RiechardtSilke Riechardt More articles by this author , Roland DahlemRoland Dahlem More articles by this author , Margit FischMargit Fisch More articles by this author , and Phillip MarksPhillip Marks More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003355.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is a huge variability of antimicrobial administration in the perioperative urethroplasty setting. We aimed to validate our institutional standardized protocol for testing and culture-specific treatment on three sequential endpoints to improve antibiotic stewardship (ABS). METHODS: Urethroplasty patients are subjected to our SOP for urinalysis and antimicrobial Tx (Figure 1). Men undergoing bulbar substitution urethroplasty between 2009-16 were stratified by urine culture (UCx) result at the time of surgery (sterile vs. nonsterile). We performed quantitative and qualitative exploration of the UCxs, and evaluated the microbial spectrum. The ability of our standardized algorithm to improve ABS over the perioperative course was tested by three endpoints: (A) immediate (2nd UCx on POD2), (B) short-term (21-day infectious complications), and (C) long-term (retreatment-free survival [RFS]). Statistical analyses included bivariate comparisons, Kaplan-Meier estimators compared RFS between the groups. Multivariable Cox regression was used to evaluate the independent effect of UCx status at the time of surgery on RFS. RESULTS: Of 374 men, 235 (63%) had a sterile and 139 (37%) a nonsterile preoperative UCx. In the latter, gram-positive cocci (63%) and enterobacteriaceae (22%) were the most frequent microbes. Nonsterile UCx was more common in patients with catheter (38 vs. 21%; p<0.001). The number of patients with sterile UCx at the time of surgery (63%) was significantly improved to 82% at POD2 (p<0.001). There were 16 infectious complications (4.3%; 14 urinary tract infections and two wound infections) with no difference between patients with sterile vs. nonsterile UCx (p=0.6). At a median follow-up of 29 mo, there was no difference in RFS (16%) between patients with sterile vs. nonsterile UCx (p=0.3). Positive UCx was no predictor of recurrence in Cox regression analysis after adjusting for age, catheter, prior stricture treatment, and graft length (p=0.5). CONCLUSIONS: A standardized perioperative protocol such as the one introduced improves ABS through frequent testing and culture-specific treatment. This is crucial in avoiding unnecessary antimicrobial treatment, and reducing infectious events and adverse effects of a positive UCx on long-term stricture recurrence. Source of Funding: n/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1132 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Malte W. Vetterlein More articles by this author Benedikt Kranzbühler More articles by this author Omar Nafez More articles by this author Clemens M. Rosenbaum More articles by this author Luis A. Kluth More articles by this author Christian P. Meyer More articles by this author Lennart Kühnke More articles by this author Frederik König More articles by this author Silke Riechardt More articles by this author Roland Dahlem More articles by this author Margit Fisch More articles by this author Phillip Marks More articles by this author Expand All Advertisement PDF downloadLoading ...

Efficacy of Minimally Invasive Crystallized Phenol Application in the Treatment of Pilonidal Sinus in Children

Background/Aims: Pilonidal sinus treatment involves surgical excision or flap reconstruction; however, the disease has a high recurrence risk. We determined the outcomes of a modified local application of crystallized phenol.&#x0D; Methods: In the outpatient clinic, the pilonidal sinus orifices were connected by an incision under local&#x0D; anesthesia. The hair in the sinus was removed. Then, crystallized phenol was applied. The incision was not&#x0D; sutured. Daily dressings and baths were recommended.&#x0D; Results: Crystallized phenol was applied to 50 patients with pilonidal sinus disease (median age = 15 years).&#x0D; During the follow-up, no bleeding or pain was reported. Recurrence was not found in the follow-ups (one year to&#x0D; three years).&#x0D; Conclusions: Surgery has disadvantages such as long-term hospitalization, recurrence risk, and high cost.&#x0D; Crystallized phenol does not have any of the aforementioned disadvantages. The modified method, in which we&#x0D; incised and applied crystallized phenol to all sinus tracts, might have also reduced the recurrence.

Endoscopic endonasal transclival approach for a ventral brainstem epidermoid cyst: illustrative case.

Intracranial epidermoid cysts are benign, slow-growing malformations that most commonly arise at the skull base. Maximizing resection of the cyst contents and the capsule reduces long-term recurrence but can be made difficult by cyst wall adherence to critical neurovascular structures. Expanded endonasal approaches (EEAs) offer an alternative to traditional open transcranial approaches for accessible epidermoid cysts. In this case report, the authors demonstrate a transclival EEA for a large, ventral brainstem epidermoid cyst. A 41-year-old woman who presented with progressive headaches, diplopia, malaise, and fatigue was found to have a 4.7-cm midline, ventral brainstem epidermoid cyst. She underwent an expanded endonasal transclival approach that exposed the brainstem from the level of the dorsum sella to the tip of the basion. A near-total resection was completed with removal of all cyst contents and most of the capsular wall. Reconstruction was completed with Duragen, an autologous fat graft, and a nasoseptal flap. Postoperatively, she had a partial left cranial nerve VI palsy that remained stable 8 weeks after surgery. The expanded endoscopic transclival approach can facilitate effective resection of midline, ventral epidermoid cysts.

Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association

Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.

Botulinum toxin as a promising surgical strategy for chronic anal fissure: do the dose and injection site matter? Comparison of doses and injection sites of botulinum toxin for chronic anal fissure: A systematic review and network meta-analysis of randomized controlled trials

Chronic anal fissure (CAF) often shows a considerable reluctance to heal for the hypertonia and spasm of the internal sphincter. CAF pain is very intense and sharp and always described as tearing, knife-cut or passing broken glass. Lateral internal sphincterotomy remains the preferred treatment modality of all surgical options with high healing rates ranging from 88 to 100%, followed by incontinence rates ranging from 8 to 30% which can have a significant impact on a person’s quality of life.1 Botulinum toxin (BT) has been widely used in the treatment of CAF due to its ability to promote healing and lower risk of incontinence. However, there is still no consensus on the BT dose and injection site which are associated with the curative effect. Vitoopinyoparb et al.2 performed a systematic review and network meta-analysis of randomized controlled trials and identified that low-dose (≤20 U) BT was optimal, and injection out of the fissure site improved short-term outcomes while injection each side of the fissure site tended to reduce recurrence in the long run. It is of great interest to provide a relatively standard protocol to guide anorectal surgeons in the management of BT. BT, as a temporary chemical sphincterotomy, can lead to the blockade of acetylcholine release and cause short-term paralysis of internal sphincter muscle to reduce the anal tone. Based on our clinical experience, the higher the BT dose (within 100 U in general), the higher the healing rate of CAF. According to the survey conducted by the American Society of Colon and Rectal Surgeons, dose above 50 U of BT appeared to correlate with higher success rate and healing rate.3 Maria et al.4 has confirmed that higher doses can improve the healing rate without increasing complications or side effects. However, a meta-analysis including 18 clinical trials concluded that the healing rate decreased with the increase of the BT dose (P=0.048), but the incontinence rate (P=0.048) and recurrence rate (P=0.002) increased slightly with the increase of the BT dose5. Another meta-analysis involving 1577 patients from 34 prospective studies showed that the healing rates ranged from 33 to 96% the BT with the reported BT doses ranging from 5 to 150 IU across the analyzed studies. However, there was no correlation between postoperative healing rate and BT dose (P=0.0708), and the rates of postoperative complications and fecal incontinence were not found to be in a dose-dependent manner.6 Conflicts over BT dose selection often cause confusion among anorectal surgeons. In this network meta-analysis, Vitoopinyoparb and colleagues found that low-dose (≤20 U) BT was optimal based on 27 randomized controlled trials, providing high-level evidence on this regard. Based on the existing knowledge, most studies recommend injecting BT into internal sphincter in three or four quadrants around the anal canal. We also believe that BT should be injected into the internal sphincter because the fundamental pathogenic is hypertonia and spasm of the internal sphincter in CAF. As Brisinda et al.4 said, the internal sphincter is readily visible and easier to inject than the external sphincter. To improve the healing rate, we usually inject the BT both outside the fissure and on each side of the fissure. A study which included 50 CAF patients showed that injections on both sides of the anterior midline were more effective than those on the posterior midline.7 In this study, the short-term healing rate of external injection was better than that of both sides of the fissure, while the long-term recurrence and incontinence of bilateral injection were less.1 In general, we believe these results of this study have high value for clinical application, and large multicenter randomized controlled studies should be advocated to further confirm the findings. Ethical approval Not applicable. Sources of funding This study is funded by the Shenkang Clinical Three-Year Action Plan (major research) (grant no. SHDC2020CR2007A), and the National Natural Science Foundation of China (81774112). Authors’ contribution H.X.: design and write the commentary. W.Y.: review the commentary. Z.M.: design, review, and revise the commentary. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantors Zubing Mei, Hao Xu.