Median ASA Research Articles

Institution of same-day total joint replacement at an urban safety net hospital during the COVID-19 pandemic

BackgroundIncreasingly, total hip and total knee replacements are being performed at outpatient ambulatory surgery centers. The purpose of this study was to investigate the feasibility and safety of instituting a same-day surgery program for hip and knee replacement at an urban, safety net hospital. MethodsRetrospective review of a prospectively collected registry for all patients scheduled for same-day total joint replacement at a safety net hospital was performed. Medical records were reviewed for patient demographics, same-day hospital admissions, and 30-day emergency room/hospital admissions. Results131 same-day total joint replacements were identified, including 76 knees and 55 hips. Median ASA was 3, and median Charlson comorbidity score was 2. Rate of same-day surgery for total joint replacements increased from 4.5% in September 2020 to 100% in September 2021. On major patient outcomes, 3.8% of patients (n = 5) required conversion to inpatient admission. Rate of 30-Day Emergency Department (ED) visits was 13.0% (n = 17). Most common complaints included postoperative pain (n = 10), incision drainage/edema/hematoma (n = 9), and cellulitis (n = 2). 30-Day Hospital Readmissions occurred in 1.5% of patients (n = 2). ConclusionSame-day hip and knee replacement can be performed safely at a safety net hospital. Unlike dedicated high-volume orthopedic hospitals or outpatient surgery centers, urban safety net hospitals face a different set of challenges and must care for a wide variety of patients who do not plan for their illness and/or may not be able to pay for their care. Outpatient total joint replacement may extend total joint replacement to patients who might not have access otherwise.

Frailty as an indicator of postoperative complications following surgical excision of non-melanoma skin cancer on the head and neck.

Non-melanoma skin cancer (NMSC) predominantly affects those aged over 90years, with 85% of lesions arising on the head and neck, where surgical excision remains the treatment of choice. Frailty is a measure of physiologic age and can be used as a predictor of adverse treatment outcomes. The aim of this study was to determine if the Rockwood Frailty Index is predictive of complications following excision of NMSC. Data were collected prospectively for patients who underwent an excision of a suspected NMSC from the head or neck across a two-month period. Details of the patient, lesion and procedure were recorded alongside ASA grade and Rockwood's Frailty score. Postoperative complications were recorded four weeks later. There was a total of 125 patients: 74 (60%) male, 51 (40%) female; mean age was 78 (±9.8) years. Of the excised sites, 61% were closed primarily, 26% with a full thickness skin graft (FTSG), 13% with a local flap. Frailty ranged from 1 to 7 (median = 4). ASA ranged from 1 to 4 (median = 3). A total of 21 (17%) patients reported postoperative complications. Within this group, the median frailty and ASA grades were 5 and 3. Both frailty and ASA were positively significantly associated with age (p ≤ 0.001). There was no significant difference between the frailty or ASA grades of patients that experienced complications and those who did not. Patients who had a FTSG were significantly more likely to experience complications (p ≤ 0.05). Frailty is not predictive of postoperative complications following excision of NMSC on the head and neck. Postoperative complications are significantly more associated with FTSG.

EP-434 Is Cholecystostomy the correct temporising strategy for complicated cholecystitis and how should it be utilised to meet the NICE criteria for ‘early cholecystectomy’

Abstract Aims The incidence of undiagnosed gallstones is reported in up to 22% of females, with acute cholecystitis (AC) being a common emergency presentation. NICE guidance recommends index cholecystectomy for patients with proven gallstones. Emergency Laparoscopic Cholecystectomy (LC) in co-morbid patients carries a risk, with percutaneous cholecystostomy tube (PTC) insertion utilised as a temporising measure to relieve sepsis. Whilst effective at decompression, the long-term outcomes are unclear. Methods We retrospectively reviewed all patients undergoing emergency PTC between 2019 and 2021 in our hospital. Data collection included: demographics, ASA classification, Clavien-Dindo grades, cholecystostomy complications. Results A total 24 patients (12:12 male:female) underwent emergency PTC. Median age was 73 years (range 31–89) and median ASA grade of 3 (ASA 1 n=3, ASA 2 n=8, ASA 3 n=7, ASA 4 n=6). Median time from PTC insertion to LC was 20 weeks (range 6–73 weeks). Morbidity post PTC according to Clavien-Dindo grades were: 4 with grade 3 (16.7%), 5 with grade 4 (8.3%) and 5 with grade 5 (20.8%). 8 patients (33.3%) re-presented with further cholecystitis. 4 (16.7%) patients had completion LC, without complication. Conclusions Our findings highlight significant morbidity and mortality in this high-risk cohort secondary to complicated AC. 20 patients (83.3%) did not undergo a completion cholecystectomy, despite 18 being ASA 1–3. We suggest a judicious use of PTC and a greater focus on index multi-disciplinary surgical fitness assessment in order to optimise a patient for acute LC. This strategy is key to enable full adoption of AUGIS guidance for performing LC within 72 hours.

Applicative Limitations of Indocyanine Green Fluorescence Assistance to Laparoscopic Lymph Node Dissection in Total Gastrectomy for Cancer.

Indocyanine green (ICG) fluorescence has been recently introduced as a novel imaging technique improving the accuracy of lymph node (LN) dissection in gastric cancer (GC) surgery, although procedure standardization and achievements have not been clearly defined. This study analyzed the feasibility and effectiveness of ICG-guidance for laparoscopic D2-lymphadenectomy during total gastrectomy for cancer. This study retrospectively analyzed a single-center series of patients who underwent laparoscopic total gastrectomy for cancer between April 2015 and August 2021. All patients underwent surgery with standard D2 LN dissection. Intraoperative ICG-fluorescence was institutionally implemented in April 2018 and was performed routinely afterward. Primary outcomes were LN harvest and ratio. Secondary endpoints included operative time and subgroup analysis to assess variables potentially affecting LN retrieval. The study population included 102 patients, and ICG-fluorescence was applied in 38 (37.3%). ICG and no-ICG groups presented similar median age, gender proportions, ASA score and comorbidities (age-adjusted Charlson Comorbidity Index), body mass index, and advanced pathological stage. The median of LNs retrieved was significantly higher after the intraoperative ICG-guidance (44 vs. 32; p = 0.004), although this association was not significant after neoadjuvant therapy or among patients with positive LNs. Lymph node ratio and operative time were not significantly impacted by ICG fluorescence. Multivariate analysis identified the ICG-assistance as the only independent determinant for LN harvest (p = 0.029). ICG-guidance contributes to a significantly wider LN retrieval after laparoscopic D2-lymphadenectomy during total gastrectomy for cancer. However, neoadjuvant therapy and positive LN stage appeared to limit the procedural effectiveness to ICG-assisted LN identification.

Perception Meets Reality – Self-Reported Health on HCAHPS and Press Ganey Surveys Is Correlated with Validated Health Scores (ASA, CCI) in Orthopaedic Trauma Patients

Introduction The American Society of Anesthesiologists score (ASA) and Charlson Comorbidity Index (CCI) are validated tools to predict post-surgical outcome, cost, and health-related quality of life. Prior studies have had mixed results when comparing self-reported health from various survey instruments with ASA and CCI. Surveys such as the government-mandated Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and optional private surveys (Press Ganey) administered following hospital discharge include self-reported health data. No prior study has examined the relationship between patient self-reported health from HCAHPS and Press Ganey surveys with validated health scores (ASA, CCI). We sought to study this possible relationship in orthopaedic trauma patients. Methods All consecutive adult patients >18y surgically treated for isolated fractures at a Level 1 Trauma Center between January 1, 2014-December 31, 2016 were retrospectively analyzed. Hospital charts, HCAHPS, and Press Ganey data were reviewed; patients without available survey responses were excluded. Patient data also included comorbidities (ASA, CCI), psychiatric history (anxiety, depression, others), substance use, type of injury, and type of surgery. Statistical analysis included Spearman’s Rho for correlations, Wilcoxon Rank-Sum and Kruskal-Wallis for continuous variables, Backwards Stepwise Regression and Ordinal Regression with bootstrapped confidence intervals for odds assessment. Results 152 total patients with mean age 57 and median length of stay 3 days were included. No significant differences existed between injury, comorbidities, psychiatric history, substance use, or surgery. Median ASA was 2 (range 2-3), median CCI was 2 (range 0.5-4), and median CCI 10-year estimated survival was 90% (range 53-97). Median self-reported health rating was 1 (range 1-2, with 0 = excellent and 4 = poor). ASA and CCI both had initial strong correlations with patient self-reported overall health. Upon age and sex adjustment, only ASA remained strongly correlated (OR 3.65, 95% CI 2.03-6.57; p<0.001) with overall health rating. Conclusion Orthopaedic trauma patients appear to have a realistic self-perception of health relative to validated scores. This is the first study to compare HCAHPS and Press Ganey self-reported patient health to ASA and CCI scores. Although further study is needed, the high agreement of self-perception of overall health with ASA scores may show that patient self-reporting is reliable in evaluating these and other outcome measurements.

Safety and feasibility of posterior fossa neurosurgery in the supine position – A UK series from a large centre

BackgroundPosterior fossa surgery in the supine position remains a relatively underutilised approach, compared to the routinely performed prone, park-bench or sitting positions. This surgical approach may confer additional advantages over other modalities commonly restricted by patient co-morbidity and anaesthetic concerns. The purpose of this article is to highlight this approach as a potential viable, safe and alternative approach. MethodsWe retrospectively collected data of all supine infra-tentorial/posterior fossa surgery by one surgeon between 2015 and the present via our electronic patient record system. Demographic data alongside duration of surgery, ASA grading, location of lesions, length of stay, presence of post-operative infections, presence of post-operative CSF leak/pseudomeningocele and post-operative mortality were assessed. ResultsA total of 64 procedures on 58 patients were identified. Of the procedures, 60 were performed for neoplasms (93.8%). Mean overall surgical time was 176 min. Median ASA grade for tumour surgery was 3. Median length of stay was 3 days. Of the non-emergency tumour cases (n = 53), 43 (81.1%) lesions were located in the cerebellar hemisphere, the remainder were in the vermis and tentorium. There were 6 documented post-operative infections (9.4%). The rates of CSF-related complications were: CSF Leak 1.6% (1/64) and Pseudomeningocele 1.6% (1/64). 30-day mortality was 1.6% (1/64). ConclusionThis study suggests that supine positioning is a safe alternative to be considered when operating upon posterior fossa lesions. Further studies are warranted to assess efficacy of this approach, but it can be considered for wider use in the UK and further afield.

Combination of holographic imaging with robotic partial nephrectomy for renal hilar tumor treatment.

To evaluate the clinical value of the holographic imaging technology in combination with robotic-assisted partial nephrectomy (RAPN) for renal hilar tumor treatment. From Dec. 2018 to Dec. 2021, patients diagnosed with renal hilar tumor were included in this retrospective study. Before the surgery, the engineers established the holographic image models based on the enhanced CT data. The models were used inpatient consultation,pre-surgery planning and surgery simulation. During the RAPN, the navigation was achieved by real-time overlapping of the holographic images on the robotic surgery endoscopic views. The navigation technique helped the surgeon to identify the important anatomic structures such as tumor, renal vein, renal artery, and pelvis. There were total of eight patients with renal hilar tumor who underwent RAPN combined with holographic imaging technique. The mean age was 57.3years, the median ASA score was 2. The mean tumor size was 42.4mm and the median RENAL Nephrometry score was 9.5. The clinical stages were cT1a (37.5%) and cT1b (62.5%). All the procedures were performed uneventfully by one surgeon. The mean operative time was 144.3min, and the mean warm ischemia time was 27.9min. The mean estimated blood loss was 86.3ml. There was no conversion to open surgery or radical nephrectomy. There were no Clavien-Dindo ≥ 3 perioperative complications. Using the holographic imaging technique, thepre-surgery planning, simulation of renal arterial clamp and excision of the tumor, and intraoperative navigation were feasible and helpful in facilitating RAPN.

MP32-13 TRANSPERITONEAL RADICAL PROSTATECTOMY USING THE SENHANCE ROBOTIC SYSTEM: INITIAL CASE SERIES, LEARNING CURVE AND COST ANALYSIS

You have accessJournal of UrologyCME1 May 2022MP32-13 TRANSPERITONEAL RADICAL PROSTATECTOMY USING THE SENHANCE ROBOTIC SYSTEM: INITIAL CASE SERIES, LEARNING CURVE AND COST ANALYSIS Yen-Chun Lin, Lun-Hsiang Yuan, Shi-Wei Huang, Yu-Wen Huang, and Chao-Yuan Huang Yen-Chun LinYen-Chun Lin More articles by this author , Lun-Hsiang YuanLun-Hsiang Yuan More articles by this author , Shi-Wei HuangShi-Wei Huang More articles by this author , Yu-Wen HuangYu-Wen Huang More articles by this author , and Chao-Yuan HuangChao-Yuan Huang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002581.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Senhance robotic surgical system (TransEnterix Inc, Morrisville, NC, USA) is a novel laparoscopy-based robotic system, equipped with eye tracking system, haptic feedback system, and reusasble instruments. Currently, only two studies reported their experiences on extra-peritoneal radical prostatectomy. To assess the feasibility, learning curve and cost analysis of the transperitoneal Senhance robotic radical prostatectomy. METHODS: From Aug 2019 to July 2021, the Senhance robotic radical prostatectomies were performed in 44 biopsy confirmed prostate cancer patients.Perioperative data were collected. Complications were graded with Clavien-Dindo classification. Learning curve was analyzed with CUSUM (cumulative summation) method classified by surgeon’s laparoscopic experiences. Total cost for the each operation was also recorded. RESULTS: The median patient age was 67 [64-71.5] years with a mean body mass index of 25.35 [23.3-27.9] kg/m2. The median ASA score was 2±0.35. Median operative time was 246 (107-340) minutes. The median blood loss was 162.5 [50-287.5]ml. Foleys were removed at a median of 7 (3-17) days after surgery. There were 10 cases (22.7%) with Clavien-Dindo grade I/II complications and no case with grade III or IV complications. Among 44 patients, 17( (38.6%) had positive margins, of those 6 cases (13.6%) in pT2 and 11 (25.0%) cases in pT3. Total cost for each Senhance robotic radical prostatectomy was NT$61000-110000 (about US $2200-3970), compared with NT$180000-250000 (abouot US 6400-8900) in da Vinci robotic radical prostatectomy in Taiwan. CONCLUSIONS: The Senhance robotic system is technically feasible and economically affordable. The learning curve depends on surgeons laparoscopic experiences. It may serve as an alternative tool for robotic radical prostatectomy. Source of Funding: nil © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e536 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yen-Chun Lin More articles by this author Lun-Hsiang Yuan More articles by this author Shi-Wei Huang More articles by this author Yu-Wen Huang More articles by this author Chao-Yuan Huang More articles by this author Expand All Advertisement PDF DownloadLoading ...

Analysis of Platelet Function Testing in Children Receiving Aspirin for Antiplatelet Effects

<h3>Purpose</h3> VerifyNow Aspirin assay (VN) assesses platelet response to ASA, with therapeutic effect defined as ≤ 549 aspirin reaction units (ARU). We aim to evaluate its clinical efficacy in children of all ages, by identifying biochemical resistance (> 549 ARU) and association with clinical thrombosis or bleeding. <h3>Methods</h3> Single-center, observational, analysis of 195 children (< 21 yo) who underwent first VN between 2015-2020 after receiving ≥ 1 enteral ASA dose. Primary outcome was proportion of these patients with ASA biochemical resistance. Secondary outcomes included incidence of new clinical thrombotic and bleeding events in 113 patients receiving ASA monotherapy for ≤ 1 year from VN. Patients receiving concomitant anticoagulation (n=61), dual antiplatelet therapy (n=7), had no follow-up (n=8), or had ASA held (n=6) were excluded from secondary outcome analysis. <h3>Results</h3> Of 195 patients, 56% were male and 53% were Caucasian. At time of VN, median age was 1.8 yrs (IQR 0.08 - 11.9), weight 10 kg (3.5 - 39.1), and BSA 0.47 m² (0.23 - 1.25). Indications for ASA included single ventricle with shunt (36.4%), ischemic stroke (22.6%), Glenn/Fontan (9.7%), vascular disease (7.2%), valvular heart disease (6.7%), VAD (6.2%), coronary disease (2%), RV-PA conduit (3.1%), intracardiac thrombus (2%), ventricular dysfunction (1.5%), and other (2.6%). Median ASA dose before VN was 4.6 (2.6 - 5.8) mg/kg/day; 36% received 1 and 64% ≥ 2 doses. Mean VN was 471 ARU (±66). 14.4% (n=28) had VN > 549 ARU. There were no significant differences in age, weight, BSA, ASA dose, platelet count, hemoglobin, or hematocrit between patients with VN ≤ 549 vs > 549 ARU. Of 113 patients receiving ASA only, mean VN was 471 (±69). Over a median of 252 days (89 - 365), 14 (12.4%) had a thrombotic event after 9 days (3.5-118) and 9 (8%) had a bleeding event after 80 days (25-150) from VN. Mean VN was significantly higher at initial testing in thrombotic (516 ARU, p=0.03) but not bleeding groups (472 ARU, p=0.97). 20% of patients in thrombotic and 33% in bleeding groups had repeat VN performed, with results not significantly different from the group as a whole (482 ARU, p=0.45, and 461 ARU, p=0.39, respectively). <h3>Conclusion</h3> VN platelet function testing identifies biochemical resistance in 14.4% of children. Higher ARU at initial testing may be associated with thrombosis; in contrast, there was no association between ARU and bleeding.

Results of 'two-in-one' single-stage revision total knee arthroplasty for infection with associated bone loss : prospective five-year follow up.

AimsPeriprosthetic joint infection (PJI) occurs in approximately 1% to 2% of total knee arthroplasties (TKA) presenting multiple challenges, such as difficulty in diagnosis, technical complexity, and financial costs. Two-stage exchange is the gold standard for treating PJI but emerging evidence suggests 'two-in-one' single-stage revision as an alternative, delivering comparable outcomes, reduced morbidity, and cost-effectiveness. This study investigates five-year results of modified single-stage revision for treatment of PJI following TKA with bone loss.MethodsPatients were identified from prospective data on all TKA patients with PJI following the primary procedure. Inclusion criteria were: revision for PJI with bone loss requiring reconstruction, and a minimum five years’ follow-up. Patients were followed up for recurrent infection and assessment of function. Tools used to assess function were Oxford Knee Score (OKS) and American Knee Society Score (AKSS).ResultsA total of 24 patients were included with a mean age of 72.7 years (SD 7.6), mean BMI of 33.3 kg/m2 (SD 5.7), and median ASA grade of 2 (interquartile range 2 to 4). Mean time from primary to revision was 3.0 years (10 months to 8.3 years). At revision, six patients had discharging sinus and three patients had negative cultures from tissue samples or aspirates. Two patients developed recurrence of infection: one was treated successfully with antibiotic suppression and one underwent debridement, antibiotics, and implant retention. Mean AKSS scores at two years showed significant improvement from baseline (27.1 (SD 10.2 ) vs 80.3 (SD 14.8); p < 0.001). There was no significant change in mean AKSS scores between two and five years (80.3 (SD 14.8 ) vs 74.1 (SD 19.8); p = 0.109). Five-year OKS scores were not significantly different compared to two-year scores (36.17 (SD 3.7) vs 33.0 (SD 8.5); p = 0.081).Conclusion‘Two-in-one’ single-stage revision is effective for treating PJI following TKA with bone loss, providing patients with sustained improvements in outcomes and infection clearance up to five years post-procedure.Cite this article: Bone Jt Open 2022;3(2):107–113.

The extended-view totally extraperitoneal (eTEP) approach for incisional abdominal wall hernias: results from a single center.

The extended-view totally extraperitoneal (eTEP) approach is a promising technique for abdominal wall hernias and has increased in popularity among hernia surgeons in recent years. This study aims to present the results of applying the laparoscopic eTEP approach for incisional abdominal wall hernias (IAWHs). This study is a retrospective analysis of a prospectively collected dataset of 30 patients who underwent laparoscopic eTEP for IAWHs between October 2018 and March 2021 (median follow-up of 15months). Thirty patients (8 male, 22 female) with a mean age, mean body mass index, and median ASA score of 53.5, 30.8, and 2, respectively, underwent the eTEP procedure for incisional abdominal wall hernias. In total, 11 (36.7%) patients had a recurrent IAWH. Seventeen (56.7%) patients were treated with eTEP RivesStoppa (eTEP-RS), whereas 10 (33.3%) patients needed the eTEP transversus abdominis release (eTEP-TAR) procedure. In three patients, conversions to other procedures (laparoscopic intraperitoneal onlay mesh-plus (IPOM-Plus) and open RivesStoppa) were needed due to intraoperative complications: iatrogenic perforation to the intestine and large peritoneal tear causing loss of the working space. The mean operative time and mean length of stay (LOS) were 203.5min and 1.5days for eTEP-RS and 291.5min and 1.6days for eTEP-TAR, respectively. Two patients developed asymptomatic seromas, and one patient developed an asymptomatic hematoma; all were treated conservatively. Only one recurrence was observed over the course of the follow-up period. The eTEP approach is a safe and feasible option for IAWH repair and a valuable addition to the armamentarium of hernia surgeons.

Jig-assisted modified Harrington reconstruction for metastatic bone destruction of the acetabulum.

We developed a technique using an indigenously designed jig to assist pin placement in producing a stable and long-lasting construct to augment the acetabulum combined with a cemented hip replacement in cases of metastatic destruction of the acetabulum. We describe our novel modified Harrington technique and retrospectively assess our cohort's clinical outcomes and complications. Between 2006 and 2019, 27 patients with a median age of 69 (49-81) years and a median ASA grade of III (II-IV) were managed using our modified 'Harrington' technique. We assessed outcomes on the following criteria: mechanical complications, post-surgery mobility, and functional outcome using Musculoskeletal Tumour Society Score (MSTS). At the last follow-up, ten patients were alive with disease [median follow-up of 26months (12-74)], and 17 patients died of their oncological disease [median follow-up of 15months (9-22)]. There were no perioperative deaths or intra-operative complications in our series. In total, ten complications were noted in nine patients (33%). Mobility-wise, 13 patients (48%) mobilised unaided, ten patients (37%) required a stick or crutch, two patients (7%) required a frame and two patients (7%) were wheel chair-dependent. The median MSTS score of all patients during their latest follow-up was 18 (8-26). Our jig-aided modified Harrington reconstruction technique assists in safe placement of antegrade pins in acetabulum during surgery and offers a long-lasting solution to these high-risk patients. The use of large diameter pins, appropriate patient selection, and cage used during construction in the acetabulum demonstrated relief of pain, improved mobility, and favorable functional outcomes with minimal complication rates.

Initial Outcomes of Robotic Pancreaticoduodenectomy in Australia

Introduction: Cost and lack of robust data have limited the uptake of Robotic Pancreaticoduodenectomy despite the potential to reduce complications and improve oncological outcomes once the learning curve has been overcome. Methods: All patients undergoing robotic pancreatectomy at the Wesley Hospital and Royal Brisbane Hospital (Queensland, Australia) between March 2015 – December 2020 were analysed. Ethics board approval was obtained. Results: Thirty-four patients underwent robotic pancreaticoduodenectomy during the study period. There were 21 males (61.7%) with a median age of 68 years (range 42-84). The median BMI was 26 (range 18-37) and median ASA 3 (range 1-4). Malignancy was the indication for resection in 19 patients (55.9%). The median operative time was 428 minutes (range 330-697) and median estimated blood loss was 400mL (range 0-1200). There were 6 unplanned conversions (17.6%). Clavien-Dindo Grade 3 or higher complications occurred in 9 patients (26.5%) with 5 cases (14.7%) of Grade B/C post-operative pancreatic fistula. There were two deaths within 90-days of surgery. Median length of stay was 11.5 days (range 4-56) with a median of 2 days spent in ICU. The R0 resection rate was 75.9% and the median lymph node harvest was 16 (range 6-24) with only 14.7% of patients having less than 12 nodes harvest. Conclusion: We have shown that in our experience RPD is safe with an equivalent complication profile compared with worldwide literature. It may also reduce the number of patients having an inadequate lymphadenectomy for staging in malignancy.

Open posterior component separation with transversus abdominis release (TAR) for large incisional abdominal wall hernias: Results from a single center

Transversus abdominis release (TAR) is the newest approach that allows effective myofascial mobilization, creating a large retromuscular space and wide mesh overlap to repair complex and large incisional ventral hernias. This article narrates the technical details and results of the TAR technique performed in a single center. The present study is a retrospective analysis of a prospective dataset from 25 patients who underwent posterior component separation (PCS) with TAR procedure for large incisional ventral hernias between October 2017 and July 2021. The minimum follow-up period was ten months. Twenty-five patients (five male, 20 female) with a mean age of 61.2 years, a mean BMI of 32.2 kg/m2, and a median ASA score of 2.0 underwent the TAR procedure. Fifteen (60%) patients had a history of incisional hernia surgery. The mean surgical time was 248 minutes. The mean total defect and mesh areas were 187.4 (90-500) cm2 and 1141.8 (750-2250) cm2, respectively. The mean visual analog scale (VAS) pain score on the first postoperative day was 4.5 and the median hospital length of stay (LOS) was 5 days. There were three (12%) surgical site infections (SSIs), two of which were deep infections that needed debridement. During the follow-up period (median of 26 months), two (8%) recurrences were recorded. The TAR technique represents an effective and safe repair modality of large and complex incisional hernias. TAR is an essential addition to the repertoire of the surgical community.

P-O17 The Royal Stoke Green Pathway: a method to undertake safe UGI surgery during the COVID pandemic

Abstract Background During the first wave of the COVID pandemic surgical services we paralysed globally, with cancellation of an estimated 28-million operations during the first 12 weeks. Worryingly, surgical patient with COVID were reported to have unacceptably high peri-operative mortality, approaching 25%. However, there was an urgent clinical need to progress with category 1 and 2 operations, to prevent disease progression and avoidable morbidity and mortality from non-COVID pathologies. During the second and subsequent waves of the pandemic it was vital to protect patients from peri-operative COVID whilst undertaking urgent surgery safely. Methods Our centre developed a ring-fenced 'Green Pathway' for category 1 and 2 patients requiring surgery. Patients were treated in physically separate area of the hospital, with no interaction between COVID and non-COVID patients, healthcare staff or facilities. Patients self-isolated for 14-days prior to admission, and had pre- and peri-operative COVID RT-PCR tests. We assessed outcomes for patients immediately prior to the introduction of the Green Pathway (1/10/2020) and following implementation (31/12/2020) to assess safety. Textbook outcomes for pancreatoduodenectomy were compared to assess safety and quality. Other data suggests that UGI surgery couldn't continue in other hospitals from December 2020. Results There were 47 admissions to surgical HDU following category 1 and 2 upper GI operations during the study; 31 pre-pathway (PP) implementation, and 16 green pathway (GP) patients. Median age 66-years (43-78 range) PP vs 65-years (range 42-74) GP, median ASA 3 vs 2. Median HDU length of stay (LOS) 5-days vs 7-days, and median hospital LOS 11.5-days vs 9-days for PP vs GP respectively. There were 6 cases of peri-operative COVID in PP cohort, and 1 in GP (contract following discharge). There was no mortality within either cohort. For the subgroup of patients undergoing PD: 10 patients PP, 6 patients GP, textbook outcomes were achieved in 90% vs 67% PP vs GP. Conclusions The implementation of the Green Pathway at our institution enabled continuation of surgery for patients with category 1 and 2 operations during the COVID pandemic with a significant reduction in peri-operative COVID infection, no mortality and no increase in length of stay. The TO rate was lower with the GP (not statistically significant), but our 4-year institution TO rate is 70.3%, comparing favourably to other studies. This pathway has enabled safe continuation of urgent surgery during the pandemic and could be a model for adoption in other centres especially if there is resurgence of COVID cases during the coming winter.

P-P57 The first experience of intraoperative radiotherapy for pancreatic cancer in the UK

Abstract Background Intraoperative radiotherapy (IORT) involves giving a targeted single fraction of high dose radiation to the resection bed. The main advantages are exclusion of vulnerable structures from the radiation field and ability to direct the electron beam to threatened margins. IORT in pancreatic cancer is not new, with Japanese centres reporting series from the 1970s. Early reports were exciting, suggesting that IORT was useful in reducing visceral pain, achieving local control and improving survival in locally advanced and unresectable patients. However, paucity of randomised trials in the ensuing decades has limited its widespread adoption. Methods With funding from the PLANETS charity (www.planetscharity.org), University Hospitals Southampton acquired a Mobetron 2000 linear accelerator (IntraOp, USA) in 2016. Testing was done at the National Physical Laboratory (Teddington, UK) over two months to collect beam data and ensure consistency in treatment delivery. Staff training included visits to the Heidelberg Cancer Centre and several dry runs. Inclusion criteria were: (i) patients with pancreatic head adenocarcinomas; (ii) threatened vascular margins; (iii) WHO performance status 1-2; (iv) no evidence of distant metastasis. Results Nineteen patients had pancreaticoduodenectomy (traditional or pylorus preserving) combined with IORT. Median age was 66 (42-81) years. Median ASA grade was 2 (2-3). 16/19 had locally advanced pancreatic cancer and 18/19 had neoadjuvant chemotherapy. Median IOERT dose was 15 (10-15) Gy, energy 7.5 (6-12) MeV, to a mean depth of 1.6 +/- 0.8 cm, with median cone size 5 (4-6) cm and bevel angle 15 (0-30) degrees. All tumours were pT1-T3 and 10/19 had positive regional nodes. 10/19 were R1 resections, with 4/19 specimens exhibiting vascular invasion and 6/19 perineural invasion. Mean operating time (including IOERT) was 534 +/- 77 min. Median length of stay was 8.5 (6-41) days. 30-day mortality was zero. 6/19 patients had post-operative complications (Clavien-Dindo 1-2 only), with clinically detectable pancreatic fistula in 1/19. Conclusions This is the first UK experience of IORT for pancreatic cancer, showing that this treatment modality is safe and feasible. With the appropriate expertise, an IORT service can be implemented within 12 months of acquiring the Mobetron system. We hope that these data will encourage other UK and European HPB units to consider setting up regional IORT services, such that larger scale prospective trials can be initiated to demonstrate its efficacy.

EP.WE.802Are we over-zealous in our management of acute diverticulitis?

AimsOf the 25% of people with diverticula who develop symptomatic diverticular disease, approximately 75% will have at least one episode of diverticulitis. However according to the latest NICE guidance those with diverticulitis who are not systemically unwell may not require either admission or antibiotics. In the financially austere environment facing the NHS within the COVID 19 pandemic, prudence in such resource allocation is of vital importance. We aim to review management of patients with acute diverticulitis over a 6-month period in a district general hospital against the 2019 NICE guidelines.Methods29 patients presenting with acute diverticulitis, M:F ratio 12:17, median age 55 (range 24-82), median ASA 2 (range 0-3) were retrospectively reviewed. Biochemical markers, lactate and vital signs were used to assess if attending patients were systemically unwell.Results23 patients were admitted and 6 managed as outpatients via the surgical ambulatory unit. Of the 29 patient cohort, 9 (31%) were systemically unwell. All 9 unwell patients received antibiotics. Of the 20 patients not considered systemically unwell, 11 (55%) received antibiotics. 16 (80%) that were admitted did not require admission on retrospective review.ConclusionPrompt administration of intravenous antibiotics for septic patients with diverticulitis reduces associated morbidity and mortality and the observed adherence to this principle is encouraging. For systemically well patients, increased clinical discernment is required to consider managing patients in the surgical ambulatory setting, avoiding unnecessary admissions. Similar caution must be used in appropriate use of antimicrobials to avoid unnecessary adverse consequences.

EP.TU.809Challenges in management of acute diverticulitis within a district general hospital

Abstract Aim Incidence of perforated sigmoid diverticular disease is estimated at 3.4 to 4.5 per 100,000. Perforation may be the first manifestation of complicated diverticulitis with a range of 50% to 70%. We aim to review management of systemically unwell patients with acute diverticulitis in a district general hospital against the 2019 NICE guidelines. Methods 29 patients presenting septic with acute diverticulitis, M:F ratio 12:17, median age 55 (range 24-82), median ASA 2 (range 0-3) were retrospectively reviewed over a 6-month period. Results Mean time to antibiotics was 3.96 hours (range 0-23.11). Of the 7 with perforated diverticulitis severity classification included: Hinchey I – n = 1, 3.4%; Hinchey IIa – 5 (17.2%), and; Hinchey IIb – 1 (3.4%). Time to CT abdomen pelvis was 3.38 hours (range 0-16.4 hours). Two pericolic abscesses met NICE drainage criteria at 3.7 cm and 3.9 cm respectively. The 3.7 cm abscess was drained radiologically at 7 days post-admission and was re-admitted 6 days later requiring further radiological drainage. The patient with a 3.9 cm abscess received a Hartmann’s procedure and had multiple re-admissions requiring a hospital stay of 34 days. There was 0% mortality at 30 days. Conclusion Management of acute diverticulitis continues to present a unique challenge. For systemically unwell patients, timely administration of antibiotics within an hour of sepsis recognition is encouraged to optimise outcomes. Timely cross-sectional imaging is pivotal in disease classification and decision-making regarding acute management. Interventional drainage and surgical resection remain important therapeutic strategies for unwell patients with Hinchey grade II diverticulitis.

EP.WE.858Risk of Post-Operative COVID-19 Infection Following Breast Surgery

AimsTo study the risk of post-operative COVID-19 infection in patients undergoing breast surgery during the height of the pandemic in 2020.MethodsWe continued to perform surgery for breast cancers and other urgent breast conditions during the pandemic in a dedicated “Green” operating theatre in a COVID-19-free hospital. NHS guidance regarding staff and patient COVID-19 screening and patient self-isolation period changed frequently during the study period, and recommended guidance was followed. PPE was worn by theatre team. Patient records were subsequently reviewed for a positive COVID-19 swab or a COVID-19-related hospital admission within 8 weeks of surgery.Results96 consecutive operations were performed by 4 consultants between April and August 2020. All but 14 were for breast carcinoma. Median age 56 (21-89). Median ASA grade 2 (1-3). 64 patients had negative preoperative COVID-19 swabs, others in the early stages were screened with chest X-ray or CT. 83% (n = 80) were done as day cases. Among breast cancer operations there were 17 mastectomies, bilateral in 2 cases. There was no cases of COVID-19 positivity or COVID-19-related hospital admission post-operatively.ConclusionsBreast surgery, done mainly as day case, did not predispose patients to COVID-19 infection in the postoperative period when guidelines were followed. Concern about postoperative COVID-19 infection should not be a cause of surgical delay in any future waves, which can be potentially harmful to breast cancer patients.

EP.TH.589Comparison of Surgeon Gaze Behaviour Against Objective Skill Assessment in Open Inguinal Hernia Repair – A Pilot Study

Abstract Aims Technical skill is associated with improved postoperative outcomes. Adoption of a formalised high-stakes assessment of surgical skill is technically challenging and limited by the financial and human resources available. We aimed to assess the ability to adopt gaze behaviour analysis as an assessment of surgical skill within live open inguinal herniorrhaphy. Methods Surgeons’ gaze was measured with Tobii Pro eye-tracking Glasses 2 (Tobii AB). All grades of surgeons were included. Primary outcomes were dwell time (%) and fixation frequency (count/s), as markers of cognition, on areas of interest correlated to mean Objective Skill Assessment of Technical Skill score. Secondary outcomes assessed effort and concentration levels through maximum pupil diameter (mm) and rate of pupil change (mm/s) correlated to perceived workload (SURG-TLX). Three operative segments underwent analysis: mesh preparation, fixation and muscle closure. Spearman’s and Pearson’s correlation were performed with significance set at p &amp;lt; 0.05. Results 5 cases were analysed, totalling 270 minutes of video footage. All participants were senior surgical trainees and right-hand-dominant. The median number of hernia operations performed was 160 (range:100-500). The median ASA score of each patient participant was 2 (range:1-2). The median operation length was 45 mins (range:40-90 mins). There were no statistically significant primary outcomes from this pilot data (p &amp;gt; 0.05). Conclusions This pilot study demonstrated the feasibility of recording gaze behaviours for comparison against formal skills assessment to determine the role of eye tracking in live high stakes technical skills assessment. A full study will now commence based on formal power calculation.