Operative Procedures Research Articles

Accommodating Learners: An Adaptive Approach to Surgical Hand Preparation With Crutches

Accommodations for injured and disabled surgical providers have to balance an individual's needs with measures that ensure sterility requirements, patient and provider safety. The highly specialized nature of the surgical environment poses challenges when implementing changes in the operating room and literature is limited on adaptive surgical hand preparation techniques necessary to maximize a disabled medical student's active participation in their surgical clerkship. This paper presents a detailed account of the development and implementation of an adaptive surgical hand preparation designed to address mobility needs, enabling a student's active participation and education in the surgical curriculum. This offers a framework for adapting traditional surgical hand preparation techniques for crutches consisting of essential requirements in terms of equipment and personnel, step-by-step guide for implementation, discussion of potential risks related to contamination and safety, and a discussion on future directions for further innovation. An adaptive surgical hand preparation technique was necessary to sterilize forearm crutches for a third-year medical student with a physical disability to ensure accessibility in the operating room and equity in surgical clerkship and medical education. Successful use of this protocol, in over 40 surgical cases throughout an 8-week surgical clerkship, created opportunity for a disabled medical student to access the sterile operating table through collaboration and innovation in the operating room. The adaptive hand preparation and sterile crutch cover solution was necessary for the student to assist in open, laparoscopic, and surgical procedures resulting in high clinical performance marks in the surgical clerkship. Beyond the individual benefit, this protocol promotes the importance of equity in medication education and encourages diversity through adaptive measures in the surgical field. Designing an adaptive sterilization protocol for use of crutches in the operating room serves as an example of educational engineering and adaptable accessibility. The entire collaborative effort involving the medical student, university, surgical providers and operating room staff demonstrates the importance of teamwork in creating access in healthcare settings. Through learned experience, the authors provide insights for future directions for innovation, aiming to enhance access and inclusivity in medical education and surgical practice. This paper reflects on the broader implications of educational engineering and inclusive practices in healthcare.

Association of Antibiotic Route and Outcomes in Children with Methicillin-Resistant Staphylococcus aureus Bacteremic Osteomyelitis.

There remains uncertainty about whether transitioning to oral antibiotic therapy is appropriate for the management of children with methicillin-resistant Staphylococcus aureus (MRSA) bacteremic osteomyelitis. We compared clinical outcomes for children with MRSA osteomyelitis with associated bacteremia who were transitioned to discharge oral antibiotic therapy to those discharged on outpatient parenteral antibiotic therapy (OPAT). We performed a retrospective, multicenter, cohort study of children ≤ 18 years hospitalized with MRSA bacteremic osteomyelitis across four children's hospitals from 2007 to 2018 discharged on oral antibiotic therapy versus OPAT. The primary outcome was treatment failure within 6 months of discharge, defined as any of the following: diagnosis of chronic osteomyelitis, conversion from oral to IV antibiotic route, an operative procedure after the index hospitalization (abscess drainage, bone biopsy, arthrocentesis, or pathologic fracture) and/or recrudescence of MRSA bacteremia. Outcomes were analyzed in an inverse propensity score weighted (IPW) cohort. A total of 106 cases of MRSA bacteremic osteomyelitis were included; 44 (42%) were discharged in the oral antibiotic therapy group and 62 (59%) patients were discharged in the OPAT group. In the IPW cohort, treatment failure within 6 months of discharge occurred in 3.4% of children in the discharge oral therapy group and 16.3% in the OPAT group (P = 0.03). The odds of 6-month composite treatment failure between discharge oral therapy and OPAT were 0.18 (95% CI 0.05-0.61). Discharge oral therapy was not associated with higher rates of treatment failure compared to OPAT for children with MRSA bacteremic osteomyelitis.

Empirical Reality versus Theoretical Framework: Street-Level Bureaucrats' Behavior in Driver's License Services at Pinrang Police Resort, Indonesia

This study investigates the behavioral dynamics of street-level bureaucrats (SLBs) in the driver's license (SIM) service at the Pinrang Resort Police (Polres Pinrang) in Indonesia, juxtaposing empirical findings with Michael Lipsky's seminal theory of street-level bureaucracy. Employing a qualitative phenomenological methodology, the research seeks to elucidate the influence of working conditions on SLBs' behavioral patterns and the consequent impact on public service quality. Data were collected through semi-structured interviews with SLBs and service recipients, non-participant observations, and document analysis, then subjected to iterative thematic analysis using interactive model. The findings reveal notable divergences from Lipsky's theoretical propositions. SLBs at Polres Pinrang encounter reduced ambiguity in policy objectives and performance evaluation, attributable to effective communication channels, comprehensive standard operating procedures, and a robust performance appraisal system. Despite resource limitations and escalating service demands, SLBs exhibit adaptability in delivering responsive services through access rationing strategies, task routinization, and collaborative partnerships with interdepartmental units and community stakeholders. Contrary to the nonvoluntary client interactions posited by Lipsky, SLB-SIM applicant engagements are characterized by enhanced humanization and responsiveness. Nevertheless, Lipsky's theoretical insights maintain relevance in the broader landscape of public service provision. The study underscores the criticality of striking a balance between procedural adherence and client-centric responsiveness to optimize service quality.

The missed diagnosis of femoral hernias in females undergoing inguinal hernia repair - A systematic review and proportional meta-analysis.

Given the 4-times higher prevalence of femoral hernias among females compared to males, this diagnosis may be missed during inguinal hernia repair (IHR), causing risk of reoperation for pseudo recurrence of femoral hernias (FH). Minimally invasive approaches are suggested as potential reducers of missed FH since they provide a posterior view of all defect areas, despite studies suggesting that women receive less MIS than men. We aim to assess the missed FH during IHR and after reoperation for recurrence following IHR in women. PubMED, Cochrane, and EMBASE databases were searched for studies assessing patients undergoing recurrent IHR, analyzing the incidence of reoperation for FH and occult femoral hernias during IHR. Statistical analysis was performed using R software. From 6,226 records, 10 retrospective observational studies were included, totaling 15,863 patients (20% females). We found that 19.56 per 100 women (95% CI 8.34, 39.37) who are reoperated for an inguinal hernia are found as having a FH during the new repair. Compared to men, women were at a significantly higher risk to be reoperated for FH after IHR (RR 8.97; 95% CI 7.35, 10.93; P < 0.001). Our analysis also showed that 20.7% of females received MIS approaches for groin hernia repair, while 79.3% received open procedures. Furthermore, our study found a pooled incidence of occult FH during the initial IHR of 6.85 per 100 patients for both genders (95% CI 2.78, 15.90), which increased to 21.42 per 100 patients when assessing females only (95% CI 15.46, 28.89). Females have a higher incidence of FH following reoperation for recurrence of inguinal hernia repair. Added to the high rate of occult FH encountered during inguinal procedures, this suggests a missed diagnosis of FH during IHR. The adoption of MIS IHR for women is fundamental to reduce the underdiagnosis of FH.

Evaluation of Preoperative Factors That Affect the Alpha Angle of Screw Insertion After the Open Latarjet Procedure.

The open Latarjet procedure yields excellent results as a treatment for anterior shoulder instability. The position of the bony fragment and the insertion angle of the screw (the alpha angle) are critical factors for a successful procedure. The alpha angle is considered overangulated at >25°, which is associated with poor bone fixation and healing. To assess preoperative patient anatomic factors that affect the alpha angle in the Latarjet procedure for anterior shoulder instability. Case-control study; Level of evidence, 3. In this retrospective study, 76 patients who underwent the open Latarjet procedure between October 2009 and December 2023 were included. Postoperative computed tomography scans were reviewed for the alpha angle, and patients were classified into 2 groups: group 1 (alpha angle ≥25°) and group 2 (alpha angle <25°). Preoperative patient characteristics and radiological parameters obtained from preoperative computed tomography scans were analyzed and compared between groups 1 and 2. We developed a novel method to measure the depth of the chest and the angle between the deltopectoral interval and the plane of screw insertion. We also measured the thickness of the pectoralis major and subscapularis muscles. Of the 76 patients in this study, 41 and 35 patients were included in groups 1 and 2, respectively. The mean alpha angles of groups 1 and 2 were 36° and 12°, respectively, and the body mass index was significantly higher in group 1 (P < .001). In addition, group 1 had a significantly longer distance from the anterior edge of the glenoid to the skin margin of the deltopectoral interval (P < .001). The angle between the deltopectoral interval and the plane of screw insertion (traction angle) was significantly larger in group 1 (P < .001), and the pectoralis major and subscapularis muscles were thicker in group 1 (P = .017 and P = .032, respectively). The alpha angle after the Latarjet procedure was strongly related to the patient's weight, body mass index, depth of the chest, and the angle between the deltopectoral interval and the plane of screw insertion. To our knowledge, this is the first study in which the preoperative factors that facilitate proper screw fixation in the Latarjet procedure are reported.

BN O04 - Trends in the management of bile duct stones in the United Kingdom: Are we following the evidence?

Abstract Background Common bile duct stones (CBDS) are typically managed in two stages: Endoscopic Retrograde Cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). However, access to ERCP can be limited or require referral, has a high failure rate, often necessitates additional imaging, and may involve multiple procedures. Increasing evidence suggests that single-stage management, involving LC with intraoperative imaging and bile duct exploration when indicated, is cheaper, more effective, and reduces overall length of stay. British Society of Gastroenterology guidance states that it is a valid alternative to ERCP. This study aimed to determine whether clinical practice aligns with this evidence. Method National Health Service (NHS) Admitted Patient Care publications summarise Hospital Episode Statistics by financial year and are openly accessible. OPCS4 Procedure Codes were screened by two authors and categorised as “operative” or “endoscopic.” Codes detailing the management of CBDS or bile duct exploration were included, while ambiguous codes or those for non-stone indications were excluded. Data pertaining to these codes were extracted from the Admitted Patient Care publications for 2012 to 2022 and summarised in a Microsoft Excel spreadsheet. Trends were analysed using a Non-Seasonal Mann-Kendall Trend Test Results A total of 249,475 procedures for CBDS were performed over the ten-year period, with a mean patient age of 67. Annually, the total number of procedures increased from 21,365 to 27,668 (p=0.002). Endoscopic procedures increased from 19,716 to 25,976 (p=0.002), while operative procedures remained stable (1,649 to 1,692, p=0.431). Consequently, the proportion of endoscopic management rose from 92.3% to 93.9% (p&amp;lt;0.001). The mean age of patients undergoing operative procedures was ten years younger than those undergoing endoscopic procedures (57 vs. 67 years) Conclusion Despite evidence and guidance supporting single-stage procedures, there is a trend towards endoscopic management of CBDS in the UK. This may be due to operational pressures on the NHS, including the sequelae of the COVID-19 pandemic, or reflect challenges within hospital culture, skill mix, or equipment availability.

OGC SO39 - The OUTLIVE Study - Oesophageal and JUncTional Cancer ELectIVE Surgery Morbidity and Mortality at 90-Day: A TUGS Multinational Audit

Abstract Background Oesophageal cancers are among the most common types of cancer and have a high mortality rate. Todate, oesophagectomy remains the gold standard treatment. However, considerable heterogeneity in the literature fails to generate a truly representative picture of short-term outcomes associated with these procedures. Method This multinational global audit includes all consecutive adults with clinically documented primary oesophageal malignancy undergoing elective surgery with curative intent. The study'sstudy's primary objective was to assess the 90-day mortality and morbidity rates in this population. Data was collected through a standardised dataset, and a descriptive analysis was employed. For analysis purposes, the patients were classified depending on the surgical procedure they underwent (laparoscopic, open, hybrid, converted and robotic surgery). Results A total of 622 individuals were analysed, most male [462 (74%)], with a mean Charlson Comorbidity Index of 4.30. The most common procedure was laparoscopic surgery [222 (35.7%)], followed by open surgery [198 (31.83%)]. 31 (5%) of the procedures reported an intraoperative complication, but more common in open procedures [11 (5.6%)]. 318 (51%) patients suffered postoperative complications within 90 days of surgery. The reoperation rate was 9.3%. McKeown staged procedure, compared to Ivor Lewis, had more infective complications [19% vs 11%, p=0.007] and a higher conversion to open procedures [69 (11.1%)]. 34 (11%) patients died because of a surgical complication. Conclusion No significant differences were found between the number of patients with at least one complication and the surgical approach. Nevertheless, robotic-assisted minimally invasive oesophagectomy (RAMIE) presented with the lowest complication, reoperation, and mortality rates. McKeown three-stage surgery also presented with worse clinical outcomes compared to Ivor Lewis procedures. Further studies and randomised control trials comparing different procedures in the field of elective oesophagectomy are needed to expand our knowledge in this field and guarantee the best outcomes for our patients.

HPB SO19 - Comparison of perioperative outcomes of open (CUSA) versus laparoscopic (LOTUS) major hepatectomy – revisited. First evaluation of efficacy and safety of AEONTM stapler

Abstract Background In 2019, preliminary data matching 40 cases demonstrated improved outcomes of laparoscopic major liver resections using the BOWA-LOTUSTM liver blade (Devon, UK). An updated and expanded comparison between open and laparoscopic major hepatectomies is presented as well as evaluating of an endovascular stapler AEON™ (Lexington Medical, Massachusetts, USA). Method January 2020 to June 2023 patients were identified from a prospectively maintained database. Propensity score matching analysis used R statistical tool in SPSS (IBM, New York, USA) to isolate matched open and laparoscopic cases. LOTUSTM ultrasonic energy device was used for parenchymal transection in laparoscopic cases and CUSA (Valleylab, Colorado, USA) in open procedures. AEONTM endovascular stapler was used from early 2021. Results 86 patients constitute the study population after applying propensity score matching analysis in a 1:1 ratio. The median (range) age in the matched sample was 63 (27-83) yrs. Hospital stay (mean 7.8 v 14.7 days; p=0.025) and blood transfusion requirement (0 v 4 units; p=0.035) were all significantly improved when comparing laparoscopic to open. Comparison of the AEONTM stapler with Endo-GIA (Medtronic, MN, USA) showed no significant difference in any outcome measure, although AEONTM demonstrated (non-significantly) a reduced trend in operating time comparing all cases (56 v 69 mins; p=0.300) and laparoscopic (56 v 71 min; p=0.295). Conclusion The LOTUS liver blade continues to be associated with acceptable outcomes in laparoscopic liver resections. The AEONTM endovascular stapler was equivalent to other staplers with a trend towards a shorter operating time in liver transectional surgery.

Implementation of Convergence (Cross-Sectoral) Action for the Acceleration of Stunting Reduction in Palopo City, South Sulawesi, Indonesia

Background: The global trend of stunting incidence has been declining from 2000 to 2022; however, the WHO still categorizes Indonesia as a country with a very high prevalence of stunting. A multisectoral and multi-stakeholder approach is one of the methods utilized in the National Action Plan for Accelerating Stunting Reduction. This study aims to analyze the implementation of convergence actions for accelerating stunting reduction in Palopo City. Methods: The study was conducted for 1 months in Palopo City. This study was a qualitative study with 14 informants from different regional government agencies (OPDs) involved in the Palopo City Stunting Reduction Task Force (TPPS). Data related to the implementation convergence action for Accelerating Stunting Reduction in Palopo City owere obtained through in-depth interviews. Qualitative data were processed by searching for keywords and then content analysis was conducted. Qualitative data analysis uses an inductive thinking process. Results: The study reveals that at the initial stage, each OPD recognizes the importance of cross-sectoral participation. However, challenges persist in the utilization of human resources and budgeting. The collaboration process requires improvements as planning, governance structure, and actor roles are not yet optimal, with some OPDs still lacking clarity on their roles. Leadership in Palopo City involves regulation and communication, yet some OPDs lack specific Standard Operating Procedures (SOPs) and regulations, though inter-agency communication is fairly effective. The outputs of stunting interventions focus on health, education, infrastructure, and social welfare, with some programs being directly integrated while others provide indirect support. Conclusion: The implementation of convergence actions for accelerating stunting reduction in Palopo City is not yet optimal, with primary challenges in the utilization of human resources and budgeting. The collaboration process, leadership, and program outputs still require improvement, particularly in planning, governance structure, and inter-agency communication.

BN SO34 - Outcomes in giant versus non-giant hiatus hernia repair: Same payment different operative burden

Abstract Background Hospital trust payment for operative procedures often rely on coding systems like the NHS's Office of Population Censuses and Surveys (OPCS) codes, which determine reimbursement rates. Both giant hiatus hernia (GHH) and non-giant hiatus hernia (NGHH) repairs often share the same code, as in our trust. This results in equal reimbursement to trusts for procedures with higher operative burden and resource needs. This study aims to assess differences in the patient population, their hiatal type, operative challenges and post-operative outcomes between GHH and NGHH repairs. Method All patients undergoing primary hiatus hernia surgery between March 2019 to March 2024 at a single institution were included. Retrospective review of electronic records were utilised to record: patient demographics, hernia type, operative details, length of stay (LOS), post-operative course and need for a return to theatre (RTT). Outcomes were comparison of surgical approach, use of mesh and gastropexy (as proxy measures to indicate difficulty of operation), 30-day morbidity measured using Clavien-Dindo (CD) grading and 30-day mortality and RTT. Analysis was undertaken using un-paired t-test and Chi2. A p-value of &amp;lt;0.05 was considered statistically significant. Results Table 1. Patients GHH NGHH p n 91 135 Age (average) 69 (±10) 52 (±16) &amp;lt;0.001 Female (%) 66.7 55.2 0.1100 BMI 30.8 (±5.4) 30.7 (±7.8) 0.2029 ASA grade (average) 2.2 1.9 &amp;lt;0.001 Hernia Types (median) 3 1 &amp;lt;0.001 Table 2. Operative details GHH NGHH p Open (%) 6.6 0 0.0020 Laparoscopic (%) 60.4 62.24 0.9840 Robotic (%) 33 33.3 0.9239 Mesh used (%) 8.8 0.7 &amp;lt;0.041 Gastropexy (%) 12 0.7 &amp;lt;0.001 Table 3. Outcomes GHH NGHH p LOS (median) 2 (0-161) 1 (0-8) 0.0179 RTT (%) 10.7 8 0.4747 30-day morbidity (CD≥3, %) 4.8 4.4 0.6519 30-day mortality 0 0 NA Conclusion This study highlights significant differences between giant hiatus hernia (GHH) and non-giant hiatus hernia (NGHH) repairs. GHH repairs have an increased likelihood of undergoing open procedures, use of mesh, and gastropexy, reflecting their greater complexity. GHH patients are older, have higher ASA grades, and present with more advanced hernia types compared to NGHH patients. Additionally, GHH repairs result in longer hospital stays. The findings underscore the need for improved coding accuracy to reflect these disparities accurately in patient demographics, operative strategies, and recovery outcomes within hospital trusts, ensuring appropriate resource allocation and reimbursement based on procedural complexity.

HPB SO07 - Update to the role of staging laparoscopies in stratifying patients by operability in perihilar cholangiocarcinoma

Abstract Background Radical resection of perihilar cholangiocarcinoma (pCCA) is only an option for the minority presenting at an early stage. Sensitivity of radiological imaging to detect liver and peritoneal metastases is insufficient. Our published 2017 cohort study demonstrated over a quarter of patients with no radiologically detectable metastatic disease were subsequently found to have unresectable disease by staging laparoscopy. However, less than 3% of these patients had preoperative PET-CT, which is now strongly recommended in new national guidance.Advances in CT and MRI sensitivity and increased PET-CT use demanded a reassessment of the need for staging laparoscopy in diagnostic assessment of resectability. Method All patients referred to a tertiary UK hepatobiliary centre with a new diagnosis of radiologically suspected or biopsy-proven pCCA from January 2020 to January 2024 were included (n=305). Patients were identified through a prospectively maintained cancer database. Electronic health records were interrogated for demographic data, preoperative radiological imaging, and details related to operative procedures. Those referred with, or subsequently found to have, any of the following conditions were excluded: recurrent pCCA, intrahepatic or distal cholangiocarcinoma, gallbladder cancer or benign hepatobiliary disease. Results All patients underwent CT chest, abdomen and pelvis. 194 (64%) received contrast MRI liver or MRCP. Based on these, 242 (79%) had locally advanced or metastatic cancer, comorbidities precluding resection or otherwise declined surgery. PET-CT was employed to investigate all remaining 63 patients, which discovered metastatic disease in 16 patients (25%). 47 patients proceeded to staging laparoscopy. This yielded metastatic or locally advanced disease in five patients (11%); a near-statistically significant drop compared to our previously published yield of 27.2% (p=0.060). Two (5%) had open-and-close laparotomies for irresectable disease, compared to 16 of 114 (14%) in our 2017 publication (p=0.14). Conclusion Technological advances of CT and MRI and use of PET-CT have vastly improved detection of irresectable pCCA. This study reinforces the merits of PET-CT in identifying occult disease, and we would encourage units that undertake these resections to utilise this imaging modality prior to undertaking staging laparoscopy. Nevertheless, peritoneal spread remains challenging to exclude radiologically, and diagnostic laparoscopy endures as a vital tool in the prevention of open-and-close laparotomies.

HPB SO08 - Safety of Robotic cholecystectomy as index training procedure – the UK experience

Abstract Background A recent large retrospective cohort study reported a higher risk of bile duct injury associated with robotic cholecystectomy when compared to the laparoscopic approach. Considering that most robotic training pathways, including the one followed in the UK, utilise robotic cholecystectomy as index training procedure, such findings mandate evaluation of the safety profile of robotic cholecystectomy in the UK to ensure its use as an alternative approach to laparoscopic cholecystectomy is not putting patients at risk. We aimed to conduct a multi-centre observational study to evaluate the safety profile of robotic cholecystectomy performed within the UK HPB Robotic training program. Method A retrospective analysis of prospectively collected data from eleven centres participating in the UK robotic HPB training program was conducted. All adult patients undergoing robotic cholecystectomy for symptomatic gallstone disease or gallbladder polyp were considered. Bile duct injury, conversion to open procedure, conversion to subtotal cholecystectomy, length of hospital stay, 30-day re-admission, and post-operative complications were the evaluated outcome parameters. Results A total of 600 patients were included. The median age was 53 (IQR 65 - 41) years and the majority (72.7%; 436/600) were female. The main indications for robotic cholecystectomy were biliary colic (55.5%, 333/600), cholecystitis (18.8%, 113/600), gallbladder polyps (7.7%, 46/600) and pancreatitis (6.2%, 37/600). The median length of stay was 0 (IQR: 0-1) days. Of the included patients, 88.5% (531/600) were discharged on the day of procedure with 30-day re-admission rate of 5.5% (33/600). There were no bile duct injuries and the rate of conversion to open was 0.8% (5/600) with subtotal cholecystectomy rate of 0.8% (5/600). Conclusion This current study confirms that robotic cholecystectomy can be safely implemented to routine practice with a low risk of bile duct injury, low conversion to open surgery and low need for subtotal cholecystectomy.

HPB SO27 - Reconsidering Routine Histopathological Examination of Gallbladder Specimens in Cholecystectomy: Optimizing Clinical Practice and Resource Management

Abstract Background Cholecystectomy, the removal of the gallbladder, is a common surgery performed globally. Routine histopathological examination (HPE) of gallbladder specimens post-surgery aims to detect pathologies like gallbladder cancer (GBC). GBC incidence varies by region and ethnicity, with higher risks in women and those over 65. Advanced GBC stages often require surgery, while early stages may only need cholecystectomy. Global HPE practices differ based on resources and GBC rates. This study evaluates the necessity of routine HPE by examining the selective processing of specimens suspected of GBC, ensuring patient safety while potentially optimizing resource use. Method This retrospective cohort study conducted at Redland Hospital, a district general hospital in Australia, investigated the necessity of routine histopathological examination (HPE) for excised gallbladder specimens. Adhering to routine HPE policy, the study encompassed all elective and emergency cholecystectomies performed from January 2023 to December 2023, excluding pediatric cases, concurrent surgical procedures, and those with suspected malignancy. Demographic data, surgery indications, intraoperative findings, histopathological results, and incidental gallbladder cancer (IGC) outcomes were analyzed. Pathology reports and case documentation were reviewed for cancerous pathology indicators. Results Over the one-year study period from January 2023 to December 2023, a total of 266 gallbladder specimens were subjected to histopathological examination (HPE) post-cholecystectomy. Of these, 201 were female and 65 were male, yielding a male-to-female ratio of 3:1. Elective cholecystectomy was performed on 56.4% (150) of patients, while 43.6% (116) underwent emergency procedures. Laparoscopic cholecystectomy (LC) was the primary surgical approach, except for one case requiring conversion to an open procedure. None of the patients exhibited gallbladder carcinoma (GBC); however, 3.3% (9) displayed premalignant histopathological features in their specimens. Conclusion In conclusion, adopting a selective approach, where only gallbladder specimens with macroscopic abnormalities undergo histopathological examination (HPE), seems prudent, especially in regions with low gallbladder cancer (GBC) incidence. Our study, which revealed no cases of GBC, supports this approach. It not only reduces the risk of missing incidental carcinoma in clinically unsuspected cases but also proves cost-effective and reduces the histopathology department workload without compromising patient outcomes. Therefore, we advocate for routine macroscopic examination of gallbladder specimens for abnormalities before HPE submission, particularly in cholecystectomy patients with gallstone disease.

ORGAN-SPARING AND ORGAN- REMOVING SURGICAL PROCEDURES FOR PATHOLOGICAL CONDITIONS OF THE SPLEEN IN CHILDREN. QUESTIONS AND ANSWERS.

Introduction. Nowadays splenic surgery is a rather urgent problem in pediatric surgery. There are diseases where only splenectomy allows a child to live a full life. These are: sickle cell anemia (SCA), idiopathic thrombocytopenic purpura, hereditary spherocytosis (Minkowski- Chauff ard disease), thalassemia, and autoimmune hemolytic anemia. The spleen is involved in 25-30 % of cases of blunt abdominal trauma in children. The loss of more than 45 % of the circulating blood volume leads to an unstable hemodynamic state in the child. The question of surgical treatment and preservation of the spleen in hemoperitoneum due to its injury is of vital importance. Aim: To study the possibilities of surgical treatment of diseases and injuries of the spleen in children. Materials and methods. An analysis of surgical interventions for diseases and injuries of the spleen in children aged 2 to 17 years from 2019 to 2024 was performed. The study was conducted in the surgical departments of the «Clinical Center of Pediatric Medicine» of the «Okhmatdyt Hospital» of the «Western Ukrainian Specialized Center» (Lviv) and the «Chernivtsi City Children’s Clinical Hospital» (Chernivtsi). 27 children (17 girls, 10 boys) had spleen diseases and 43 children (23 girls, 20 boys) had spleen injuries. Splenectomy was performed for the following splenic diseases: sickle cell anemia (9 children), idiopathic thrombocytopenic purpura (4 children), hereditary spherocytosis (Minkowski- Chauff ard disease) (6 children), thalassemia (1 child), and autoimmune hemolytic anemia (1 child). Six children had splenic cysts: 3 children had posttraumatic cysts and 3 children had parasitic cysts. Twenty children underwent surgery for splenic injuries. The following surgical procedures were performed: laparoscopic abdominal cavity repair with spleen preservation followed by conservative therapy (13 children); laparoscopic splenectomy (2 children); laparotomy, splenic suture (2 children); and open splenectomy (3 children).Results. Conservative management of splenic injuries of varying degrees according to the American Association for the Surgery of Trauma (AAST) was performed in 23 (53.49 %) children. Resorption of hemoperitoneum in cases of conservative treatment of splenic injuries occurred 11-14 days after the start of treatment. Safe, full physical activity was resumed after 6 weeks of conservative treatment of splenic injury. Surgical procedures were performed in 20 (46.51 %) children using various techniques. 17 patients underwent laparoscopy. 2 children underwent laparoscopic splenectomy for grade IV AAST injury and hemodynamic instability. In 15 cases, treatment was started with conservative therapy, but during monitoring an increase in hemoperitoneum was observed, indicating the need for laparoscopy. Laparoscopy was performed in 13 children. A minimum of 100 ml and a maximum of 400 ml of blood was collected laparoscopically in the children. The abdominal cavity was examined and hemostasis was confi rmed. In cases where the spleen was «wrapped» with the omentum, the omentum was not separated from the spleen. The operation was completed by placing a drainage tube in the perisplenic space. In 2 children, grade IV AAST injuries were converted to an open procedure in which the spleen was sutured to stop bleeding and a drain was left near the splenic bed. Grade V AAST splenic injury in 3 children was an indication for left subcostal laparotomy and splenectomy. For splenic disease, laparoscopic splenectomy was performed in 12 (44.44 %) children, with high effi cacy in Minkowski- Chauff ard disease combined with gallstones (3 children) where simultaneous cholecystectomy was possible. Laparoscopic removal of splenic cysts was also justifi ed in 3 (11.11 %) children. However, removal of parasitic cysts required open splenectomy in 3 patients. Open splenectomy was performed in 9 children with splenic disease. In 5 children the inappropriateness of laparoscopy was due to severe perisplenitis, large spleen weight and young age of the children.Conclusions1. The morpho- functional structure of the spleen promotes spontaneous hemostasis, which is the basis for conservative treatment of spleen injuries in 53.49 % of children.2. The AAST classifi cation of splenic injuries from grade I to V, hemodynamic indicators and ultrasound monitoring of blood in the abdominal cavity can be used as a basis for choosing the method of treatment of closed blunt splenic injuries in children.3. Ineff ectiveness of conservative treatment, hemodynamic instability and increase of blood in the abdominal cavity in a child with splenic injury within 4 hours is an indication for laparoscopy.4. Splenic suturing and laparoscopic monitoring should be the preferred methods for treating closed splenic injuries in children to preserve the organ.5. The choice of surgical intervention for splenic diseases in children should be individualized and depend on the disease, the child’s age, the size of the spleen, and the presence of complications of the disease.

Abstract 4120469: Racial and ethnic disparities in catheter based interventions vs. open heart surgery in congenital heart disease

Introduction: Transcatheter cardiac interventions have emerged as a viable alternative to open heart surgery for specific congenital heart disease lesions. There is literature to support racial and ethnic disparities in medicine, indicating that patients from racially and ethnically marginalized populations are less likely to receive advanced less invasive procedures. This study seeks to delve into the existence of such inequities between transcatheter and surgical interventions, shedding light on potential inequalities in access and outcomes. Methods: We analyzed California and Florida's State Inpatient and Ambulatory Surgery Databases from 2005 to 2017 to study patients under 18 admitted with diagnosis of atrial septal defect, pulmonary stenosis, aortic stenosis, and ventricular septal defects. Multivariable logistic regression, adjusted for patient characteristics, assessed race and ethnicity's influence on procedure type and in-hospital mortality. We also used log-transformed linear regression to examine associations with length of stay, hospitalization cost, and cost per day. Results: We identified 13,771 records who had open surgeries, and 2,045 records who had CBI. Compared to non-Hispanic White patients, Black patients were significantly more likely to undergo open surgical procedures (adjusted Odds Ratio [aOR] 1.49, p &lt; .001). Additionally, Black, Hispanic, and other race patients had higher risks of in-hospital death (aOR 1.92, p = 0.016 for Black; aOR 1.93, p &lt; 0.01 for Hispanic; aOR 2.37, p &lt; 0.01 for other races). Black and Hispanic patients also experienced longer lengths of stay (Adjusted Means Ratio [aMR] 1.34, p &lt; 0.01 for Black; aMR 1.16, p &lt; 0.01 for Hispanic), and higher costs (aMR 1.12, p = .01 for Black; aMR 1.11, p = .01 for Hispanic), but Black patients had a lower cost per day (aMR 0.96, p = .02). Conclusion: Racial and ethnic gaps persist in pediatric cardiac care, with Black patients facing reduced access to less invasive procedures, higher mortality rates, longer hospital stays, and increased costs compared to non-Hispanic whites. However, the higher costs are likely attributed to longer hospital stays rather than expensive interventions. It is imperative to tackle these disparities to prioritize patient-centered care and streamline resource allocation in healthcare.

A Novel Preoperative Classification System for Selecting Suitable Surgeries in Liver Transplant Patients with Portal Vein Cavernous Transformation

Background To evaluate the new preoperative Changgung classification (CC) system of portal vein thrombosis (PVT) in choosing suitable operative procedures to reconstruct portal veins during liver transplantation (LT) in patients with portal vein cavernous transformation (PVCT). Methods This retrospective observational study analyzed data from allograft LTs performed for various liver diseases Results The study included 22 males and 4 females with LT indications comprising cirrhosis (n = 9), hepatocellular carcinoma (n = 12), PVCT (n = 2), liver failure from fulminant hepatitis B (n = 1), dysfunction of transplanted liver (n = 1), and chronic rejection of transplanted liver (n = 1). Patients were classified according to Yerdel (21 Yerdel II and 5 Yerdel III) and CC (C1–C5). In total 16 simple operations were performed on C1–C3 cases and 9 complex operations on C4–C5 cases, with one additional simple operation. The distribution according to the Yerdel classification was 16 simple and 5 complex operations in Yerdel II cases and 1 simple and 4 complex operations in Yerdel III cases. The median follow-up time was 27.5 months with overall one-year and three-year OS rates of 88.1% and 83.9% for the cohort. Specifically, the one-year OS rates for patients classified as C1-3 vs. C4-5 were 93.3% and 80.0%, while the three-year OS rates were 86.7% and 80.0%, respectively (p = 0.526). Conclusion The CC proposed in this study shows comparable potential to the Yerdel classification in preoperatively identifying the need for complex surgical techniques in LT patients with PVCT and may also have predictive power for the survival benefits following LT.

Evaluasi Tingkat Kematangan Sistem Informasi Rumah Sakit Menggunakan Information Technology Infrastructure Library Versi 3

Hospital Information System (HIS) is an important component in supporting effective and efficient health services. Evaluation of the maturity of information systems is needed to ensure that the implementation of SIRS is in accordance with the standards and needs of the organization. This study aims to evaluate the maturity level of information systems at Amanah Hospital using the Information Technology Infrastructure Library (ITIL) version 3 framework, specifically in the Service Operation domain. The research method uses a quantitative approach with data collection through questionnaires distributed to respondents involved in managing information systems. The evaluation was carried out on five subdomains, namely Event Management, Incident Management, Request Fulfillment, Problem Management, and Access Management. The results showed that the maturity level of the Amanah Hospital information system was at level 3.81 (Managed), with the highest value in the Incident Management and Access Management subdomains (4.00), while the lowest value in Event Management and Request Fulfillment (3.66). Based on these results, several improvements are recommended including the development of an integrated monitoring system, strengthening operational procedures, improving HR competencies, and implementing more structured periodic evaluations to achieve an optimal level of maturity.

Quality Assurance System when Studying the Pharmacological Safety of Etmaben

Quality assurance plays a key role in preclinical research, where every detail must be strictly controlled and verified. Standard operating procedures are essential part of any quality assurance system, defining precisely the steps and methods of implementing certain tasks or processes in a laboratory. In this article, the main components of a quality assurance system are discussed using the example of studying the pharmacological safety of a malonic acid derivative.

Optimal sampling strategy for probability estimation: An application to the Agricultural Quarantine Inspection Monitoring program.

Imported agricultural pests can cause substantial damage to agriculture, food security, and ecosystems. In the United States, the Agricultural Quarantine Inspection Monitoring (AQIM) program conducts random sampling to estimate the probabilities that cargo and passengers arriving at ports of entry carry pests. Assessing these risks accurately is critical to enable effective policies and operational procedures. This study introduces a pathway-level analysis with an objective function aligned with AQIM's goal, offering a new perspective compared to the current container-by-container approach, which relies on heuristics to set inspection rates. We formulate an optimization model that minimizes the mean squared error of the probability estimates that AQIM obtains. The central decision-making tradeoff that the model explores is whether it is preferable to sample more arriving containers (and fewer boxes per container) or more boxes per container (and fewer containers), given limited resources. We first derive an analytical solution for the optimal sampling strategy by leveraging several approximations. Then, we apply our model to a numerical case study of maritime cargo sampling at the Port of Long Beach. Across a wide range of parameter settings, the optimal strategy samples more containers (but fewer boxes per container) than the current AQIM protocol. The difference between the two strategies and the accuracy improvement with the optimal approach are larger if the pest statuses of boxes in the same container are more strongly correlated. We recommend that AQIM record box-level (beyond only container-level) inspection data, which could be used to estimate this correlation and other modelparameters.

Open donor nephrectomy via singular pararectal extraperitoneal mini-incision: single-center experience with 425 consecutive cases

BackgroundLaparoscopic techniques have been successfully implemented for living kidney donation. However, open surgical procedures also yield excellent perioperative outcomes. Endoscopic donor nephrectomy is associated with minimal trauma but is difficult for right-sided nephrectomies. Here, an open nephrectomy approach using a singular pararectal extraperitoneal mini-incision (SPEM) and the perioperative results are presented to elucidate whether open surgery is still justified in the modern era of endoscopic surgery.MethodsIn this single-center retrospective study, all living kidney donations performed at the Department of General, Visceral and Transplant Surgery of the Hannover Medical School from January 2007 to December 2017 were assessed. Donor characteristics, operation time, transfusion requirements, perioperative complications, and graft outcomes were analyzed.ResultsOut of a total of 1681 kidney transplantations, 425 living kidney donations (25.2%) were performed. Donors were primarily female (273; 64.2%) and had a median age and body-mass index of 53 (24–76) years and 25.3 (16.8–36.4) kg/m2, respectively. The left kidney was harvested in 50.1% (211) of cases. Median operative time was 95 (48–212) min. Intraoperative transfusion was not required in any of the donors. Intraoperative complications were observed in 2.6% of cases (11), with injury of the donor kidney (5; 1.2%) and acute hemorrhage (3; 0.7%) being the most common complications. Postoperative complications were hematomas (32; 7.7%), seromas (28; 6.7%), and wound infections (7; 1.7%). Except for a single surgical revision owing to colon perforation (1; 0.002%), no other major complications (Clavien–Dindo ≥ IIIa) were observed in any of the donors. The donor’s and recipient’s median estimated glomerular filtration rate at discharge was 55 (29–114) and 51 (14–129) ml/min/1.73 m2, respectively. Initial nonfunction occurred in seven cases (1.6%).ConclusionsUnlike the endoscopic technique, SPEM is equally suitable for right- and left-sided nephrectomy. SPEM nephrectomy is safe and results in minimal trauma. Despite performing SPEM nephrectomy in the era of endoscopic surgery, this technique provides excellent results with regard to donor and graft outcomes.