Perioperative Outcomes Research Articles

Minimally Invasive Surgery for the Management of Ovarian Cancer

OBJECTIVE: To examine perioperative and survival outcomes of patients with ovarian cancer managed by minimally invasive surgery compared with laparotomy in the context of 1) early-stage epithelial ovarian cancer, 2) primary cytoreduction for advanced disease, and 3) interval debulking after neoadjuvant chemotherapy. DATA SOURCES: A literature search was conducted PubMed, MEDLINE and ClinicalTrials.gov, Web of Science, Cochrane Library, and meeting abstract libraries (International Gynecological Cancer Society, Society of Gynecologic Oncology, American Society of Clinical Oncology) from 1994, the year of the first published laparoscopic clinical study in ovarian cancer, to May 2024. Studies that compared minimally invasive surgery with laparotomy for staging of ovarian cancer and reported perioperative or survival outcomes data were included. Single-arm studies, case studies, meeting abstracts, and studies involving borderline tumors, fertility-sparing surgery, or management of recurrent disease were excluded. METHODS OF STUDY SELECTION: Three authors independently screened citations for relevance and inclusion and exclusion criteria and assessed the risk of bias of individual studies using the methodologic index for nonrandomized studies criteria for nonrandomized studies. TABULTATION, INTEGRATION, AND RESULTS: From a total of 2,777 identified citations, 36 nonrandomized studies were included: 21 early-stage, five primary debulking for advanced stages, seven interval debulking after neoadjuvant chemotherapy, and three with heterogeneous populations. No randomized studies were identified. For early-stage cancer, nine studies found no difference in progression-free survival (risk ratio [RR] 1.05, 95% CI, 1.00–1.10, I 2=34.7%, P=.151), and 12 studies found no difference in overall survival (RR 1.00, 95% CI, 0.98–1.03, I 2=49.7%, P=.025). For primary debulking of advanced disease, rate of optimal debulking (five studies) (RR 1.11, 95% CI, 1.00–1.25, I 2=41.5%, P=.144) slightly favored minimally invasive techniques. For interval debulking, there was no difference in rates of optimal debulking (five studies) (RR 1.03, 95% CI, 0.96–1.11, I 2=54.6%, P<.051) between the two surgical modalities. CONCLUSION: The inclusion of observational studies in this analysis with a fair amount of bias warrants caution in the interpretation of the findings. However, minimally invasive surgery may offer some perioperative advantages over laparotomy and may be an acceptable alternative for selected patients. For early-stage disease, there was no difference in survival outcomes between minimally invasive surgery and laparotomy. For those with advanced disease, rates of optimal debulking were similar. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022359051.

First impressions of Telesurgery robotic-assisted radical prostatectomy using the Edge medical robotic platform.

We reported, as a referral center in prostate cancer, our perspectives and experience performing Telesurgery using robotic surgery and 5G network. We described and illustrated the Telesurgery applications and outcomes to treat a patient with prostate cancer located 1300 kilometers away from the surgeon (Beijing-Harbin) in China. We used the Edge Medical Robot (MP1000) in November 2023 in a 71-year-old patient with Gleason 6 (ISUP 1) in 8 cores from 13, PSA of 14 ng/dL, and clinical stage cT2a. MRI described a PIRADS 5 nodule on the left peripheral zone at the base, and 20gr prostate. We described details about the connection between centers, perioperative outcomes, and our perspectives as a referral center in prostate cancer. We had no delays, or problems with network connection between the centers. The procedure was performed in 60 minutes, with no intra- or postoperative complications. Estimated blood loss was 100 mL. The patient was ambulating soon after anesthesia recovery. Final pathology described a Gleason 6 (ISUP 1) involving the left base and left seminal vesicle, negative surgical margins, and no lymph node involvement (pT3bN0). The patient was continent soon after catheter removal (7 days). As technological progress introduced novel robotic platforms and high-speed networks, the concept of Telesurgery became a tangible reality while 5G technology solved latency and transmission concerns. However, with these advancements, ethical considerations and regulatory frameworks should underline the importance of transparency and patient safety with responsible innovation in the field.

Robot-assisted, laparoscopic and open radical cystectomy for bladder cancer: A systematic review and network meta-analysis.

To evaluate the safety and effectiveness of robot-assisted radical cystectomy (RARC), laparoscopic radical cystectomy (LRC), and open radical cystectomy (ORC) in bladder cancer. A literature search for network meta-analysis was conducted using international databases up to February 29, 2024. Outcomes of interest included baseline characteristics, perioperative outcomes and oncological outcomes. Forty articles were finally selected for inclusion in the network meta-analysis. Both LRC and RARC were associated with longer operative time, smaller amount of estimated blood loss, lower transfusion rate, shorter time to regular diet, fewer incidences of complications, and fewer positive surgical margin compared to ORC. LRC had a shorter time to flatus than ORC, while no difference between RARC and ORC was observed. Considering lymph node yield, there were no differences among LRC, RARC and ORC. In addition, there were statistically significant lower transfusion rates (OR=-0.15, 95% CI=-0.47 to 0.17), fewer overall complication rates (OR=-0.39, 95% CI=-0.79 to 0.00), fewer minor complication rates (OR=-0.23, 95% CI=-0.48 to 0.02), fewer major complication rates (OR=-0.23, 95% CI=-0.68 to 0.21), fewer positive surgical margin rates (OR=0.22, 95% CI=-0.27 to 0.68) in RARC group compared with LRC group. LRC and RARC could be considered as a feasible and safe alternative to ORC for bladder cancer. Notably, compared with LRC, RARC may benefit from significantly lower transfusion rates, fewer complications and lower positive surgical margin rates. These data thus showed that RARC might improve the management of patients with muscle invasive or high-risk non-muscle invasive bladder cancer.

Comparison of Transcatheter versus Surgical Tricuspid Repair among Patients with Tricuspid Regurgitation: Two-Year Results

Background: Evidence is limited as to whether outcomes differ between patients with tricuspid regurgitation (TR) treated with tricuspid transcatheter edge-to-edge repair (T-TEER) versus surgical tricuspid valve repair. We aimed to compare outcomes between these two approaches. Methods: We analyzed the data on Medicare fee-for-service beneficiaries aged 65 to 99 with TR who underwent T-TEER or isolated surgical repair between July 2016 and December 2020. The primary outcome was two-year all-cause mortality. Other outcomes included in-hospital mortality and permanent pacemaker implantation as well as two-year heart failure hospitalization and tricuspid valve reintervention. A propensity score matching weight analysis was used to adjust for potential confounders. Results: A total of 1,143 patients were included (409 T-TEER versus 734 surgery). The proportion of T-TEER cases increased from 2% in the third quarter of 2016 to 67% in the last quarter of 2020 among all isolated TR procedures. After adjustment for potential confounders, we found no evidence that two-year all-cause mortality differs between patients treated with T-TEER versus surgical repair (adjusted HR, 0.84; 95% CI, 0.63–1.13). Patients treated with T-TEER experienced lower in-hospital mortality (2.5% versus 12.5%, P<0.001) and permanent pacemaker implantation rates (0.0% versus 12.7%, P<0.001) than those treated by surgical repair. At two years, we found no differences in heart failure hospitalizations, but tricuspid valve reinterventions were more frequent in the T-TEER group (subdistribution HR, 8.03; 95% CI, 2.87–22.48). Conclusions: Among Medicare beneficiaries with TR, two-year mortality rate was comparable between T-TEER and surgical repair. T-TEER showed advantages in perioperative outcomes, including lower in-hospital mortality and pacemaker implantation rates, while tricuspid valve reinterventions were more frequent in the T-TEER group. Further studies are necessary to refine indications, patient selections, and optimal timing for intervention with either treatment strategy.

Anatomic versus non-anatomic resection for intrahepatic cholangiocarcinoma: a systematic review and meta-analysis

Background: The value of anatomic resection (AR) in intrahepatic cholangiocarcinoma (ICC) remains controversial. This study compares the perioperative safety and long-term outcomes of AR versus non-anatomic resection (NAR) in ICC patients. Methods: A systematic search was conducted in PubMed, Medline, Embase, Cochrane Library, China National Knowledge Infrastructure(CNKI) and Wanfang database for prospective or retrospective studies comparing the efficacy of AR and NAR in, ICC published to June 1, 2024. Meta-analyses were performed on surgical factors, perioperative outcomes and long-term prognosis for both the entire cohort and the propensity score-matched (PSM) cohort. The primary outcome measures were overall survival (OS) and disease-free survival (DFS). Results: Seven studies, including 1801 ICC patients, were analyzed. In both the entire and the PSM cohort , the AR group demonstrated superior OS (HR=0.71, 95% CI=0.57-0.88, P=0.002 and HR=0.70, 95% CI=0.59-0.83, P<0.0001, respectively) and DFS (HR=0.75, 95% CI=0.62-0.91, P=0.004 and HR=0.68, 95% CI=0.58-0.79, P<0.00001, respectively) compared to the NAR group. AR significantly improves 1-year, 3-year, 5-year DFS and 5-year OS(all P<0.05). In the PSM cohort, AR and NAR groups showed comparable blood loss, operative times, overall complications, and major complications (all P>0.05). Subgroup analysis revealed that among patients with tumor >5 cm, AR achieved better OS and DFS, whereas patients with tumors ≤5 cm did not experience survival benefits from AR. Conclusion: This study suggests that AR, compared to NAR, can improve OS and DFS without increasing perioperative risks, particularly in ICC patients with tumors larger than 5 cm.

Risk factors for urinary retention after robot-assisted radical cystectomy with orthotopic neobladder diversion: a multicenter study.

To determine risk factors for urinary retention (UR) after robot-assisted radical cystectomy (RALC) with orthotopic neobladder diversion. A total of 269 patients who underwent RALC with orthotopic neobladder diversion from 2008 to 2019 at seven tertiary hospitals were retrospectively analyzed. There were 68 patients who had UR (UR arm) and 201 patients who did not have UR (no-UR arm). UR was defined as voiding dysfunction without catheterization or more than 100mL of residual urine after voiding. Preoperative demographics, perioperative factors, pathology outcomes, and postoperative complications of UR and no-UR arms were compared and predictors of UR were identified. Among demographic factors, only gender proportion showed a difference, with male proportion being significantly lower in the UR arm than in the no-UR arm (81% vs 92%, p = 0.010). For perioperative outcomes, anastomosis site stricture (27% vs 11%, p = 0.003) and length of hospital stays (23days vs. 19days, p = 0.001) were significantly higher in the UR arm than in the no-UR arm. In multiple logistic regression analysis, female (OR 3.32, 95% CI: 1.43-7.72) and body mass index (BMI) (OR 1.10, 95% CI 1.00-1.20) were UR predictors. UR after RALC with orthotopic neobladder diversion is significantly increased in females. Multiple logistic regression analysis identified female and BMI elevation as UR predictors.

Comparison of the outcomes between ultrasonic devices and clamping in hepatectomy: a meta-analysis.

Recent advances in ultrasound technology have led to widespread adoption of ultrasonic energy devices in liver resections. While various studies have assessed the comparative advantages of ultrasonic devices and traditional clamp-crushing, their findings vary. Moreover, a specific systematic review on this topic has not yet been conducted. This study aims to present a comprehensive, up-to-date analysis comparing outcomes between ultrasonic devices and conventional clamp-crushing methods in liver resection, based on currently available literature. We conducted a systematic literature search in databases such as PubMed, Embase, Web of Science, and CNKI up to November 2023. Studies that compared the efficacy or safety of ultrasonic devices against traditional clamp-crushing methods in hepatectomy were included. The analysis covered intraoperative outcomes like operating time, blood loss, and transfusion rate, as well as postoperative outcomes such as complication rate, mortality, postoperative bleeding, and bile leakage. Review Manager version 5.3 (Cochrane Collaboration, Oxford, UK) and Stata 17.0 (Stata Corp, College Station, TX, USA) were used for data analysis. Thirteen studies, involving a total of 1,417 patients (630 using ultrasonic devices and 787 using clamp-crushing methods), were included. The clamp-crush method resulted in a shorter operation time. Contrarily, the ultrasonic device group experienced reduced blood loss and lower transfusion rates. Postoperatively, there was no significant difference in mortality or postoperative bleeding between the groups. However, the ultrasonic group had a lower overall complication rate, particularly a reduced incidence of bile leakage. Overall, the ultrasonic devices were associated with improved perioperative outcomes. The findings suggest that ultrasonic devices provide better outcomes in hepatectomy compared to traditional clamp-crushing techniques. Nonetheless, large-scale randomized controlled trials are needed to confirm these results due to potential heterogeneity and biases. The choice of using ultrasonic devices should consider the surgeon's experience and individual patient circumstances.

A Network Meta-Analysis of Vasodilator Therapies in Pulmonary Hypertension Patients Undergoing Mitral Valve Replacement Surgery: Insights for Optimizing Hemodynamics.

Pulmonary hypertension (PH) is a progressive hemodynamic condition associated with significant morbidity and mortality, especially in patients undergoing cardiac surgery. Therefore, the objective of this network meta-analysis (NMA) is to compare the efficacy of various pulmonary vasodilators in perioperative control of PH among patients undergoing mitral valve replacement surgery (MVRS), aiming to address the existing knowledge gap and improve perioperative outcomes. Electronic databases including PubMed, Cochrane Central Registry of Controlled Trials, Scopus, Embase, and Web of Science (WOS) from inception to 17 September 2024. Only randomized controlled trials (RCTs) evaluating vasodilators in PH patients undergoing MVRS were included. We used netmeta package in RStudio to analyze the outcome data with their corresponding mean difference (MD) and confidence intervals (CI). Seventeen RCTs including 862 patients were analyzed. Prostacyclin, nitric oxide (NO), and sodium nitroprusside (SN) significantly reduced mean pulmonary arterial pressure with effect sizes [MD, 95% confidence interval (CI)] of (11.77, -18.78; -4.76; -8.3, -15.9; -0.6; -11.02, -20.1; -3.8, respectively). While no treatment showed significant efficacy on pulmonary capillary wedge pressure, systolic pulmonary arterial pressure, or heart rate, nitroglycerin, NO, and prostacyclin, showed significant increases in cardiac index with effect sizes (MD, 95% CI) of (1, 0.3; 1.7; 1.2 0.8; 1.6; 1.2 0.8; 1.6, respectively). Additionally, NO, prostacyclin, SN, and nitroglycerin demonstrated significant reductions in systemic vascular resistance (SVR), with effect sizes of. (-0.54, -0.82; -0.26, -0.37, -0.65; -0.09; -0.47, -0.77; -0.16; -0.14, -0.24; -0.03, respectively). This NMA highlights prostacyclin, nitroglycerin, NO, and SN as consistently effective in improving hemodynamics for patients with PH undergoing MVRS, and provides valuable insights for surgeons to choose the suitable vasodilator for these surgeries. However, limitations and the need for further RCTs are acknowledged.

Impact of glucagon-Like peptide-1 agonists in optimizing abdominal wall Reconstruction patients.

Pre-optimization of obese patients prior to abdominal wall reconstruction (AWR) is essential in mitigating their increased preoperative risks. Traditionally diet, exercising, bariatric surgery are the tools typically prescribed for weight loss. The advent of glucagon-like peptide-1 agonists (GLP-1A) which stimulate insulin secretion and inhibit gastric emptying have improved the weight loss armamentarium. However, there is a limited amount of literature on GLP-1A effectiveness and postoperative outcomes in AWR patients. This study compares the efficacy of GLP-1A to Bariatric Surgery (BAS) in perioperative AWR patient. A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2021 and March 2024. We included patients who required GLP-1A or BAS for weight optimization prior to AWR. We excluded patients on GLP1-A or history BAS not performed for AWR preoptimization. Basic demographics such as age, sex, race, weight and BMI at initial clinic visit and at surgery were compared. Primary endpoints included time to surgery, time to bowel recovery and length of stay (LOS). Time to surgery was defined as the number of months between the initial clinic visit and AWR. Time to bowel recovery was defined as the number of days it took for the first postoperative bowel function. Secondary endpoints included standard 30-days postoperative variables. Nominal variables were analyzed using a Fisher exact test and continuous variables were analyzed with Student's T test. 35 patients were included in this study (GLP-1A: 17, BAS: 18). The GLP-1A cohort had a lesser BMI at the initial clinic visit (40.8 vs 43.4, p = 0.188). GLP-1A cohort made it to the operating room faster (9.1 months vs 13.5 months, p = 0.06) from the first clinic visit; and (7.9 months vs 9.7 months, p = 0.4) from initiation of weight loss intervention. Albeit losing less weight (14.9 kg vs 27.1 kg, p = 0.008) with a lesser reduction in the BMI (4.69 vs 9.23, p = 0.004). The GLP-1A cohort showed a non-significant elevated LOS (5.2 days vs 3.6 days, p = 0.25) and an increased ileus rate (17.6% vs 0%, p = 0.1). However, there were no differences noted in time to bowel recovery (2.9 days vs 3.1 days, p = 0.76). GLP-1A is effective in optimizing patients needing weight loss before AWR. They shorten the timeline to AWR intervention and have comparable peri-operative outcomes to BAS patients.

Comparison of outcomes between single-port and multi-port robotic radical nephrectomy.

Single-port (SP) robotic surgery is a novel technology, and although there is emerging data, it remains limited in assessing single-port (SP) robot-assisted surgery as an alternative to multi-port (MP) platforms. To compare perioperative and postoperative outcomes between SP and MP robotic technologies for radical nephrectomy (RN). This is a retrospective cohort study of patients who have undergone robot-assisted radical nephrectomy using either the SP or MP technology. Baseline demographics, clinical, tumor-specific characteristics, and perioperative and postoperative outcomes were compared using χ2, t-test, Fisher exact test, and Mann-Whitney U test. Multivariable analyses were conducted using robust, Poisson, and logistic regressions. A total of 341 patients underwent robotic RN with 47 patients (14%) in the SP group. The two groups exhibited similar baseline characteristics, with no significant differences in age, sex, body mass index, Charlson comorbidities index, and tumor laterality. However, SP group had a smaller average tumor size (5.1cm vs 6.4cm, p = 0.009). The SP had longer operative time (178 ± 84min vs 142 ± 75min; p = 0.011) but showed no significant difference in the estimated blood loss, blood transfusion rate, length of stay, overall 30-day and major complication rates. Controlling for other variables, SP was significantly associated with a longer operative time and shorter length of stay. SP is associated with longer operative time but offers advantages such as smaller incisions and shorter hospital stays with a comparative safety profile to MP for radical nephrectomy.

Endoscopic-assisted, minimally invasive versus sternotomy total arterial multivessel bypass grafting.

This single center study compared the perioperative outcomes after total arterial multivessel revascularization through endoscopic-assisted, minimally invasive surgery compared to a conventional sternotomy approach. In this retrospective, propensity score matched (PSM) cohort study, a total of 740 patients were analyzed (Endo-CAB, N = 92; Sternotomy N = 648). After PSM (1:2 ratio), 73 Endo-CAB and 137 sternotomy patients were compared with an equal number of distal anastomoses (Endo-CAB 2.3 vs Sternotomy 2.4 anastomoses per patient, p = 0.082). We used "textbook outcome" as a patient-orientated outcome measure, defined as the absence of 30-day mortality, re-exploration for bleeding, postoperative ischaemia, cardiac tamponade, cerebrovascular events, wound infection, new onset arrhythmias, pneumonia, placement of chest drains and prolonged hospital stay (>7 days). Patients undergoing Endo-CAB had significantly more often a textbook outcome compared to the sternotomy group (78.1% vs 59.1%, p = 0.009). Endo-CAB patients had shorter hospital stay (4.0 vs 6.0 days, p < 0.001), less postoperative blood loss (360 vs 490 ml, p < 0.001) and a significant reduction of new onset postoperative atrial fibrillation (5.5% vs 17.5%, p = 0.015). Other postoperative outcomes were comparable for both groups. Total arterial Endo-CAB demonstrates excellent postoperative outcomes compared to a sternotomy approach for multivessel coronary artery disease. These findings provide a strong basis for further expanding the multivessel Endo-CAB program.

A comparative study on outcomes of ABO-incompatible kidney transplants between robot-assisted vs. open surgery-propensity score-matched analysis: a retrospective cohort study.

Robot-assisted kidney transplantation (RAKT) is increasingly being adopted worldwide. Despite this growing interest, there remains a notable gap in the literature, especially concerning its effectiveness in immunologically high-risk patients compared to conventional open kidney transplantation (OKT). This study investigates the viability and success of RAKT in comparison with OKT, particularly for recipients with ABO incompatibility (ABOi). This retrospective, single-center study included 239 living-donor transplants between October 2020 and February 2023, with 210 patients undergoing ABOi-OKT and 29 undergoing ABOi-RAKT. A composite of biopsy-proven acute rejection (BPAR), graft failure, and the development of de novo donor-specific antibodies was analyzed through univariate and multivariate models. Propensity score matching (PSM) was utilized to ensure a balanced comparison between the two groups. Following PSM, a total of 131 cases in the OKT group and 26 cases in the RAKT group were analyzed. After PSM, the mean recipient age was 48.56 years for OKT and 47.96 years for RAKT. Both groups had comparable one-year (RAKT: 92.4%, OKT: 93.1%) and two-year BPAR-free survival rates (RAKT: 92.4%, OKT: 91.9%). Mean estimated glomerular filtration rate values were similar at 12 months post-transplant (RAKT: 62.15ml/min/1.73m², OKT: 64.53ml/min/1.73m²). Operative times were significantly longer for RAKT (291.42 vs. 150.81min, p < 0.001), while cold ischemic time was also longer for RAKT (119.77 vs. 47.22min, p < 0.001). Hospital stays were shorter for RAKT (median 6 vs. 8 days, p < 0.001). There was no significant difference in the composite outcome of BPAR, graft failure, and de novo donor-specific antibodies between the two groups (HR 0.858, 95% CI: 0.180-4.096, p = 0.848). RAKT is a safe and effective alternative to OKT in ABOi patients, demonstrating similar perioperative outcomes, graft survival rates, and renal function. The application of ropensity score matching analysis strengthens the reliability of these findings, confirming RAKT's viability for high-risk kidney transplant recipients. The clinical trial associated with this study was registered on 2024-02-24 with the Clinical Trial Number NCT06287008|| https://www. gov/ ).

Short-term Outcomes of a Dedicated Pelvic Exenteration Unit in a Tertiary Hospital in Malaysia

Background : Pelvic exenteration offers potentially curative resection for locally advanced pelvic malignancy. A dedicated unit performing this complex surgery is recommended to achieve optimal outcomes. Objectives : The aim of this paper is to show that pelvic exenterations can be performed with acceptable oncological and safe perioperative results in an appropriately resourced specialist centre. Methods : Patients undergoing pelvic exenteration in the Colorectal Unit, Hospital Kuala Lumpur between January 2017 and January 2024 were included. Patients operated in the initial setup period of the unit (January 2017 – July 2020) were compared to the second half (August 2020 – January 2024) with univariate analysis. Results : A total of 30 patients were included, with a significant increase in the unit caseload over the study period (n = 11 versus n = 19). There was an increased use of neoadjuvant therapy and an increase in stage of disease at presentation (p = 0.014) in the second half of the study period. More complex procedures were performed in the latter period, involving both bony and pelvic side wall resections. There was no difference in complication severity (Clavien Dindo) (p = 0.257) and R0 resection was achieved in 76.7% of operated cases. Conclusion : The development of a dedicated pelvic exenteration unit, leads to an increase in patient volume and an increase in the complexity of the procedures performed, without compromising short term outcomes and safety.

Endovascular abdominal aortic aneurysm repair (EVAR) outcomes of unibody and single/double docking limb endografts in Medicare beneficiaries between 2012 and 2018.

The evaluation of perioperative and long term outcomes for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) using anatomic (unibody) and proximal neck fixated (docking limbs) endografts across consecutive time cohorts. This study compares the outcomes of EVAR in Medicare patients stratified by mode of fixation. All patients who underwent EVAR between 2012 and 2018 were identified in the Medicare database. Anatomic fixation (AF) and proximal fixation (PF) grafts were differentiated using Current Procedural Terminology (CPT) codes. The AF population was divided into three-time cohorts based on iterative changes in graft design: Cohort 1: (01/01/2012-20/07/2014); Cohort 2: (21/07/2014-09/05/2016); and Cohort 3: (10/05/2016-31/12/2017). The PF cohort was similarly divided into these three periods. Outcomes were evaluated through 31/12/2020 and included all-cause mortality, aortic rupture, and aortic-related reintervention. 32,031 patients underwent EVAR during the study period; 4729 were AF and 27,302 were PF. There were more women (p < .001) and patients with peripheral vascular disease (PVD) (p < .001) in the AF group. There were no group differences in perioperative outcomes. In Cohort 1, there was a higher rate of reintervention (11.9% vs 7.6%; p < .001) and aortic rupture (5.3% vs 4.0%; p = .019) in the AF group compared to the PF group. In Cohort 2, reintervention, aortic rupture, and reintervention rates were similar between the two groups (p = NS). In Cohort 3, the reintervention and aortic rupture rates were similar between the two groups (p = NS). The higher rates of aortic rupture and reintervention seen in the AF group in Cohort 1 when compared with the PF group did not persist in Cohorts 2 and 3. This suggests that improvements in graft design may have led to durability which is similar to that of PF grafts. However, late aneurysm related complications are inherent risks after EVAR and long-term surveillance remains necessary.

OGC O02 - Measurement of functional, psychosocial, and quality of life impacts of Robotic versus Hybrid Oesophago-gastrectomy

Abstract Background Since the introduction of Robotic-Assisted Minimally-Invasive Oesophago-gastrectomy (RAMIO), comparisons to other surgical approaches have focussed primarily on peri-operative and oncological outcomes. Few studies have focused on quality-of-life measures once the patient has been discharged home. We sought to compare physical, psychosocial, sleep, pain and employment related measures at six weeks following discharge in patients undergoing RAMIO versus Hybrid Oesophago-gastrectomy. Method We performed a prospective cohort study comparing RAMIO and Hybrid Oesophago-gastrectomy. Twenty-five consecutive patients on a curative surgical pathway were recruited to each group. Participants were contacted via telephone pre-operatively and six weeks post-operatively. Parameters studied were: physical activity, social activity, sleep, pain control, and employment. Psychological wellbeing was measured using the Hospital Anxiety and Depression Scale, and quality of life with the European Organisation for Research and Treatment of Cancer questionnaires C30 (all cancer patients) and OG25 (patients undergoing oesophago-gastric cancer treatment). Results were analysed using Chi Square and Mann-Whitney-U statistical tests. Results There were no differences in age, ASA, or anaerobic threshold between study groups. At six weeks the RAMIO group was more likely than Hybrid to have returned to pre-operative physical and social activity (physical 7/25 vs. 1/25, p=0.04, social 13/25 vs. 5/25, p=0.03). The RAMIO group stopped regular analgesia earlier, and required fewer opiates. Patients were more likely to return to work in the RAMIO group (7/15 vs. 1/12,p=0.04). The RAMIO group had fewer cases of depression (2 vs. 9, p=0.03), lower QLQ C30 and OG25 scores, and reported higher overall health and quality of life scores (p=0.001). Conclusion We have demonstrated an improvement in physical and social activity, a faster return to work, a reduction in analgesia requirements, lower rates of depression and improved health and quality of life, six weeks post-operatively when comparing RAMIO to hybrid oesophago-gastrectomy. This study has highlighted additional considerations for the selection of surgical modality in oesophago-gastrectomy beyond peri-operative outcomes. Further investigation across a larger sample size and longer time frame to quantify the full spectrum of potential benefits of robotic oesophago-gastric surgery is warranted.

OGC SO46 - Improving outcomes after oesophagectomy: The benefits of full robotic-assisted minimally invasive oesophagectomy (RAMIO) demonstrated in the first 100 cases, at a high-volume UK unit

Abstract Background There is a rapid movement towards adoption of robotically assisted minimally invasive oesophagectomy (RAMIO) in the United Kingdom. Transition from an open or laparoscopic oesophagectomy to a RAMIO programme, which carries considerable financial and training cost, must ensure parity of oncological and perioperative outcomes. We sought to compare our centre’s results of the three standard approaches to two-phase oesophagectomy: Open/Open (Open); laparoscopic/robotic abdomen with open chest (Hybrid); and RAMIO. Method This prospective cohort study investigated the experience of five surgeons in a single high-volume UK institution. We analysed consecutive patients undergoing two-phase transthoracic oesophagectomy for oncological reasons between 2018 and 2024. The study period was divided into three cohorts: Open (2018-2020, n=61), Hybrid (2020-2023, n=82) and RAMIO (2023-2024, n=100). Patient demographics, tumour characteristics, perioperative outcomes, and oncological data were compared. Data were analysed using Kruskal-Wallis and Chi-squared statistical tests. Results No significant differences were observed in patient demographics or tumour stage between the groups. Comparison of Open vs. Hybrid vs. RAMIO demonstrated a significant reduction in major complications (Clavien-Dindo ≥III), 34.4% vs. 23.2% vs. 14% (p=0.0014); pulmonary complications, 36.1% vs. 25.4% vs. 13% (p=0.0004); anastomotic leak rate, 11.5% vs. 2.4% vs. 4.0%, (p=0.0370); median length of stay, 14 vs. 12 vs. 8 days (p=0.0001); and mortality, 4.9% vs. 1.2% vs. 0% (p=0.0133) all favouring the RAMIO group in sub-group analysis. Median lymph node yields were comparable across groups, 49 vs. 43 vs. 43 (p=0.0876). Conclusion This single-institution study demonstrates potential benefits of transitioning from open or hybrid to RAMIO for oesophagectomy. RAMIO was associated with significantly reduced pulmonary complications, major complications and a shorter length of hospital stay. Oncological outcomes were maintained across all 3 techniques. These findings have important patient, financial, and resource implications, and support the continued adoption of RAMIO in the UK.

Intraoperative Goal-Directed Fluid Therapy and Outcomes After Oncologic Surgeries: A Systematic Review and Meta-Analysis

BACKGROUND: Surgery is the first-line curative treatment for most solid-organ malignancies. During major surgeries, fluid under- or over administration can have a significant impact on recovery and postoperative outcomes. For patients undergoing oncologic surgery, delayed recovery or complications could additionally impact subsequent oncologic treatment planning. This systematic review and meta-analysis aims to evaluate the impact of goal-directed fluid therapy (GDFT) on perioperative outcomes after oncologic surgeries. METHODS: We systematically searched PubMed, EMBASE, CINAHL, and Web of Science citation index for clinical trials comparing the GDFT to routine clinical care. The primary outcomes of interest are the hospital length of stay and the total incidence of postoperative complications. Secondary outcomes include organ-specific complications and recovery of bowel function. RESULTS: The literature search was last updated on February 17, 2024. We identified a total of 24 randomized controlled trials (RCTs) comparing GDFT to routine care with 1172 and 1186 patients, respectively. The GDFT arm had a significantly shorter length of hospital stay (mean difference [MD], 1.57 days, 95% confidence interval [CI], −2.29 to −0.85, P &lt; .01), as well as lower incidence of complications (risk ratio, 0.74, 95% CI, 0.56–0.97, P = .03). The GDFT arm also had a shorter time to bowel function recovery (MD, 0.58 days, 95% CI, −1.02 to −0.14, P = .01). None of the included trials reported the longer-term oncologic outcomes. The overall certainty of evidence is low due to between-study variance and study risk of bias. Trial sequence analysis indicates that further studies are unlikely to alter the conclusion regarding postoperative length of stay but may provide further information on the postoperative complications. CONCLUSIONS: Our systematic review and meta-analysis suggests that in oncologic surgery, intraoperative GDFT significantly reduces the length of hospital stay, lowers the risk of complications, and facilitates bowel function recovery. Further studies are required to evaluate whether the improvement in early postoperative outcomes leads to better long-term oncologic outcomes.

MS O06 - HPB The ORDEAL Study: A National Survey of Surgeon Operative Preferences for Resection of Duodenal Adenocarcinoma

Abstract Background Duodenal adenocarcinoma (DA) accounts for over 50% of all small bowel adenocarcinomas, however there is a paucity of data on outcomes, no UK guidelines for surgical management, and current national standards of practice are unknown. There is ongoing debate whether long-term survival, perioperative outcomes, resection margin, and lymph node yield differ between pylorus-preserving pancreaticoduodenectomy (PPPD) and classical PD (cPD) in proximal DA (D1/D2), and between PD and limited resection (LR) in distal DA (D3/D4). The study aimed to discern current standards of practice and identify underlying reasons for operative preferences for proximal and distal DA. Method An anonymised survey was included as part of the registration form for a wider multicentre retrospective study looking at outcomes following resection for proximal and distal DA on Google Forms®. The survey was distributed via direct surgeon email correspondence, weekly newsletters and surgical society endorsement by PSGBI. Responses were collected between February-June 2024 and responses were analysed with quantitative and qualitative (inductive thematic analysis) methods. Results Responses were received from 61 surgeons across 27 centres. For proximal DA, surgeons are more likely to consider a classical Whipple’s (93.4%) compared to PPPD (29.5%). For distal DA, surgeons are equally likely to consider LR (73.8%) as PD (classical Whipple’s -37.7%, PPPD - 41%). These preferences have mostly remained consistent over time. Key themes identified from thematic analysis included oncological considerations, morbidity, surgeon preference, tumour characteristics, standards of practice, patient factors and anatomical considerations, with the former two themes being the most prominent. Conclusion For proximal DA, cPD is preferred over PPPD and for distal DA, LR and PD are equally considered, with oncological and morbidity considerations largely influencing decision making. This qualitative data will be compared to actual practice following completion of the wider ORDEAL study to identify discrepancies in practice and possible effect on patient outcomes.

MS O05 - HPB The ORDEAL Study: A Multi-Centre Retrospective Cohort Study Assessing the Optimal Resection for Proximal and Distal Duodenal Adenocarcinoma

Abstract Background Duodenal adenocarcinoma (DA) accounts for over 50% of all small bowel adenocarcinomas, however there is a paucity of cases and outcome data, no UK guidelines for surgical management, and a lack of contemporaneous UK patient data. There is debate as to whether oncological and perioperative outcomes differ between pylorus-preserving pancreaticoduodenectomy (PPPD) and classical PD (cPD) in proximal DA (D1/D2), and between PD (cPD or PPPD) and limited resection (LR) in distal DA (D3/D4). This study aimed to determine the optimal type of resection for proximal and distal DA through investigating differences in long-term survival and perioperative outcomes. Method A national retrospective audit of consecutive patients from 2008-2023 undergoing curative resection for DA was conducted, with data collected anonymously via REDCap. Baseline demographics, radiological, operative, pathological and short and long-term outcomes were collated. Analysis was performed using SPSS with standard descriptive statistical methods. Chi-Square, Mann-Whitney and ANOVA were used as appropriate to compare variables and outcomes between two groups, with statistical significance set at p&amp;lt;0.05. Survival analysis (overall survival (OS) and disease-free survival (DFS)) was performed using the Kaplan–Meier method and the log-rank test to compare differences between survival curves. Time-to-event analysis was calculated with Cox regression. Results The study cohort (median age 68 years, 54.4% males) had a mean follow-up of 35.6 months. For proximal DA, 56 underwent PPPD and 87 underwent cPD; for distal DA, 26 underwent PD and 37 underwent LR. For proximal DA, survival and lymph node clearance were similar, with severe complications and no adjuvant chemotherapy independently decreasing survival. For distal DA, survival was similar despite greater lymph node clearance with PD, with age and no adjuvant chemotherapy independently decreasing survival. Complications including pancreatic fistula, delayed gastric emptying, and post-pancreatectomy haemorrhage, were comparable for proximal DA but greater with PD in distal DA. Conclusion Preliminary findings suggest adequate lymphadenectomy and comparable long-term survival for cPD and PPPD in proximal DA. For distal DA, LR is associated with similar long-term survival but lower morbidity despite greater lymph node clearance with PD. Additional records will validate these findings further.

Perioperative outcomes and hospitalization costs of radical vs. conservative surgery for hepatic cystic echinococcosis: A retrospective study.

Surgical intervention is a crucial treatment for hepatic cystic echinococcosis. However, the choice between radical and conservative surgery remains controversial. This study aimed to compare the perioperative outcomes and hospitalization costs between radical and conservative surgery for hepatic cystic echinococcosis. A retrospective cohort study was conducted on patients undergoing surgical treatment at the First People's Hospital of Kashi Prefecture from July 1, 2012, to October 1, 2023. Propensity score-matching analysis was utilized to mitigate patient selection bias between the two surgical groups. Of the 434 patients included, 324 underwent conservative surgery and 110 underwent radical surgery. After propensity score-matching, 182 conservative surgery and 102 radical surgery patients were compared. Radical surgery patients experienced longer operative time, higher intraoperative blood loss, increased blood transfusion, and higher costs compared to conservative surgery patients. However, no differences were observed in short-term outcomes, including overall morbidity, death, bile leak, effusion, pulmonary infection, incision infection, intestinal obstruction, ICU stay, abdominal drainage time, and postoperative hospital stays. This study suggests that radical surgery is associated with greater surgical complexity and higher hospitalization costs, while it doesn't offer a significant short-term advantage. Conservative surgery may be a viable option in resource-limited settings or for patients unsuitable for complex procedures. Further research with long-term follow-up is needed to determine the optimal approach.