Postoperative Day Research Articles

322. IMPACT OF POSTOPERATIVE NUTRITIONAL SUPPORT MODES ON CLINICAL AND PATIENT-REPORTED OUTCOMES IN ENHANCED RECOVERY AFTER ESOPHAGECTOMY FOR CANCER

Abstract Background Enhanced Recovery After Surgery (ERAS) for esophagectomy has been demonstrated to be safe and effective. However, there is significant variation in the nutritional support treatment modes during the perioperative period. We have recently developed a novel ERAS nutritional support mode. In this study, we compared this new mode with the previous ERAS nutritional support treatment mode to assess their impact on clinical and Patient-Reported Outcomes (PROs), aiming to develop an optimal approach. Methods We enrolled 357 patients who underwent esophagectomy for esophageal thoracic cancer or esophagogastric junction cancer from June 2021 to August 2023. Two different ERAS nutritional support treatment protocols were used postoperatively: the control group previously received enteral nutrition by nasojejunal tube + parenteral nutrition + early oral diet after surgery, while the study group currently received parenteral nutrition + early oral diet. We compared the two groups in terms of clinical observation indicators, hematological analysis, serum protein changes and clinical outcomes. The comparison of quality of life on PROs was assessed using the MD Anderson Symptom Inventory. Symptom changes were analyzed using a mixed-effects model. Results A total of 324 patients successfully completed the ERAS nutritional support protocols. The success rates were 91% in the control group and 90.2% in the study group, with no statistically significant difference (p>0.05). The incidence of complications did not significantly differ between the two groups (p>0.05). Compared to the control group (n=223), the study group (n=101) significantly shortened the chest drain time (6.2±2.6 days vs. 6.6±1.5 days, p<0.05) and elevated the levels of serum total protein and albumin on the 4th postoperative day (53±5 g/L vs. 51±4 g/L, 30±2 g/L vs. 28±2 g/L, p<0.05). There were no statistically significant differences in the first flatus time, first defecation time, infusion time and postoperative hospital stay between the two groups (p>0.05). The comparison of hematological analysis, serum protein changes, changes in body weight during the perioperative period and 30-day readmission rate showed no statistically significant differences (p>0.05). In the MD Anderson Symptom Inventory, the study group had significantly better scores in sadness, dry mouth, enjoyment of life, and general activity dimensions compared to the control group (p=0.013, p<0.001, p=0.045, p=0.008). Conclusion Based on the similar rehabilitation outcomes, the simplified ERAS nutritional support treatment mode without postoperative enteral nutrition by nasojejunal tube is more optimized because it is physiological sound and significantly improves quality of life on PROs.

759. P02.04 PARAVERTEBRAL VERSUS EPIDURAL ANALGESIA IN MINIMALLY INVASIVE ESOPHAGEAL RESECTION (PEPMEN): A RANDOMIZED CONTROLLED MULTICENTER TRIAL

Abstract Background Thoracic epidural analgesia has been the mainstay for pain control in esophageal cancer patients undergoing minimally invasive esophagectomy (MIE). Although effective epidural analgesia potentially contributes to achieving enhanced recovery after surgery (ERAS) goals in patients undergoing MIE, it can have counterproductive side effects such as hypotension, urinary retention and reduced mobility. Paravertebral analgesia may be a promising alternative to epidural analgesia, avoiding potential side effects and improving postoperative recovery. Methods This open randomized controlled superiority trial was conducted across four Dutch centers. A total of 192 patients with esophageal cancer, scheduled for elective transthoracic MIE with intrathoracic anastomosis, were included and randomized to receive either epidural analgesia or paravertebral analgesia. The primary outcome was Quality of Recovery (QoR-40) on the third postoperative day (POD). Secondary outcomes included the quality of life, postoperative pain, opioid consumption, need for inotropic/vasopressor medication, duration of admission, mobilization, complications, readmission, and mortality. Results From December 2019 to February 2023, 94 patients were assigned to epidural and 98 to paravertebral analgesia. QoR-40 score on POD3 did not differ between groups (mean difference 3.7; P=.268). The epidural group had higher QoR-40 scores on POD1 and 2 (mean difference 7.7; P=.018, mean difference 7.3; P=.020) and lower pain scores (1 versus 2; P=<.001, 1 versus 2; P=.033). More patients in the epidural group required vasopressor-medication on POD1 (38.3% versus 13.3%; P<.001). In the paravertebral group, the urinary catheter was removed one day earlier (P=<.001). No significant differences in complications or length of stay were observed. Conclusion This multicenter randomized controlled clinical trial did not show superiority of paravertebral analgesia over epidural analgesia in quality of recovery on the third day after minimally invasive esophagectomy. These results, however, support the safety of paravertebral analgesia as a viable alternative to epidural analgesia, enabling the provision of both techniques to patients in clinical practice.

Effect of Preoperative Carbohydrate Loading on Postoperative Recovery of Individuals Who Have Type 2 Diabetes After Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundMany individuals undergoing surgery involving general anesthesia are asked to fast for a prolonged period to ensure perioperative safety, yet this can initiate stress reactions and insulin resistance, harming postoperative recovery. Such fasting may be particularly problematic for those who have type 2 diabetes. Here we assessed how giving such individuals oral carbohydrates before total knee arthroplasty can affect outcomes. MethodsWe randomized 90 patients who had non-insulin dependent type 2 diabetes mellitus who were scheduled for elective total knee arthroplasty at one medical center between April 2022 and January 2023 to receive oral carbohydrates at 2 or 4 hours before surgery or to receive a carbohydrate-free "placebo" drink at 4 hours before surgery. The three groups were compared in terms of postoperative blood glucose, insulin resistance, β cell activity, postoperative wound complications, and other clinical outcomes. ResultsThe group who received oral carbohydrates at 2 or 4 hours before surgery showed significantly lower insulin resistance than the placebo group (group at 2 hours, 9.0 ± 3.4; group at 4 hours, 15.8 ± 6.9 versus placebo, 30.9 ± 10.5, P < 0.001) and lower β cell activity (207.7 ± 106.7%; group at 4 hours, 243.2 ± 114.9% versus 421.5 ± 209.3%, P < 0.001). Those groups were also significantly less likely than the placebo group to experience preoperative hunger or postoperative hyperglycemia. Among patients who received oral carbohydrates, those who received them 2 hours before surgery showed significantly lower insulin resistance and better glycemic control on postoperative day 1 than those who received carbohydrates 4 hours before surgery. None of the subjects developed intraoperative aspiration or experienced severe postoperative complications. ConclusionOral carbohydrates at 2 to 4 hours before total knee arthroplasty are safe and can significantly alleviate preoperative hunger while mitigating postoperative insulin resistance and improving glycemic control in patients who have non-insulin-dependent type 2 diabetes mellitus.

783. ROBOTIC ASSISTED CISTERNA CHYLI EMBOLIZATION FOR ABDOMINAL CHYLE LEAKAGE AFTER IVOR LEWIS ESOPHAGECTOMY

Abstract Background High output chyle leakage is a challenging complication following esophagectomy, carrying substantial morbidity and even mortality. Initial conservative management with parenteral feeding is commonly advised resulting in lengthy episodes of hospitalization and prolonged chest tube placement. Here, we present a case post Ivor-Lewis esophagectomy with high-output chyle leakage where we localized the leakage site to be at the cysterna chyli and subsequently treated it operatively combining robotics, fluorescence and embolization with glue. Methods A 74-year-old male underwent robotic-assisted minimally invasive Ivor Lewis esophagectomy for distal esophageal adenocarcinoma. Postoperatively, chylous fluid was drained from the chest up to 700-1300cc per day despite parenteral feeding. Lipiodol lymphangiography identified extravasation of contrast at the cysterna chyli and correct clipping of the thoracic duct. Due to failure of conservative management, on postoperative day 14, robotic-assisted exploration of the truncal region with intranodal injection of indocyanine green was performed. Results This innovative procedure revealed the leakage site medially of the coeliac trunc at the cysterna chyli. Lymphatic sealing was achieved via percutaneous endoluminal embolization using a microcatheter and Histoacryl® injections, resulting in an abrupt resolution of the leak and discharge with oral MCT diet on day 5 after reoperation. Conclusion This case demonstrated the feasibility and efficacy of an innovative multimodal technique combining the dexterity and fluorescence of robotic surgery with a laparoscopic application of an interventional radiology embolization technique. Because of the risk of venous emboli, we note that this technique should only be applied in cases of abdominal chyle leakage when the thoracic duct is interrupted. https://www.dropbox.com/scl/fi/sktltdc1be41jfq4dk3lt/Video-Presentation-ISDE-2024-Robotic-Embolisation-Abdominal-Chyle-leakage-Def.mp4?rlkey=1wni1dpnjg4swiajcjdfa6isn&amp;st=wx30jbi7&amp;dl=0

812. INTRAOPERATIVE USE OF IMPEDANCE PLANIMETRY FOR RECURRENT ACHALASIA AFTER HELLER-NISSEN

Abstract Background Re-operations after Heller myotomy for esophageal achalasia is a challenging operation due to the fibrotic tissue surrounding the esophago-gastric junction (EGJ). The risk of both undertreatment or, on the other hand, esophageal perforation is significant. The impedance planimetry could guide the operation and assess whether the patients needs further dissection of adhesions, an extension of the previous myotomy and anti-reflux treatment. Methods A 70-year-old woman treated with Heller-Nissen in 1983 for type II achalasia was referred to our tertiary care center with absolute dysphagia for three days. In the past 41 years she reported occasional and self-limited episodes of dysphagia, regurgitation and chest pain. Aside from that, her medical history was unremarkable. An esophagogastroduodenoscopy (EGD) with airway protection was performed, showing retained solid food. A water-soluble swallow study showed a tortuous megaesophagus and a misaligned esophageal gastric junction (EGJ), which did not allow endoscopic dilation. Esophageal wall thickening and focal lesions were ruled out by a CT scan. Results A laparoscopy with impedance planimetry technology support was scheduled. The first EGJ distensibility index (EGJ-DI) measurement was 2.1 mm2/mmHg. Esophagus was freed, encircled and released from the hiatus. An EGD confirmed the reposition of the cardia in the abdomen and the previous anterior esophageal myotomy. The Nissen fundoplication was not detectable. At this stage, an EGJ-DI of 4,2 mm2/mmHg was found. To obtain a regular esophageal outflow an anterior myotomy of the EGJ and proximal stomach was carried out and the edge was everted with absorbable barbed suture. A posterior cruroplasty was then performed. The final EGJ-DI was 8,8 mm2/mmHg. Conclusion The postoperative course was uneventful and she was discharged on post-operative day 4 eating a soft diet. In conclusion, the intraoperative use of the impedance planimetry technology has been crucial for a correct decision-making process during complex redo operations for esophageal achalasia as it has helped to tailor the surgical treatment. https://www.dropbox.com/scl/fi/pednopcqnalooidynge3q/ISDE-Definitivo.mov?rlkey=8exx0oe6ompxoex8wqmlsgi0i&amp;st=xgnfnjyt&amp;dl=0

Anti-Shortening Screw for the Prevention of Postoperative Shortening in Displaced Femoral Neck Fractures: A Retrospective Cohort Study.

Early femoral neck shortening after femoral neck system (FNS) fixation for displaced femoral neck fractures can occur in 22.3%-39.1% of cases, leading to decreased hip joint function. This study aimed to investigate the effectiveness of using an anti-shortening screw (ASS) in FNS fixation to prevent postoperative femoral neck shortening in displaced femoral neck fractures. We retrospectively analyzed 106 cases of displaced femoral neck fractures treated with FNS at the Hospital from April 2020 to April 2023. Patients were divided into two groups based on the use of an ASS: the traditional group and the ASS group, each consisting of 53 cases. The ASS group was age-matched with the traditional group treated during the same period without an ASS. The study variables included age, sex, body mass index (BMI), smoking and drinking history, injury mechanism, side of injury, fracture type, surgical time, intraoperative blood loss, Harris Hip Score (HHS) at the final follow-up, radiographic assessment (femoral neck shortening), and complications (infection, femoral head necrosis, nonunion, and secondary surgery). Statistical analysis was performed using SPSS software, with continuous and categorical variables analyzed using appropriate parametric (t-test) and nonparametric (Mann-Whitney U test) tests, and chi-square or Fisher's exact tests, respectively. A p-value <0.05 was considered significant. There were no significant differences in background characteristics between the traditional and ASS groups. The shortening distance at postoperative day 1 did not differ significantly between the two groups (0 vs. 0 mm, p = 0.120). However, at 1, 3 months, and 1 year postoperatively, the femoral neck shortening in the ASS group was significantly less than that in the traditional group (1 month: 2.3 vs. 3.1 mm, p = 0.007; 3 months: 2.6 vs. 3.5 mm, p = 0.005; 1 year: 2.6 vs. 3.5 mm, p = 0.002). The ASS group also had a significantly lower shortening distance during the fracture healing process (0.9 vs. 2.7 mm, p = 0.005). The incidence of moderate to severe shortening (≥5 mm) at 1 year postoperatively was lower in the ASS group compared with the traditional group (15.1% vs. 37.7%, p = 0.001). The ASS group had a longer surgical time (63.0 ± 13.4 vs. 73.0 ± 23.2 min, p = 0.008) and a higher HHS (90.7 vs. 94.8, p = 0.008). There was no significant difference in fracture healing time or postoperative complications between the two groups. The traditional group had 3.8% cutouts, 7.5% nonunions, 5.7% avascular necrosis, and 7.5% secondary hip replacements. The ASS group saw 0% cutouts, 1.9% nonunions, 3.8% avascular necrosis, and 3.8% hip replacements. No significant differences in complication rates (p > 0.05). The use of an ASS in FNS fixation for displaced femoral neck fractures can reduce the degree of postoperative shortening and improve hip joint function.

438. TECHNIQUE OF COMPLETELY ROBOTIC MCKEOWN (3-HOLE) ESOPHAGECTOMY WITH INTRA-CORPOREAL GASTRIC CONDUIT CREATION, AND CERVICAL ESOPHAGO-GASTRIC ANASTOMOSIS FOR MID-ESOPHAGEAL ADENOCARCINOMA

Abstract Background Esophageal cancer is the 7th leading cause of cancer deaths, with an estimated total case of 22,370 in both males and females in 2024. Adenocarcinoma and squamous cell carcinoma account for over 90% of histology at diagnosis. The incidence of adenocarcinoma continues to rise due to the rising incidence and prevalence of obesity, gastro-esophageal reflux disease and Barrett's esophagus. Multi-modality treatment is currently the standard of care for locally advanced disease. This consists of neoadjuvant concurrent chemotherapy and radiation therapy, followed by esophagectomy. Minimally invasive approaches to esophagectomy are associated with decreased post-operative morbidities and overall satisfactory outcomes. While the Ivor Lewis esophagectomy with intra-thoracic anastomosis is the most common surgical approach to resection of distal esophageal and gastroesophageal (GE) junction tumors, the McKeown (3-hole) esophagectomy with cervical esophago-gastric anastomosis is best suited for tumors located in the proximal and mid-esophagus. Methods We describe our technique of robotic McKeown (3-hole) esophagectomy for mid-esophageal adenocarcinoma after neoadjuvant concurrent chemo-radiation therapy for clinical stage uT3N0M0 tumor. The thoracic esophagus is completely mobilized from the esophageal hiatus of the diaphragm up to the thoracic inlet via a right thoracoscopic approach, with harvesting of the regional lymph nodes together with the specimen. The left neck incision is made along the anterior border of the sternocleidomastoid muscle and the inferior belly of the omohyoid muscle is transected. The cervical esophagus is then completely mobilized into the wound and secured using a Penrose drain. Using a laparoscopic approach, the entire stomach is mobilized with division of the left gastric vessels but careful preservation of the right gastro-epiploic arcade while transecting the greater omentum and the short gastric vessels. An intra-corporeal creation of the gastric conduit then follows. The gastric conduit, secured to the proximal stomach at the resection staple line, is subsequently tunneled via the esophageal hiatus and through the mediastinum to exit at the left neck incision by applying traction on the cervical esophagus. The specimen is separated from the conduit, and the cervical esophagus is transected at the desired location for the anastomosis. A stapled end-to-side but functional end-to-end esophago-gastric anastomosis (Orringer's technique) is then created. Results A completely robotic technique of McKeown (3-hole) esophagectomy without the need to exteriorize the stomach to fashion the gastric conduit via a (mini)laparotomy is successfully accomplished in the majority of our patients with proximal or mid-esophageal tumors. An uneventful postoperative recovery was made. Fluoroscopic esophagram on post-operative day 5 did not demonstrate leakage from the anastomotic site. Gastric conduit emptying was satisfactory despite the lack of a routine gastric drainage procedure or injection of botulinum toxin into the pyloric ring. Conclusion Robotic-assisted thoracoscopic esophageal mobilization combined with laparoscopic completely intra-corporeal fashioning of gastric conduit with cervical esophago-gastric anastomosis is a technically feasible minimally invasive approach to performing McKeown esophagectomy with satisfactory post-operative outcomes and conduit functioning. https://www.dropbox.com/scl/fi/gzc1vzdzhzqn7niz95b8t/Robotic-McKeown-Esophagectomy-Video-3.mp4?rlkey=c4ja7s1aob10ah6ps500z7y29&amp;dl=0

Perioperative extracorporeal membrane oxygenation in liver transplantation—bridge to transplantation, intraoperative salvage, and postoperative support: outcomes and predictors for survival in a large-volume liver transplant center

Data on perioperative extracorporeal membrane oxygenation (ECMO) in liver transplantation (LT) are scarce. ECMO has been used preoperatively, intraoperatively, and postoperatively for a variety of indications at our center. This retrospective, single-center study of ECMO use peri-LT aimed to describe predictors for successful outcome in this highly select cohort of patients. Demographics, support method, and indication for LT were compared between survivors and nonsurvivors. Twenty-nine patients received venovenous (V-V; n = 20), venoarterial (V-A; n = 8), and venoarteriovenous (n = 1) ECMO. Twelve (41.4%) patients were bridged to emergency LT for acute liver failure, and emergency redo LT. Four (13.3%) patients required intraoperative V-A ECMO salvage, 2 necessitating extracorporeal cardiopulmonary resuscitation. Thirteen (43.3%) patients required ECMO support after LT: V-V ECMO (n = 9); V-A ECMO (n = 1); and extracorporeal cardiopulmonary resuscitation (n = 3) between postoperative days 2 to 30. Overall, 19 patients (65.5%) were successfully weaned off ECMO; 15 (51.7%) survived to intensive care unit discharge. All patients who underwent intraoperative salvage ECMO and all who were bridged to emergency redo LT died. Peri-LT ECMO is feasible. Post-LT ECMO outcomes are encouraging, in particular for V-V ECMO. Intraoperative ECMO salvage, uncontrolled sepsis, and graft failure are associated with poor outcomes.

Artery Grafting for Arterial Anastomoses in Head and Neck Free Tissue Transfer Reconstruction.

Vessel grafting is an important technique in head and neck free tissue transfer (FTT) reconstruction when a tension-free anastomosis is not otherwise feasible. To our knowledge, there are limited data regarding interposition artery grafts for arterial anastomoses in head and neck reconstruction. Here, we present a multi-institutional cohort of arterial interposition grafts for FTT reconstruction for head and neck defects. A retrospective review was conducted at four tertiary care institutions for patients who underwent FTT reconstruction for head and neck defects which utilized an interposition artery graft for the arterial anastomosis. Charts were reviewed for type and length of artery grafts harvested, surgical indication, indication for artery graft, types of flaps harvested, and various preoperative characteristics (including history of radiation or previous FTT reconstruction surgery). Postoperative complications within postoperative day 30 were measured and reported. Nine patients met inclusion criteria. The lateral circumflex femoral artery (either transverse or descending branches) (n = 3) and facial artery (n = 3) were the most commonly harvested arteries. The scalp (n = 5) was the most common primary defect site. Seven grafts were harvested initially and in a planned fashion, while two were harvested as salvage techniques (either for flap salvage or vein graft failure). In planned grafts, arteries were the preferred interposition grafting method due to either size match preferences (n = 4) or similarities in wall thickness (n = 3) between graft and recipient artery. There were no reported cases of unplanned readmission, postoperative hematoma, fistula formation, wound infection, or donor site morbidities. Two patients required unplanned return to the operating room for flap compromise, both of which ultimately resulted in flap failure secondary to clot formation at both arterial and venous anastomoses. When arterial pedicle length is insufficient, interposition artery grafting is both a feasible and viable technique to achieve tension-free arterial anastomoses for select cases of highly complex head and neck free tissue reconstruction.

449. CAN LARGE ANASTOMOTIC LEAKAGE AFTER ESOPHAGEAL SURGERY BE TREATED BY ENDOLUMINAL VACUUM-ASSISTED CLOSURE (EVAC THERAPY)?: A CASE REPORT

Abstract Background Anastomotic leakage after esophageal surgery is a deadly complication which approach is still under debate. The high morbimortality of the surgical approach has led to debate whether there are any alternative treatments. The appropriate strategy is based on many factors that include patient’s general conditions, size of anastomotic leakage and diagnosis delay. EVAC (Endoscopic vacuum assisted wound closure) is an emerging technique to treat these patients that can be placed either into the cavity or in the lumen under endoscopic guidance. It is then connected to a negative continuous pressure of 75-125mmhg and then reviewed after 3-4 days. Methods A 62-year-old man with esophageal squamous cell carcinoma underwent neoadjuvant chemoradiotherapy, followed by a minimally invasive Mckeown esophagectomy. On the fourth postoperative day, inflammatory indexes increased, and a CT scan showed an anastomotic leakage. It was decided to perform an endoscopy that showed that the leakage was about 70% of the anastomosis opening to a wound cavity of 5cm with necrotic tissue and fibrosis. Due to the clinical stability of the patient, it was decided to treat the anastomotic leakage conservatively by EVAC therapy. Results To start the EVAC therapy a polyurethane sponge was placed in the cavity via an overtube during the first endoscopy. The patient underwent a total of 14 EVAC sessions over 85 days. As we performed the sessions, healthy granulation tissue appeared leading the leakage and the cavity size to progressively improve. After the 13th session, the endoscopic evaluation showed a healed anastomosis. A CT scan with oral contrast was performed showing leak resolution. The patient started oral intake and was discharged after four days. Conclusions Treatment of anastomotic leakage after esophagectomy is still challenging and presenting high morbidity. The appropriate strategy needs to be individualized. Although surgical reintervention was the classical approach for these patients, new strategies have appeared like the EVAC. It is a promising option to improve the outcome of patients with transmural leakages who would otherwise require surgery. It has demonstrated that it is a reliable, safe and effective treatment.

784. NO SUPPORT FOR IMMEDIATE POSTOPERATIVE REMOVAL OF NASOGASTRIC TUBE AFTER ESOPHAGECTOMY, RESULTS FROM A NORDIC MULTICENTER RANDOMIZED CONTROLLED TRIAL

Abstract Background Esophagectomy is central in curative treatment of esophageal and gastroesophageal junctional cancer. Postoperative nasogastric (NG) tube for drainage of the gastric conduit is routine in most centers. The NG tube is typically associated with significant discomfort for the patients and may have risks of its own. Immediate postoperative removal of the NG tube has been suggested and deemed safe in several smaller trials. We hypothesized that immediate postoperative removal of the NG tube is non-inferior to keeping the NG-tube in place for 5 days postoperatively, with regard to anastomotic leak and other early outcomes. Methods Esophagectomy patients with a gastric conduit reconstruction were included in a multicenter, randomized controlled trial between February 2022 and March 2024. A 1:1 randomization stratified for center, age and anastomotic site (thorax/neck) was performed between immediate postoperative removal of NG tube (intervention) and 5 days of NG tube use (control). All patients underwent chest CT postoperative day 7. Anastomotic leak was the primary endpoint and a non-inferiority threshold of -9% difference in proportion of anastomotic leak, including 95% confidence interval, was set. Secondary endpoints included overall complications, pneumonia, length of stay as well as days in high dependency ward. Results Intention to treat analyses were performed on 444 patients whereof 215 were randomized to immediate NG-tube removal and 229 to control. Mean age was 67 years and neck anastomosis was performed in 78 patients (18%). 47 patients (22 %) had leak in the no NG tube group compared to 35 (15%) in the control group. Non-inferiority could not be established with a difference leak proportion to the advantage of NG tube use of 6.6% (95% CI: 13.8%-(-0.7%)). Overall complications (Clavien-Dindo &amp;gt;2) occurred in 94 patients (44%) in the experimental group and 91 patients (40%) in the control group. Overall 30d mortality was 1.1%. Conclusion In this randomized controlled multicenter trial, the by far largest to be performed so far, we could not establish non-inferiority for abstaining from postoperative NG tube use after esophagectomy with regards to anastomotic leak, and therefore support NG tube use. The somewhat high proportion of leak could be partly due to meticulous complication registration, including CT with peroral contrast on day seven in all patients. Use of postoperative decompression of the gastric conduit with an NG tube should be encouraged.

Sublingual sufentanil tablet system (SSTS) versus a single shot peri-nervous injection of ropivacaine for the management of postoperative pain after total knee arthroplasty: a single-center randomized trial.

For several years, ropivacaine has been the standard-of-care for establishing postoperative femoral nerve block in total knee arthroplasty (TKA) setting and is still widely in use but new approaches such as the patient-controlled administration of sublingual sufentanil tablets system (SSTS) seem to offer good clinical results. Our aim is to compare the SSTS to single shot peri-nervous injection of ropivacaine (single shot) after TKA in terms of effectiveness in pain management and of time to recovery. A total of 165 patients undergoing TKA were enrolled. Eighty-four patients were randomly allocated in the SSTS group and 81 patients in the single shot group. The primary objective of the study was to evaluate performance of Timed Up and Go test. Secondary objectives were to measure the length of stay, NRS pain scale, the adherence to the prescribed plan, the joint mobility, the frequency of rescue analgesic use, side effects and patients' satisfaction. Of all patients of the single shot group, 64 were withdrawn from the study as they unable to achieve pain control; only one patient was withdrawn from the SSTS group. Times for the "Timed Up and Go" test on the 3rd postoperative day were 8.4 ± 1.6 and 11.8 ± 3.6 in the SSTS group (n = 83) and single shot group (n = 17), respectively (p < .001). SSTS provides better pain management when compared to peri-nervous ropivacaine single shot injection after TKA.

458. THORACOSCOPY VERSUS ENDOSCOPY IN THE TREATMENT OF ESOPHAGEAL LEIOMYOMA: A SINGLE-CENTER RETROSPECTIVE STUDY

Abstract Background Esophageal leiomyoma, also called Esophageal Smooth Muscle Tumor (SMT), is one of the most common benign tumors of the esophagus. Surgical treatment is the most widely used method, including thoracic surgery such as thoracotomy, and VATS, and endoscopic surgery such as ESD and STER. We aimed to conduct a retrospective analysis of all esophageal leiomyoma surgeries in our center to assist decision-making in minimally invasive surgery for leiomyomas. Methods From January 2015 to September 2023 patients with pathologically diagnosed esophageal leiomyoma at our hospital were retrospectively enrolled. Those who had any pathological malignant component or lack of detailed clinical information were excluded. At the same time, a 1:1 propensity matching analysis was conducted for thoracoscopy and endoscopic surgery. The matching factors included age, gender, tumor location, and size and the caliper was set as 0.2. Results Finally, 1376 patients were included, of whom 153 underwent thoracic surgery and 1223 underwent endoscopic treatment. Endoscopic surgeries were mainly composed of ESD (54.5%) and STER (45.5%), with respective proportions, of which 2 cases used thoracoscopic-assisted endoscopic resection. In the surgical group, 131 patients, accounting for 85.6%, underwent thoracoscopic surgery, of which 65 patients (42.5%) used endoscopic-assisted examination during the operation. In terms of operation time, endoscopic resection was shorter than surgical surgery (44.9 ±39.7 versus 109.4 ± 67.9 min, p&amp;lt;0.001). Similarly, for the postoperative hospitalization days, endoscopic resection was shorter than surgical surgery (2.0 [1.0, 3.0] versus 5.0 [3.0, 6.0] days, p&amp;lt;0.001), we also found that the maximum diameter of surgical resection specimens was significantly larger than that of endoscopic surgery (1.3 [0.8, 2.5] versus 5.0 [3.5, 7.0] cm, p &amp;lt;0.001). After PSM, the operation duration (p=0.031) and hospital stay (p&amp;lt;0.001) were still statistically different between the surgical treatment group and the endoscopic group. Conclusion Most esophageal leiomyomas can be resected endoscopically, which can shorten the operation duration and hospital stay compared with thoracic surgery. When the maximum diameter of the tumor is too large or near important organs, thoracic surgery should be the first choice. In order to prevent possible esophageal mucosal damage, thoracoscopic surgery combined with intraoperative endoscopy examination is a safe and effective surgical treatment method.

Feasibility and usefulness of postoperative mobilization goals in the enhanced recovery after surgery (ERAS®) clinical pathway for elective colorectal surgery

PurposeDespite mobilization is highly recommended in the ERAS® colorectal guideline, studies suggest that more than half of patients don’t reach the daily goal of 360 min out of bed. However, data used to quantify mobilization are predominantly based on self-assessments, for which the accuracy is uncertain. This study aims to accurately measure postoperative mobilization in ERAS®-patients by validated motion data from body sensors.MethodsERAS®-patients with elective bowel resections were eligible. Self-assessments and motion sensors (movisens: ECG-Move 4 and Move 4; Garmin: Vivosmart4) were used to record mobilization parameter from surgery to postoperative day 3 (POD3): Time out of bed, time on feet and step count.Results97 patients were screened and 60 included for study participation. Self-assessment showed a median out of bed duration of 215 min/day (POD1: 135 min, POD2: 225 min, POD3: 225 min). The goal of 360 min was achieved by 16.67% at POD1, 21.28% at POD2 and 20.45% at POD3. Median time on feet objectively measured by Move 4 was 109 min/day. During self-assessment, patients significantly underestimated their “time on feet”-duration with 85 min/day (p = 0.008). Median number of steps was 933/day (Move 4).ConclusionThis study confirmed with objectively supported data, that most patients don’t reach the daily mobilization goal of 360 min despite being treated by an ERAS®-pathway with ERAS®-nurse. Even considering an empirically approximated underestimation, the ERAS®-target isn’t achieved by more than 75% of patients. Therefore, we propose an adjustment of the general ERAS®-goals into more patient-centered, individualized and achievable goals.RegistrationThis study is part of the MINT-ERAS-project and was registered prospectively in the German Clinical Trials Register on 25.02.2022. Trial registration number is “DRKS00027863”.

Hepatic compartment syndrome, a rare complication after any liver insult or liver transplantation: Three case reports and literature review.

Hepatic compartment syndrome (HCS) is a rare but life-threatening entity that consists of a decreased portal flow due to intraparenchymal hypertension secondary to subcapsular liver hematoma. Lethal liver failure can be observed. We report three cases, and review the literature. A 54-year-old male was admitted for extensive hepatic subcapsular hematoma after blunt abdominal trauma. Initially, he underwent embolization of the hepatic artery's right branch, after which he presented clinical deterioration, major cytolysis (310 times the upper limit of normal [ULN]), and liver failure with a prothrombin time (PT) at 31.0%. A 56-year-old male underwent liver transplantation for acute alcoholic hepatitis. On postoperative day 2, he presented a hemorrhagic shock associated with deterioration of liver function (cytolysis 21 ULN, PT 39.0%) due to extensive hepatic subcapsular hematoma. A 59-year-old male presented a hepatic subcapsular hematoma five days after a cholecystectomy, revealed by abdominal pain with liver dysfunction (cytolysis 10 ULN, PT 63.0%). All patients ultimately underwent urgent surgery for liver capsule excision, hematoma evacuation, and liver packing, if needed. The international literature was screened for this entity. These three patients' outcomes were favorable, and all were alive at postoperative day 90. The literature review found 15 reported cases. HCS can occur after any direct or indirect liver trauma. Surgical decompression is the main treatment, and there is probably no place for arterial embolization, which may increase the risk of liver necrosis. A 13.3% mortality rate is reported. HCS is a rare complication of subcapsular liver hematoma that compresses the liver parenchyma, and leads to liver failure. Urgent surgical decompression is needed.

Anatomic endoscopic enucleation of the prostate using a novel hybrid thulium:yttrium-aluminium-garnet laser generator: surgical technique and clinical outcomes.

We aim to report here the first clinical series of patients treated with AEEP using a novel hybrid thulium:yttrium-aluminium-garnet (Tm:YAG) laser generator (RevoLix HTL, LISA Laser Products, Germany), i.e. capable of emitting both in pulsated and continuous-wave. We included 39 consecutive patients who underwent hybrid Tm:YAG AEEP (hybrid ThuLEP) at a single center starting from July 2022 and were followed-up until 3months after surgery. Complete baseline, intraoperative, and follow-up demographic and clinical data were collected. The International Prostatic Symptoms Score (IPSS) questionnaire was used to quantify urinary symptoms at baseline and during follow-up. Post-operative follow-up further included a PSA test, uroflowmetry with post-void residual volume (PVR) measurement. Clavien-Dindo classification was used to classify complications. Median (IQR) age at surgery and prostate volume were 68 (IQR 63-74) years and 85 (60-105) cc. Both en-bloc or two-lobes technique enucleation were performed according to the intraoperative and endoscopic anatomy, with a median operative time of 85 (63-108) minutes. Bladder catheter was removed in all cases on postoperative day two. Intraoperative bleeding requiring conversion to bipolar enucleation was observed in two patients. After discharge, one patient developed arm phlebitis which was treated with anticoagulants leading to new onset haematuria requiring short term catheterisation (Clavien-Dindo grade II) and two more patients had a single episode of acute urinary retention (Clavien-Dindo grade I). Median pre- vs postoperative Qmax and IPSS were 8.0 (7.0-9.4) vs. 25.0 (22.5-32.5) ml/s and 22 (20-28) vs. 1 (0-2), whereas PVR decreased from 70 (50-115) to 0 (0-26) ml. Hybrid ThuLEP is a feasible and effective surgical procedure for the management of benign prostatic obstruction.

The role of cytokines in acute and chronic postsurgical pain after major musculoskeletal surgeries in a quaternary pediatric center

Study ObjectiveTo determine if baseline cytokines/chemokines and their changes over postoperative days 0–2 (POD0-2) predict acute and chronic postsurgical pain (CPSP) after major surgery. DesignProspective, observational, longitudinal nested study. SettingUniversity-affiliated quaternary children’s hospital. PatientsSubjects (≥8 years old) with idiopathic scoliosis undergoing spine fusion or pectus excavatum undergoing Nuss procedure. MeasurementsDemographics, surgical, psychosocial measures, pain scores, and opioid use over POD0-2 were collected. Cytokine concentrations were analyzed in serial blood samples collected before and up to two weeks after surgery, using Luminex bead arrays. After data preparation, relationships between pre- and post-surgical cytokine concentrations with acute (% time in moderate-severe pain over POD0-2) and chronic (pain score > 3/10 beyond 3 months post-surgery) post-surgical pain were analyzed using univariable and multivariable regression analyses with adjustment for covariates and mixed effects models were used to associate longitudinal cytokine concentrations with pain outcomes. Main ResultsAnalyses included 3,164 repeated measures of 16 cytokines/chemokines from 112 subjects (median age 15.3, IQR 13.5–17.0, 54.5 % female, 59.8 % pectus). Acute postsurgical pain was associated with higher baseline concentrations of GM-CSF (β = 0.95, SE 0.31; p = 0.003), IL-1β (β = 0.84, SE 0.36; p = 0.02), IL-2 (β = 0.78, SE 0.34; p = 0.03), and IL-12 p70 (β = 0.88, SE 0.40; p = 0.03) and longitudinal postoperative elevations in GM-CSF (β = 1.38, SE 0.57; p = 0.03), IFNγ (β = 1.36, SE 0.6; p = 0.03), IL-1β (β = 1.25, SE 0.59; p = 0.03), IL-7 (β = 1.65, SE 0.7; p = 0.02), and IL-12 p70 (β = 1.17, SE 0.58; p = 0.04). In contrast, CPSP was associated with lower baseline concentration of IL-8 (β = -0.39, SE 0.17; p = 0.02), and the risk of developing CPSP was elevated in patients with lower longitudinal postoperative concentrations of IL-6 (β = -0.57, SE 0.26; p = 0.03), IL-8 (β = -0.68, SE 0.24; p = 0.006), and IL-13 (β = -0.48, SE 0.22; p = 0.03). Covariates female (vs. male) sex and surgery type (pectus surgery vs. spine) were associated with higher odds for CPSP in baseline adjusted cytokine-CPSP association models for IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, TNFα, and IL-8, IL-10, respectively. ConclusionWe identified pro-inflammatory cytokine profiles associated with higher risk of acute postoperative pain. Interestingly, pleiotropic cytokine IL-6, chemokine IL-8 (which promotes neutrophil infiltration and monocyte differentiation), and monocyte-released anti-inflammatory cytokine IL-13, were associated with lower CPSP risk. Our results suggest heterogenous outcomes of cytokine/chemokine signaling that can both promote and protect against post-surgical pain. These may serve as predictive and prognostic biomarkers of pain outcomes following surgery.

Contribution of fluorescence imaging to thoracoscopic anatomical segmentectomy: a multicenter propensity matching analysis.

Thoracoscopic anatomical segmentectomy is increasingly recognized for managing early-stage lung cancer. However accurately identifying intersegmental planes (ISPs), especially in complex lung segments, remains challenging. In comparison to conventional methods, fluorescence imaging represents a novel solution. This study aimed to examine the potential benefits of fluorescence imaging in single-port thoracoscopic anatomical segmentectomy. A multicenter (three regional hospitals), retrospective, comparative analysis was conducted using data from 402 consecutive patients who underwent single-port thoracoscopic anatomical segmentectomy from June 2020 to December 2022. The cohort included 191 patients treated with the fluorescence method and 211 patients treated with the modified inflation-deflation method. Among the cohort, 130 patients were placed in the simple segmentectomy group and 272 in the complex segmentectomy group. Propensity score matching (PSM) was used to adjust for baseline differences between the fluorescence and modified inflation-deflation subgroups in the complex segmentectomy group. Perioperative outcomes were compared between the groups. In the simple segmentectomy group, no significant differences were observed between the fluorescence and modified inflation-deflation methods regarding segmental resection time, intraoperative blood loss, postoperative chest tube drainage and duration, postoperative pain, length of hospital stay, complication rate, or hospital costs. In the complex segmentectomy group, however, fluorescence imaging significantly shortened segmental resection time (69.37±28.22 vs. 78.80±34.66 min; P=0.03), while reducing intraoperative blood loss (P=0.046); and improving visual analogue scale (VAS) pain scores on the first postoperative day (P=0.006). Both methods demonstrated comparable safety and oncologic effectiveness. Fluorescence-guided single-port thoracoscopic anatomical segmentectomy demonstrated comparable perioperative safety and effectiveness to the modified inflation-deflation technique while offering advantages, such as shorter segmental resection time, for complex segmentectomies.

Impact of mechanical bowel preparation on the gut microbiome of patients undergoing left-sided colorectal cancer surgery: randomized clinical trial.

Postoperative complications after colorectal cancer surgery have been linked to the gut microbiome. However, the impact of mechanical bowel preparation using oral preparation agents or rectal enema on postoperative infections remains poorly understood. This study aimed to compare the impact of oral preparation and rectal enema on the gut microbiome and postoperative complications. This open-label pilot RCT was conducted at the National Cancer Institute, Vilnius, Lithuania. Patients with left-side colorectal cancer scheduled for elective resection with primary anastomosis were randomized 1 : 1 to preoperative mechanical bowel preparation with either oral preparation or rectal enema. Stool samples were collected before surgery, and on postoperative day 6 and 30 for 16S rRNA gene sequencing analysis. The primary outcome was difference in β-diversity between groups on postoperative day 6. Forty participants were randomized to oral preparation (20) or rectal enema (20). The two groups had similar changes in microbiome composition, and there was no difference in β-diversity on postoperative day 6. Postoperative infections occurred in 12 patients (32%), without differences between the study groups. Patients with infections had an increased abundance of bacteria from the Actinomycetaceae family, Actinomyces genus, Sutterella uncultured species, and Enterococcus faecalis species. Mechanical bowel preparation with oral preparation or rectal enema resulted in similar dysbiosis. Patients who experienced postoperative infections exhibited distinct gut microbiome compositions on postoperative day 6, characterized by an increased abundance of bacteria from the Actinomycetaceae family, Actinomyces genus, Sutterella uncultured species, and Enterococcus faecalis species. NCT04013841 (http://www.clinicaltrials.gov).

Inhibition of the P38 MAPK/NLRP3 Pathway Mitigates Cognitive Dysfunction and Mood Alterations in Aged Mice after Abdominal Surgery Plus Sevoflurane

BackgroundCognitive dysfunction, encompassing perioperative psychological distress and cognitive impairment, is a prevalent postoperative complication within the elderly population, and in severe cases, it may lead to dementia. Building upon our prior research that unveiled a connection between postoperative mood fluctuations and cognitive dysfunction with the phosphorylation of P38, this present investigation aims to delve deeper into the involvement of the P38 MAPK/NLRP3 pathway in perioperative neurocognitive disorders (PND) in an abdominal exploratory laparotomy (AEL) aged mice model. MethodsC57BL/6 mice (male, 18-month-old) underwent AEL with 3% anesthesia. Then, inhibitors targeting P38 MAPK (SB202190, 1mg/kg) and GSK3β (TWS119, 10mg/kg) were administered multiple times daily for 7 days post-surgery. The NLRP3-cKO AEL and WT AEL groups only underwent the AEL procedure. Behavioral assessments, including the open field test (OFT), novel object recognition (NOR), force swimming test (FST), and fear conditioning (FC), were initiated on postoperative day 14. Additionally, mice designated for neuroelectrophysiological monitoring had electrodes implanted on day 14 before surgery and underwent novel object recognition while their local field potential (LFP) was concurrently recorded on postoperative day 14. Lastly, after they were euthanasized, pathological analysis and western blot were performed. ResultsSB202190, TWS119, and astrocyte-conditional knockout NLRP3 all ameliorated the cognitive impairment behaviors induced by AEL in mice and increased mean theta power during novel location exploration. However, it is worth noting that SB202190 may exacerbate postoperative depressive and anxiety-like behaviors in mice, while TWS119 may induce impulsive behaviors. ConclusionsOur study suggests that anesthesia and surgical procedures induce alterations in mood and cognition, which may be intricately linked to the P38 MAPK/NLRP3 pathway.