Postoperative Day Research Articles

The Efficacy of Modified Ilizarov Distraction-Tension Device on Limb Wound Difficult to Cover with Skin Flaps.

Closure of complex limb wounds poses challenges and requires innovative approaches. This research aimed to evaluate the effectiveness of a modified distraction-tension device using Ilizarov external fixation for wound closure in challenging cases. A retrospective analysis was conducted on 43 patients with extremity wounds that were difficult to cover with skin flaps between January 2019 and December 2022. Tension-relieving traction was applied using the Ilizarovexternal fixator apparatus, tailored to individual wound characteristics. Three types of wire-pin connections were used in this study. The distraction begins on the third postoperative day, with a speed of 0.5mm/d. Clinical wound healing scores were evaluated at 5 and 30 days postoperatively. Complications were documented following the Paley classification system. Traction using modified Ilizarovexternal fixation promoted a significant reduction in wound size. The mean traction period was 11.2 ± 7.3 days, and the mean healing duration was 17.0 ± 3.7 days. The clinical wound healing score improved from 3.7 ± 2.9 at 5 days to 1.7 ± 0.7 at 30 days postoperatively (p < 0.05). Complications were minimal, with no significant obstacles or sequelae observed. Direct closure healing was achieved in 21 cases, skin graft healing in 13 cases, and suture healing in 9 cases. No recurrences were reported. Using Paley's classified complications, there were 17 problems, 9 obstacles, and 0 sequelae. The Ilizarov tension-relieving traction shows promise in facilitating wound closure that is challenging to manage with skin flaps. The modified three types of pin-skin connection configuration could satisfy various types of wound closure.

600. DETECTION OF ANASTOMOTIC LEAK THROUGH THE VALUE OF DRAIN FLUID AMYLASE

Abstract Background Anastomotic leak in cervical anastomosis after esophagectomy has consistently been a serious problem. Esophagram has long been utilized to make sure the integrity of anastomosis before starting oral diet. However, the diagnostic accuracy is limited. Drin fluid amylase collected from the cervical anastomotic site is another useful method for its conveniency in specimen collection and the numerical value. But the clinical interpretation varied. The aim of the study was to share the experience in our facility regarding the diagnostic value of esophagram and drain fluid amylase exam. Methods A total of 116 patients with esophageal cancer were reviewed. All patients received open or minimally invasive Mckeown esophagectomy with cervical anastomosis, with or without a neoadjuvant chemoradiotherapy. For the prediction of leak, esophagram and drain fluid amylase were utilized. Esophagram was arranged on the 7th post operative day. And drain fluid amylase was collected twice on the 3rd and the 7th post operative day. We assumed that presence of an elevating trend of the drain fluid amylase level, and the amylase level on the 7th post operative day being more than 80 IU/L, would suggest an anastomotic leak. Results For the entire cohort, the leakage rate was 18.9% (22/116). 67 patients and 48 patients received esophagram exam and drain fluid amylase testing, respectively. The sensitivity and specificity for esophagram were 28.6% and 95%, respectively. The positive and negative predictive values were 40% and 91.9%, respectively. The diagnostic accuracy was 88.1%. The diagnostic value of testing drain fluid amylase by using our criteria yielded a sensitivity and specificity of 75% and 95%, respectively. The positive and negative predictive values were 75% and 95%, respectively. The diagnostic accuracy was 91.7%. Conclusion Comparing with esophagram, testing the drain fluid amylase provided an easier and more accurate way to predict the possible anastomotic leak. The criteria for prediction of leak by using drain fluid amylase were presence of an elevating trend (amylase on POD7 / POD3 &amp;gt;1) and the amylase level on the 7th post operative day being more than 80 IU/L.

Contrast-Enhanced Ultrasonography Findings Within 3 Days Postoperatively Are Associated With 1-Month Graft Failure After Split Liver Transplantation

Purpose:To evaluate whether Doppler ultrasonography (DUS) and contrast-enhanced ultrasonography (CEUS) within 3 days postoperative can identify 1-month graft failure after split liver transplantation (SLT). Materials and methodsA total of 58 consecutive patients who underwent SLT between February 2022 and September 2023 were included. The DUS and CEUS images and parameters within 3 days postoperatively were analyzed and recorded. The DUS parameters included peak systolic velocity (PSV), resistive index, and systolic acceleration time for the hepatic artery, PSV for the portal vein and hepatic vein. The CEUS qualitative analysis variables included the liver parenchyma enhancement pattern and the posterior enhancement attenuation. Logistic regression and Cox proportional hazard regression were used to evaluate the relationship between DUS/CEUS findings and 1-month graft failure. ResultsSeven of the 58 liver grafts failed within one month. Poor CEUS enhancement (pattern Ⅱ/Ⅲ) was observed in 5 of 7 patients (71.4%) of graft failure, whereas good contrast enhancement (pattern Ⅰ) was found in 47 of the 51 patients (92.1%) in the successful group on postoperative day 3. Multivariate logistic regression analysis revealed that 1-month graft failure was independently predicted by operative time (OR=3.79, 95% CI: 1.27–11.29, p=.017) and CEUS enhancement pattern on postoperative day 3 (OR=90.88, 95% CI: 2.77–2979.56, p=.011). Cox proportional hazard regression showed that operative time ( HR=1.6, 95% CI: 1.15–2.22, p =.005) and CEUS enhancement pattern on postoperative day 3 (HR=11.947, 95% CI: 2.04–69.98, p =.006) were independent predictors for graft failure. ConclusionsPoor CEUS enhancement (pattern Ⅱ/Ⅲ) was associated with 1-month graft failure in SLT recipients. CEUS may serve as a noninvasive, valuable prognostic tool to predict clinical outcomes early after SLT.

Diurnal variation of postoperative delirium in elderly patients undergoing esketamine anesthesia for elective noncardiac surgery: a randomized clinical trial.

Postoperative delirium (POD) is a serious and common complication. The aim of present study is to investigate the diurnal variation of POD and the effects of esketamine in elderly patients. A randomized, double-blind, placebo-controlled clinical trial with factorial design was conducted. Patients (aged 65 to 85 years) with normal Mini-Mental State Examination (MMSE) score were stratified by age (≤70 vs. >70) and American Society of Anesthesiologists physical status classification (Ⅱ vs. Ⅲ), then randomly assigned to either morning (08:00-12:00) or afternoon (14:00-18:00) noncardiac operation under general anesthesia with or without esketamine administration (0.2mg/kg). The primary outcome was the incidence of POD (3-Minute Diagnostic Interview for Confusion Assessment Method-defined Delirium, 3D-CAM) on postoperative days 1, 3, and 7. The secondary outcomes were the scores of MMSE and Hospital Anxiety and Depression Scale. The intention-to-treat analysis of the outcomes were performed by generalized estimating equation. Six patients who did not receive an intervention because of canceled operation were excluded after randomization. The datasets containing 426 cases were analyzed following the intention-to-treat principle after handling missing data via multiple imputation method. The incidence of POD declined from about 55% on postoperative day 1 to 31 and 18% on postoperative days 3 and 7, respectively. Afternoon operation [B=-0.583, OR (95% CI) 0.558 (0.319-0.976); P=0.041], but not esketamine, significantly decreased the incidence of POD. Both esketamine and operation time failed to significantly affect MMSE, HAD, and NRS score. There was no interaction among operation time, esketamine, and follow up time. Elderly patients undergoing elective noncardiac surgery in the afternoon displayed lower POD incidence than those operated in the morning. A single low-dose of esketamine before general anesthesia induction failed to significantly decrease the risk of POD but decrease the risk of intraoperative hypotension and emergence agitation.

P193 BLOOD PRESSURE CHANGES IN THE IMMEDIATE POST OPERATIVE PERIOD OF LIVE-RELATED KIDNEY DONORS IN AN INDIAN COHORT: SHOULD WE BE LOOKING MORE?

Background &amp; Objective: Kidney donation is associated with physiological changes (hyperfiltration, changes in renin-angiotensin-aldosterone system &amp; vascular tone) and its effects can be more pronounced in the elderly. The immediate reduction in GFR after nephrectomy can pose a risk for development or worsening of hypertension. There is a paucity of data determining the impact of reduced GFR on BP in post-operative period. Our study aims to analyze the hemodynamics in the post-operative period after nephrectomy. Methods This was a prospective observational study of 30 donors who underwent live-related Donor Nephrectomy. Parameters like demography, pre- and post-nephrectomy BP (reading taken daily for every 3 hours till post-operative day (POD) 4 using BPL oscillometric device) were studied. Continuous variables were were expressed as mean &amp; standard deviation. The Student's paired t-test was used for comparison using SPSS Windows software. Results The age of donors ranged from 23-73 years. Mean SBP/DBP was 112.69 ± 5.44/76.77 ± 3.78 mmHg in donors &lt;50 years, while in donors aged &gt;50 years the mean SBP/DBP was 126.6 ± 7.9/81.7 ± 3.82 mmHg. Post-donation in donors aged &lt;50 years (17 donors), mean S.B.P/DBP on POD 1 was 108.38 ± 4.77/76.20 mmHg followed by 108.92 ± 4.24/76.84,110.12 ± 5.42, 114 ± 4.8/78.88 ± 2.66 on POD-2, 3 &amp; 4 respectively. After Nephrectomy in donors aged more than 50 years(13 donors), mean SBP/DBP on POD 1 was 124.38 ± 4.56/78.20 mmHg followed by 126.40 ± 4.54/79.88,127.72 ± 6.22, 130.22 ± 3.8/84.58 ± 4.24 on POD-2, 3 &amp; 4 respectively. The BP on POD-4 was significantly higher in donors with age more than 50 years than donors with age less than 50 years (p&lt;0.05). Conclusion: After nephrectomy, blood pressure changes in the immediate post-operative period in the elderly need to be monitored closely. Frequent BP monitoring after nephrectomy should be implemented to determine risk of HTN in kidney donors.

250. CHANGES IN AND CLINICAL UTILITY OF MAXIMUM PHONATION TIME AND REPETITIVE SALIVA SWALLOWING TEST SCORES AFTER ESOPHAGECTOMY

Abstract Background Postoperative pneumonia in patients with esophageal cancer occurs due to swallowing dysfunction and aspiration. Recently, intervention by speech-language pathologists (STs) has reported to be important for the prevention of postoperative pneumonia. In this study, we report on the perioperative swallowing rehabilitation led by STs at our hospital. In addition, we focused maximum phonation time (MPT) assessment and repetitive saliva swallowing test (RSST) as swallowing function assessment methods that can identify patients as high risk for pneumonia. We aimed to evaluate the clinical utility of MPT assessment and RSST in patients undergoing oncological esophagectomy. Methods ST intervention was started at the induction of preoperative chemotherapy, and pre-surgical swallowing rehabilitation including oral care, incentive spirometry, abdominal breathing, and breath-hold swallowing was started and continued after surgery. MPT is the longest speech duration after maximal inspiration, and RSST is the number of empty swallowing that can be repeated in 30 seconds. In total, 47 consecutive patients who underwent esophagectomy for esophageal cancer between 2020 and 2023 were eligible. The perioperative changes in MPTs and RSST scores were examined. In addition, univariate and multivariate analyses were performed to identify the predictive factors of postoperative pneumonia. Results The median MPTs before surgery and on postoperative days (PODs) 3, 6, and 10 were 18.4, 7.2, 10.6, and 12.4 s, respectively; postoperative MPTs were significantly lower than preoperative MPT. Meanwhile, there were no significant changes in perioperative RSST scores. A short MPT on POD 6 was one of the independent predictive factors for the incidence of postoperative pneumonia (OR: 12.6, 95%CI: 1.29–123, P = 0.03) in the multivariate analysis. Regarding the onset of postoperative pneumonia, the MPT on POD6 was significantly associated with late-onset pneumonia, but not with early pneumonia (P = 0.02 and P = 0.25, respectively). Conclusion The MPT significantly decreased after esophagectomy. However, the RSST score did not. The MPT on POD6 can be a predictor of postoperative pneumonia. Early resumption of oral intake after esophagectomy might be a risk factor of aspiration pneumonia since expectoration function is not restored, especially in patients with a low MPT on POD 6.

Magnesium sulfate enhances the effect of the peripheral analgesic cocktail in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials.

Although magnesium sulfate (MgSO4) is widely used as an analgesic adjuvant to peripheral analgesic cocktails, its efficacy in total knee arthroplasty (TKA) is still controversial. Therefore, we systematically reviewed and meta-analyzed the literature to assess the analgesic efficacy of MgSO4 as an adjuvant to the analgesic cocktail in TKA. The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched. The meta-analysis was performed according to the PRISMA guidelines. Data were qualitatively synthesized or meta-analyzed using a random-effects model. Five randomized controlled trials involving 432 patients were included. Meta-analyses detected significant differences between the MgSO4 and control groups in the visual analog scale (VAS) pain scores (rest) at 6, 12, and 24 h postoperatively; VAS pain scores (motion) at 12, 24, and 48 h postoperatively; morphine consumption within 24 h, 24-48 h, and during the total hospitalization period; time to first rescue analgesia after TKA; and length of hospital stay. Regarding the functional recovery, the meta-analysis demonstrated significant differences between groups in terms of knee range of motion on postoperative day 1; daily mobilization distance on postoperative day 1; and daily mobilization distance. There was no significant intergroup difference in surgical complications. The findings suggest that MgSO4 is a promising adjunct to the analgesic cocktail, achieving significant improvements in pain scores and total opioid consumption during the early postoperative period after TKA.

Initial Clinical Experience With a Novel Robotically Assisted Platform for Combined Mini-Percutaneous Nephrolithotomy and Flexible Ureteroscopic Lithotripsy.

We sought to evaluate the technical feasibility of performing a combined robotically assisted mini-percutaneous nephrolithotomy (PCNL) and flexible ureteroscopy (URS) procedure by a single urologist using the MONARCH Platform, Urology (Johnson & Johnson MedTech, Redwood City, California). In this prospective, first-in-human clinical trial, 13 patients underwent robotically-assisted PCNL for renal calculi at the University of California-Irvine, Department of Urology. Successful completion of the procedure was assessed as the primary endpoint. Postoperative adverse events were monitored for 30 days following the completion of the procedure. Stone ablation efficiency was evaluated on postoperative day 30 with low-dose 2-3 mm slice CT scans. Patients were classified according to the maximum length of their residual stone fragments as either absolute stone-free (Grade A), < 2 mm remnants (Grade B), or 2.1-4.0 mm remnants (Grade C). The combined robotic mini-PCNL and URS procedure was successfully completed in 12 of 13 procedures. No robotic device-related adverse events occurred. Preoperative stone burden was quantified by both maximum linear measurement (median 32.8 mm) as well as by CT-based volume (median 1645.9 mm3). Using the unique robotically assisted targeting system, percutaneous access was gained directly through the center of the renal papilla in a single pass in all cases. Median operative time was 187 minutes (range: 83-383 minutes). On postoperative day 30, a 98.7% (range: 72.9%-100.0%) volume reduction was achieved, with 5 Grade A (38.5%), 1 Grade B (7.7%), and 2 Grade C (15.4%). Three patients experienced complications (2 grade 1 and one grade 2 Clavien-Dindo). Our preliminary investigation demonstrates the safety, efficacy, and feasibility of a unique robotic-assisted combined mini-PCNL and URS platform.

379. SUCCESSFUL MANAGEMENT OF ANASTOMOTIC LEAKAGE FOLLOWING ESOPHAGECTOMY USING ENDO-VACUUM ASSISTED CLOSURE (EVAC) THERAPY: A CASE REPORT

Abstract Background Esophagectomy is a crucial curative treatment for potentially resectable esophageal cancer. However, anastomotic leakage poses a significant complication, with reported incidences ranging from 11.4% to 21.2% and mortality rates between 7.2% and 35%. Endoluminal or cavitary type of vacuum therapy (EVAC) represents a minimally invasive approach adapted from negative pressure wound closure techniques. Our case demonstrates the successful application of EVAC in managing a significant postoperative leak. Methods A 70-year-old male who underwent esophagectomy for early esophageal cancer. On postoperative day 23, a 20mm-sized large anastomotic leakage was detected, leading to the insertion of Endo-VAC for treatment. Endoscopically exchange was regularly. Results Endoscopically exchange was performed seven times, gradually reducing the size of the leakage hole. In the end, the anastomotic leakage was completely healed, and the patient was discharged on postoperative day 86. The patient id currently undergoing outpatient follow-up with no recurrence or metastasis of the disease confirmed. Conclusion Through our case, we highlight the potential suitability of EVAC therapy as a less invasive and effective treatment modality for anastomotic leakage following esophagectomy. This approach may be considered as a priority treatment for anastomotic leak.

Predictive factors for postoperative ileus after elective right hemicolectomy performed on over 80% Enhanced Recovery After Surgery-adherent patients: a retrospective cohort study.

Laparoscopic right hemicolectomy is the standard surgical approach for treatment of right-sided colonic neoplasms. Although performed within a strict Enhanced Recovery After Surgery (ERAS) program, patients still develop postoperative ileus. The aim of this study was to describe the factors responsible for postoperative ileus after right hemicolectomy in a patient population with over 80% ERAS adherence. In this retrospective study, we analyzed 499 consecutive patients undergoing elective right-sided colectomy for neoplastic disease in a single high-volume center. All patients followed an updated ERAS program. The overall median ERAS adherence was 80%. Patients with ≥ 80% adherence (n = 271) were included in further analysis. Their median ERAS adherence was 88.9% (interquartile range, 80-90; range, 80-100). Twenty-four of 271 patients (8.9%) developed postoperative ileus. A univariate regression analysis revealed carcinoma situated in the transverse colon, duration of operation over 200 minutes, and opiate consumption over 10 mg on the second postoperative day (POD) to be associated with a significantly higher risk of postoperative ileus. Multivariate regression analysis revealed that duration of surgery over 200 minutes (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.0-5.8; P = 0.045) and opiate consumption over 10 mg on POD 2 (OR, 4.8; 95% CI, 1.6-14.3; P = 0.005) independently predict a higher risk for postoperative ileus. The median length of hospital stay was significantly longer in patients with postoperative ileus (8 days vs. 3 days, P < 0.001). None of the 271 patients died during a 30-day follow-up. Long duration of surgery, even minor postoperative opiate use, predict a higher risk for postoperative ileus in strictly ERAS-adherent patients undergoing laparoscopic right hemicolectomy.

627. LEFT THORACOSCOPIC PRIMARY REPAIR OF ESOPHAGEAL PERFORATION SECONDARY TO BOERHAAVE SYNDROME

Abstract Background With the advancement of the minimally invasive surgical techniques, more and more acute surgical conditions including esophageal perforations can be performed safely using minimally invasive surgical approach. Methods A middle aged male patient presented to our department with 3 days history of epigastric pain and vomiting. He was febrile on admission and investigation revealed the left sided esophageal perforation due to Boerhaave Syndrome with left sided pleural effusion. He underwent left thoracoscopic primary repair of esophageal perforation and wash out successfully. This is the video of the thoracoscopic primary repair of the perforation. Patient was put in the right lateral semi prone position, the area of perforation was identified by careful dissection of the pleura and repaired was performed in 2 layers. The pleura cavity was washed out with warm saline and underwater sealed chest tube drain was inserted. Results Post operatively patient was transferred to surgical intensive care unit for 1 day. Patient was kept nil by mouth with parenteral nutrition for 7 days. Contrast study was performed on post operative day 7 and started oral feeding when there was no evidence of leakage. Patient recovered and discharged well. Conclusion Thoracoscopic primary repair with wash out of spontaneous esophageal perforation secondary to Boerrhave Syndrome is challenging however it is safe and can be performed successfully. https://drive.google.com/file/d/1JTfJLV-ngUBwzMybGV4FL8EEQB-ysj9O/view

Vaginal Packing After Pelvic Floor Reconstructive Surgery: Does the Soaking Agent Used for Packing (Bupivacaine, Estrogen or Saline) Impact Postoperative Pain Scores?

Study ObjectiveVaginal packing is traditionally placed after pelvic floor reconstructive surgery (PFRS) to prevent hematoma formation. We seek to determine if there is a difference in post-operative pain scores after PFRS if vaginal packing is soaked with estrogen cream, bupivacaine, or saline. The primary outcome was pain as measured by a visual analog scale (VAS) at 2 hours, 6 hours, and 1 day post-operatively. Secondary outcomes include change in hemoglobin, urinary retention and length of stay (LOS) in hospital. DesignProspective cohort study SettingTertiary care academic teaching hospital. All PFRS performed by fellowship-trained urogynecologists. ParticipantsConsenting patients undergoing PFRS. InterventionsAt the completion of surgery, gauze packing soaked with either estrogen cream 0.25% bupivacaine with 1% epinephrine, or normal saline was placed inside the vagina and removed on post-operative day 1. ResultsWe included 210 patients (74 estrogen, 66 bupivacaine, 70 saline). There was no significant difference in mean post-operative pain scores between the groups (estrogen, bupivacaine, saline-soaked vaginal packs respectively) at 2 hours (2.66±2.25, 2.30±2.17, 2.24±2.07; p=.4656), 6 hours (2.99±2.38, 2.52±2.30, 2.36±2.01; p=.2181) or on post operative day 1 (1.89±2.01 vs. 2.08±2.15 vs. 2.44±2.19; p=.2832) as measured by VAS scores (0-10). There was no difference in the secondary outcomes of change in pre-/post-operative hemoglobin (21.8±10.73g/L, 20.09±11.55g/L, 21.7±9.62g/L, p=.68), urinary retention (37%, 45% and 48%, p=.45), LOS (1.05±0.46 days, 1.02±0.12, 1.03±0.24, p=.97) or in-hospital opioid usage during admission (represented in morphine milligram equivalents (median (IQR1, IQR3), Kruskal-Wallis test): 11.25mg (0,33), 7.5mg (0, 22.5) and 15mg (0, 33.88) p =0.41. ConclusionThere was no difference found between soaking vaginal packing with estrogen cream, bupivacaine, or saline after PFRS with respect to post-operative pain scores, LOS, in-hospital opioid usage, or urinary retention. Saline-soaked packing is an equivalent alternative to estrogen or bupivacaine vaginal packing. Clinical Trial RegistrationNCT03266926. Registered February 1, 2017. https://clinicaltrials.gov/study/NCT03266926

515. LAPAROSCOPIC PHARYNGO-COLOPLASTY WITH RIGHT COLON FOR A CASE OF COROSSIVE INJURY

Abstract Introduction Corrosive stricture of esophagus and stomach is more common in Acid poisoning. Management these cases requires good surgical planning, technical expertise in doing these complex procedures Case report A34 year gentleman consumed small quantity of sulphuric acid. Feeding jejunostomy was done for improving the nutrition. After 9 months of initial insult Upper GI scopy and CT NECK, CHEST, ABDOMEN was done which confirmed complete esophageal stricture from cricopharyx, thickened entire stomach. We Did LAPAROSCOPIC PHARYNGO-COLOPLASTY WITH RIGHT COLON. Intraoperatively thickened stomach, total gastrectomy done, Right colon used for Coloplasty.Post procedure patient recovered well, Drins removed on 4th post op day, patient was discharged on 6 th day. https://drive.google.com/file/d/15OkPYKjsoQ-NVceBUzUArFAqMzcnA02S/view?usp=drive_web

810. 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

Laparoscopic cornual resection for interstitial pregnancy: Staying in the Marginal Zone.

Fortunately, interstitial pregnancies are a rare early pregnancy presentation, yet they can be challenging to managed and are associated with a high risk of intra-abdominal haemorrhage. Once detected, surgical laparoscopic resection can be the preferred management method for both patient safety and for definitive treatment. The video presents a new technique for laparoscopic resection of an interstitial pregnancy which enables the procedure to be effectively bloodless. We report on a new technique for laparoscopic cornual resection. As shown in the video, staying in the marginal zone may result in the enblock resection of the gestational sac. Using meticulous applications of bipolar energy and cutting with scissors in the marginal zone, the operation may be completed with almost no blood loss and minimal damage to the adjacent healthy myometrium. The operation lasted 30 min with almost no blood loss. The patient had an uneventful recovery and was discharged on the first postoperative day. Staying in the marginal zone during dissection permits even less experienced laparoscopists to complete laparoscopic cornual resection with minimal blood loss concomitantly with minimal trauma to the adjacent myometrium.

Effect of External Ventricular Drainage on Shunt-Dependent Hydrocephalus and Prognosis After Microsurgical Clipping in Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage

In poor-grade aneurysm subarachnoid hemorrhage (PaSAH), the use of external ventricular drainage (EVD) may be closely related to the occurrence of shunt-dependent hydrocephalus (SDHC). The purpose of this study was to investigate the effect of EVD on SDHC and prognosis after microsurgical clipping patients with PaSAH. The clinical data of 99 patients with PaSAH admitted to the 904th Hospital of PLA from October 2011 to December 2020 were analyzed retrospectively. Univariate and multivariate logistic regression analyses were used to clarify the relationship between EVD implantation and its drainage volume and SDHC after PaSAH. ROC curves were plotted to compare the prognostic efficiency of different drainage volumes on SDHC. Modified possion regression analysis was used to determine the effect of SDHC on prognosis after PaSAH. EVD implantation increased the risk of SDHC (OR=6.715, 95% CI 1.120-40.248, P=0.037). The increased drainage volume on day 1, mean daily drainage volume within 2 days, and average within 3 days increased the risk of SDHC. EVD drainage volume on the first postoperative day has a good predictive ability for SDHC after PaSAH, with an AUC of 0.829 (95% CI 0.731 - 0.928), the optimal cut-off value was 208 ml, with a sensitivity of 79.4%, a specificity of 81.6%, and a Youden index of 0.61. The occurrence of SDHC after aneurysm clipping significantly increases the risk of poor prognosis of PaSAH. EVD implantation is an independent risk factor for SDHC after PaSAH, and a large drainage volume in the first 3 days after EVD implantation is an independent risk factor for SDHC after PaSAH. The drainage volume on the first day after surgery is the best predictor of SDHC after PaSAH. SDHC after PaSAH is the strongest independent risk factor for poor prognosis and prolongs hospital stay.

Effects of lower limb vibration on hip pain and function after total hip arthroplasty: A randomized controlled trial

BackgroundA vibration roller is an effective tool for reducing muscle soreness and improving damaged muscle function. However, its efficacy in reducing hip pain and improving function after total hip arthroplasty is unclear. We investigated the effect of lower limb vibration using a vibration roller on postoperative hip pain and function after total hip arthroplasty in a randomized controlled clinical trial. MethodsThirty patients scheduled for total hip arthroplasty were randomly assigned to vibration and control groups. The patients in the vibration group performed lower limb vibration using a vibration roller. The patients in the control group performed sham therapy using a hot pack. Patients performed both interventions for 10 min daily on postoperative days 1–7, in addition to regular physical therapy. Primary outcome was hip pain intensity as measured using a visual analog scale. Secondary outcomes were pain-pressure threshold and serum creatine kinase and C-reactive protein levels. We also assessed physical functions, including the Harris Hip Score, range of motion of the hip joint, muscle strength, gait velocity, and timed up-and-go test. The effects of the interventions on outcome measurements in the groups were compared using a split-plot design variance analysis. ResultsAfter one week of the intervention and three weeks of follow-up, the vibration group showed statistically significant improvement in the exercise-induced hip pain, pain-pressure threshold of lateral thigh, and serum creatine kinase compared to the control group (p = 0.006, 0.003, and 0.012, respectively). No statistically significant differences were found between the groups regarding the physical functions. ConclusionsLower limb vibration using a vibration roller after total hip arthroplasty was an effective intervention to reduce exercise-induced hip pain and improve serum creatine kinase, but there was no synergistic effect on the physical functions.

300. SURFACE MICRODIALYSIS MEASURES LOCAL TISSUE METABOLISM AFTER IVOR LEWIS ESOPHAGECTOMY; AN ATTEMPT TO PREDICT ANASTOMOTIC DEFECT

Abstract Introduction Anastomotic defect after esophagectomy can lead to severe complications with need for surgical or endoscopic intervention. Early detection enables early treatment and can limit the consequences of the anastomotic defect. As of today, there are limited methods to predict anastomotic defect. In this study we have used microdialysis to measure local metabolism at the intrathoracic anastomosis. Feasibility and possible diagnostic use were investigated. Methods Sixty patients planned for Ivor Lewis esophagectomy were enrolled. After construction of the anastomosis, surface microdialysis probes were attached to the outer surface of the esophageal remnant and the gastric conduit in close vicinity of the anastomosis and left in place for seven postoperative days. Continuous sampling of local tissue concentrations of metabolic substances (glucose, lactate, pyruvate) was performed postoperatively. Outcome, defined as anastomotic defect or not according to ECCG (Esophagectomy Complications Consensus Group) definitions, was recorded at discharge or at first postoperative follow up. Difference in concentrations of metabolic substances were analysed retrospectively between the two groups by means of artificial neural network technique. Results Surface micodialysis probes can be attached and removed from the gastric tube reconstruction without any adverse events. Deviating metabolite concentrations on POD 1 were associated with later development of anastomotic defect. In subjects who developed anastomotic defects, no difference in metabolic concentrations between the esophageal and the gastric probe was recorded. The technical failure rate of the microdialysis probes/procedure was high. Discussion Surface microdialysis can be used in a clinical setting after Ivor Lewis esophagectomy. Deviation in local tissue metabolism on POD 1 seems to be associated with development of anastomotic defects. Further development of microdialysis probes and procedure is required to reduce technical failure.

613. LAPAROSCOPIC MANAGEMENT OF TYPE IV HIATAL HERNIA WITH MESH AUGMENTATION CRUROPLASTY - EXPERIENCE AT A TERTIARY CARE CENTRE

Abstract Background Type IV para-esophageal hernias, which are characterized by herniation of other organs in addition to stomach, are rare - comprising only 2-5% of all para-esophageal hernias. They are associated with life-threatening complications such as strangulation or perforation of stomach. Laparoscopic treatment of these hernias requires excellent advanced laparoscopic suturing and dissecting skills. Although laparoscopic approach is now universally accepted, the role of mesh augmentation remains debated. Methods Case records of patients who underwent Laparoscopic mesh augmentation cruroplasty for Type IV hiatal hernia since 2012 were retrospectively analyzed. Results Out of 340 patients who underwent hiatal hernia repair, 7 patients (3males, 4females) fulfilled the selection criteria. Median age was 64(53-89) years. Median duration of symptoms was 2months (15days-6months). All patients complained of heartburn. Vomiting was present in 5(71%) patients; only 1(14%) patient had persistent vomiting with dysphagia. Respiratory symptoms were present in 2(29%) patients. No patient had features of peritonitis or sepsis. One patient had undergone laparoscopic heller’s cardiomyotomy twice before. All patients underwent MDCT which confirmed type IV paraesophageal hernia. Median operating time was 150(100-280) minutes. Median blood loss was 150(50-400) ml. 6(85%) patients had herniation of omentum in addition to stomach while 1 patient had herniation of omentum and transverse colon. No patient had ischemia/perforation of stomach. Median hiatal defect was 6(5-8) cm. Sac was excised completely in all cases following reduction of contents. Crural repair was done with1-0 polyester interrupted sutures. In some patients, anterior cruciate ligament repair was done to avoid tenting of esophagus. Rectangle shaped Composite mesh with key-hole slit in upper border was placed. Mesh was anchored with interrupted 1-0ethilon sutures. Fundoplication (Nissen’s/Toupet) was done in all patients, none required esophageal lengthening procedure. Median post-operative stay was 5(2-8) days, median ICU stay was 1(0-4) days. Oral liquids were started on 2 nd (1-3) post-op day and solids on 4 th (2-5) day. 2(29%) patients had post- operative complications - atrial fibrillation and transient respiratory failure respectively. Median follow-up was 14(1-40) months. No patient had symptomatic recurrence. OGDscopy at 6months was normal in 5 patients. No mesh related complication was observed. Discussion Wide hiatal defects were noted in all patients. This necessitated mesh augmentation of crural repair. Both short-term (morbidity, mortality) and long-term outcomes (recurrence, patient satisfaction) were excellent.

341. EXCISION OF EPIPHRENIC DIVERTICULUM WITH CARDIOMYOTOMY AND FUNDOPLICATION

Abstract Background Epiphrenic diverticulum, a type of pulsion diverticulum, is a rare esophageal diverticulum that occurs in up to 2% of the population. It is commonly located in the distal esophagus, 4 to 8 centimeters (cm) above the gastric cardia. Etiology includes raised intraluminal esophageal pressure and is often associated with an underlying esophageal motility disorder. Indications for surgical intervention depends on presence of symptomatic disease including worsening dysphagia, food retention, regurgitation and complications such as aspiration pneumonia. This video illustrates the surgical management of epiphrenic diverticulum and associated surgical outcomes. Methods 60-year-old male initially presented with symptoms of dysphagia, food regurgitation and reflux. Gastroscopy performed identified a large esophageal diverticulum, 3cm from cardioesophageal junction (CEJ) and barium swallow study as well as high resolution manometry verified normal esophageal motility. Biopsies did not show any dysplasia. Patient subsequently underwent laparoscopic excision of epiphrenic diverticulum, cardiomyotomy and anterior 180 degrees fundoplication. Intra-operatively, epiphrenic diverticulum was noted on right lateral aspect of esophagus with a 3cm wide neck, 3cm from CEJ. Diverticulum was resected using a linear stapler and cardiomyotomy was perfomed on the contralateral side along with a partial fundoplication. Results Patient had an uneventful post-operative recovery with no post-operative complications. Histology confirmed esophageal diverticulum with no dysplasia or malignancy seen. Water soluble contrast study performed on post-operative day 1 and 1 year later demonstrated smooth passage of contrast with no hold up. There was also complete resolution of presenting symptoms on follow-up reviews. Conclusion Epiphrenic diverticulum is a rare entity but may present with debilitating symptoms that can affect patient’s quality of life and function. Management of symptomatic patients involves resection of the diverticulum as well as a myotomy and fundoplication to address any underlying motility disorder. This case aims to illustrate the efficacy and positive surgical outcomes that can be achieved with this combined surgical approach. https://www.dropbox.com/scl/fi/v6ow104q16lgfjhdqajix/Diverticulum-excision-v6.mp4?rlkey=nlmta6y835myqzf2rdf9mqocm&amp;dl=0