Postoperative Plan Research Articles

808 Metastatic Breast Cancer to the Spine: Outcomes After the Introduction of Small Molecule Inhibitors

INTRODUCTION: Over the past decade, with the development of small molecule inhibitors and immunotherapies, expanded attention is being paid to the somatic mutations expressed within a patient’s individual breast tumor, especially in the case of advanced or metastatic disease. A number of mutations have been found to occur most commonly in patients with metastatic breast cancer, including TP53, PI3K, CDH1, and MAP3K. Specifically, with regards to patients with metastases to bone, PIK3 mutations have been found to increase in frequency. METHODS: This is a retrospective study of patients who underwent treatment (surgery/radiation) at a tertiary care center for their diagnosis of breast cancer metastatic to the spine between 2010 and 2020. Review of peripheral sample gene sequencing reports was conducted to calculate the prevalence of different somatic gene mutations within our population. The use of small molecule inhibitors in the post-treatment period was determined and patient post-treatment mortality was calculated in order to elucidate the effect of systemic therapy on overall survival. RESULTS: 77 patients were included in our final analysis. Within our population of spine metastases patients, 44 (57%) were found to have a PI3K mutation, followed by 20 (26%) with a TP53 mutation. Furthermore, those patients given targeted molecular therapies in the post-treatment period were found to have a median overall survival of 1356 days. In comparison, those who did not receive targeted molecular therapies were found to have a median overall survival of 503 days (p<0.001). CONCLUSIONS: The results of the present study demonstrate that not only is there an increased prevalence of PI3K mutations within spine metastases in comparison to the general metastatic breast cancer population, there is also a significant mortality benefit with adding targeted molecular therapies to the patient’s post-operative treatment plan.

390 Assessing the Standard of Operative Notes Within a Vascular Surgery Department: An Audit Cycle

Abstract Aim Both the General Medical Council and Royal College of Surgeons of England’s (RCSEng) ‘Good Surgical Practice’ state that all clinical documentation must be recorded clearly, accurately, and legibly. The operative note is not just a means of communicating post-operative plans but can also be used for medico-legal purposes. The aim of this audit cycle was to ascertain how well the operative notes within a Vascular Surgery department adhered to the guidelines devised by RCSEng. Method 40 operative notes were analysed prospectively against the criteria stated in the ‘Good Surgical Practice'. The surgeons were made aware of the initial results via a departmental meeting. Using the Plan-Study-Do-Act (PDSA) model, we studied the pre-existing operative note template and created an aide-memoire highlighting the criteria with poor compliance. This was placed in all the vascular theatres. A re-audit was then undertaken 2 months after. Results In the first audit, we noted good compliance in areas that were included in the pre-existing template such as date (97.5%), name of operator (97.5%), name of anaesthetist (100%), operative procedure (100%), and closure technique (95%). Areas in need for improvement included time (0%), anticipated blood loss (2.5%) and elective/emergency procedure (10%). The second cycle demonstrated improvements (100% compliance) in most parameters. Documentation of time, elective/emergency procedure, and legibility showed minimal improvement. Conclusions This audit highlighted the importance of greater awareness of the expected standard of note documentation. Implementation of proformas and electronic documentation can effectively circumvent issues related to variability and legibility, and ultimately improve patient safety.

Mechanical support for the failing single ventricle after Fontan

Mechanical support for the failing single ventricle after Fontan

Epicardial pacemaker implantation and outcome in eight pet ferrets (Mustela putorius furo)

Introduction/objectivesMinimal information exists regarding epicardial pacemaker (EP) implantation in pet ferrets (Mustela putorius furo). The objectives were to describe the indications, surgical technique, and outcome of EP implantation in ferrets for the treatment of advanced atrioventricular block (AVB). Animals, materials, and methodsEight client-owned ferrets presenting to five veterinary referral centers. Signalment, physical exam findings, diagnostic tests, anesthesia protocols, surgical implantation techniques, postoperative treatment plans, and EP interrogations were reviewed. Intra- and postoperative, minor and major, and EP-related complications were established. Descriptive statistics were performed to report complication rates. Survival analyses were performed. ResultsAll ferrets had advanced AVB: 3/8 had high-grade second-degree and 5/8 had third-degree. The primary clinical signs were collapse and weakness. Seven EP were implanted via a transdiaphragmatic approach and one via a left intercostal thoracotomy. Intraoperative complications occurred in 2/8 ferrets, both major. One ferret with severe comorbidities died during general anesthesia. Postoperative pacemaker-related complications were minor: inappropriate sinus beat sensing in 2/8 and occasional muscle fasciculations in 1/8. Two ferrets were alive at the time of manuscript submission, at 10 and 21 months postoperatively. The overall median survival time was 24 months. ConclusionsImplantation of EP was performed successfully in most ferrets for treatment of advanced AVB and was well tolerated. Ferrets with advanced AVB may experience resolution of clinical signs associated with their cardiac disease following EP implantation. Additional studies are warranted to investigate the effects of epicardial pacing on survival times in this species.

Considerations for Cannabinoids in Perioperative Care by Anesthesiologists.

Increased usage of recreational and medically indicated cannabinoid compounds has been an undeniable reality for anesthesiologists in recent years. These compounds’ complicated pharmacology, composition, and biological effects result in challenging issues for anesthesiologists during different phases of perioperative care. Here, we review the existing formulation of cannabinoids and their biological activity to put them into the context of the anesthesia plan execution. Perioperative considerations should include a way to gauge the patient’s intake of cannabinoids, the ability to gain consent properly, and vigilance to the increased risk of pulmonary and airway problems. Intraoperative management in individuals with cannabinoid use is complicated by the effects cannabinoids have on general anesthetics and depth of anesthesia monitoring while simultaneously increasing the potential occurrence of intraoperative hemodynamic instability. Postoperative planning should involve higher vigilance to the risk of postoperative strokes and acute coronary syndromes. However, most of the data are not up to date, rending definite conclusions on the importance of perioperative cannabinoid intake on anesthesia management difficult.

The quality and continuity of systemic postoperative analgesia: a single center two-stage follow-up study

The aim of two prospective 1-month follow-up studies was to assess and compare the quality and continuity of postoperative systemic analgesia in Departments of Anaesthesiology and Surgery I and II, as well as adherence to prescribed plan of analgesia with respect to the effect of postoperative analgesia guidelines adopted in 2018. The studies included 94 (2016) and 80 (2018) patients who were operated under general anaesthesia, transferred to post-anaesthetic care unit (PACU), then to surgical wards and received systemic analgesia postoperatively. Comparison was based on adherence to postoperative analgesia plan during patient transfer. Recommendations for multimodal postoperative analgesia were given by the anaesthesiologist in 35.1% (ketoprofen + opioid) and 40.4% (paracetamol + opioid) in 2016 vs. 91.3% of cases in 2018, p < 0.001. Comparing 2016 to 2018, adherence to planned analgesia in PACU, % of cases was 35.1% vs. 92.5% for paracetamol (p < 0.001), 30.9% vs. 80% for ketoprofen (p < 0.001) and 75.5% vs. 72.5% for pethidine (p = 0.649). Adherence to planned analgesia after transfer to Department of Surgery I, % of cases was 3.3% vs. 80% for paracetamol (p < 0.001), 1.7% vs. 22% for ketoprofen (p < 0.001) and 61.7% vs. 20% for pethidine (p < 0.001). Adherence to planned analgesia after transfer to Department of Surgery II, % of cases was 0% vs. 10% for paracetamol (p = 0.059), 61.8% vs. 73.3% for ketoprofen (p = 0.325) and 29.4% vs. 13.3% for pethidine (p = 0.12), respectively. In conclusion, patients receive recommended systemic analgesia in PACU. Implementation of guidelines in Department of Surgery I resulted in 42% reduction of opioid and 76%increase of paracetamol use. Adherence to recommended analgesia in Department of Surgery II remains low.

INTERFASCIAL PLANE BLOCKS IN OBSTETRIC AND GYNECOLOGIC SURGERY.

Interfascial plane blocks (IPB) are truncal blocks with local anesthetic injected into space between two muscle layers. IPBs are easy to learn, simple to perform, provide satisfactory analgesia up to 24 hours, having a minimal risk of complications. We present a retrospective analysis of the patients who had IPB as a part of postoperative pain management plan following either CD or hysterectomy in Leskovac General Hospital, Serbia during the period April 2017 - February 2022. We had 131 patients who had IPB perioperatively. Bilateral QLB type 1 was performed in 53 patients after CD and in 68 patients after hysterectomy. Bilateral ESPB T10-11 was done following one CD case and in 9 patients before hysterectomy. Patients had both acetaminophen and nonsteroidal anti-inflammatory drug for postoperative pain control. Decreased usage of fentanyl and sevoflurane was noticed in the cases where IPB was performed preoperatively. Almost all patients had well-controlled pain, and were very satisfied with pain score of 0-4/10 at numeric rating scale during 24 hours after surgery, with no opioid use. There were no complications regarding block performance. QLB and ESPB have great potential to improve and facilitate postoperative pain management in obstetric and gynecologic surgery.

CT-guided trans-sternal iodine-125 seeds implantation for masses in the anterior or middle mediastinum.

PurposeThe aim of this study was to explore the feasibility and clinical value of computed tomography (CT)-guided trans-sternal puncture to implant 125I seeds to treat masses in the anterior or middle mediastinum.Material and methodsFrom September 2017 to December 2019, twenty patients with masses in the anterior or middle mediastinum were enrolled and treated with CT-guided trans-sternal 125I seeds implantation. Dosimetry parameters were compared between post-operative and pre-operative plans. Satisfaction rate of 125I seed distribution, complications, and local efficacy were evaluated.ResultsA total of 22 lesions were treated with 125I implantation in twenty patients, all procedures being successfully completed. The dosimetry parameters of the 20 patients immediately after surgery were as follows: mean D90 = 134.30 ±14.53 Gy; mean V90, V100, V150, and V200 were 96.10 ±1.55%, 92.69 ±1.93%, 66.86 ±7.53%, and 42.95 ±9.11%, respectively; mean conformity index (CI), external index (EI), and homogeneity index (HI) were 0.65 ±0.06, 40.79 ±13.72%, and 27.90 ±7.53%, respectively. The satisfaction rate of 125I seed distribution was 90%. The mean follow-up duration was 12 ±4.75 months (range, 4-24 months). The local control rates of 2 months, 6 months, and 1 year after surgery were 65.0%, 64.7%, and 53.8%, respectively. One patient had a small degree of pneumothorax, and one had hemoptysis after surgery.ConclusionsCT-guided trans-sternal puncture plant 125I seeds for the treatment of masses in the anterior or middle mediastinum might serve as an alternative approach for treating specific mediastinal metastatic tumors.

The impact of diabetes and obesity on postoperative complications after cesarean delivery

Obesity and diabetes are risk factors for postoperative complications. Independent vs. additive effects on perioperative outcomes are understudied. We measured the association between obesity, diabetes, and both on postcesarean complications. Retrospective cohort study of patients who underwent cesarean delivery at 182 US hospitals in 2019 (NSQIP). Missing BMI or diabetes were excluded. Patients were categorized as neither obesity nor diabetes (referent), obesity alone, diabetes alone, or obesity and diabetes. Primary outcome was a composite of severe maternal morbidity (SMM), defined by the CDC. Secondary outcomes were operative time, surgical site infection (SSI), length of postop stay and other complications. Multivariable logistic regression and general linear models with poisson or gamma distribution and log link were used to estimate measures of association. Of 9727 patients, 32% had neither obesity nor diabetes, 61% obesity alone, 1% diabetes alone, and 6% obesity and diabetes. Groups differed by age, race, HTN, and bleeding disorders (Table). Insulin-dependence did not differ between those who had diabetes alone versus obesity and diabetes (p=0.99). SMM occurred in 2% and did not differ by obesity and/or diabetes (Figure). Odds of SSI was higher in those with obesity and diabetes as well as obesity alone. Obesity was associated with higher odds of readmission. Operative time was longer in those with obesity and diabetes (adjusted mean 56.8min, 95% CI 52.8-61.2) and obesity alone (55.3min, 95% CI 51.1-59.1) vs. neither obesity nor diabetes (53.7 min, 95% CI 50.2-57.0; p< 0.05 for both). Postoperative length of stay was longer in those with diabetes (3.1 days, 95% CI 2.7-3.6) vs. neither obesity nor diabetes (2.7 days, 95% CI 2.5-3.0; p< 0.05). There was no difference in SMM between groups. Differences in postop stay and operative times are small and may not be clinically significant. Increased SSI and readmission in obese patients should be considered when considering surgical bundles, perioperative protocols, and postoperative plans to optimize outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Fully automated rigid image registration versus human registration in postoperative spine stereotactic body radiation therapy: a multicenter non-inferiority study.

To confirm the fully automated rigid image registration (A-RIR) accuracy in postoperative spine stereotactic body radiation therapy (SBRT), we conducted a multicenter non-inferiority study compared to the human rigid image registration (H-RIR). Twenty-eight metastatic cancer patients who underwent postoperative spine SBRT are enrolled—image registration (IR) of planning computed tomography (CT) and CT-myelogram for delineating the spinal cord. The adopted A-RIR workflow is a contour-focused algorithm performing a rigid registration by maximizing normalized mutual information (NMI) restricted to the data contained within the automatically extracted contour. Three radiation oncologists (ROs) from multicenters were prompted to review two blinded registrations and choose one for clinical use. Indistinguishable cases were allowed to vote equivalent, counted A-RIR side. A-RIR is considered non-inferior to H-RIR if the lower limit of the 95% confidence interval (CI) of A-RIR preferable/equivalent is greater than 0.45. We also evaluated the NMI improvement from the baseline and the translational/rotational errors between A-RIR and H-RIR. The A-RIR preferable/equivalent was selected in 21 patients (0.75, 95% CI: 0.55–0.89), demonstrating non-inferiority to H-RIR. The A-RIR’s NMI improvement was greater than H-RIR in 24 patients: the mean value ± SD was 0.225 ± 0.115 in A-RIR and 0.196 ± 0.114 in H-RIR (P < 0.001). The absolute translational error was 0.38 ± 0.31 mm. The rotational error was −0.03 ± 0.20, 0.05 ± 0.19, −0.04 ± 0.20 degrees in axial, coronal, and sagittal planes (range: −0.66–0.52). In conclusion, A-RIR shows non-inferior to H-RIR in CT and CT-myelogram registration for postoperative spine SBRT planning.

Respiratory prehabilitation in pediatric anesthesia in children with muscular and neurologic disease.

Children with neuromuscular, chronic neurologic, and chest wall diseases are at increased risk of postoperative respiratory complications including atelectasis, pneumonia, and respiratory failure with the possible need for reintubation or even tracheostomy. These complications negatively impact patient outcomes, including increased healthcare resource utilization and increased surgical mortality. In these children, the existing respiratory reserve is often inadequate to withstand the stresses brought on during anesthesia and surgery. A thorough clinical assessment and objective evaluation of pulmonary function and gas exchange can help identify which children are at particular risk for poor postoperative outcomes and thus merit preoperative interventions. These may include initiation and optimization of non-invasive ventilation and mechanical insufflation-exsufflation. Furthermore, such an evaluation will help identify children who may require a postoperative extubation plan tailored to neuromuscular diseases. Such strategies may include avoidance of pre-extubation lung decruitment by precluding continuous positive airway pressure trials, aggressively weaning to room air and directly extubating to non-invasive ventilation with a high inspiratory to expiratory pressure differential of at least 10cm H20. Children with cerebral palsy and other neurodegenerative or neurodevelopmental disorders are a more heterogeneous group of children who may share some operative risk factors with children with neuromuscular disease; they may also be at risk of sleep-disordered breathing, may also require non-invasive ventilation or mechanical insufflation-exsufflation, and may have associated chronic lung disease from aspirations that may require perioperative treatment.

Anterior Corpectomy and Plating with Carbon-PEEK Instrumentation for Cervical Spinal Metastases: Clinical and Radiological Outcomes

Background: Anterior cervical corpectomy and plating has been recognized as a valuable approach for the surgical treatment of cervical spinal metastases. This study aimed to report the surgical, clinical and radiological outcomes of anterior carbon-PEEK instrumentations for cervical spinal metastases. Methods: Demographical, clinical, surgical and radiological data were collected from 2017 to 2020. The Neck Disability Index (NDI) questionnaire for neck pain, EORTC QLQ-C30 questionnaire for quality of life, Nurick scale for myelopathy and radiological parameters (segmental Cobb angle and cervical lordosis) were collected before surgery, at 6 weeks postoperatively and follow-up. Results: Seventeen patients met inclusion criteria. Mean age was 60.9 ± 7.6 years and mean follow-up was 12.9 ± 4.0 months. The NDI (55.4 ± 11.7 to 25.1 ± 5.4, p < 0.001) scores and the EORTC QLQ-C30 global health/QoL significantly improved postoperatively and at the last follow-up. The segmental Cobb angle (10.7° ± 5.6 to 3.1° ± 2.2, p < 0.001) and cervical lordosis (0.9° ± 6.7 to −6.2 ± 7.8, p = 0.002) significantly improved postoperatively. Only one minor complication (5.9%) was recorded. Conclusions: Carbon/PEEK implants represent a safe alternative to commonly used titanium ones and should be considered in cervical spinal metastases management due to their lower artifacts in postoperative imaging and radiation planning. Further larger comparative and cost-effectiveness studies are needed to confirm these results.

Airway Management of Type-III Arnold Chiari Malformation: An Anaesthetic Challenge.

Arnold Chiari malformation (ACM) is defined as protrusion of the meninges and brain components into a congenital defect in the cranium or in the vertebral column. It was originally described by Austrian pathologist Hans Chiari. Among the four types, type-III ACM is the rarest and may associate with encephalocele. We report a case of type-III ACM associated with large occipitomeningoencephalocele with herniation of dysmorphic cerebellum, vermis, kinking/herniation of medulla with cerebrospinal fluid, tethering of spinal cord with posterior arch defect of C1-C3 vertebrae. The anaesthetic challenge for such patients lies in the proper preoperative work up; proper positioning of the patient during intubation; safe anaesthetic induction; intraoperative management of intracranial pressure, normothermia, and fluid and blood loss; and postoperative planning of extubation to prevent aspiration are the prerequisites to overcome the dificult airway management and anaesthetic challenge in the management of type III ACM.

Voice Outcome After Cold Knife Surgery According to the Characteristics of Vocal Fold Polyp

Voice change is one of the major symptoms in patients with vocal fold polyp. As a result, phonomicrosurgery is commonly required in these patients. Since voice outcomes after polyp treatment can be variable according to polyp characteristics, we aimed to investigate the predicting factors of postoperative voice improvements in terms of polyp characteristics in patients with vocal fold polyp who underwent cold knife surgery. A total of 77 patients who were diagnosed with vocal fold polyp and underwent phonomicrosurgery with cold knife instruments. The polyp characteristics of color, size, shape, and location were evaluated at baseline. Acoustic and aerodynamic analyses, voice handicap index questionnaire and grade, roughness, breathiness, asthenia, strain scale were evaluated at baseline and 6 weeks after surgery. All values of postoperative voice parameters improved after cold knife surgery. (P < 0.05) In patient with an organized vocal fold polyp, less improvement in postoperative values of maximum phonation time were observed. (P < 0.05) Likewise, less improvement of voice handicap index questionnaire score and grade, roughness, breathiness, asthenia, strain scale after surgery was shown in organized vocal fold polyp. (P < 0.05) CONCLUSIONS: Among the various polyp characteristics, the organized polyp was significantly related to relatively less improvement of objective and subjective voice parameters after surgery. These polyp characteristics would help to predict postoperative voice improvement and plan for personalized treatment in patients with vocal fold polyp.

Introducing a daily MDT board round: A quality improvement project to reduce length of stay for knee replacements at GSTT

Purpose: ERAS has long been proven to help reduce hospital length of stay (LOS) and complications following total knee replacement (TKR) surgery. Guy's and St Thomas’ NHS Foundation Trust’ (GSTT) ERAS programme targets an inpatient stay of three nights as best practice for TKR's; yet in 2018 this was not being met. Anecdotal data was suggestive of a growing cohort of multi-morbid older adults undergoing surgery with associated complex post-operative management and discharge planning. Despite Guy's Orthopaedic Outreach Team (GOOT) being an established service it was being under-utilised to facilitate discharges potentially due to poor MDT communication. The aim of this service improvement project was to determine the MDT acceptance of a daily geriatrician-led multidisciplinary meeting and its impact on LOS.

Reasons for Preoperative Opioid Use Are Associated with Persistent Use following Surgery Among Patients Undergoing Total Knee and Hip Arthroplasty

Abstract Objective Most studies on preoperative opioid use only describe whether or not patients use opioids without characterizing reasons for use. Knowing why patients use opioids can help inform perioperative opioid management. The objective of this study was to explore pain specific reasons for preoperative opioid use prior to total hip and knee arthroplasty (THA and TKA) and their association with persistent use. Methods This is a prospective study of 197 patients undergoing THA (n = 99) or TKA (n = 98) enrolled in the Analgesic Outcomes Study between December 2015 and November 2018. All participants reported preoperative opioid use. Results Reasons for preoperative opioid use were categorized as surgical site pain only (81 [41.1%]); pain in other body areas only (22 [11.2%]); and combined pain (94 [47.7%]). Compared to patients taking opioids for surgical site pain, those with combined reasons for use had 1.24 (P = .40) and 2.28 (P = .16) greater odds of persistent use at 3 and 6 months postoperatively, adjusting for relevant covariates. Conclusions This study provides novel insights into the heterogeneity of reasons for presurgical opioid use in patients undergoing a THA or TKA. One key take away is that not all preoperative opioid use is the same and many patients are taking opioids preoperatively for more than just pain at the surgical site. Combined reasons for use was associated with long-term use, suggesting nonsurgical pain, in part, drives persistent opioid use after surgery. Future directions in perioperative care should focus on pain and non-pain reasons for presurgical opioid use to create tailored postoperative opioid weaning plans.

Assessing the Safety and Utility of Wound VAC Temporization of the Sarcoma or Benign Aggressive Tumor Bed Until Final Margins Are Achieved.

Local recurrence of microinvasive sarcoma or benign aggressive pathologies can be limb- and life-threatening. Although frozen pathology is reliable, tumor microinvasion can be subtle or missed, having an impact on surgical margins and postoperative radiation planning. The authors' service has begun to temporize the tumor bed after primary tumor excision with a wound vacuum-assisted closure (VAC) pending formal margin analysis, with coverage performed in the setting of final negative margins. This retrospective analysis included all patients managed at a tertiary referral cancer center with VAC temporization after soft tissue sarcoma or benign aggressive tumor excision from 1 January 2000 to 1 January 2019 and at least 2 years of oncologic follow-up evaluation. The primary outcome was local recurrence. The secondary outcomes were distant recurrence, unplanned return to the operating room for wound/infectious indications, thromboembolic events, and tumor-related deaths. For 62 patients, VAC temporization was performed. The mean age of the patients was 62.2 ± 22.3 years (median 66.5 years; 95% confidence interval [CI] 61.7-72.5 years), and the mean age-adjusted Charlson Comorbidity Index was 5.3 ± 1.9. The most common tumor histology was myxofibrosarcoma (51.6%, 32/62). The mean volume was 124.8 ± 324.1 cm3, and 35.5% (22/62) of the cases were subfascial. Local recurrences occurred for 8.1% (5/62) of the patients. Three of these five patients had planned positive margins, and 17.7% (11/62) of the patients had an unplanned return to the operating room. No demographic or tumor factors were associated with unplanned surgery. The findings showed that VAC-temporized management of microinvasive sarcoma and benign aggressive pathologies yields favorable local recurrence and unplanned operating room rates suggestive of oncologic and technical safety. These findings will needvalidation in a future randomized controlled trial.

The Reliability of 3-T Magnetic Resonance Imaging to Identify Arthroscopic Features of Meniscal Tears and Its Utility to Predict Meniscal Tear Reparability

Background: The ability to predict meniscus tear reparability based on preoperative magnetic resonance imaging (MRI) is desirable for postoperative planning; however, the accuracy of predictive methods varies widely within the orthopaedic and radiology literature. Purpose/Hypothesis: The purpose was to determine if the higher resolution offered by 3-T MRI improves the accuracy of predicting reparability compared with previous investigations using 1.5-T MRI. Our hypothesis was that a higher field strength of 3-T MRI would result in improved reliability assessments and predictions of meniscus tear reparability compared with previous studies utilizing a 1.5-T MRI platform. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 44 patients who underwent meniscus repair were matched by age, sex, and body mass index to 43 patients who underwent partial meniscectomy. Overall, 2 orthopaedic surgeons and 2 musculoskeletal radiologists independently and blindly reviewed the preoperative MRI scans for all 87 patients. For each meniscus tear, reviewers evaluated the following criteria: tear pattern, tear length, tear distance from the meniscocapsular junction, tear thickness, and integrity of any inner meniscal fragment. The resultant data were then applied to 5 different approaches for predicting meniscal reparability. Results: The accuracy for all examined prediction methods was poor, ranging from 55% (3-point method) to 72% (classification tree method) among all reviewers. Interobserver reliability for examined criteria was also poor, with kappa values ranging from 0.07 (inner meniscal fragment status) to 0.40 (tear pattern). Conclusion: MRI continues to be a poor predictor of meniscus tear reparability as assessed by arthroscopic criteria, even when using higher resolution 3-T scanners. Interobserver reliability in this setting can be poor, even among experienced clinicians.

EP.TU.601Improving extended venous thromboembolism prophylaxis prescription compliance at discharge for colorectal cancer resection patients

Abstract Aims Extended venous thromboembolism prophylaxis (exVTEp) is used to reduce venous thromboembolism (VTE) incidence following colorectal cancer (CRC) resection. Within our tertiary care centre patients undergoing CRC resection should receive an electronic VTE risk assessment (eVTE) within 24 hours and exVTEp at discharge, compliance targets set at 95%. Our aim was to improve absolute compliance rates of exVTEp prescription at discharge following CRC surgery. Methods Data were collected prospectively on CRC resection patients pre and post an educational intervention for doctors during surgical induction, with posters placed in key areas highlighting discharge exVTEp importance. Patients discharged between August-December 2019 served as pre-intervention and those between December 2019-March 2020 as post-intervention cohorts. Time periods reflected junior doctor rotating periods within the country’s healthcare system thus providing more comparable data sets. The service evaluation was registered within the Trust (19-562Q) Results Of 80 pre-intervention and 40 post-intervention eligible patients: 81.25% vs. 92.68% received exVTEp at discharge, 70.19% vs. 72.34% had a valid eVTE and 32.50% vs. 36.59% had exVTEp recorded in the post-operative note. Those missing exVTEp documentation in the post-operative plan were significantly less likely to receive exVTEp at discharge with an 80% decrease in exVTEp prescription compared to patients with exVTEp documented within the post-operative note (unadjusted-OR 0.2051, 95%CI 0.0431-0.9773; p = 0.0276). Conclusions Educational and visual interventions have shown improvement in exVTEp prescription at discharge. Despite suboptimal eVTE scores true service quality in delivering exVTEp is high. The relationship between exVTEp post-operative instruction and exVTEp prescription needs further investigation.

The Effect of Bulk Electron Density on the Accuracy of Treatment Planning for Postoperative Cervical Cancer

MRI (Magnetic Resonance Images) only treatment planning is desirable due to its high soft tissue contrast and nature of non-radiation. This study investigates the impact of bulk electron density assignment on the dose accuracy in MRI-only treatment planning for postoperative cervical cancer treatment.20 cases of postoperative cervical cancer treatment plans were selected to generate new plans using bulk electron density assigning to OARs (Organs at Risk) and tissues on CT images in treatment planning systems. Contours include OARs such as bladder, rectum, small intestine, kidney, spinal cord, femoral head and Planning Target Volumes (PTV). The plans employed Volumetric Modulated Arc Therapy (VMAT) with double arcs (360°) and 0.3 cm × 0.3 cm × 0.3 cm calculation grid with 0.6 cm minimum subfield. New plans (PlanN) were generated from original plans with bulk electron density assigning to organs. Fluence optimization and IMRT dose constraints are the same as that with original plans (Plano). Dose Volume parameters (DVPs) of OARs and PTV were extracted from the two groups plans including: V30, V40-relative volume received 30 Gy, 40 Gy; mean dose-Dmean; D2, D98-dose received by 2%,98% of the target volume. The DVPs were compared between original and new plans using scatter plots. Paired-t test for DVPs was used to test the significance of the statistics.Relative deviation of most of the dosimetry parameters between original and new plans are less than 1%. PCTV1 Dose of the PlanN are higher 0.1% ∼ 0.2% (P > 0.05) than Plano. The dose difference of PCTV2 and PCTVln for the two group of plans is within 0.6(P < 0.05), 0.4% (P > 0.05), respectively. The OARs dosimetry differences including V20, V30, D1cc, Dmean for bladder, rectum, small intestine is within 0.2%, 0.6%, 0.2%. There is no noticeable distinction observed from dose distribution between Plano and PlanN. Monitor Units for PlanN are higher 0.84% than Plano. The statistical results of all parameters showed that there was no significant difference between the two groups.The dose deviation between the MRI-only plan and the routine CT-based plan was less than 2%, which met the clinical requirements. It provided a feasible method for MRI to replace CT in radiotherapy plan design and dose calculation.