Postoperative Appointment Research Articles

EP-90 Bouveret Syndrome: A challenging case of impacted gallstone within the fourth part of the duodenum

Abstract Aims Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. We present a case of a 68-year-old with recurrent small bowel obstruction secondary to a large gallstone impacted in the fourth part of the duodenum and cholecysto-duodenal fistula. We describe our atypical approach to surgical retrieval. Methods The patient presented acutely with abdominal pain and vomiting, on a background of recent admission for gallstone ileus managed conservatively. Initially, due to high anaesthetic risk (P POSSUM score = 14% mortality, 60% morbidity), the patient was managed conservatively with nasogastric drainage and total parenteral nutrition. On day 6 of admission, emergency laparotomy was performed after identifying radiological signs of impending perforation and clinical deterioration. Endoscopic management was not available locally. The stone could not be milked proximally for retrieval via pyloroplasty. Subsequently, high-pressure water flushes delivered via the gastrostomy expelled the stone distally. The stone was then retrieved via a jejunotomy at the DJ flexure. Results The patient required a 2-day high dependency unit admission and she was discharged 3 weeks post-operatively at her functional baseline. She was clinically well and asymptomatic when reviewed at the four-month post-operative surgical follow-up appointment. Conclusions This is the first report to our knowledge to describe successful surgical management of a gallstone impacted in the fourth part of the duodenum. Enterolithotomy can be considered safe option in patients with large, impacted stone and multiple co-morbidities.

Telemedicine and Socioeconomics in Orthopaedic Trauma Patients: A Quasi-Experimental Study During the COVID-19 Pandemic.

Socioeconomic factors may introduce barriers to telemedicine care access. This study examines changes in clinic absenteeism for orthopaedic trauma patients after the introduction of a telemedicine postoperative follow-up option during the COVID-19 pandemic with attention to patient socioeconomic status (SES). Patients (n = 1,060) undergoing surgical treatment of pelvic and extremity trauma were retrospectively assigned to preintervention and postintervention cohorts using a quasi-experimental design. The intervention is the April 2020 introduction of a telemedicine follow-up option for postoperative trauma care. The primary outcome was the missed visit rate (MVR) for postoperative appointments. We used Poisson regression models to estimate the relative change in MVR adjusting for patient age and sex. SES-based subgroup analysis was based on the Area Deprivation Index (ADI) according to home address. The pre-telemedicine group included 635 patients; the post-telemedicine group included 425 patients. The median MVR in the pre-telemedicine group was 28% (95% confidence interval [CI], 10% to 45%) and 24% (95% CI, 6% to 43%) in the post-telemedicine group. Low SES was associated with a 40% relative increase in MVR (95% CI, 17% to 67%, P < 0.001) compared with patients with high SES. Relative MVR changes between pre-telemedicine and post-telemedicine groups did not reach statistical significance in any socioeconomic strata (low ADI, -6%; 95% CI, -25% to 17%; P = 0.56; medium ADI, -18%; 95% CI, -35% to 2%; P = 0.07; high ADI, -12%; 95% CI, -28% to 7%; P = 0.20). Low SES was associated with a higher MVR both before and after the introduction of a telemedicine option. However, no evidence in this cohort demonstrated a change in absenteeism based on SES after the introduction of the telemedicine option. Clinicians should be reassured that there is no evidence that telemedicine introduces additional socioeconomic bias in postoperative orthopaedic trauma care. III.

Expert Consensus on the Use of the PRESERFLO™ MicroShunt Device in the Treatment of Glaucoma: A Modified Delphi Panel.

IntroductionThe implantation of the PRESERFLO™ MicroShunt (PMS) device has been shown to significantly lower increased intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG). However, guidelines on best practice for patient selection and pre-/peri-/postoperative care management are lacking. The aim of this modified Delphi panel was to achieve expert consensus on the role of the PMS to treat patients with glaucoma in Europe.MethodsTwelve European glaucoma surgeons experienced with the PMS procedure participated in a three-round modified Delphi panel. A targeted literature review and expert steering committee guided round 1 questionnaire development. Consensus was set at a pre-defined threshold of at least 70% of panellists selecting ‘Strongly disagree’/‘Disagree’ or ‘Strongly agree’/‘Agree’ for six–point Likert scale questions, or at least 70% selecting the same option for multiple-choice questions. Questions not reaching consensus were restated/revised for the next round, following guidance from free-text responses/scoping questions.ResultsConsensus was achieved for 60.3% (n = 38/63), 60.0% (n = 18/30), and 100.0% (n = 11/11) of Likert/multiple-choice questions in rounds 1, 2, and 3, respectively. There was agreement that the PMS procedure is effective at reducing IOP in patients with high-tension POAG (greater than 21 mmHg). Although surgical techniques may vary slightly, consensus was reached on several points, including the importance of posterior application of mitomycin C (MMC). Panellists agreed that the PMS postoperative follow-up appointment schedule is reasonably predictable and mostly characterised by fewer visits than with trabeculectomy, particularly in the early phase. Although panellists agreed that combined cataract/PMS surgery and the use of non-MMC wound-healing modulators/antifibrotics during the procedure are possible, further data are needed to determine efficacy.ConclusionThe expert consensus reached in this panel will help inform best practice guidelines in the treatment of patients with glaucoma in Europe. Panellists also highlighted key areas for future research to improve understanding of the PMS in the treatment algorithm of glaucoma.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40123-022-00529-4.

Short-Term Efficacy and Safety of Open Conjunctiva Ab Externo XEN45 Gel Stent Implantation in Glaucoma Patients.

We examined the safety and efficacy of the open conjunctiva ab externo approach for XEN45 gel stent implantation. There was a significant reduction in intraocular pressure (IOP) and number of glaucoma medications at 12 months follow-up. This study aims to determine the safety and efficacy of the open conjunctiva ab externo approach to XEN45 stent implantation. Retrospective chart review of all patients between July 2018 and March 2020 who underwent XEN45 implantation. IOP and the number of glaucoma medications were measured at the preoperative, 1 day, 1 week, 1 month, 3 months, 6 months, and 12 months postoperative appointments. The primary outcome of this study is the number of cases achieving complete success at 12 months postoperatively. Forty-four eyes of 44 patients were included. Mean preoperative IOP was 26.2±8.7mmHg on 3.2±0.7 IOP-lowering medications. At 12 months postoperative, mean IOP was 18.9±9.1mmHg (n=35, P <0.0001; mean reduction of 27.9%) on 0.9±1.4 (n=35, P <0.0001) IOP-lowering medications. Postoperative needling was performed in 5 cases (11.4%). Of the 35 cases with a postoperative visit at 12 months, complete success was achieved in 14 cases (40.0%) and qualified success in 3 cases (8.6%). Eighteen cases (51.4%) were recorded as failures at 12 months, comprised of 4 cases requiring reoperation for glaucoma (2 XEN45 implants, 1 trabeculectomy, and 1 Baerveldt implant), and 14 cases that did not meet the IOP-lowering criteria for success. During the postoperative course, there was 1 case of self-limited hypotony, 2 self-resolving choroidal effusions, and 3 cases of bleb leakage. The open conjunctiva ab externo approach to XEN45 implantation achieved successful levels of IOP reduction in 48.6% of glaucoma cases within the first year. The most common adverse events included the need for additional glaucoma surgery (excluding needling procedures), transient hypotony, and bleb leak.

Let our patients shine: Survivorship and health interventions in nutrition and exercise program for breast cancer survivors.

e24032 Background: Nutrition and lifestyle interventions are instrumental in modifying cancer risk. These changes are often challenging for patients to make due to residual side effects from active treatment and/or ongoing toxicities from current treatment. The SHINE (Survivorship and Health Interventions in Nutrition and Exercise) Program is a wellness program for patients with breast cancer focusing on three pillars of nutrition, exercise and community in order to improve overall health outcomes and decrease the risk of cancer recurrence. Methods: Participants in SHINE have either been diagnosed with ductal carcinoma in situ (DCIS) and/or stage I-IV breast cancer. They are referred to the program at the three-month breast surgery post-operative follow-up appointment or any time after that. All patients are referred to meet with a registered dietitian (RD) and integrative health coach, who provides counseling and education on how to reduce risk through diet and lifestyle, using evidence-based recommendations. Patients are provided with support and accountability. A collaborative program, the Physician Referred Exercise Program (PREP), was established with our health system’s medical fitness center, Valley Health LifeStyles. Patients undergo a fitness assessment that focuses on aerobic fitness, muscle strength and endurance, flexibility, &amp; functional activity. Each patient then receives an exercise prescription developed by a degreed exercise specialist, taking into account both the physician’s &amp; patient’s recommendations &amp; goals. Results: Each component of the SHINE Program has been developed in various stages due to the COVID-19 pandemic. 336 patients with either DCIS or stage I-IV breast cancer have been seen by the RD from December 2020 through January 2022. Mean number of visits/patient: 1.89 (range 1-8). N = 48 were participants in a 12-week study on the feasibility of nutrition counseling and impact on quality of life (QOL) which is still in progress. 76 patient referrals have been placed to the PREP program from August 2021-February 2022. Multiple community programs (Table) have been created for patients to help them develop shared experiences &amp; camaraderie with each other so that they can better integrate new ideas and lifestyle modifications. Conclusions: The SHINE Program addresses care for the whole person, empowering individuals to live their healthiest lifestyle. Future work will focus on clinical trials to evaluate the benefits of these individual and collective interventions on overall QOL, QOL subscales (physical, psychological, social &amp; spiritual well-being), &amp; survivorship symptoms.[Table: see text]

Coming Soon: Ability to Orgasm After Gender Affirming Vaginoplasty

Many patients have goals related to sexual health when seeking gender-affirming vaginoplasty, and previous investigations have only studied the ability to orgasm at cross-sectional timepoints. Our aim is to quantify the time to orgasm postoperative gender-affirming vaginoplasty and describe potential correlative factors, including preoperative orgasm, to improve preoperative counseling. A retrospective chart review was utilized to extract factors thought to influence pre and postoperative orgasm in patients undergoing robotic peritoneal flap vaginoplasty. Mean days to orgasm plus one standard deviation above that mean was used to define the time at which patients would be considered anorgasmic. Orgasm was documented as a categorical variable on the basis of surgeon interviews during pre and postoperative appointments while time to orgasm was measured as days from surgery to first date documented as orgasmic in the medical record. A total of 199 patients underwent surgery from September 2017 to August 2020. The median time to orgasm was 180 days. 178 patients had completed 1 year or greater of follow-up, and of these patients, 153 (86%) were orgasmic and 25 patients (14%) were not. Difficulty in preoperative orgasm was correlated only with older age (median age 45.9 years vs 31.7, P=.03). Postoperative orgasm was not significantly correlated with preoperative orgasm. The only factor related to postoperative orgasm was smoking history: 12 of 55 patients (21.8%) who had a positive smoking history and sufficient follow-up reported anorgasmia (P-value .046). Interventions for anorgasmic patients include testosterone replacement, pelvic floor physical therapy, and psychotherapy. Preoperative difficulty with orgasm improves with gender-affirming robotic peritoneal flap vaginoplasty, while smoking had a negative impact on postoperative orgasm recovery despite negative cotinine test prior to surgery. This investigation is the first effort to determine a timeline for the return of orgasmic function after gender-affirming vaginoplasty. It is limited by retrospective review methodology and lack of long-term follow-up. The association of smoking with postoperative orgasm despite universal nicotine cessation prior to surgery may indicate prolonged smoking cessation improves orgasmic outcomes or that underlying, unmeasured exposures correlated with smoking may be the factor inhibiting recovery of orgasm. The majority of patients were orgasmic at their 6-month follow-up appointments, however, patients continued to become newly orgasmic in appreciable numbers more than 1 year after surgery. Blasdel G, Kloer C, Parker A, et al. Coming Soon: Ability to Orgasm After Gender Affirming Vaginoplasty. J Sex Med 2022;19:781-788.

Parastomal hernias and information retention: how and when to educate ostomates on risk minimisation

Background: Parastomal herniation is a common complication of stoma formation, caused by protrusion of the bowel through the abdominal wall, with a major negative impact on quality of life. Stoma care nurses should educate ostomates on how to minimise the risk of a parastomal hernia. However, new ostomates must absorb so much pre- and postoperative information that some of it may be missed, misunderstood or forgotten. Aims: A survey was conducted to determine how much information about parastomal hernias and risk minimisation patients remember, as well as the best way and time to deliver this information, including how often it should be repeated. Method: The survey comprised 13 multiple-choice questions and was distributed to adults with any type of stoma through medical equipment supplier SecuriCare Medical's postal mailing list and social media pages. These results were compared with findings from the literature. Findings: Of 544 participants, most were over 70 years old (55.2%) and had had a stoma for more than 10 years (59.1%). Of these, 70.6% had heard of parastomal hernias and 29.4% had not. Most of those who had heard of parastomal herniation heard of it when they were diagnosed with the complication (37.3%). Only 9.8% first heard of it from a stoma care nurse. Of those who had discussed herniation with a nurse, the largest group (26.4%) had done so at a postoperative home visit or clinic appointment. Conclusion: Those who have had their stoma for a long time are particularly likely to have never been educated on parastomal herniation or forgotten what they had learned, so are a priority for patient education. This education should be tailored to a patient's age, learning style and ability to process information in a short period, as well as anxiety level. Stoma care nurses should be careful to limit their use of jargon, abbreviations and the passive voice, as well as the amount and type of information being delivered. Such education should be delivered early and then repeated at regular intervals.

Improvement of Depressive Symptoms Following Surgical Correction of Hallux Valgus and Hallux Rigidus via 1st MTP Fusion

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Psychiatric comorbidity has been shown to significantly impact postoperative course, leading to increasingly complicated hospitalizations, increased pain, and worse overall patient outcomes. Achieving adequate pain management is paramount in restoring mobility and ultimately reaching treatment goals, making an understanding of the interplay between psychiatric conditions and orthopedics vitally important. Specifically, deformity of the first MTP joint has been associated with increased psychiatric symptoms preoperatively. However, despite this particular population's vulnerability to depressive symptoms, the effects of surgical correction on mental function outcomes have not been well observed. The purpose of this study was to assess the association of psychotropic medication use in patients with diagnoses of hallux rigidus and hallux valgus undergoing first MTP fusion and differences in patient-reported pain and functionality scores.Methods:A retrospective analysis of prospectively collected patient outcomes for those undergoing MTP fusion for hallux valgus and hallux rigidus between August 1, 2015, and July 1, 2018, was conducted. A total of 95 patients were included in the study.Demographics and surgical data were collected from a review of the electronic medical record, and patients were grouped based on chronic use of psychotropic medications at the time of surgery. Patient-reported VAS, SF-36 Mental Component Scores (MCS), and Physical Component Scores (PCS) scores were collected at preoperative and routine 6-month and 12-month postoperative follow-up clinic appointments. Categorical variables were compared using Pearson's chi-squared test. For normally distributed data outcome scores were compared using the independent sample t-test while non-normal data comparisons were made with the Mann-Whitney U test. For all statistical tests, assumptions of α <.05 and β =.8 were made.Results:The average age of the patients in our cohort was 63.3 (range, 39 - 83), with 42 patients in the psychotropic medication (MED) and 53 patients non-psychotropic medication (NO MED) cohorts. Mean time to final follow-up was similar between NO MED and MED groups (p=.987). No differences in mean VAS scores were detected at preoperative (p=.455), 6-month (p=.505), nor 1-year (p=.269) visits. Similarly, no differences in SF-36 PCS were detected at preoperative (p=.087), 6-month (p=.314), nor 1- year (p=.103) postoperative visits. Patients taking psychotropic medications had significantly lower mean SF-36 MCS at preoperative and 6-month postoperative visits (p=.004, p=.033, respectively). No difference in mean mental component score was detected at the 1-year postoperative visit (p=.184).Conclusion:This study is the first to examine the surgical outcomes of patients undergoing 1st MTP fusion for hallux rigidus and hallux valgus while concurrently taking psychotropic medications. SF-36 mental component scores were depressed at preoperative baseline in the psychotropic medication cohort and improved postoperatively to a level similar to that of their non- psychotropically medicated peers. These findings suggest that psychiatric diagnoses should be considered in the discussion of conservative vs. surgical management of hallux valgus and rigidus, as a secondary benefit of surgical correction may be partial relief of depressive symptoms.

Pigmented ependymoma, a tumor with predilection for the middle-aged adult: case report with methylation classification and review of 16 literature cases.

Ependymomas have rarely been described to contain pigment other than melanin, neuromelanin, lipofuscin or a combination. In this case report, we present a pigmented ependymoma in the fourth ventricle of an adult patient and review 16 additional cases of pigmented ependymoma from the literature. A 46-year-old female showed up with hearing loss, headaches, and nausea. Magnetic resonance imaging revealed a 2.5 cm contrast-enhancing cystic mass in the fourth ventricle, which was resected. Intraoperatively, the tumor appeared grey-brown, cystic, and was adherent to the brainstem. Routine histology revealed a tumor with true rosettes, perivascular pseudorosettes and ependymal canals consistent with ependymoma, but also showed chronic inflammation and abundant distended pigmented tumor cells that mimicked macrophages in frozen and permanent sections. The pigmented cells were positive for GFAP and negative for CD163 consonant with glial tumor cells. The pigment was negative for Fontana-Masson, positive for Periodic-acid Schiff and autofluorescent, which coincide with characteristics of lipofuscin. Proliferation indices were low and H3K27me3 showed partial loss. H3K27me 3 is an epigenetic modification to the DNA packaging protein Histone H3 that indicates the tri-methylation of lysine 27 on histone H3 protein. This methylation classification was compatible with a posterior fossa group B ependymoma (EPN_PFB). The patient was clinically well without recurrence at three-month post-operative follow-up appointment. Our analysis of all 17 cases, including the one presented, shows that pigmented ependymomas are most common in the middle-aged with a median age of 42 years and most have a favorable outcome. However, one patient that also developed secondary leptomeningeal melanin accumulations died. Most (58.8%) arise in the 4th ventricle, while spinal cord (17.6%) and supratentorial locations (17.6%) were less common. The age of presentation and generally good prognosis raise the question of whether most other posterior fossa pigmented ependymomas may also fall into the EPN_PFB group, but additional study is required to address that question.

Effect of Insurance Type on Postoperative Tympanostomy Tube Follow-up.

Bilateral myringotomy with tube insertion (BMT) is a common procedure performed in children. Appropriate follow-up is necessary to ensure management of postoperative sequalae. The objectives are to investigate (1) the relationship between insurance type and postoperative follow-up attendance and (2) the effect of follow-up on need for further care after BMT. Retrospective cohort study. The study included patients <3 years of age undergoing BMT for recurrent acute otitis media at a tertiary care children's hospital within a single year and followed for 3 years. Patients were excluded if they had received a prior BMT; underwent a concurrent otolaryngologic procedure; or had a syndromic diagnosis, craniofacial abnormality, or any significant cardiac or respiratory comorbidity. Number of follow-up appointments, demographics, socioeconomic status, and postoperative outcomes were analyzed. A total of 734 patients were included with mean (SD) age of 1.4 years (0.50). The majority of patients had private insurance (520/734, 70.8%). Patients with public insurance attended fewer postoperative appointments (1.5 vs 1.8, P < .001) and had a higher incidence of BMT-related emergency department (ED) visits (10.3% vs 3.8%, P = .001). There was no significance found when different insurance providers were compared. An adjusted multivariate regression analysis showed that patients with private insurance were more likely to attend postoperative appointments (odds ratio, 3.52 [95% CI, 2.12-5.82]; P < .001) and less likely to have a BMT-related ED visit (odds ratio, 0.42 [95% CI, 0.20-0.89]; P = .024). Insurance type is related to outcomes after the treatment of recurrent acute otitis media with BMT. Future studies that survey individuals will help identify barriers that contribute to patient absence at follow-ups and need for subsequent ED visits.

Protocol for a multicenter, randomised controlled trial of surgeon-directed home therapy vs. outpatient rehabilitation by physical therapists for reverse total shoulder arthroplasty: the SHORT trial

BackgroundReverse total shoulder arthroplasty (RTSA) has emerged as a successful surgery with expanding indications. Outcomes may be influenced by post-operative rehabilitation; however, there is a dearth of research regarding optimal rehabilitation strategy following RTSA. The primary purpose of this study is to compare patient reported and clinical outcomes after RTSA in two groups: in one group rehabilitation is directed by formal, outpatient clinic-based physical therapists (PT group) as compared to a home therapy group, in which patients are instructed in their rehabilitative exercises by surgeons at post-operative appointments (HT group). Secondary aims include comparisons of complications, cost of care and quality of life between the two groups.MethodsThis randomised controlled trial has commenced at seven sites across the United States. Data is being collected on 200 subjects by clinical research assistants pre-operatively and post-operatively at 2, 6, and 12 weeks, 6 months, 1 and 2 year visits. The following variables are being assessed: American Shoulder and Elbow Surgeons (ASES), pain level using the numeric pain scale, the Single Assessment Numeric Evaluation (SANE) score, and shoulder active and passive range of motion for analysis of the primary aim. Chi square and t-tests will be used to measure differences in baseline characteristics of both groups. Repeated measures linear mixed effects modeling for measurement of differences will be used for outcomes associated with ASES and SANE and scores, and range of motion measures. Secondary aims will be analyzed for comparison of complications, cost, and quality of life assessment scores using data obtained from the PROMIS 29 v. 2, questionnaires administered at standard of care post-operative visits, and the electronic health record. Subjects will be allowed to crossover between the PT and HT groups, and analysis will include both intention-to-treat including patients who crossed over, and a second with cross-over patients removed, truncated to the time they crossed over.DiscussionRTSA is being performed with increasing frequency, and the optimal rehabilitation strategy is unclear. This study will help clarify the role of formal physical therapy with particular consideration to outcomes, cost, and complications. In addition, this study will evaluate a proposed rehabilitation strategy.Trial registrationThis study is registered as NCT03719859 at ClincialTrials.gov.

THE ASSOCIATION OF CATARACT TYPE ON CENTRAL CORNEAL THICKNESS AFTER PHACOEMULSIFICATION CATARACT SURGERY

Objective: To assess any association between the type of cataract and the central corneal thickness at pre-operative and postoperative three-day and one-month appointments after phacoemulsification surgery.&#x0D; Study Design: Prospective, comparative study.&#x0D; Place and Duration of Study: Eye Department Combined Military Hospital Multan, from Jun 2020 to Apr 2021.&#x0D; Methodology: A total of 89 patients requiring cataract surgery by phacoemulsification were recruited. Age and gender were recorded for each patient. Patient’s type of cataract based on maturity was recorded before the surgery. Phacoemulsification cataract surgery using ‘divide and conquer’ technique was carried out. Patients’ central corneal thickness was measured at the pre-operative, three-day post-operative and one-month post-operative appointment using traditional non-contact tonopachymeter.&#x0D; Results: There were 49 (55.1%) male and 40 (44.9%) female patients with a mean age of 62.15 ± 12.40 years. No significant association was found between the type of cataract and central corneal thickness at the three-time intervals (p=0.14). Central corneal thickness significantly increased from 0.48 ± 0.04 mm pre-operatively to 0.51 ± 0.04 mm at the three-day post-operative appointment (p&lt;0.001). It then reduced to 0.49 ± 0.04 mm at the one-month appointment (p=0.01).&#x0D; Conclusion: The type of cataract is not associated with the variation in central corneal thickness due to cataract surgery. Central corneal thickness significantly increases from the pre-operative to right after the cataract surgery. However, it returns to preoperative levels after a one-month period.

Management of sleeve gastrectomy leakage: case report

Treatment of postoperative gastric fistula complicated by local and systemic infection is difficult and controversial, particularly when treating obese patients with multiple prior surgical procedures. A 41-year-old male patient was transferred to our hospital to be admitted in the Intensive Care Unit with respiratory failure and postoperative sepsis, after being submitted to bariatric surgery. He had been through four subsequent surgical procedures: 1- a laparoscopic sleeve gastrectomy; 2- an exploratory laparotomy for unproven suspected subphrenic abscess; 3- a laparotomy with splenectomy and peritoneal drainage for splenic and peri-splenic abscess; 4-celiotomy and lavage for purulent peritonitis. Due to persistent clinical and analytical deterioration, and suspicion of left subphrenic abscess and digestive fistula, we proceeded to: identification and drainage of the abscess, adhesiolysis, identification of fistula orifice at the cardiac incisure (methylene blue and perioperative endoscopy), placement of a Pezzer tube for directed and controlled fistulization, Shirley’s drain in the subphrenic space for continuous lavage, jejunostomy for enteral nutrition. Under clinical and imaging control (esophageal transit, fistulography and computed tomography with water-soluble contrasts) he was started on a water diet 2 months after and the Shirley’s drain was later removed. Patient was discharged two and a half months after the intervention, maintaing the Pezzer tube and under enteral nutrition by jejunostomy. Oral feeding started in the 3rd postoperative month and jejunostomy and Pezzer probes were removed. Patient was asymptomatic at seven-month postoperative outpatient appointment.

A Resident's Guide to Laparoscopic Hysterectomy of Large Fibroid Uterus

Study Objective The objective is to demonstrate laparoscopic technique for hysterectomy of large, multifibroid uterus. Design N/A. Setting Patient is a 49-year-old para 2 with history of 2 prior cesarean sections and hysteroscopic myomectomy undergoing total laparoscopic hysterectomy and bilateral salpingectomy for massively enlarged fibroid uterus with heavy menses despite Mirena IUD in place and associated bulk symptoms manifested by pelvic pain, pressure, and urinary frequency. Pelvic MRI demonstrated a massively enlarged fibroid uterus measuring 204 × 87 × 141 mm in size with the largest fibroid located in the posterior lower uterine segment measuring 90 × 80 × 93 mm. Patients or Participants N/A. Interventions Preoperative medication with 3 cycles of leuprolide followed by laparoscopic hysterectomy and bilateral salpingectomy with removal of 20-week uterus via cold knife morcellation and mini-laparotomy. Measurements and Main Results At her postoperative appointment, the patient reported feeling well without vaginal bleeding and improvement in her bulk symptoms. Conclusion Hysterectomy offers definitive treatment for symptomatic fibroids in women who do not desire future fertility. Although technically challenging, large fibroid uteruses are amenable to laparoscopic resection and preoperative treatment with GnRH agonists such as leuprolide may aid in surgical optimization. The objective is to demonstrate laparoscopic technique for hysterectomy of large, multifibroid uterus. N/A. Patient is a 49-year-old para 2 with history of 2 prior cesarean sections and hysteroscopic myomectomy undergoing total laparoscopic hysterectomy and bilateral salpingectomy for massively enlarged fibroid uterus with heavy menses despite Mirena IUD in place and associated bulk symptoms manifested by pelvic pain, pressure, and urinary frequency. Pelvic MRI demonstrated a massively enlarged fibroid uterus measuring 204 × 87 × 141 mm in size with the largest fibroid located in the posterior lower uterine segment measuring 90 × 80 × 93 mm. N/A. Preoperative medication with 3 cycles of leuprolide followed by laparoscopic hysterectomy and bilateral salpingectomy with removal of 20-week uterus via cold knife morcellation and mini-laparotomy. At her postoperative appointment, the patient reported feeling well without vaginal bleeding and improvement in her bulk symptoms. Hysterectomy offers definitive treatment for symptomatic fibroids in women who do not desire future fertility. Although technically challenging, large fibroid uteruses are amenable to laparoscopic resection and preoperative treatment with GnRH agonists such as leuprolide may aid in surgical optimization.

Minimally Invasive Approach to Pelvic Arteriovenous Malformation (AVM) Refractory to Embolization

Study Objective To describe a minimally invasive approach to hysterectomy and excision of a pelvic AVM after embolization failed twice. Design Case report. Setting Single center academic institution. Patients or Participants A 33-year-old female presented with chronic pelvic pain after a cesarean section. Ultrasound and CT angiogram showed a left-sided dilated vessel with turbulent flow adjacent to the uterus consistent with pelvic AVM. The AVM persisted despite two embolizations by vascular surgery. Interventions Upon abdominal entry, extensive vascularity was noted in the left gonadal vessels, paravesical space, and pararectal space. A 5cm AVM was noted adjacent to the uterus. Each of the multiple blood vessels leading to the AVM, including those to the bladder serosa, were isolated, fulgurized, and cut. Concomitant left ureterolysis was completed. The paravesical space dissection involved separating dense bladder adhesions, left ovarian fossa, external iliac vein and medial umbilical ligament, from the malformation. Blood vessels from the deep sidewall encircling and feeding the AVM were serially fulgurated and separated from the ureter. The ascending branch of the uterine artery on the underside of the AVM was serially fulgurated. Lateral to the ureter, the uterine artery from origin to insertion was unroofed and excised. The AVM was excised by isolating it from the level of the cervix upwards along the pelvic sidewall and uterus. The remainder of the modified radical hysterectomy was uncomplicated. Measurements and Main Results Estimated blood loss was 50cc. Total surgical time was 4.5 hours. The postoperative course was uncomplicated. Final pathology was consistent with AVM. At her post-operative appointment, the patient experienced a significant reduction of symptoms. Conclusion In the absence of large series or randomized trials, we suggest that robotic-assisted surgery is a valid treatment option for pelvic AVM in the setting of failed embolization. To describe a minimally invasive approach to hysterectomy and excision of a pelvic AVM after embolization failed twice. Case report. Single center academic institution. A 33-year-old female presented with chronic pelvic pain after a cesarean section. Ultrasound and CT angiogram showed a left-sided dilated vessel with turbulent flow adjacent to the uterus consistent with pelvic AVM. The AVM persisted despite two embolizations by vascular surgery. Upon abdominal entry, extensive vascularity was noted in the left gonadal vessels, paravesical space, and pararectal space. A 5cm AVM was noted adjacent to the uterus. Each of the multiple blood vessels leading to the AVM, including those to the bladder serosa, were isolated, fulgurized, and cut. Concomitant left ureterolysis was completed. The paravesical space dissection involved separating dense bladder adhesions, left ovarian fossa, external iliac vein and medial umbilical ligament, from the malformation. Blood vessels from the deep sidewall encircling and feeding the AVM were serially fulgurated and separated from the ureter. The ascending branch of the uterine artery on the underside of the AVM was serially fulgurated. Lateral to the ureter, the uterine artery from origin to insertion was unroofed and excised. The AVM was excised by isolating it from the level of the cervix upwards along the pelvic sidewall and uterus. The remainder of the modified radical hysterectomy was uncomplicated. Estimated blood loss was 50cc. Total surgical time was 4.5 hours. The postoperative course was uncomplicated. Final pathology was consistent with AVM. At her post-operative appointment, the patient experienced a significant reduction of symptoms. In the absence of large series or randomized trials, we suggest that robotic-assisted surgery is a valid treatment option for pelvic AVM in the setting of failed embolization.

Robotic Approach to Ectopic Endometriosis in a Patient with Duplicated Ureters

<h3>Study Objective</h3> To demonstrate a minimally invasive approach to excision of ectopic urinary tract endometriosis in a patient with an anomalous duplicated left renal collecting system. <h3>Design</h3> Case report surgical video. <h3>Setting</h3> Single center academic institution. <h3>Patients or Participants</h3> A 45-year-old female with a history of endometriosis with prior robotic hysterectomy and left salpingo-oophorectomy presented with worsening urge incontinence, flank and pelvic pain. Patient was referred after evaluation revealed a mass adjacent to the left ureterovaginal junction and bladder trigone. <h3>Interventions</h3> Initial cystoscopy revealed a left non-intrusive bladder mass near the left ureteral orifices. A 2 cm firm, fixed nodule in the left fornix of the vagina was excised. Endometriosis was confirmed on frozen section. Upon laparoscopic entry, anatomy was noted to be distorted due to extensive scarring in the left pelvic sidewall including the vaginal cuff and bladder. The posterior cul-de-sac, pararectal, and paravesical spaces were then dissected open, allowing for visualization of the intersigmoid recess and the double ureters encased in scar tissue. After creating two small windows to open the peritoneum, continued dissection proceeded laterally along the pelvic sidewall. En bloc endometriosis was noted on the left infundibulopelvic ligament, vaginal cuff, bladder, and ureters. The scarred peritoneum was excised by encircling the affected areas. Concomitant ureteral dissection ensued with simultaneous removal of endometriotic nodules at the vaginal cuff and ureterovaginal junction. The patient then had an uncomplicated right salpingo-oophorectomy. <h3>Measurements and Main Results</h3> The patient was discharged home on postoperative day one and had an overall uncomplicated postoperative course. Final pathology was consistent with endometriosis. At her post-operative appointment, the patient experienced complete resolution of her symptoms. <h3>Conclusion</h3> In a patient with a known history of endometriosis and a newfound bladder mass, ectopic endometriosis should be considered. Robotic surgical excision is an appropriate minimally invasive approach after adequate preparation.

Adherence to Post-operative Appointments Is Associated with Weight Loss Following Bariatric Surgery.

Adherence to Post-operative Appointments Is Associated with Weight Loss Following Bariatric Surgery.

Post-operative Pain Outcomes of Laparoscopic Ventral Hernia Repair (LVHR): An eight-year experience

Objective:To evaluate post-operative pain, recovery time and standard of living in patients undergoing LVHR in detail. Study design and Setting: This prospective cohort study was conducted at a tertiary care hospital of Karachi, Pakistan,after getting approval from the “National Medical Centre EthicalReview Board”, from January 2011 to December 2019, Methodology: Total n= 577 patients undergoing standard LVHR procedure (defect closed with non-absorbable monofilamentsuture, reinforced with intra-abdominal dual layer mesh, anchored with non-absorbable tacks &amp; sutures). Patient demographics,perioperative &amp; postoperative findings and post-operative pain analysis were investigated and presented as descriptivestatistics. Follow-up was carried out at 1stweek, 2ndweek, 3rdmonthly, 6 monthly and 12 monthly post-operative appointments. Results: During the study period of nine years (January 2011 to December 2019), 577 patients (primary ventral hernia n=232, recurrent ventral hernian=188 patients, incisional hernian=157) underwent LVHR. Mean post-operative hospitalstay was 1.53 ± 1.8 days. Mean post-operative pain assessment onvisual analog scale (VAS) after surgery (0-3days) wasreported to be 38.5±29 by 65 patients out of 577 (11.26%), which significantly decreased at the end of 1st week to 27.9 ± 25.6. Only 3 patients (0.51%) reported chronic pain during the span of 3-6 months. Conclusion: LVHR was associated with considerably less post-operative pain, shorter hospital stay and reduced time of convalescence. It is demonstrated that LVHR to be a safe and superior approach for the repair ventral hernias

Are Antidepressant Medications Associated with Increased Dental Implant Failure?

Statement of the problemThe purpose of this study was to determine whether antidepressant medications were associated with a lower dental implant success rate. Materials and methodsA retrospective cohort study was conducted to evaluate dental implants placed in 2015 at the VA North Texas Health Care System. The following inclusion criteria were defined: 1) patients with adequate postoperative follow-up appointments for 5 years; 2) cases with sufficient medical records; 3) patients who had a current diagnosis of depression at the time of implant placement and were taking an antidepressant medication. Patients were excluded as study subjects if: 1) they had inadequate medical records; 2) they were a current tobacco smoker or were undergoing treatment for systemic conditions such as bisphosphonate use, radiation, or chemotherapy. The primary predictor variable was current use of an antidepressant medication. The primary outcome variable was implant success, defined as an implant without pain upon function, no mobility, < 2mm radiographic bone loss from initial surgery, and no history of exudates.1 Secondary predictor variables were age ≥ 65 years and sex, defined as male or female. Descriptive, bivariate, and multiple logistic regression analyses were performed with P < .05 used to determine statistical significance. Results and outcomesThirty-one patients and 67 implants met the defined inclusion and exclusion criteria. The average age was 65 years. Fifty-two implants were placed in patients 65 years and older. Sixty implants were placed in males, and 7 were placed in females. Sixty-one implants met the defined success criteria (91%), with 7 implant failures (7%). Forty-six implants were placed in patients on antidepressant medication. The antidepressant treatment group had 41 implants that met success criteria (89%) and 5 implant failures (11%). Analysis of the predictor variable and primary outcome variable revealed that antidepressant therapy was associated with a nearly 60% decrease in success (OR 0.41; 95% CL 0.04-3.75), but was not statistically significant (P = .6542). Analysis of the secondary variables reveled that age ≥ 65 and female sex were not associated with statistically significant differences in dental implant success (P = 1 and P = .4927, respectively). Discussion and conclusionThe results of this retrospective analysis suggest that antidepressant use does not affect the success rate of dental implants. A systemic review by Silva et al found an increased risk for implant failure in antidepressant users compared to non-users, but cautioned their conclusions due to a lack of methodological rigor and standardization.2 They found an increased rate of dental implant failures in tobacco smokers who also took antidepressants. They hypothesized that tobacco smoke can be a surrogate for dental implant failure in patients taking antidepressants as nicotine can impair new bone formation and impair osseointegration, artificially inflating the rate of implant failure in this cohort. One of the strengths of the current study is strict rule-out criteria for current tobacco smokers, as patients who receive implants at this center have point-of-care nicotine testing prior to implant placement. The results of this present study suggest that antidepressant use does not decrease implant success rates over a 5-year period. Future prospective studies, with larger cohorts, will be performed to further elucidate the association between antidepressant use and dental implant success.

682 ENDOFLIP TAILORED PER-ORAL ENDOSCOPIC MYOTOMY (POEM): EXPERIENCE IN TWO UK CENTRES.

Abstract Per-oral endoscopic myotomy (POEM) is an effective treatment for achalasia. Efficacy is equivalent to Laparoscopic Heller’s myotomy with the advantage of minimal access and shorter length of stay. Post-operative reflux rates are higher in POEM. The Functional Luminal Imaging Probe (FLIP) allows the measurement of lower oesophageal distensibility during per-oral endoscopic myotomy. In theory, this enables the operator to tailor the myotomy to ensure adequate distensibility whilst minimising post-operative reflux risk. Methods Two prospectively collected POEM databases were analysed from 2 UK tertiary upper GI centres. The operators in each centre used intraoperative FLIP measurements to ensure adequate myotomy. Outcome measures included Eckardt score (where ≤3 indicated clinical success) and proton pump inhibitor use (PPI), collected at the first post-operative appointment. Length of stay was recorded, as were complications. Results 142 patients underwent POEM between 2015 and 2019 with 90% (128/142) clinical success. This improved to 93% (68/73) in the latter half of each series. 79% of the poor responders had previous interventions compared to 55% of responders (p = 0.09). Average post myotomy distensibility was 5.2 mm2/mmHg in responders and 3.11 in non-responders(p = 0.11). DI of &amp;gt;4.5 mm2/mmHg was associated with 100% clinical success. Myotomy length of &amp;lt;7 cm was associated with 93% clinical success and 40% post op PPI use compared to 60% with longer myotomies. There were 2 type IIIa, 2 type IIIb and one type IV Clavien-Dindo complications. Conclusion This study represents one of the largest UK series of FLIP tailored per-oral endoscopic myotomy. FLIP allows intraoperative monitoring of oesophageal distensibility allowing tailoring of myotomies. Tailored myotomies ≤6 cm were effective and were associated with less PPI use post operatively. Early referral of patients to high volume centres, where myotomies can be tailored using FLIP may lead to improved outcomes. More collaborative data from high volume centres is needed to decipher optimal myotomy profiles.