Preoperative Imaging Research Articles

Clinical Evaluation of the NaviNetics Stereotactic System Using Intraoperative Portable Surgical Imaging System in DBS Surgery

BACKGROUND AND OBJECTIVES: A typical workflow for deep brain stimulation (DBS) surgery consists of head frame placement, followed by stereotactic computed tomography (CT) or MRI before surgical implantation of the hardware. At some institutions, this workflow is prolonged when the imaging scanner is located far away from the operating room, thereby increasing workflow times by the addition of transport times. Recently, the intraoperative O-arm has been shown to provide accurate image fusion with preoperative CT or MR imaging, suggesting the possibility of obtaining an intraoperative localization scan and postoperative confirmation. In this article, we aim to evaluate the compatibility of the stereotactic frame system with the intraoperative O-arm system regarding lead accuracy and surgical flow. METHODS: A total of 17 patients undergoing DBS surgery for movement disorders were evaluated. One patient underwent both the stereotactic CT and O-arm localization, while 16 patients underwent only intraoperative O-arm localization. Following lead placement, intraoperative O-arm imaging was obtained to evaluate the accuracy of the lead placement. Accuracy was defined as the error measured as the distance from the center of the planned trajectory to the cannula. RESULTS: Less than 0.1 mm difference was found between the O-arm imaging technique and CT image localization of the NaviNetics stereotactic head frame in DBS surgery. Of the 16 patients who underwent the intraoperative O-arm imaging alone, the targets included bilateral ventral intermediate nucleus (16 leads), bilateral globus pallidus internus (4 leads), and subthalamic nucleus (12 leads). The mean ± SD radial error in the probe's eye view was 0.71 ± 0.33 mm for n = 32 leads. No tract hemorrhage was observed. CONCLUSION: Intraoperative O-arm imaging can be used safely and effectively for stereotactic registration and lead placement confirmation with the stereotactic system in both awake and asleep DBS surgery.

Utilization of preoperative EOS imaging to prevent adverse events following total hip arthroplasty

ABSTRACT Introduction Previous studies have demonstrated the use of technology in total hip arthroplasty (THA) provided favorable outcomes. This study sought to describe the effect preoperative two-dimensional low-dose (2DLD) full-body radiographs had on the prevention of adverse outcomes following THA. Methods We reviewed 11,814 cases of patients who underwent primary, elective THA from 2016 to 2021. Patient demographics and clinical data were compared between patients who did or did not have preoperative standing and sitting 2DLD images (29.5% vs. 70.5%, respectively) using Chi-squared test and multivariate logistic regressions. Results The rate of patients with preexisting spinal fusion was higher in the 2DLD cohort (2.2 vs. 0.6%, respectively, p < 0.001). Preoperative 2DLD images were favored in outcomes including length of stay (40.15 vs. 67.16 hours; p < 0.001), rate of discharge to home (94.1 vs. 80.0%; p < 0.001), and 90-day readmission rate (3.5 vs. 6.0%; p < 0.001). Multivariate analysis demonstrated preoperative 2DLD images to be significantly associated with lower odds of dislocation, independent from surgical approach, coexisting spinal fusion, and utilization of dual-mobility implants. Conclusion Preoperative 2DLD images were independently associated with decreased risk for dislocations. Even in a higher risk cohort with spinal fusion, the rate of dislocation in the 2DLD cohort was significantly lower.

Impact of preoperative clinical and imaging factors on post-pericardiectomy outcomes in chronic constrictive pericarditis patients.

The present study was designed to identify the preoperative clinical and imaging findings influencing adverse clinical outcomes in patients with chronic constrictive pericarditis after pericardiectomy. Patients with constrictive pericarditis who underwent pericardiectomy between January 2009 and September 2023 were retrospectively analyzed. Preoperative evaluations included assessments of clinical symptoms, comorbidities, laboratory tests, cardiac computed tomography (CT), and transthoracic echocardiography. The volume of pericardial calcifications was quantified on calcium scoring CT. Adverse clinical events were defined as cardiovascular death or hospitalization due to cardiac causes, and all-cause mortality was assessed. Univariable and multivariable Cox proportional hazard model analysis were performed to find factors associated with adverse clinical events. Among the 91 patients with available preoperative CT scans, 26 (28.6%) experienced adverse clinical events after pericardiectomy, with 19 (20.9%) experiencing cardiovascular deaths. On multivariable Cox analysis, larger pericardial calcium volume hazard ratio [HR], 1.004 (95% confidence interval [CI], 1.001-1.006) per 1cm3 increase; p = 0.005), higher E/E' ratio (HR, 1.059, 95% CI, 1.015-1.105, p = 0.008), and lower albumin level (HR, 0.476, 95% CI, 0.229-0.986, p = 0.046) were significant factors associated with the adverse clinical events after pericardiectomy. The amount of pericardial calcification could be associated with the efficacy of pericardiectomy and potentially have implications for postoperative outcomes. Additionally, a high E/E ratio on echocardiography is indicative of unfavorable postoperative prognosis.

Diagnostic performance of adult-based thyroid imaging reporting and data systems in pediatric thyroid carcinoma: a retrospective study.

Thyroid nodules diagnosed in children pose a greater risk of malignancy compared to those in adults. However, there is no ultrasound thyroid nodule evaluation system aimed at children. The objective of this research is to assess the diagnostic performance of the adult-based American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS) and Chinese Thyroid Imaging Reporting and Data System (C-TIRADS) in pediatric thyroid carcinoma. The preoperative ultrasound images of 177 thyroid lesions in 136 pediatric patients aged 18 or younger who underwent thyroid surgery or fine needle aspiration (FNA) at our center from July 2017 to July 2022 were reviewed. The sonographic characteristics of pediatric thyroid carcinoma were compared and analyzed in contrast to benign nodules. All the nodules were evaluated by the ACR-TIRADS and the C-TIRADS respectively. Ultrasound features such as solid composition (94.8%), hypoechogenicity or marked hypoechogenicity (94.8-95.7%) and microcalcification (78.3-84.3%) were more common in pediatric malignant nodules (P-values < 0.05). The areas under receiver operating characteristic curves (AUC) of the ACR-TIRADS and the C-TIRADS in diagnosing pediatric thyroid carcinoma were 0.903-0.906,0.907-0.909 (P-value > 0.05). The interobserver agreement of both the ACR-TIRADS and the C-TIRADS was strong (weighted Kappa > 0.90). Both the C-TIRADS and the ACR-TIRADS owned great diagnostic performance and strong interobserver agreement in diagnosing pediatric thyroid carcinoma. However, a more complete and specific ultrasound evaluation system for pediatric thyroid nodules is still needed.

Preoperative quantitative imaging use in predicting intraoperative decision for hip labral repair versus reconstruction

Abstract Intraoperative assessment of labral quality determines arthroscopic repair versus reconstruction for hip labral tear treatment. T2 mapping technology discriminates between healthy and damaged cartilage. This study investigated if T2 mapping magnetic resonance imaging (MRI) can preoperatively predict labral repair versus reconstruction. This retrospective comparative study included patients with preoperative T2 mapping MRI who underwent hip labral repair or reconstruction at a single institution between March 2021 and February 2023. Three reviewers using Syngo.via recorded average T2 mapping values for the labrum, acetabular cartilage, and femoral cartilage on patients’ sagittal cut. Intraclass correlation values estimated rater agreement of T2 values. T2 means were compared using t-tests. Three Bayesian regression models were created, separately analyzing the labrum, acetabular cartilage, and femoral cartilage mapping values. The 95% credible intervals determined the significance of regression coefficients. A total of 63 operations were included: 14 reconstructions and 49 repairs. Participants were 14- to 50-years-old, with 35 females and 28 males. There was excellent agreement among raters for T2 measurements. There was no significant difference in average T2 values between the repair and reconstruction groups. All three models showed that the odds of labral reconstruction were negatively associated with T2 mapping values, positively associated with age, and increased in males. Preoperative T2 mapping values from the labrum, acetabular, and femoral cartilage are negatively associated with the odds of needing a labral reconstruction. Increased age and being male are associated with increased odds of needing a labral reconstruction. This study will allow further evaluation into other variables that predict labral repair versus reconstruction.

Effectiveness of modified temporomandibular joint disc reduction and suture with tragus incision assisted by arthroscopy

To investigate the effectiveness of modified temporomandibular joint disc reduction and suture with tragus incision assisted by arthroscopy for temporomandibular joint anterior disc displacement (ADD). A clinical data of 30 patients (45 sides) with temporomandibular joint ADD, who met selective criteria and were admitted between September 2022 and February 2024, was retrospectively analyzed. Among them, 15 patients (23 sides) were treated with temporomandibular joint disc reduction and suture via small incision (open operation group), and 15 patients (22 sides) with modified temporomandibular joint disc reduction and suture with tragus incision assisted by arthroscopy (arthroscopy group). There was no significant difference in gender, age, disease duration, affected side, Wilkes-Bronstein stage, preoperative visual analogue scale (VAS) score, maximal interincisal opening (MIO), and temporomandibular joint dysfunction index (DI), craniomandibular index (CMI), palpation index (PI), and other baseline data between groups ( P>0.05). VAS score, MIO, and temporomandibular joint function indicators (PI, DI, CMI) of patients were recorded at 3 months after operation, and the difference (change value) of the above indicators between pre- and post-operation was calculated. At 1 week after operation, MRI was performed to evaluate the reduction of the articular disc compared to the preoperative image. The results were classified as excellent, good, and poor, with excellent and good being considered effective reduction. The condition of condyle process repair was observed by cone beam CT (CBCT) at 3 months after operation. All incisions healed by first intention in the two groups. All patients were followed up 3-18 months (mean, 8.2 months). Facial nerve injury occurred in 3 cases in the open operation group and 1 case in the arthroscopy group, all of which returned to normal after physiotherapy and drug treatment. At 3 months after operation, MIO and VAS scores of both groups significantly improved when compared with those before operation ( P<0.05), and temporomandibular joint function indicators (PI, DI, CMI) significantly decreased ( P<0.05). The change values of MIO and temporomandibular joint function indicators in arthroscopy group were significantly higher than those in open operation group ( P<0.05). There was no significant difference in the change value of VAS score between groups ( P>0.05). There was no recurrence during follow-up. Postoperative MRI review showed that the effective reduction rate of joint disc was 95.65% (22/23) in the open operation group and 95.45% (21/22) in the arthroscopy group, with no significant difference between groups ( P>0.05). Postoperative CBCT found that early and timely effective reduction of joint disc was conducive to condyle process repair and reconstruction. Modified temporomandibular joint disc reduction and suture with tragus incision assisted by arthroscopy has a clear effect in the treatment of ADD, with less trauma, fewer postoperative complications, and good early effectiveness.

Concordance between preoperative ultrasound arterial mapping in the femoropopliteal and distal sector and intraoperative angiography.

The present study analyzes the concordance between arterial mapping of this sector using duplex ultrasound and intraoperative angiography. A retrospective, single-center observational study was carried out. The study sample consisted of patients subjected to open or endovascular surgery of the femoropopliteal and distal sector with prior ultrasound arterial mapping from January 2017 to December 2022. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of arterial mapping with duplex ultrasound versus intraoperative angiography were evaluated, the degree of concordance between the two techniques and the correlation between surgical planning and the surgery finally performed. 167 patients were analyzed. A total of 1837 segments were explored, of which 149 (8.1%) were not able to be evaluated. Regarding the global precision of ultrasound in predicting significant arterial lesions (stenosis > 50% or occlusion), sensitivity was 85.26% (95% confidence interval [95%CI]: 82.33-88.19%), specificity 88.57% (95%CI: 86.63-90.51%), PPV 80.41% (95%CI: 77.24-83.58%), and NPV 91.61% (95%CI: 89.89-93.34%). Global concordance assessed by the kappa index was 0.725 (95%CI: 0.691-759). The surgical indications based on arterial mapping coincided with the final surgery performed in 97.6% of the cases. Arterial mapping of the femoropopliteal and distal sector with duplex ultrasound could be considered as the sole preoperative imaging technique for surgical planning.

Displacement of maxillary dental implants: a case series on various scenarios.

Oral rehabilitation with dental implants is a common procedure in modern dentistry due to its high success rates. However, complications such as implant displacement can occur, particularly in the maxillary region due to factors like atrophied maxilla, thin alveolar bone, and low bone density. This case series explores scenarios of maxillary dental implant displacement, emphasizing the impact of immediate preoperative imaging on patient outcomes. Three cases of maxillary implant displacement are presented, each illustrating a different scenario. Complications resulting from the displacement of implants into adjacent structures such as the maxillary sinus and nasal cavity are described. All cases involved implants that were displaced during second-stage surgery, occurring four to six months post-implantation. Removal attempts used transnasal endoscopic, intraoral, or combined approaches, with only one implant successfully retrieved. Delays in surgery ranged up to 72h, leading to one implant being swallowed and another unlocated. Outcomes varied, with some patients requiring hospitalization for up to five days. This series highlights the crucial role of immediate preoperative 3D imaging in precisely locating displaced implants to ensure their safe and efficient removal. While implant displacement may not always be preventable, optimizing the timeframe between diagnostic imaging and surgical intervention can significantly enhance management. Accurately locating the implant minimizes treatment invasiveness and patient discomfort, thereby improving clinical outcomes.

SURGICAL APPROACH TO THALAMIC CAVERNOUS MALFORMATIONS

Introduction Thalamus is a high eloquent brain region, because it contains important relay nucleus and is surrounded by vital neural and vascular structures. Cavernous malformations involving deep structures such as the basal ganglia and thalamus account for 5–10% of all cerebral cavernomas and can cause devastating neurological deficits. Surgical approach to thalamic cavernomas is associated with risks of new or worsening neurologic deficits. The benefit of surgery must be carefully weighed on an individualized basis. There are several surgical routes that can be used to approach thalamic lesions, mainly transcortical and interhemispheric approaches. A particular approach should be selected based on the location of the cavernoma in the thalamus to minimize lesion of the unaffected brain. Methods We present the case of a 43-year-old right-handed lady with right bleeding posterolateral thalamic cavernoma, admitted to the neurosurgery department of Sibiu MedLife Polisano Hospital in February 2024. The patient underwent surgery, through a transcortical trans-sulcal para-fascicular, navigation guided approach. Preoperative tractography imaging, tubular cerebral corridor retractor system and intraoperative monitoring of the cortico-spinal tract, through motor evoked potentials (transcortical, cortical and subcortical mapping) and of the spinotahamic tract through somatosensory evoked potentials were used. The postoperative course was uneventful and the patient was discharged on the 7th postoperative day. Conclusions Thalamus is a complex structure located in a deep brain area and surgery for these region carries high risks, so the surgeon must carefully tailor these patients. The transcortical transsulcal para-fascicular approach is feasible and safe using the cerebral tubular corridor, neuronavigation and neuromonitoring. Advanced surgical technology offers the advantages of minimizing the risks of new neurological deficits.

True Median Cleft With Sinus Tract in the Nasal Septum: A Case Report.

A true median cleft is an extremely rare congenital anomaly characterized by a midline vertical cleft and various deformities, also known as Tessier number 0 cleft. Here we report a case of a 5-year-old Asian boy with true median cleft associated with sinus tracts in the nasal septum, a phenomenon not previously reported in the literature. The tracts were identified as the cause of recurrent infections around the oral vestibule and upper lip. The tracts were resected successfully, and postoperative progress has been satisfactory. We discuss the importance of preoperative image evaluations and the selection of a suitable surgical approach.

EGS SO31 - Does in-hospital delay in appendicectomy lead to complicated appendicitis and affect post operative outcome - a single centre study

Abstract Background Acute appendicitis is one of the most common reasons for emergency general surgical admissions in the U.K. The standard treatment for acute appendicitis is emergency appendicectomy. However, the urgency to operate on patients admitted to hospital with acute appendicitis has been widely debated, with no current standard guideline to follow. The aim of this study was to identify the effect of in-hospital delay in appendicectomy on intra operative findings of complicated appendicitis. The secondary outcome measures were the requirement of a surgical drain, overall length of stay, post-operative complications and re-admission rates. Method This was a single centre retrospective study. All patients who underwent an emergency appendicectomy, between 01/09/2023 and 30/11/2023 were included in this study. Hospital electronic patient records were screened to record the time of decision to operate, surgical start time, the delay between decision to operate and surgical start, intra-operative findings, and post-operative course. A total of 105 patients were included. These were divided into two sub-groups based on the delay between decision to operate and surgical start time; patients who had surgery within 12-hours (early) and those who had surgery after 12-hours (delayed) from the decision to operate time. Results Surgery was performed within 12-hours in 42% cases. The remaining 68% had more than a 12-hour delay, with almost 1 in 4 cases (26 /105) delayed over 24 hours. 15% cases (16) with uncomplicated appearance on pre-op imaging and delayed more than 12-hours progressed to complicated appendicitis intra-operatively. Surgical drains were required in 10% delayed cases and 6% early cases. The median length of stay was 2-days in delayed, compared to 1 day in cases performed early. Post-operative complications were higher in cases early. Although majority of these had complicated appearance in pre-op imaging. Both groups had same readmission rate. Conclusion Our study found that in-hospital delay in appendicectomy can potentially result in increased length of stay, higher rate of requirement of surgical drains and progression from imaging severity. This needs better prioritisation and theatre allocation.

Hyperspectral imaging in neurosurgery: a review of systems, computational methods, and clinical applications.

Accurate identification between pathologic (e.g., tumors) and healthy brain tissue is a critical need in neurosurgery. However, conventional surgical adjuncts have significant limitations toward achieving this goal (e.g., image guidance based on pre-operative imaging becomes inaccurate up to 3cm as surgery proceeds). Hyperspectral imaging (HSI) has emerged as a potential powerful surgical adjunct to enable surgeons to accurately distinguish pathologic from normal tissues. We review HSI techniques in neurosurgery; categorize, explain, and summarize their technical and clinical details; and present some promising directions for future work. We performed a literature search on HSI methods in neurosurgery focusing on their hardware and implementation details; classification, estimation, and band selection methods; publicly available labeled and unlabeled data; image processing and augmented reality visualization systems; and clinical study conclusions. We present a detailed review of HSI results in neurosurgery with a discussion of over 25 imaging systems, 45 clinical studies, and 60 computational methods. We first provide a short overview of HSI and the main branches of neurosurgery. Then, we describe in detail the imaging systems, computational methods, and clinical results for HSI using reflectance or fluorescence. Clinical implementations of HSI yield promising results in estimating perfusion and mapping brain function, classifying tumors and healthy tissues (e.g., in fluorescence-guided tumor surgery, detecting infiltrating margins not visible with conventional systems), and detecting epileptogenic regions. Finally, we discuss the advantages and disadvantages of HSI approaches and interesting research directions as a means to encourage future development. We describe a number of HSI applications across every major branch of neurosurgery. We believe these results demonstrate the potential of HSI as a powerful neurosurgical adjunct as more work continues to enable rapid acquisition with smaller footprints, greater spectral and spatial resolutions, and improved detection.

HPB SO24 - Recurrence Pattern of Pancreatic Ductal Adenocarcinoma based on Time-to-Recurrence: A 5-year Single-Centre Retrospective Study

Abstract Background A vast majority of patients with pancreatic ductal adenocarcinoma (PDAC) develop early disease recurrence, even after curative-intent surgical resection. Understanding the pattern of disease recurrence will enable identification of areas for improvement within the preoperative diagnostic and management algorithms for these patients. The aim of the retrospective cohort study was to compare the recurrence pattern of PDAC in patients with early (&amp;lt;12 vs &amp;gt;12 months) and very early (&amp;lt;6 vs &amp;gt;6 months) recurrence following surgical resection. Method A retrospective review of histologically confirmed pancreatic ductal adenocarcinoma patients who underwent pancreaticoduodenectomy (N=151) between 2015-2020 at a tertiary HPB centre was undertaken. All patients underwent CT and PET-CT for initial staging before resection. Initial recurrence after resection was identified through postoperative imaging and/or HPB MDT outcomes. Early recurrence (ER) was defined as recurrence within the first 12 months after surgery (n=78). Additionally, very early recurrence (VEM) was defined as recurrence within the first six months after surgery (n=46). Statistical analysis was performed using GraphPad Prism 8.0. Results In total, 117 (77.5%) of patients experienced recurrence, with a median recurrence-free survival of 11.3 (5.1-19.6) months. Patients with ER had significantly higher pathological T staging (p=0.01), greater margin positivity rate (p=0.01) and higher lymph node ratio (p=0.046), while those in VER had significantly larger maximum tumour diameter and number of involved lymph nodes (p=0.04) compared to their counterparts. Patients with ER (47.4 vs 31.5%, p=0.046) and VER (60.9 vs 30.5%, p&amp;lt;0.001) had significantly greater rates of liver metastasis compared to their counterparts. There were no differences in loco-regional recurrence, peritoneal or pulmonary metastasis between the groups. Conclusion Approximately 20% of patients undergoing surgical resection for PDAC developed liver metastasis within six months of surgery. This raises concerns for the presence of micro-metastatic disease within the liver unidentified on preoperative imaging. Therefore, there is a need to enhance preoperative imaging and treatment algorithms to improve survival of patients with PDAC.

BN SO21 - Factors influencing subtotal cholecystectomy

Abstract Background Laparoscopic Cholecystectomy (LC) is the main treatment for symptomatic gallstone disease. Sub-total cholecystectomy (SC) has become increasingly utilised as a safe alternative to conversion to open when unable to visualise the critical view of safety. This avoids the morbidity of an open operation whilst minimising the risk of iatrogenic injury to the common bile duct. Male sex, increasing age, previous acute cholecystitis and ERCP have previously been identified as independent risk factors for SC. We aim to identify factors that increased the likelihood of SC within our cohort and the effect of SC on post-operative morbidity. Method All patients who had LC as either an elective or emergency procedure between 1st July 2020 and 30th June 2022 were identified and included in this study. Patient and operative details were retrieved from their electronic record and a Charlson co-morbidity index was calculated. Any post-operative complication was noted and graded according to the Clavien-Dindo classification. Statistical analysis was performed using SPSS with ANOVA analysis being performed for continuous data. Odds ratios were calculated with a 95% confidence interval. Statistical significance was taken as a p value &amp;lt; 0.05. Results 974 patients underwent LC with 4.8% having SC. Factors associated with increased risk of SC included: previous acute cholecystitis (OR 9.37 (4.69-18.70), increased age (mean = 58.7 vs 50.9), higher Charlson co-morbidity index (mean = 2.60 vs 1.43) male sex (OR 2.49 (1.38-4.48), emergency operation (OR 2.30 (1.23-4.30), Diabetes Mellitus (OR 2.58 (1.23-5.36); and previous ERCP (OR 2.62 (1.13-6.11). 30-day morbidity was higher for SC (25.5% vs 8.1%) with major complication (Clavien-Dindo &amp;gt; 2) being significantly more frequent (OR 6.64(2.53-17.4). Median post-operative length of stay was 2 days for SC and 0 days for LC. Conclusion Although regarded as a safe option in difficult cholecystectomy, our study shows that there is significant morbidity associated with subtotal cholecystectomy. However, the majority of patients only require a short hospital stay post-operatively. Multiple risk factors were identified for SC with previous acute cholecystitis being the most strongly associated with SC. Diabetes was identified as an independent risk factor alongside higher Charlson co-morbidity index as a generic marker of co-morbidity. Interestingly, CBD diameter &amp;gt; 8mm on pre-operative imaging was not shown to increase risk of SC.

OGC SO38 - Laparoscopic repair of para-conduit hernia post minimally invasive esophagectomy using anterior hiatal suture repair and mobilisation of left liver lobe as reinforcement

Abstract Background Para-conduit hernia (PCH) formation is a rare and late complication of oesophagectomy that is associated with high risk morbidity. Minimally invasive oesophagectomy is associated with increased incidence of PCHs when compared to open or trans-hiatal oesophagectomies. Various techniques to repair PCHs including mesh repair, anterior/posterior hiatal suture repairs or even careful 360 degree repairs have been described in the literature1,2. But the risk of recurrence of PCH still remains high. We describe a unique laparoscopic technique which we believe to be associated with reduced risk of recurrence of PCH post-surgical repair. Method We present 4 cases of symptomatic PCH repairs performed laparoscopically. In this unique technique the contents of the sac is reduced and the hiatus is repaired anteriorly with interrupted ethibond sutures. The left lobe of the liver is mobilised and glued to the greater curve omentum along the conduit and the hiatus. This latter step is an additional way of preventing intraabdominal contents from entering the mediastinum. Data was collected retrospectively to include: patient demographics, details of original MIO surgery, pre-op imaging and details of the presenting symptoms with PCH including imaging, operative details and all available follow up. Results Between January 2022 and July 2024, 4 patients underwent laparoscopic repair of paraconduit hernia within 1-2 years post MIO. 3 were male and 1 female aged between 56-71 years. 3 of the procedures were performed electively and one as an emergency. All presented with symptomatic paraconduit hernias and managed with surgery using the technique described above. We present a video of laparoscopic repair as described. Conclusion We report a case series of 4 patients presenting with symptomatic PCH that were managed safely with a unique laparoscopic technique using suture repair and left liver lobe mobilisation to prevent recurrence of PCH.

An AI-driven preoperative radiomic subtype for predicting the prognosis and treatment response of patients with papillary thyroid carcinoma.

8-28% of Papillary thyroid carcinoma (PTC) experience recurrence, complicating risk stratification and treatment. We previously identified an inflammatory molecular subtype of PTC associated with poor prognosis. Based on this subtype, we aimed to develop and validate a noninvasive radiomic signature to predict prognosis and treatment response in PTC patients. We collected preoperative ultrasound images from two large independent centers (n=2506) to develop and validate a Deep Learning Radiomics signature of Inflammation (DLRI) for predicting the inflammatory subtype of PTC, including its correlation with prognosis and anti-inflammatory traditional Chinese medicine (TCM) treatment. Training set 1 (n=64) and internal validation set 2 (n=1108) were from Tianjin Medical University Cancer Institute and Hospital. External validation set 1 (n=76) and 2 (n=1258) were from Fudan University Shanghai Cancer Center. We developed DLRI to accurately predict PTC's inflammatory subtype (AUC=0.97 in the training set 1 and AUC=0.82 in the external validation set 1). High-risk DLRI was significantly associated with poor disease-free survival in the first cohort (HR=16.49, 95% CI: 7.92-34.35, P<0.001) and second cohort (HR=5.42, 95%: 3.67-8.02, P<0.001). DLRI independently predicted disease-free survival, irrespective of clinicopathological variables (P<0.001 for all). Furthermore, patients with high-risk DLRI were likely to benefit from anti-inflammatory TCM treatment (HR=0.19, 95% CI: 0.06-0.55, P=0.002), whereas those in low-risk DLRI did not. DLRI is a reliable noninvasive tool for evaluating prognosis and guiding anti-inflammatory TCM treatment in PTC patients. Prospective studies are needed to confirm these findings.

HPB SO07 - Update to the role of staging laparoscopies in stratifying patients by operability in perihilar cholangiocarcinoma

Abstract Background Radical resection of perihilar cholangiocarcinoma (pCCA) is only an option for the minority presenting at an early stage. Sensitivity of radiological imaging to detect liver and peritoneal metastases is insufficient. Our published 2017 cohort study demonstrated over a quarter of patients with no radiologically detectable metastatic disease were subsequently found to have unresectable disease by staging laparoscopy. However, less than 3% of these patients had preoperative PET-CT, which is now strongly recommended in new national guidance.Advances in CT and MRI sensitivity and increased PET-CT use demanded a reassessment of the need for staging laparoscopy in diagnostic assessment of resectability. Method All patients referred to a tertiary UK hepatobiliary centre with a new diagnosis of radiologically suspected or biopsy-proven pCCA from January 2020 to January 2024 were included (n=305). Patients were identified through a prospectively maintained cancer database. Electronic health records were interrogated for demographic data, preoperative radiological imaging, and details related to operative procedures. Those referred with, or subsequently found to have, any of the following conditions were excluded: recurrent pCCA, intrahepatic or distal cholangiocarcinoma, gallbladder cancer or benign hepatobiliary disease. Results All patients underwent CT chest, abdomen and pelvis. 194 (64%) received contrast MRI liver or MRCP. Based on these, 242 (79%) had locally advanced or metastatic cancer, comorbidities precluding resection or otherwise declined surgery. PET-CT was employed to investigate all remaining 63 patients, which discovered metastatic disease in 16 patients (25%). 47 patients proceeded to staging laparoscopy. This yielded metastatic or locally advanced disease in five patients (11%); a near-statistically significant drop compared to our previously published yield of 27.2% (p=0.060). Two (5%) had open-and-close laparotomies for irresectable disease, compared to 16 of 114 (14%) in our 2017 publication (p=0.14). Conclusion Technological advances of CT and MRI and use of PET-CT have vastly improved detection of irresectable pCCA. This study reinforces the merits of PET-CT in identifying occult disease, and we would encourage units that undertake these resections to utilise this imaging modality prior to undertaking staging laparoscopy. Nevertheless, peritoneal spread remains challenging to exclude radiologically, and diagnostic laparoscopy endures as a vital tool in the prevention of open-and-close laparotomies.

Innovative 3D Imaging in Pre-Operative Evaluation for Secondary Cytoreductive Surgery in Recurrent Ovarian Cancer: A Pilot Study.

The efficacy of secondary cytoreductive surgery (SCS) in recurrent ovarian cancer remains controversial, necessitating meticulous preoperative planning. While 3D imaging has transformed surgical approaches in various disciplines, its application in gynaecologic oncology is nascent. This study introduces a novel investigation employing preoperative 3D modeling in SCS preparation. A retrospective analysis was undertaken at a university affiliated tertiary medical center, examining patients who underwent SCS for recurrent ovarian cancer between 2017 and 2022. Patients were stratified into two cohorts: those with pre-operative CT-based 3D imaging (Group A) and those without (Group B). Demographic profiles, clinical data, and surgical outcomes were compared between the groups. Among the 76 identified patients, 18 were deemed suitable for surgery, with 7 in Group A undergoing preoperative 3D modeling. Demographics encompassing age and performance status were consistent across both groups, while Serous histology was more prominent in Group B. Although operative metrics and collaborative endeavors exhibited no statistically significant variance, the attainment of optimal debulking with no residual disease (R0) was substantially higher in Group A (100%) compared to Group B (54%), with a significance level of P = 0.05. CT-based 3D modeling in the preoperative phase of secondary cytoreductive surgery for ovarian cancer shows potential for enhancing surgical planning. While this pioneering research highlights the potential benefits of integrating 3D imaging into gynaecologic oncology, the limitations of this retrospective study imply that these findings are primarily hypothesis-generating. Further prospective studies are necessary to validate impact.

OGC SO21 - Role of Staging Laparoscopy on oesophageal and junctional cancer management

Abstract Background Staging laparoscopy and peritoneal cytology is currently recommended as a staging tool required for oesophageal and gastro-oesophageal junction (OGJ) adenocarcinomas. However, evidence is variable regarding the utility of this investigation, leading to heterogenous practice in the UK. With improved staging sensitivity of CT and PET imaging and inclusion of routine MDT discussion for upper GI cancer patients, staging laparoscopy may not be necessary for all patients with oesophago-gastric cancer, and in fact may delay their treatment. We thus aimed to assess the impact of staging laparoscopy on the treatment algorithm of patients with oesophago-gastric cancer. Method All staging laparoscopies undertaken between January 2022 and March 2024 were identified from our surgical database. Patients were included if they had oesophago-gastric adenocarcinoma, with a plan for curative treatment. Data collected included age, gender, location of primary tumour, CT/PET staging, laparoscopy findings, impact on treatment intention, neoadjuvant treatment, and final histology. Primary outcome was incidence of positive microscopic or macroscopic peritoneal disease for oesophageal and OGJ malignancy. Results 127 patients were identified - 69 (55%) oesophageal, 25 (20%) GOJ, and 32 (24.4%) gastric cancer. 1/70 (1.4%) patient diagnosed endoscopically with oesophageal cancer had positive peritoneal disease, which was suspected due to pre-operative imaging findings of ascites and suspicions of linitis plastica. Of patients diagnosed with GOJ cancer, 4/25 patients (16%) had peritoneal disease present. None of the 39 patients with oesophageal/junctional tumours with clinical T1-2 disease were found to have peritoneal disease on staging laparoscopy. 6/32 (19%) patients with gastric cancer were found to have unexpected peritoneal disease present. Conclusion This study found minimal impact staging laparoscopy has on the management of primary oesophageal cancers. Consideration can be made of limiting staging in oesophageal cancer to patients with suspicious findings on CT/PET imaging. For GOJ tumours, there may be a role for limiting staging laparoscopy for Siewert 1 tumours to T3/4 tumours based on CT/PET findings. Importantly, accurate identification on primary endoscopy of the location of the tumour in relation to the gastro-oesophageal junction is necessary to help guide ongoing management.

BN SO46 - PANDORA's BOX- When anatomy trumps the pathology

Abstract Background Obturator hernias are usually attributed to elderly females presenting with small bowel obstruction. We present a case of an elderly gentleman with severe Kyphoscoliosis presenting with small bowel obstruction. His past medical history included Ischaemic Heart Disease with stents in the coronary arteries and on dual antiplatelets. His Kyphoscoliosis precluded him from being able to lie flat on his back. The spinal deformity as revealed in the CT scans proved challenging to position him dsafely for surgery. The lack of access between costal margins and the pelvis meant that surgical access with Laparoscopy was going to be impossible. Method After initial resuscitation, he underwent CT scan of his Chest, abdomen and pelvis which revealed an obstructed Obturator Hernia on the left side with small bowel obstruction. The CT was also concerning for the Anaesthetists due to the challenge posed by the severe Kyphoscoliosis. After fibreoptic intubation, abdomen was accessed through a transverse muscle cutting incision, at the level of the umbilicus. The Obturator membrane was approached from above and the hernia was reduced. The obstructed small bowel was viable and the defect in the obturator membrane was closed with No1 Ethibond sutures. The abdomen was closed with mass closure. Results Patient had a smooth post operative period and was discharged home after 2 weeks. Obturator hernias are notorious for their occult presentation. Unless the patient is scanned with CT imaging, it is impossible to make the diagnosis although clinical signs like Howship- Romberg sign may be present with pain on internal rotation of the hip, as a result of irritation of the Obturator nerve. Obturator Neuralgia may be elicited with positive Hannington- Kiff sign, which is an absence of absent adductor reflux in the thigh. Conclusion Obturator hernias are typically seen in skinny old females. When presenting with small bowel obstruction, Obturator herniae are challenging both in terms of diagnosis as well as in management. In our case, the challenging anatomy posed greater risk to safe airway control. From surgical view, laparoscopy as a less invasive option was ruled out because of the restricted access. When anatomy is challenging, the Surgeon will be forced to think outside the box and consider access to the abdomen through incisions which are not routinely used. The preoperative imaging shows the challenge posed by the extreme spinal deformity.