Previous Surgery Research Articles

Addressing corneal opacity after herpes zoster infection

A 15-year-old boy was referred for corneal opacity evaluation. The patient had a previous herpes zoster virus (HZV) infection—varicella-zoster virus (VZV)—with ocular manifestation 1 year ago. After the infection, he developed a central corneal scar and decreased corrected distance visual acuity (CDVA) in the right eye. The slitlamp examination showed the right eye with central corneal opacity (involving anterior stroma), lacuna area between the haze, fluorescein negative, and no vascularization near the scar (Figure 1 JOURNAL/jcrs/04.03/02158034-202406000-00019/figure1/v/2024-05-21T162725Z/r/image-tiff ). The patient had been treated with oral valacyclovir and topical corticosteroids without any improvement of visual acuity or changes in opacity within the 1-year follow-up. His CDVA was 20/200 (−4.50 −0.75 × 25) in the right eye and counting fingers (−4.00) in the left eye. Intraocular pressure was 12 mm Hg in both eyes. Fundoscopy was normal in the right eye, but he had a macular scar in the left eye (diagnosed when he was 7 years). The left eye had no cornea signs. The patient has no comorbidity or previous surgeries. Considering this case, a corneal central scar in a 15-year-old boy, legally single eye only, and assuming it is an opacity in the anterior stroma, would you consider surgery for this patient? If so, which would you choose: Would you consider an excimer laser treatment of his ametropia while partially removing his opacity, a phototherapeutic keratectomy (PTK), or a PTK followed by a topography-guided treatment, femtosecond laser-assisted anterior lamellar keratoplasty (FALK), or deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (depending on the scar depth)? Would you consider prophylactic acyclovir during and after surgery? Would you consider any other surgical step to prevent delayed corneal healing-persistent epithelial defect? Before the surgical approach, would you consider treating this patient with topical losartan (a transforming growth factor [TGF]-β signaling inhibitor)? Would you first perform the surgery (which one) and then start the medication? Furthermore, if so, how long would you treat this patient? Would you consider treatment with another medication?

Postoperative outcomes of surgical delay in inflammatory bowel disease patients: a multicenter cohort study.

Postponement of surgical inflammatory bowel disease (IBD) care may lead to disease progression. This study aims to determine the influence of delayed surgical IBD procedures on clinical outcomes. This multicenter retrospective cohort study included IBD patients who underwent a surgical procedure during the Coronavirus disease 2019 (COVID-19) pandemic from March 16, 2020, to December 31, 2020, and were compared to a pre-COVID-19 cohort. The primary endpoint was determining the number of (major) postoperative complications. Secondary endpoints were the time interval between surgical indication and performance of the surgical procedure and the risk factors of postoperative complications using multivariate analysis. Eighty-one IBD patients who underwent a surgical procedure were included. The median time interval between surgical indication and performance of the surgical procedure did not differ between the COVID-19 and pre-COVID-19 cohorts (34 vs. 33.5 days, p = 0.867). Multivariate analysis revealed a longer time interval between surgical indication and surgical procedure significantly correlated with the risk of developing postoperative complications [odds ratio (OR) 1.03, p = 0.034]. Moreover, previous surgery was identified as an independent predictor (OR 4.25, p = 0.018) for an increased risk of developing major postoperative complications. There was no significant surgical delay for patients with IBD in the COVID-19 pandemic cohort compared to the pre-pandemic cohort. However, a longer time interval between surgical indication and surgical procedure significantly correlated with the risk of developing postoperative complications. In the event of future scarcity in healthcare, efforts should be made to continue surgical procedures in IBD patients.

Pathological characteristics of reoperated regrowing clinically nonfunctioning pituitary tumor cases in comparison with initial surgical cases

ObjectivePostoperative nonfunctioning pituitary tumor (NFPT) regrowth is a significant concern, but its predictive factors are not well established. This study aimed to elucidate the pathological characteristics of NFPTs indicated for reoperation for tumor regrowth.MethodsPathological, radiological, and clinical data were collected from patients who underwent repeat operation for NFPT at Moriyama Memorial Hospital (MMH) between April 2018 and September 2023. For comparison, we also gathered data from patients who underwent initial surgery for NFPT during the same period at MMH.ResultsOverall, 61 and 244 NFPT patients who respectively underwent reoperation and initial operation were evaluated. The mean period between the previous operation and reoperation was 113 months. Immunonegativity for any adenohypophyseal hormone was significantly more frequent in the reoperation group than in the initial operation group. In addition, the rate of hormone-negative but transcription factor–positive (H-/TF+) tumors among silent gonadotroph tumors was significantly higher in the reoperation group than in the initial operation group. Furthermore, seven silent corticotroph tumors (SCTs) in the reoperation group were ACTH-negative but TPIT-positive. Because most of the previous surgeries were performed in other hospitals a long time ago, we could procure the previous pathological results with immunohistochemistry (IHC) only from 21 patients. IHC for TF had not been performed in all the previous specimens. IHC for adenohypophyseal hormone was almost the same as the current results, and many H-/TF+ tumors were previously diagnosed as NCT. In addition, the reoperated patients were classified into 3 groups on the basis of the condition of the previous operation: gross total resection (GTR), 12 patients; subtotal resection (STR), 17 patients; and partial resection (PR), 32 patients. The mean Ki-67 LI in the GTR, STR, and PR subgroups were 1.82, 1.37, and 0.84, respectively, with the value being significantly higher in the GTR subgroup than in the PR subgroup (P < 0.05).ConclusionsThe ratio of H-/TF+ tumors is significantly higher in symptomatically regrown tumors than in the initial cases, which used to be diagnosed as NCT. PR cases tend to grow symptomatically in a shorter period, even with lower Ki-67 LI than GTR cases.

MODIFIED PORT POSITION FOR BILATERAL INGUINAL TAPP CREATING UNILATERAL PERITONEAL FLAP

Abstract Introduction Usually, the TAPP approach for bilateral inguinal hernia requires bilateral port placement and two separate peritoneal flaps to facilitate dissection and mesh placement. Our technique with modified port placement allows bilateral repair through unilateral flap with equal ease and feasibility and thus not only reduces the efforts of two flap suturing but also mimics TEP approach for hernia contralateral to ports. Material and Method During a period from February 2015 to December 2022 we have managed 48 patients with this approach. Patients with bilateral, primary, reducible inguinal hernias were managed, all of them do not have any history of previous surgery. With experience even complete irreducible hernias were managed in the same manner. Ports were placed on the side of the symptomatic or bigger hernia in triangular fashion for better ergonomics. Results In all patient’s adequate dissection of myopectineal orifice was achieved on either side through single flap. In few patients there were accidental small peritoneal rents on contralateral side which required single suture to close them. Medium weight PP mesh of size 15 × 12 cm was used in all except few, in which either 3D meshes or self-adhesive Progrip mesh was placed. No post-operative complications were seen in the form of recurrence or seroma and chronic pain in all patients. Discussion and conclusion Our technique of single peritoneal flap requires small unilateral flap to be raised to deal with bilateral defects without compromising on the steps of the procedure. Modification in port placement for the approach allows better ergonomics and ease of contralateral dissection and mesh placement along with easy closure of small peritoneal flap.

LAPAROSCOPIC TREATMENT OF RIGHT INGUINAL HERNIA RE-RECURRENCE

Abstract We report the case of an 81-year-old man presenting with a right inguinal hernia re-recurrence. He had undergone a laparoscopic transabdominal preperitoneal hernioplasty in 2001. The recurrence occurred in 2021, and therefore, he had to be treated with an open approach. Past medical history included arterial hypertension, COPD, coronary artery stenting for ischemic heart disease, stage II chronic renal failure. Previous surgeries consisted of bilateral iliac arteries, percutaneous angioplasty and stenting with a right femoral arterial access, laminectomy of L3–L5, and laparoscopic cholecystectomy. Surgical procedure Laparoscopy confirmed a right hernia re-recurrence. Herniated ileal loop was completely reduced. Peritoneal incision was performed with a lateral-to-medial approach. The mesh was dissected away from the pre-peritoneal fat. The shrunk mesh was pulled downwards to allow the identification of the epigastric vessels, which were then dissected according to a cranial-to-caudal approach. The large hernia sac was completely reduced thus exposing the re-recurrence orifice. Dissection was carried out towards the Bogros’ space. Epigastric vessels were detached from the mesh thus allowing to expose the medial part of the myopectineal orifice. Cooper’s ligament and pubic symphysis were therefore identified. The epigastric and spermatic vessels were freed from the mesh only after the critical view of the myopectineal orifice (MPO) was achieved. The mesh was completely mobilized from the peritoneum and removed. A “landing zone” was obtained, a 15 × 10 cm self-fixating mesh positioned around the re-recurrence orifice. Peritoneum closure was performed by means of a 3–0 running barbed suture from medial to lateral.

The Appraisal of Adults with Congenital Heart Disease: Lesson from Comparison of Surgical Outcomes.

The population of adults with congenital heart disease (ACHD) is constantly growing. There seems to be a consensus that these patients are difficult to manage especially if compared to patients with acquired heart disease. The aim of this study is to compare outcomes and results of cardiac surgery in ACHD patients with a reference population of adults with acquired cardiac disease. Retrospective study of 5053 consecutive patients older than 18years hospitalized for cardiac surgery during a 5-years period in our Institution. Two groups of patients were identified. Group I: 419 patients operated for congenital heart disease; Group II: 4634 patients operated for acquired heart disease. In each Group were identified low, medium, and high-risk patients, according to validated scores. Right ventricular outflow tract surgery was the most frequent procedure in Group I, while coronary artery by-pass grafting was the most common in Group II. Patients with ACHD were younger (37.8 vs. 67.7years), with higher number of previous operations (32.1% vs. 6.9%), had longer post-ICU hospital stay (11 vs. 8days) but had lower ICU stay (1 vs. 2days), shorter assisted mechanical ventilation (12 vs. 14h) and lower surgical mortality (1 vs. 3.7%) (all p < 0.001). No differences were found in term of post-operative complications (12.4 vs. 15%). The surgical treatment of ACHD patients can be done with excellent results and if compared with acquired cardiac disease patients they have better results with shorter ICU stay and lower mortality.

Establishment of a Clinical Prediction Model Based on the Study of Risk Factors for Pain Recurrence after Percutaneous Radiofrequency Thermocoagulation in Patients with Primary Trigeminal Neuralgia

Objectives: This study aimed to investigate the follow-up outcomes and risk factors associated with pain recurrence after percutaneous radiofrequency thermocoagulation (PRT) among patients with primary trigeminal neuralgia (PTN) and to establish a clinical prediction model based on these risk factors. Methods: The data of PTN patients who underwent PRT were collected in our study. All subjects were randomly divided at a 7:3 ratio into a training group (T Group) and a test group (C Group) to select risk factors. According to the follow-up results, the patients were divided into a recurrence group (F Group) and a nonrecurrence group (NF Group). Predictive factors were selected through LASSO regression analysis based on T Group. The identified variables were subjected to multivariate logistic regression analysis to construct a nomogram. Receiver operating characteristic (ROC) curves and calibration curves were uesd to evaluate discrimination and calibration ability separately. Results: A total of 884 patients were initially included, 857 patients achieved satisfactory results, and the pain relief rate at discharge was 96.95%. A total of 529 subjects were included after screening, and the recurrence rate was 27.22% after 1 year. Six non-zero variables were selected through LASSO regression analysis: the disease course, atypical pain, previous surgery, facial numbness before PRT, neurovascular contact (NVC), and operation duration. Six variables were included in the multivariate logistic regression analysis, and the results showed that they were independent risk factors (P&lt;0.05). The predictive model is represented by a nomogram. The area under the curves (AUC) of the ROC curves were 0.868 (0.826~0.909) and 0.874 (0.802~0.950) for T Group and C Group, respectively. The prediction curves for T Group (P=0.784) and C Group (P=0.293) fit the ideal prediction curve, and the Brier scores were 0.120 and 0.099 for T Group and C Group, which indicates that the probability predicted by the model is consistent with the actual occurrence. Conclusion: The Pain relief rate at discharge was 96.95% for PTN patients after PRT, and the recurrence rate was 27.22% after 1 year. The disease course, atypical pain, previous surgery, facial numbness before PRT, NVC, and operation duration are independent risk factors for the recurrence of pain. A nomogram model for pain recurrence was established, which has good predictive ability.

Endoscopic pilonidal sinus treatment (EPSiT) for sacrococcygeal pilonidal sinus disease: a prospective long-term study

Objective: To assess short-term and long-term outcomes of endoscopic pilonidal sinus treatment for pilonidal sinus disease. Method: The prospective study was conducted at Shifa International Hospital, Islamabad, Pakistan, from July 2015 to July 2021, and comprised all pilonidal sinus cases undergoing minimal invasive endoscopic pilonidal sinus treatment who were treated by a single surgical team. The primary outcomes were duration of healing, post-operative morbidities, persistence of discharge and recurrence at 1-7 years. The secondary outcomes were operative time, return to work, cosmetic results and patient satisfaction. The patients were observed for wound healing and discharge on follow-up in the out-patient department at 1, 3, 6 and 24 weeks. They were further followed up every year through telephonic survey for persistence or recurrence of symptoms. Patient satisfaction was assessed using the 36-item Short Form Survey questionnaire filled at admission and then at 6 weeks post-surgery. Data was analysed using SPSS 23. Results: Of the 67 patients, 55(82%) were males and 12(18%) were females. The overall mean age was 25.69±8.305 years. There were 13(19.4%) patients with a history of recurrent disease and previous procedures for pilonidal sinus, while 54(80.6%) had no previous surgery. The median operative time was 35 minutes (interquartile range: 20-45 minutes). Complete wound healing was achieved in 60(89.6%) patients, while recurrence was seen in 7(10.4%). The median time off work was 2.5 days (interquartile range: 1-3 days). Patient satisfaction with the procedure was significantly high (p&lt;0.05). Conclusion: Endoscopic pilonidal sinus treatment appeared to be a good minimally invasive surgical technique for the treatment of pilonidal sinus disease in terms of both short-term and long-term outcomes. Key Words: Pilonidal sinus disease, Minimally invasive surgery, Endoscopic pilonidal sinus treatment, EPSiT, Recurrent pilonidal sinus.

Severe lead induced tricuspid regurgitation - clinical impact of repair or replacement of tricuspid valve

Abstract The prevalence of lead-induced tricuspid regurgitation (LITR) ranges between 7 to 45%. The most frequent mechanism of LITR is the impingement of the leaflets, but right ventricle remodelling, pacing-induced cardiomyopathy and tricuspid annular dilatation also can contribute to the severity of tricuspid regurgitation (TR). Different studies concluded that LITR was associated with an increased risk of all-cause mortality and heart failure hospitalizations. Beyond diuretics, patients (P) may be candidates for interventional treatment, including lead extraction, surgery, or percutaneous tricuspid trans-catheter ‘edge-to-edge’ repair (TEER) and heterotopic bicaval devices (HBD). Despite its importance, there is a scarcity of data concerning the management and clinical impact of severe LITR. The purpose of the current analysis is to improve the knowledge regarding the impact of interventional treatment on the outcomes in this population. Methods A retrospective, single-centre analysis was made including P with severe LITR referred to evaluation regarding eligibility for tricuspid percutaneous intervention in a tertiary hospital. All P were evaluated using both transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE). Data were collected regarding clinical characterization, management, intervention and follow-up. Results From January 2020 to September 2023, of the 97 P referred for tricuspid intervention eligibility, 36 (37%) had LITR, with 14 cases (39%) presenting lead impingement as the TR mechanism. The majority of P were female (58%), with a median age of 78 [IQR 72-83] years. Median Euroscore II was 6 % [IQR 3-9]), with 51% of the P having a previous heart surgery, and 97% presenting atrial fibrillation. Prior to cardiac electronic device (CIED) implantation, 14% already presented TR. When analysing post-CIED TR, 30% increased 1 grade of TR at 1-year follow-up, and 68% increased 2 grades of TR at 5 years. According to TTE, ventricular desynchrony was present in 30% of the P. After evaluation of TR, 30% underwent intervention (22% percutaneous - TEER or HBD - and 8% surgical). All P remained with the previous electrodes. Mortality was 21.1% in the intervention population and 78.9% on the remaining pts (p=0.027). The type of intervention had no statistically significant differences in outcome. Conclusions In our study, more than 1/3 of the cases referred due to severe TR presented lead impingement as the mechanism underlying TR. As previously reported, the intervened population had better outcomes than the remaining pts.

Peak frequency mapping characteristics in patients with scar-related atypical atrial reentrant tachycardias; findings from a novel automated annotation algorithm to detect near field signals

Abstract Background Atypical atrial tachycardias are commonly encountered rhythm disorders especially in patients with atrial low-voltage areas mainly due to previous catheter ablations or surgery. The peak frequency (PF) analysis of bipolar EGMs is a novel automated annotation tool which is mainly based on differentiation of near field signals from far field signals. Purpose In this study, we aimed to evaluate the association between PF analysis of voltage maps in low-voltage zones with the critical isthmus and termination sites of ATs. Methods In this retrospective analysis, we included a total of 36 patients (7 with right AT, 25 left AT, 4 biatrial). Omnipolar maps of RA and LA were created during AT using Ensite X Mapping system and HD-Grid catheter. Normal voltage is defined as ≥ 0.5 mV, borderline 0.1-0.5 mV and scar &amp;lt;0.1 mV. Only patients with acute termination of tachycardia with RF ablation were included. The sites within the 10 mm radius from the tachycardia termination site with RF were analysed in terms of voltage characteristics and PF analysis. Results The mean age of the study population was 53±15. Among 36 patients a total of 46 activation maps were created and 44 reentrant ATs were mapped. (24 (54.6%) ATs were macroreentry, 17 (38.6%) ATs were localized reentry and 3 ATs (6.8%) were dual-loop reentry). The low-voltage (LV) zones comprised 31.5±20.6% and 24.5±12.6% of total LA and RA, respectively. All AT termination sites using radiofrequency energy were located within the LV zones having high frequency activity using 250 Hz as the cut-off. The sensitivity of LV-NF zones to predict termination sites of re-entry was 97.2%. Conclusion The PF analysis of atrial substrate in the vicinity of the termination site of re-entrant ATs demonstrated high frequency signals within the low voltage zones. Therefore, addition of PF analysis with emphasis over voltage mapping may refine critical sites of reentry in LV regions.

B.3 Neuroimaging markers of cerebrovascular disease and cognition in adults with moderate-great complexity congenital heart disease

Background: Adults with congenital heart disease (ACHD) are at risk for stroke and dementia. We report baseline and Year 1 results from an ongoing study assessing brain health in people with moderate- and great-complexity ACHD. Methods: Participants aged ≥18 undergo baseline and Year-3 brain MRI/MRA and annual cognitive assessment (MoCA, NIH Toolbox-Cognitive Battery (NIH-TB)). Results: Of 93 participants to date, 79 (85%) have completed Year 1 follow-up. At baseline, the great-complexity group had lower MoCA (26.32 vs. 27.38; p=0.04) and NIH-TB scores (total composite 45.63 vs. 52.80; p=0.002) than the moderate-complexity group. Year-1 testing showed numerical improvements across cognitive batteries in both groups. More participants with great-complexity ACHD had white matter hyperintensities (WMH; 72% vs. 55%; p=0.21) and cerebral microbleeds (CMBs; 72% vs. 54%; p=0.17) on baseline neuroimaging, but differences were not significant. Conclusions: Baseline neuroimaging shows a greater-than-expected burden for age of CMB and WMH in the context of previous cardiac surgery. Baseline cognitive performance was worse with great-complexity ACHD. Improved cognitive battery performance across both subgroups at Year-1 suggests a practice effect. Repeat neuroimaging will be performed in Year-3 and cognitive performance is reassessed annually.

Clinical impact of catheter ablation for atrial fibrillation on heart failure parameters

Abstract Background Catheter ablation for atrial fibrillation have already been an established therapy to maintain sinus rhythm in patients with or without heart failure. Atrial fibrillation is often associated with functional valve regurgitations, left ventricular dysfunction and biomarkers of HF. However, it is still unclear how often such parameters improve after catheter ablation. Purpose The aim of this study is to clarify the clinical impact of catheter ablation on heart failure in patients with atrial fibrillation. Methods We retrospectively analysed 139 consecutive patients who underwent catheter ablation for atrial fibrillation and cardiac echocardiography before and one-year after catheter ablation. Patients who underwent hemodialysis or previous valve surgery were excluded. Results Mean age was 69.8±9.5 years and 84(60.4%) patients had persistent atrial fibrillation before ablation procedure. Fourteen (10.1%) patients had severe left ventricular dysfunction (EF&amp;lt;40%). Thirty-four (24.5%) and 37(26.6%) patients had moderate or greater mitral and tricuspid valve regurgitation (MR and TR), respectively. BNP or NTproBNP was significantly elevated in 93(66.9%) patients before catheter ablation. During one-year follow-up, 11 (7.9%) patients underwent second procedure and atrial fibrillation were remained in 2 (1.4%) patients. Additional medications for heart failure were prescribed in 19 (13.7%) of patients after initial procedure. One year after catheter ablation, 19/34(55.9%) and 20/37(54.1%) of moderate or greater functional MR and TR improved to mild or less. Furthermore, 5/14 (35.7%) patients with severe left ventricular dysfunction improved to normal with combined optimal medical treatment. In 64/93 (68.8%) with elevated BNP or NTproBNP, the increase was no longer significant. Even in patients with still elevated BNP or NTproBNP one-year after catheter ablation, their values were decreased by more than 50% in 17/29 (58.6%) patients. Conclusion Catheter ablation for atrial fibrillation can improve heart failure parameters including valve function, systolic ventricular function and biomarkers.

LUMiC Endoprosthetic Reconstruction of Periacetabular Tumor Defects: A Multicenter Follow-up Study.

We previously reported promising early results for periacetabular tumor reconstructions using the LUMiC prosthesis. The current study evaluates mid-term complications, revision rates, cumulative incidence of implant revision, and risk factors for complications in a multicenter cohort. We assessed patients in whom a tumor defect after type P1b+2, P2, P2+3, or P1b+2+3 internal hemipelvectomy was reconstructed with a LUMiC prosthesis during the period of 2008 to 2022. Complications were reported according to the Henderson classification. Competing risks models were used to estimate the cumulative incidence of implant revision for mechanical and nonmechanical reasons, and reoperations for any complication. Cox models were used to study the effect of risk factors on dislocation and infection. One hundred and sixty-six patients (median follow-up, 4.2 years [interquartile range, 2.6 to 7.6 years]) were included. A total of 114 (69%) were treated for a primary malignant tumor, 46 (28%) for metastatic carcinoma, 5 (3%) for a benign aggressive lesion, and 1 (1%) for another reason. One hundred and sixty-five reoperations were performed in 82 (49%) of the patients; 104 (63%) of the reoperations were within 6 months. Thirty-two (19%) of 166 implants were revised: 13 (8%) for mechanical reasons, mainly dislocation (n = 5, 3%), and 19 (11%) for nonmechanical reasons, mainly periprosthetic joint infection (PJI) (n = 15, 9%). The cumulative incidences of revision for mechanical reasons and PJI (Henderson 1 to 4) at 2, 5, and 10 years were 11% (95% confidence interval [CI], 7% to 17%), 18% (12% to 25%), and 24% (16% to 33%), respectively. Previous surgery at the same site was associated with an increased dislocation risk (cause-specific hazard ratio [HRCS], 3.0 [95% CI, 1.5 to 6.4]; p < 0.01), and resections involving the P3 region were associated with an increased infection risk (HRCS, 2.5 [95% CI, 1.4 to 4.7]; p < 0.01). Despite a substantial reoperation risk, the LUMiC prosthesis demonstrated its durability in the mid-term, with a low mechanical revision rate and most patients retaining their primary implant. Most complications occur in the first postoperative months. Patients with previous surgery at the same site had an increased dislocation risk and might benefit from more conservative rehabilitation and aftercare. Measures should be aimed at reducing the PJI risk, especially in resections involving the P3 region. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

#1852 When ‘pebbles’ affect the kidney: nephrolithiasis and chronic renal failure in Crohn's disease. The experience of a 3rd level centre

Abstract Background and Aims Nephrolithiasis is the most common expression of kidney involvement in chronic inflammatory bowel disease (IBD), especially in Crohn's disease (CD). Stone formation favoring factors are hyperoxaluria, dehydration, acidosis, common conditions in CD patient, who present a little higher incidence of renal stones, made of calcium oxalate, than the normal population. Only few studies focused on the relationship between CD activity (defined by CDAI score) and the development of nephrolithiasis and possible subsequent development of chronic renal failure (CRF). Materials and Method We conducted a retrospective study on a cohort of 1236 patients affected by CD referring to our Centre of IBD- Sant'Orsola between 2014 and 2021. We identified two cohorts from this population: 118 patients with nephrolithiasis and 118 patients without nephrolithiasis. Among these two groups, we identified variable clinical manifestations of CD and their relation with CRF and lithiasis. Results The prevalence of nephrolithiasis in all CD patients was 10.3%, a little higher than in the general population. The results of the analysis of patient and disease variables in the two groups are shown in Table 1. The mean age at diagnosis of CD was higher in the group without nephrolithiasis, so the treatment was started later. The presence of perianal disease, extraintestinal manifestations (MEI), like ankylosing spondylitis (APS), biliary tract involvement, or previous surgery, and presence of ileostomy correlate with the formation of stones in univariate regression analysis (Table 2). Perianal disease and MEI also maintained significance in multivariate analysis. Conclusion Our data suggest that a higher degree of disease activity, defined by the presence of perianal disease (a variable on CDAI score) and the presence of MEI, correlates with higher risk of lithiasis. It is advisable to start early the study of nephrolithiasis in these patients to adopt preventive strategies against formation and progression of renal stones. Future studies are required for a better definition of this deep relationship.

#2189 Percutaneous peritoneal dialysis catheter implantation

Abstract Background and Aims There are three main techniques to implant a peritoneal dialysis catheter (PDC): percutaneously, laparoscopically or through open surgery; and current guidelines recommend individualising according to previous abdominal surgeries and anaesthetic risk. Recent metanalysis show the percutaneous technique to be safe, non-inferior in catheter survival, and with an equal incidence in mechanic complications (within &amp;lt;3 months after implantation) and infectious complications (within &amp;lt;1 month after implantation) to laparoscopic technique. On the other side, as the percutaneous PDC implantation is a minimal intervention that requires neither surgery room nor over 24h hospitalisation, it allows for a lower waiting time to PDC implantation, a shorter period until usage, and it's economically efficient. Considering these benefits and its non-inferiority described in the literature, our centre started using this technique since 2018. In this study we analyse our results. Method This is an observational retrospective unicentric study, which included the first PDC implantation in adult patients between January 2019 and August 2023, were we analysed the mechanical and infectious complications associated with the implantation technique. All PDC were double-cuff straight Tenckhoff, placed using Seldinger technique with radioscopy. A single dose of prophylactic antibiotic was used. We considered as mechanic complication all those non-infectious incidences that required repositioning or replacement of the PDC within 3 months of implantation (excluding those patients whose catheter was removed because of kidney transplantation, death by other reasons non related to the procedure, or trespass to haemodialysis); and we considered as infectious complications all those peritonitis diagnosed the first month after implantation. Results We analysed a total of 147 patients, 71.4% were male, mean age was 61 years old, and mean kidney function at implantation time was 11.5 ml/min/1.73 m2. We found a total of 8.1% of mechanical complications (33% required repositioning and 66% required replacement) and 5.4% infectious complications. There were no deaths related to percutaneous PDC technique. Conclusion In this study we observe that mechanic or infectious complications associated with percutaneous PDC technique are similar to those published in the literature: ISPD guidelines recommend the incidence of peritonitis associated to catheter implantation to be less than 5%. And though there is no clear percentage of mechanical complications that are considered acceptable or unavoidable, many studies report a survival of 76-86% PDC at 90 days of implantation in percutaneous and laparoscopic procedures, without significant differences between them.

#2923 Intracardiac vascular access as a last resort for hemodialysis in patients with exhausted traditional vascular access: a case report

Abstract Introduction The dysfunction of vascular access (VA) constitutes one of the main problems faced by nephrologists and patients in chronic hemodialysis (HD). This challenge becomes particularly worrying in patients who have depleted their upper extremity venous resources and have no longer arteriovenous fistula available, requiring the placement of a central venous catheters. It leads to an increase in morbidity and mortality and a higher of infections, thrombosis and exhaustion of access points. In such cases, alternatives to conventional VA are limited, with intracardiac access being an emerging option, albeit with very limited documented experience. Case Report We describe the case of a 68-year-old male with a history of hypertension, nasopharyngeal carcinoma in 2012 treated with chemotherapy and radiotherapy. In 2018 he was diagnosed with low-grade urothelial bladder carcinoma (PT1G1) that infiltrated the subepithelial corion while sparing the muscular layer. He also had severe hydronephrosis with impaired renal function, requiring radical cystoprostatectomy with Bricker bladder reconstruction and subsequent bilateral nephrostomy due to persistent dilatation and progressive deterioration of renal function. He began chronic HD in June 2020 through a left femoral catheter due to the inability to access the upper thoracic vascular tree due to stenosing fibrosis from previous radiotherapy. He was placed on the waiting list for a kidney transplant (KT) in the right iliac fossa but experienced multiple catheter dysfunction episodes, requiring the placement of a right femoral venous catheter to continue with his HD sessions. Additionally, peritoneal dialysis was not considered due to previous urological surgery. Considering the limitation of VA and the possibility of KT as its best alternative, we opted for the insertion of a tunnelled intracardiac catheter at the right atrium. This procedure was conducted by the Cardiac Surgery Department on 03/12/2021 through a median sternotomy in the 4th intercostal space. A permanent hemodialysis catheter was inserted in the right atrium through the 3rd intercostal space and fixed with a purse-string suture. It was then tunnelled under the breast to the 2nd intercostal space through a counter-incision. The cuff was appropriately placed in the subcutaneous tissue (Figs 1 and 2). The intervention proceeded without any complication and the catheter exhibited normal functionality. After that, the patient received anticoagulation with enoxaparin the days between dialysis sessions. Consequently, the right femoral catheter was safely removed. Two weeks later, the patient successfully received a KT from a deceased donor. He was discharged on the day 11st post-KT with any complication and maintains a good renal function after 2 years of follow-up with a serum creatinine 1.7 mg/dL (eGFR: 39 ml/min). The intracardiac catheter was removed one month later through a mini-thoracotomy. Conclusions Intracardiac VA is an unusual and high-risk resource that seems an alternative in patients with exhausted VA with no alternative emergency renal replacement therapy, so it should be considered as the last resort. In the case of our patient, the implantation of this catheter allowed for the continuation of dialysis and access to KT.

Subtotal esophagectomy and concurrent reconstruction with free jejunal flap for primary esophageal cancer after pancreatoduodenectomy.

Pancreatoduodenectomy and subtotal esophagectomy are widely considered the most invasive and difficult surgical procedures in gastrointestinal surgery. Subtotal esophagectomy after pancreatoduodenectomy is expected to be extremely difficult due to complicated anatomical changes, and selecting an appropriate intestinal reconstruction method will also be a difficult task. Therefore, perhaps because the method is considered impossible, there have been few reports of subtotal esophagectomy after pancreatoduodenectomy. A 73-year-old man with a history of pancreatoduodenectomy was diagnosed with superficial thoracic esophageal squamous cell carcinoma. Definitive chemoradiation therapy was recommended at another hospital; however, he visited our department to undergo surgery. We performed the robot-assisted thoracoscopic subtotal esophagectomy. There were some difficulties with the reconstruction: the gastric tube could not be used, the reconstruction was long, and the organs reconstructed in the previous surgery had to be preserved. However, the concurrent reconstruction was achieved with the help of a free jejunal flap and vascular reconstruction. All reconstructions from the previous surgery, including the remnant stomach, were preserved via regional abdominal lymph node dissection. After reconstruction, intravenous indocyanine green showed that circulation in the reconstructed intestines was preserved. On postoperative day 1, no recurrent nerve paralysis was observed during laryngoscopy. The patient could start oral intake smoothly 2weeks after surgery and did not exhibit any postoperative complications related to the reconstruction. The patient was transferred to another hospital on postoperative day 21. Owing to the free jejunal flap interposition method, we safely performed one stage subtotal esophagectomy and concurrent reconstruction, preservation of the remnant stomach, and pancreaticobiliary reconstruction in patients with a history of pancreatoduodenectomy. We believe that this method is acceptable and useful for patients undergoing complicated reconstruction.

Internal and external adenomyosis phenotypes: ultrasound features and association with clinical outcomes.

What are the sonographic and clinical findings in women diagnosed with external and internal adenomyosis by ultrasound? Patients with external and internal adenomyosis phenotypes, diagnosed by ultrasound, present differences in sonographic features of the disease and demographic characteristics including age, parity, and association with deep endometriosis (DE) and leiomyomas. Two different phenotypes of adenomyosis have been described based on the anatomical location of adenomyotic lesions in the myometrium, suggesting that adenomyosis affecting the inner myometrium and that affecting the external myometrial layer may have distinct origins. A cross-sectional study including 505 patients with a sonographic diagnosis of adenomyosis was performed between January 2021 and December 2022. Women sonographically diagnosed with adenomyosis in a tertiary referral hospital that serves as a national reference center for endometriosis were included over a 2-year period. Patients were divided into two groups (internal and external adenomyosis) according to the myometrial layer affected by adenomyosis. We compared sonographic and clinical outcomes including a multivariate analysis between the two groups. According to ultrasound findings, 353 (69.9%) patients presented with internal adenomyosis, while 152 (30.1%) presented with external adenomyosis. Women with internal adenomyosis were significantly older and less frequently nulliparous compared to those with external adenomyosis. Sonographically, internal adenomyosis appeared diffusely, it had a greater number of adenomyosis features, it presented a globular morphology of the uterus more frequently, and it coexisted with leiomyomas more frequently, compared to external adenomyosis. Conversely, the presence of translesional vascularity and associated DE were more common among the external adenomyosis group. No significant differences were found between internal and external adenomyosis groups regarding pain, heavy menstrual bleeding, spotting, or infertility. In the multivariate analysis, nulliparity, the presence of leiomyomas, and the presence of DE were independently associated with adenomyosis phenotypes (the presence of DE and nulliparity increased the risk of external adenomyosis, whereas the presence of leiomyomas was a risk factor for internal adenomyosis). Considering the impact of hormonal treatment, we found that the number of ultrasound adenomyosis criteria was significantly greater in patients without hormonal treatment. Non-treated patients more commonly presented dysmenorrhea or bleeding-associated pain and heavy menstrual bleeding than women on hormonal treatment, although there were no significant differences according to adenomyosis phenotypes. As the population was selected from the Endometriosis Unit of a tertiary center, there may be patient selection bias, given the high prevalence of individuals with associated endometriosis, previous endometriosis-related surgery, and/or receiving hormonal treatment. Transvaginal ultrasound is the most available and cost-effective tool for the diagnosis of adenomyosis. Adenomyosis phenotypes based on ultrasound findings may be key in achieving an accurate diagnosis and in decision-making regarding the most adequate therapeutic strategy for the management of patients with adenomyosis. Determination of the sonographic features associated with symptoms could help in the evaluation of treatment response. No funding was obtained for this study and there are no conflicts of interest to declare. N/A.

Ophthalmic quality of life in the adult Danish population: an epidemiological study

BackgroundOphthalmic quality of life (OQoL) has been investigated in selected parts of general populations and in patients with ocular disease, but OQoL in unselected general populations has not been studied...

Outpatient and Ambulatory Extended Recovery Robotic Hepatectomy: Multinational Study of 307 Cases.

For open minor hepatectomy, morbidity and recovery are dominated by the incision. The robotic approach may transform this "incision dominant procedure" into a safe outpatient procedure. We audited outpatient (<2 midnights) robotic hepatectomies at six hepatobiliary centers in two nations to test the hypothesis that the robotic approach can be a safe and effective short-stay procedure. ERAS programs were active at all sites, and home digital monitoring was available at one of the institutions. Three hundred and seven outpatient (26 same-day, 281 next-day discharge) robotic hepatectomies were identified (2013-2023). Most were minor hepatectomies (194 single-segments, 90 bi-segmentectomies, 14 three-segments, 8 four-segments). Thirty-nine (13%) were for benign histology, while 268 were for cancer (33 hepatocellular carcinoma, 27 biliary, 208 metastatic disease). Patient characteristics were - median age 60 (18-93), 55% male, and median BMI 26 (14-63). Thirty (10%) had cirrhosis. One-hundred-eighty-seven (61%) had previous abdominal surgery. Median operative time was 163 minutes (30-433), with a median blood loss of 50 cc (10-900). There were no deaths and six complications (2%): 2 wound infections, 1 failure to thrive, and 3 perihepatic abscesses. Re-admission was required in 5 patients (1.6%).Of the 268 malignancy cases, 25 (9%) were R1 resections. Of the 128 with superior segment resections (segments 7/8/4A/2/1), there were 12 positive margins (9%) and two readmissions for abscess. Outpatient robotic hepatectomies in well-selected cases are safe (0 mortality, 2% complication, 1.6% re-admission), including resections in the superior or posterior portions of the liver that are challenging with non-articulating laparoscopic instruments.