Primary Surgery Research Articles

Textbook oncologic outcome is an easy-to-use composite quality measure that is strongly associated with survival in advanced-stage ovarian cancer

ObjectiveTextbook oncologic outcome (TOO) has been validated in surgical oncology as a composite quality measure correlated with oncologic outcomes. We aimed to assess the association between TOO and overall survival (OS) in patients undergoing primary treatment for advanced epithelial tubo-ovarian cancer (AEOC). MethodsPatients undergoing surgery for AEOC between 2008 and 2019 were identified in the National Cancer Database (NCDB). Primary debulking surgery (PDS) and interval debulking surgery (IDS) cohorts were analyzed separately. TOO was defined as achieving complete debulking, length of hospital stay <10 days, no 30-day readmission, no death within 90 days, and initiation of adjuvant chemotherapy within 42 days. The Kaplan-Meier method was used to estimate 5-year OS by TOO status and Cox regression to evaluate the relationship between TOO and death within 5 years. ResultsA total of 21,657 patients were included: 51.4% in the PDS cohort and 48.6% in the IDS cohort. TOO was achieved (TOO+) in 20.5% of the PDS cohort and 39.2% of the IDS cohort. For the PDS cohort, achieving TOO was associated with improved 5-year OS: 59.0% TOO+ vs. 39.5% TOO- (HR 0.53, 95% CI 0.49–0.57). For the IDS cohort, a similar benefit was seen for 5-year OS: 43.9% TOO+ vs. 31.2% TOO- (HR 0.67, 95% CI 0.63–0.70). Multivariable analysis demonstrated that patients achieving TOO were at lower risk of death within 5 years in both the PDS cohort (HR 0.58, 95% CI 0.54–0.62) and the IDS cohort (HR 0.69, 95% CI 0.65–0.73). ConclusionsThe TOO composite measure is associated with improved long-term survival and could be a useful quality assessment tool for patients undergoing primary treatment for AEOC, irrespective of surgical timing. This tool reflects the ability to deliver risk-based individualized decision-making using a multidisciplinary approach.

Immunological impact of intraperitoneal and intravenous chemotherapy in ovarian cancer, translational analyses of the Phase 3 iPocc trial

BackgroundThe iPocc trial, a randomized, global phase 3 study that compared intraperitoneal (IP) and intravenous (IV) carboplatin with dose-dense paclitaxel chemotherapy in epithelial ovarian cancer (EOC) patients, demonstrated improved progression-free survival in patients who received IP chemotherapy. The present study aimed to investigate the role of preexisting tumor immunity in the clinical outcomes of patients receiving IP chemotherapy. MethodsThis study involved analyzing patient data from the iPocc trial, selectively of those whose tumor specimens were preserved at the time of primary surgery. A total of 116 cases ((IP; n = 59), (IV; n = 57)) were subjected to microarray analysis. Single-sample gene set enrichment analyses were performed to evaluate the tumor immune microenvironment. ResultsPatients with enhanced tumor infiltration of T cells, natural killer (NK) cells, and cytotoxic lymphocytes in the IP group had a longer overall survival (OS) than those in the IV group, but not in the group with low infiltration. IP therapy improved the OS of patients with high expression of immune-related genes such as CD8A and FOXP3. In patients' subdivided into “immune Hot” and “immune Cold” groups based on hierarchical clustering analysis using four parameters representing “Innate immunity,” “T cells,” “IFNG response” and “Inhibitory molecules,” IP therapy significantly improved prognosis in the “immune Hot” group, but not in the “immune Cold” group compared to that of IV therapy. ConclusionsIP chemotherapy enhances the survival rates of patients with EOC with an immune-Hot phenotype in the tumor microenvironment prior to treatment.(Japan Registry of Clinical Trials number, jRCTs031180141.)

Intraocular lens exchange or explantation post cataract surgery

AIM: To report incidence, indications, and visual outcomes of intraocular lens (IOL) exchange/explantation surgery. METHODS: Retrospective analysis of 60 eyes requiring IOL exchange/explantation surgery between 1st January 2017 and 31st December 2022. The overall outcomes as well as comparison between the trainee versus experienced surgeons were analyzed. RESULTS: Out of 39 778 cataract surgeries (with no preexisting ocular co-morbidities) during a six-year period (2017–2022), 60 (0.15%) needed IOL exchange/explantation. Surgeons-under-training performed 36/60 cases (60%) while 24/60 (40%) were by experienced surgeons. The commonest indication was subluxated IOL in 26 (43.3%), followed by dislocated IOL in 20 (33.3%), postoperative refractive surprise in 7 (11.6%), IOL induced uveitis in five and broken haptic in two eyes. Twenty-four (40%) eyes had intraoperative complications during primary surgery. Posterior chamber IOL (PCIOL) was the commonest secondary IOL in 21 (35%) eyes, scleral fixated in 20 (31.6%), anterior chamber IOL (ACIOL) in 13 (21.6%), iris fixated IOL in three (5%) and three eyes (5%) were left aphakic. The mean time between primary and secondary surgery was 168d (168±338.8). Best corrected visual acuity (BCVA) of &amp;#x003E;20/60 was obtained in 43 eyes (71.66%), 20/80–20/200 in 14 (23.33%), 20/250 in two and hand movements in one. No statistically significant difference in visual outcome was noted at post-op one month between trainees versus experienced surgeons (UCVA 0.45±0.29 vs 0.53±0.32, P=0.20, BCVA 0.34±0.25 vs 0.37±0.26, P=0.69). CONCLUSION: IOL subluxation as the commonest indication and posterior capsular rupture is the commonest intraoperative risk factor. This complication can be effectively addressed with selection of the appropriate secondary IOL achieving good visual outcomes in over 70% of patients.

Pediatric Scaphoid Nonunions: Does Insurance Status Play a Role?

Objective: There are no studies that evaluate the effects that insurance or socioeconomic status may have on treatment and outcomes of scaphoid nonunions in children. We evaluated whether there is an association between insurance status and (1) time from injury to hand surgeon evaluation, (2) time from specialist evaluation to surgery, and (3) postoperative outcomes of scaphoid fracture nonunions in children. Methods: A chart review was performed for patients who underwent surgical treatment of scaphoid fracture nonunion from January 2015 and April 2021 at a large tertiary care pediatric hospital. Underinsured patients were defined as those with no medical insurance or Medicaid/state-funded insurance. Results: There were 21 privately insured patients and 17 patients who were underinsured. There was no difference in age, race, or fracture characteristics between the two groups. The mean time between injury and hand surgeon evaluation was 192 SD 195 days for the privately insured group compared with 155 SD 205 days for the underinsured group (P = 0.57). The mean time between specialist evaluation and surgical treatment was 35 SD 54 days for the privately insured group and 31 SD 31 days for the underinsured group (P = 0.82). Union was achieved in 80% of patients with private insurance compared with 88% of underinsured patients after primary surgery (P = 0.67). There was no difference detected in the proportion of patients who had residual pain (15% vs 19%), range of motion deficits (38% vs 40%), strength deficit (6% vs 7%), and return to activity (94% vs 93%) between privately insured and underinsured patients, respectively (P = 1.00). Conclusions: There was no difference in time from injury to specialist evaluation, time from evaluation to surgery, or postoperative outcomes based on insurance status for pediatric patients with scaphoid fracture nonunions. Although insurance status was not associated with access to care for pediatric scaphoid fracture nonunions at our institution, this information may not be generalizable to other populations, including patients who sustain primary scaphoid fractures and who have not yet developed nonunions. Level of Evidence: Level III—retrospective cohort study.

Abstract C046: PARP inhibitors as immune modulators in metastatic ovarian cancer treatment

Abstract Epithelial ovarian carcinoma (EOC) is one of the top five causes of cancer-related death in women. Most patients with EOC achieve initial remission after primary or interval cytoreductive surgery combined with platinum-taxane chemotherapy. However, mutations in BRCA1 or BRCA2 genes, which lead to homologous recombination (HR) defects, play a crucial role in platinum sensitivity and justify the use of poly (ADP-ribose) polymerase (PARP) inhibitors as maintenance therapy, commonly linked to extended progression-free survival (PFS). Besides their direct cytotoxic and cytostatic effects, PARP inhibitors (PARPi) have shown significant immunostimulatory properties by disrupting DNA repair in cancer cells, and opening possibilities for synergy with immune checkpoint inhibitors (ICIs). In this study, we investigate the immunomodulatory effects of PARPi using multiparametric flow cytometry, multiplexed immunolabeling, single-cell transcriptomics, and functional assays in an experimental BR5Brca1-/- syngeneic mouse model and human EOC tumor samples. We examine the molecular and cellular mechanisms that can be exploited to develop more effective combination therapies. PARPi may increase the mutational burden in EOCs due to unresolved DNA damage and the release of damage-associated molecular patterns (DAMPs), thereby increasing T-cell infiltration. In addition, PARPi appear to promote potent type I interferon (IFN) secretion through the activation of cGAMP synthase and the stimulator of the interferon genes (STING) pathway. In combination with ICIs, PARPi showed a beneficial effect on the balance between adaptive anti-tumor immunity and innate myeloid components, leading to an improved cytotoxic T-cell response, as observed in mouse models and HGSOC tumor samples. These observations emphasize the role of strategically designed combinations of PARPi and immunotherapeutic agents, which could be the key to overcoming immunosuppression in the EOC microenvironment, thereby improving clinical outcomes. Citation Format: Sarka Vosahlikova, Peter Holicek, Irena Moserova, Michal Hensler, Romana Mikyskova, Lenka Kasikova, Josef Pasuvka, Jana Drozenova, Katerina Mojzisova, Marek Kovar, Iain McNiesh, Michael Halaska, Lukas Rob, Sandra Orsulic, Milan Reinis, Lorenzo Galluzzi, Radek Spisek, Jitka Palich Fucikova. PARP inhibitors as immune modulators in metastatic ovarian cancer treatment [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Tumor-body Interactions: The Roles of Micro- and Macroenvironment in Cancer; 2024 Nov 17-20; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2024;84(22_Suppl):Abstract nr C046.

Abstract C028: Decreased heterogeneity in immune interactions in oral cavity squamous cell carcinoma patients with recurrence

Abstract There have been improvements in clinical risk stratifications for oral cavity squamous cell carcinoma (OSCC) with the AJCC 8th edition staging system. Other studies suggest the addition of a metric of specific immune interactions in and around the tumor may be helpful to further stratify patients, with mixed findings. The advent of spatial imaging has allowed a global view for assessing tumor features in the context of all surrounding cell interactions. We hypothesize that the lack of architectural information could contribute to varied clinical outcomes in previous studies, such as tumor recurrence. This highlights how spatial technologies could aid in understanding the role of tissue architecture and its influence on biology and medicine. To study tissue remodeling spatially, we focused on multiplexed-ion beam imaging (MIBI), a spatial proteomics platform to visualize 40 immuno-onco proteins simultaneously. Our banked patient cohort consists of 20 recurrent and 49 non-recurrent OSCC primary surgery samples. Clinical metadata capturing pathologic stage, alcohol use, smoking history, survival data, and more were also collected. With our pathologist, we curated 290 field-of-views (FOVs) of matched primary tumors, uninvolved lymph nodes, and metastatic lymph nodes (if any). Downstream computational analysis using existing MIBI codebases augmented with in-house spatial analytics has revealed a robust spatial dataset. After using machine-learning algorithms to cell segment our images, we validated these assigned cells and marker staining to further annotate cell populations. When we analyzed direct cell interactions, there was a decrease in heterogeneity in immune interactions within recurrent patients compared to non-recurrent patients. To ascertain how the loss of these interactions affected recurrence prognosis, we investigated their prevalence within the tumor border vicinity. We hypothesize that the proximity and cell-cell interactions near the border will promote a tumor-suppressive environment. Utilizing centroid-to-centroid distance measurements, we distilled the top 30 cell-cell interactions within a 100-micron distance from the tumor border. Cell pairs involving macrophage tissue-resident memory cells and CD8 T memory resident cells were more abundant in recurrent patients, while pairs involving CD4 T regulatory and CD8 cells were found in non-recurrent patients. Reassuringly, cell pairings involving myeloid cells were upregulated in the recurrent cohort as expected. Interestingly, cancer-associated fibroblast cell pairings were upregulated indiscriminately in both patient sub- cohorts. This suggests that the impact of certain known immunosuppressive changes may contribute in varying amounts to disease control. Our data demonstrates differences in the architecture of tumors with known divergent outcomes, which suggests global tissue-level changes could be a predictive factor. Clinically, interrogating these interactions of interest could guide treatment escalation or de-escalation in the future. Citation Format: Connie J. Zhou, Jane Lee, Rebecca Jaszczak, Steven R. Long, Patrick K. Ha, Matthew H. Spitzer. Decreased heterogeneity in immune interactions in oral cavity squamous cell carcinoma patients with recurrence [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Tumor-body Interactions: The Roles of Micro- and Macroenvironment in Cancer; 2024 Nov 17-20; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2024;84(22_Suppl):Abstract nr C028.

Re-do hypospadias surgery following failed previous repair: lessons learned over two decades of experience.

To evaluate our experience with different surgical techniques and to find clinical factors that affect the outcome of treatment in cases of redo-hypospadias. We have retrospectively evaluated demographic and clinical data of children who underwent redo or cripple-hypospadias repair. Between 2004 and 2021, 76 patients met the inclusion and exclusion criteria. The median age of the first cripple-hypospadias surgery was 64.8 ± 62.9 months. Upon primary surgery 5(6.6%) patients presented with distal-hypospadias, 13(17.1%) midshaft-hypospadias, 37(48.7%) proximal-hypospadias and 21(27.6%)with an unknown initial meatal status. To correct cripple-hypospadias 3(3.9%) patients underwent meatal-advancement and meatoplasty 32(42.1%) different tubularization techniques, 25(32.9%) required flap/graft, 13(17.1%) staged procedure and in 3(3.9%) surgical technique was undefined. Fifty-four (71%) children presented with post-surgery complications: 25(32.9%) meatal retraction, 19(25.3%) meatal stenosis and 17(22.3%) developed urethro-cutaneous fistula. Thirty-six (47.4%) patients underwent additional surgeries. There was no association between surgical technique or age and the need for additional surgeries (P = 0.831, P = 0.425 respectively). There was no association between surgical technique or age and surgical complications (P = 0.514, P = 0.425 respectively). All surgical techniques except meatal-advancement might lead to urethral stricture on long term follow-up (P = 0.028). Our data show that treatment of cripple-hypospadias is challenging for both surgeon and patients alike. There is a need to tailor a surgical technique to each patient and there is no one technique which is appropriate for all patients.

For short-segment Hirschsprung disease, daily trans-anal irrigation before pull-through surgery is necessary?

To explore the role of daily trans-anal irrigation (TAI) before pull-through surgery in preventing Hirschsprung disease-associated enterocolitis (HAEC) and improving other clinical outcomes in short-segment Hirschsprung disease (HSCR). We enrolled the children with short-segment HSCR who received primary pull-through surgery from February 2012 to August 2019 at our hospital. They were divided into two groups. Daily TAI group: daily TAI once diagnosed until undergoing surgery. Non-daily TAI group: anal dilation or glycerine enema, supplemented with TAI if these were noneffective. HAEC, nutritional status at surgery, postoperative rehabilitation, and long-term defecation function were compared. A total of 191 children were enrolled, 147 in the Daily TAI group and 44 others. 44 pairs of children were successfully matched by 1:1 propensity score matching. In all, 10 (11.36%) of the 88 children developed HAEC, 5 (5/44, 11.36%) in the Daily TAI group and 5 (5/44, 11.36%) in another, and the difference was not statistically significant (χ2 = 0.000, p = 1.000). Besides, there was no significant difference in the nutritional status at surgery, postoperative rehabilitation indicators, and the defecation function. For children with short-segment HSCR, preoperative daily TAI had no significant advantage over non-daily TAI in preventing HAEC and improving other clinical outcomes. For children with short-segment Hirschsprung disease, one or more times trans-anal irrigations (TAI) per day before pull-through surgery may not be necessary. Daily TAI had no significant advantage over non-daily TAI in preventing preoperative and postoperative HAEC. Whether to receive daily TAI before surgery did not affect postoperative recovery and long-term defecation function.

Germline BRCA1/2 status and chemotherapy response score in high-grade serous ovarian cancer.

High-grade serous ovarian cancer (HGSOC) can be treated with platinum-based neoadjuvant chemotherapy (NACT) and delayed primary surgery (DPS). Histopathological response to NACT can be assessed using Böhm's chemotherapy response score (CRS). We investigated whether germline BRCA1/2 (gBRCA1/2) genotype associated with omental CRS phenotype. A retrospective study of patients with newly diagnosed FIGO stage IIIC/IV HGSOC prescribed NACT and tested for gBRCA1/2 pathogenic variants (PVs) between September 2017 and December 2022 at The Christie Hospital. The Cox proportional hazards model evaluated the association between survival and key clinical factors. The chi-square test assessed the association between CRS3 (no/minimal residual tumour) and gBRCA1/2 status. Of 586 eligible patients, 393 underwent DPS and had a CRSreported. Independent prognostic factors by multivariable analysis were gBRCA1/2 status (PV versus wild type [WT]), CRS (3 versus 1 + 2), surgical outcome (complete versus optimal/suboptimal) and first-line poly (ADP-ribose) polymerase-1/2 inhibitor maintenance therapy (yes versus no) (all P < 0.05). There was a non-significant trend for tumours with a gBRCA2 PV having CRS3 versus WT (odds ratio [OR] = 2.13, 95% confidence intervals [CI] 0.95-4.91; P = 0.0647). By contrast, tumours with a gBRCA1 PV were significantly less likely to have CRS3 than WT (OR = 0.35, 95%CI 0.14-0.91; P = 0.0291). Germline BRCA1/2 genotype was not clearly associated with superior omental CRS. Further research is required to understand how HGSOC biology defines CRS.

Effects of Autologous Platelet Concentrate Injection on Persistent Macular Hole

Purpose: To evaluate the effects of secondary pars plana vitrectomy (PPV) with autologous platelet concentrate (APC) injection in patients with a persistent macular hole that failed to close after the primary surgery.Methods: This study included 10 eyes of 10 patients who required secondary PPV and APC injection due to unsuccessful hole closure following primary macular hole surgery between February 2021 and July 2023. We measured the minimum and base diameters of the holes before primary and secondary PPV, respectively. Furthermore, we evaluated the anatomical closure of the holes and changes in best corrected visual acuity (BCVA) for 6 months following secondary PPV.Results: The mean age of the 10 patients was 61.6 ± 9.5 years. Prior to the primary PPV, the mean BCVA (LogMAR) was 1.6 ± 0.7, the mean minimum diameter of the hole was 654.4 ± 98.9 μm, and the mean base diameter of the hole was 1,135.4 ± 276.5 μm. Prior to the secondary PPV with APC injection, the mean BCVA (LogMAR) was 1.3 ± 0.7, the mean minimum diameter of the hole was 666.8 ± 270.2 μm and the mean base diameter of the hole was 845.4 ± 292.4 μm. Following secondary surgery, all holes were successfully closed, the mean BCVA (LogMAR) was 0.9 ± 0.6 and the BCVA was significantly improved (&lt;i&gt;p&lt;/i&gt; = 0.007).Conclusions: PPV with APC injection can be an effective therapeutic option for persistent macular hole that failed to close following primary surgery both in terms of anatomical and functional outcomes.

Surgical Outcomes of Unilateral One-muscle Surgery in Basic Intermittent Exotropia with Larger Near Deviation

Purpose: To compare the postoperative changes between unilateral medial rectus resection and lateral rectus recession and evaluate surgical outcomes of unilateral one-muscle surgery in basic intermittent exotropia under 25 prism diopters (PD) with a larger near than distance deviation.Methods: This study was conducted on patients with basic intermittent exotropia under 25 PD and a larger near than distance deviation. A retrospective analysis was conducted on 23 patients who underwent unilateral medial rectus resection (Group 1) and 32 patients who underwent unilateral lateral rectus recession (Group 2) as primary surgery. The angle of deviation at near and distance was measured at 1 week, 1 month, 3 months, 6 months, and 1 year postoperatively. Surgical success was defined as within 4 PD of esophoria or 10 PD of exophoria at 1 year after surgery.Results: The mean preoperative deviation angle was 20.18 ± 2.55 PD for Group 1 and 19.30 ± 2.77 PD for Group 2, while the mean near-distance disparity was 6.83 ± 2.67 PD for Group 1 and 5.18 ± 1.56 PD for Group 2. At 1 year postoperatively, the mean distance deviation angle was 9.43 ± 5.82 PD for Group 1 and 5.94 ± 6.49 PD for Group 2. The mean near-distance disparity at 1 year was 0.91 ± 3.96 PD for Group 1 and 0.81 ± 2.07 PD for Group 2. The success rates at 1 year were 65.2% for Group 1 and 72.7% for Group 2 (&lt;i&gt;p&lt;/i&gt; = 0.362). Both groups showed effective reductions in the postoperative angle of deviation and near-distance disparity with no significant difference between the groups.Conclusions: Unilateral medial rectus resection and lateral rectus recession both effectively manage basic intermittent exotropia under 25 PD with larger near than distance deviation as the primary surgery.

Femoral neck fractures: a cohort comparison of nonunion and complication rates after ballistic versus blunt mechanism fractures.

This study aims to review complications and union rates of ballistic femoral neck fractures when compared to their blunt counterparts. We hypothesize that gunshot injuries to the femoral neck may have higher rates of complications (nonunion, avascular necrosis [AVN], and implant failure) as a result of increasing comminution and disruption to the already tenuous blood supply through the femoral neck. Following the Institutional Review Board approval, a retrospective chart review was performed identifying femoral neck fractures at a single level 1 trauma center from 2018 to 2023. Inclusion criteria were age 16-45years old with intracapsular femoral neck fractures. Exclusion criteria were absence of radiographic and clinical follow-up beyond 6 weeks, prior femur fractures, pathologic fractures, or primary surgery of total hip arthroplasty. Garden classification and Pauwels angle were reported. Clinical union was defined as the absence of painwith ambulation in the absence of radiographic changes. Radiographic union was defined using the validated Radiographic Union Score for Hip (RUSH) scoring system. Complication rates (deep and superficial infection, failure of fixation, and AVN) and subsequent surgery were recorded. After exclusion, 12ballistic and 16 blunt femoral neck fractures met inclusion criteria and were reviewed. The ballistic cohort had significant more Garden I fractures than the blunt cohort (4 [33%] vs. 0 [0%]), and significantly fewer Garden IV fractures than the blunt cohort (2 [17%] vs. 9 [56%]). Despite different Garden classification types of fracture patterns, the Pauwels angle between the two cohorts was similar (51° ballistic vs. 60° blunt, p = 0.16). The overall nonunion rate was 24.1%. Nonunion rates were similar between the two cohorts (3, 25% ballistic vs. 4, 25% blunt, p = 0.99). The mean final RUSH score between the two cohorts was similar (20.1ballistic vs. 23.4 blunt [p = 0.05]). The total complication rate was 31% (9/28) consisting of 7 nonunions and 2 malunions across both cohorts. The current study found no difference in the union rates between blunt and ballistic femoral neck fractures. Although comparing these fractures using traditional classification systems (Garden and Pauwels) are difficult due to the inherent differences in mechanism and the applicability of these tools, both groups presented with high rates of nonunion and complications. We believe the similar RUSH scores and complication rates in both cohorts show these fractures fundamentally behave similarly and remain challenging injuries to manage with ORIF.

BN SO32 - Operative techniques and outcomes following giant hiatus hernia repair: 5 years of tertiary centre experience

Abstract Background Giant hiatus hernia (GHH) repair is a complex surgical challenge, often requiring advanced techniques and specialised expertise. Whilst the repair of small hiatus hernias is well-documented, the optimal strategy for giant hernias remains debated. This study reviews five years of experience at a tertiary centre, focusing on operative techniques and outcomes. The aim is to identify trends and best practices that enhance patient outcomes and minimise complications in the repair of GHH. Method All patients undergoing primary GHH surgery between March 2019 and March 2024 at a tertiary institution and a five surgeon upper GI service. Retrospective review of electronic records were utilised to document patient demographics, type of hernia, operative details including surgical approach (open/laparoscopic/robotic), use of fundoplication, use of mesh and gastropexy. Outcomes measured included 30-day morbidity (Clavien-Dindo (CD) grading), 30-day mortality, binary symptom recurrence, length of stay (LOS), need for return to theatre (RTT) and RTT versus mesh use. Analysis undertaken using paired t-test. Statistical significance was set as p&amp;lt;0.05. Results 91 patients underwent GHH repair with median age 70 (31-93) years, 66.7% female, average BMI 30.8(±5.4). ASA: ≤2 (72.4%), 3 (25.5%), 4 (2.1%). Hernia types: 2 (15.7%), 3 (55.4%), 4 (28.9%). Approach: open 6.6%, laparoscopic 61.5%, robotic 31.9%. Fundoplication in 88%, gastropexy in 13%, 2 cases utilised both. Mesh: 91.2% without, 8.8% biologic, nil prosthetic. Median LOS 2 days (0-161). Median follow-up 8 weeks (1-172). Symptoms recurred in 25.6%. 94.5% had no significant complications (CD≤2). 5.5% had RTT≤30 days. 4.4% RTT&amp;gt;30 days. No mortalities. No significant difference in RTT and mesh use (p=0.7832). Conclusion This five-year review confirms that GHH repair using open, laparoscopic, and robotic techniques is effective and safe, even in an older population with high ASA scores. The study highlights minimal complications (94.5% with CD≤2). Only 4.8% required a RTT within 30 days. RTT was not significantly impacted by the use of mesh however this may represent a type two error given the limited use of mesh and low number of patients that RTT. These findings support the tailored use of advanced surgical techniques, mesh, and gastropexy as effective strategies for managing GHH in a tertiary care setting.

BN SO34 - Outcomes in giant versus non-giant hiatus hernia repair: Same payment different operative burden

Abstract Background Hospital trust payment for operative procedures often rely on coding systems like the NHS's Office of Population Censuses and Surveys (OPCS) codes, which determine reimbursement rates. Both giant hiatus hernia (GHH) and non-giant hiatus hernia (NGHH) repairs often share the same code, as in our trust. This results in equal reimbursement to trusts for procedures with higher operative burden and resource needs. This study aims to assess differences in the patient population, their hiatal type, operative challenges and post-operative outcomes between GHH and NGHH repairs. Method All patients undergoing primary hiatus hernia surgery between March 2019 to March 2024 at a single institution were included. Retrospective review of electronic records were utilised to record: patient demographics, hernia type, operative details, length of stay (LOS), post-operative course and need for a return to theatre (RTT). Outcomes were comparison of surgical approach, use of mesh and gastropexy (as proxy measures to indicate difficulty of operation), 30-day morbidity measured using Clavien-Dindo (CD) grading and 30-day mortality and RTT. Analysis was undertaken using un-paired t-test and Chi2. A p-value of &amp;lt;0.05 was considered statistically significant. Results Table 1. Patients GHH NGHH p n 91 135 Age (average) 69 (±10) 52 (±16) &amp;lt;0.001 Female (%) 66.7 55.2 0.1100 BMI 30.8 (±5.4) 30.7 (±7.8) 0.2029 ASA grade (average) 2.2 1.9 &amp;lt;0.001 Hernia Types (median) 3 1 &amp;lt;0.001 Table 2. Operative details GHH NGHH p Open (%) 6.6 0 0.0020 Laparoscopic (%) 60.4 62.24 0.9840 Robotic (%) 33 33.3 0.9239 Mesh used (%) 8.8 0.7 &amp;lt;0.041 Gastropexy (%) 12 0.7 &amp;lt;0.001 Table 3. Outcomes GHH NGHH p LOS (median) 2 (0-161) 1 (0-8) 0.0179 RTT (%) 10.7 8 0.4747 30-day morbidity (CD≥3, %) 4.8 4.4 0.6519 30-day mortality 0 0 NA Conclusion This study highlights significant differences between giant hiatus hernia (GHH) and non-giant hiatus hernia (NGHH) repairs. GHH repairs have an increased likelihood of undergoing open procedures, use of mesh, and gastropexy, reflecting their greater complexity. GHH patients are older, have higher ASA grades, and present with more advanced hernia types compared to NGHH patients. Additionally, GHH repairs result in longer hospital stays. The findings underscore the need for improved coding accuracy to reflect these disparities accurately in patient demographics, operative strategies, and recovery outcomes within hospital trusts, ensuring appropriate resource allocation and reimbursement based on procedural complexity.

Management of persistent exudative retinal detachment: exploring etiology and surgical outcomes.

This report aims to present the causes, clinical features, and surgical outcomes of persistent exudative retinal detachment (ERD) in a single tertiary referral center experience. We retrospectively analyzed 48 patients who underwent vitreoretinal intervention for persistent ERD between 2017 and 2024. The study assessed patient demographics, underlying causes of ERD, the success rate of surgical interventions, and postoperative visual outcomes. Of the 2040 eyes with retinal detachment treated at our center, 48 (2.35%) were diagnosed with ERD. Coats disease was the most frequent underlying cause, identified in 18 (37.5%) of ERD cases. Choroidal hemangioma (n = 6, 12.5%) and nanophthalmos (n = 5, 10.4%) were the next most common etiologies. The study population comprised 48 patients (30 males and 18 females) with a mean age of 37.48 years (range, 4-88 years). The mean best-corrected visual acuity remained stable from baseline to follow-up. The recurrence rate following primary surgery was 29.2%. Patients underwent a mean of 1.75 ± 1.00 surgeries. Globe preservation was achieved in 44 eyes (91.7%), while phthisis bulbi developed in 4 eyes (8.3%). Vitreoretinal surgery may be considered as a salvage procedure in cases where persistent ERD threatens the posterior pole. In our study, Coats' disease, choroidal hemangioma, and nanophthalmos were identified as the most common etiologies associated with persistent ERD. Surgical intervention has the potential to preserve vision, but the high recurrence rate necessitates a cautious approach and the possibility of multiple surgeries.

Can KOOS-PS be replaced with a simple anchor question in patients after total knee arthroplasty?: an agreement study of 2,478 primary surgeries.

Physical function and pain are the most important outcomes following total knee arthroplasty (TKA). These can be evaluated by patient-reported outcome measures (PROMs), or by an anchor question. The primary aim of the study was to evaluate whether a simple anchor question can replace KOOS-PS in assessing postoperative knee function until 1-year follow-up, evaluated by analyzing the agreement between the 2 methods using the diagnostic odds ratio (DOR). Secondary aims were pain (NRS) at rest and during mobilization. This is a diagnostic accuracy study with primary TKAs performed between 2010 and 2022. The surgeries were categorized as improved (I) or worsened (W) based on a dichotomized anchor question related to self-perceived change in physical function, and the dichotomized change in KOOS-PS until 1-year follow-up. This led to 4 groups: (II, IW, WI, and WW). Agreement was found with a DOR of 11.3 (CI 7.9-16.2). 2,335 (94%) reported improved function on the anchor question and 143 (6%) worsened function. Among those with improved anchor 2,132 (91%) had improved KOOS-PS, but among those with worsened anchor only 74 (52%) had worsened KOOS-PS. Pain at 1-year follow-up was lower in the groups reporting improved anchor. The KOOS-PS can be replaced with an anchor question to assess change in function until 1 year. However, the KOOS-PS might be a valuable supplement in patients reporting worsened anchor as only half of those had worsened KOOS-PS.

The epidemiological and histopathological factors for delayed local recurrence in oral squamous cell carcinoma.

Oral squamous cell carcinoma (OSCC) is a prevalent malignancy in oral cancer. Approximately 26% of OSCC cases recur after initial curative treatment, with over 80% of these recurrences occurring within the first 2years. Delayed local recurrence (DLR) occurring beyond the 2-year period in cases of OSCC is infrequent. The aim of this study is to investigate the histopathological characteristics associated with DLR. This study included 197 patients diagnosed with OSCC who underwent primary surgery from 2006 to 2022. Epidemiological features, such as age and gender, and histopathological features, including primary tumor sites, TNM staging, histopathological grading, depth of invasion, the presence of lymphovascular or perineural invasion, and the utilization of radiation therapy (RT) and neck dissection (ND) were analyzed. The mean interval until local recurrence was 22 ± 27months. There were 10 cases of DLR (20.83%) among 51 patients with local recurrence. The epidemiological and histopathological analysis of these cases is as follows: 10 patients (3 males and 7 females) aged 51-80years (median, 56.5years). Primary tumor sites were tongue (n = 3), maxillary gingiva (n = 1), mandibular gingiva (n = 3), retromolar trigone (n = 1), and buccal mucosa (n = 2). Tumor size was advanced (T3/T4) in 5 cases, while a smaller size (T1/T2) was observed in 5 cases. No lymph node metastasis was 80.0%. Histopathological grading was well differentiated in 9 cases and moderately differentiated in 1 case, with no cases of poorly differentiated tumors. Depth of invasion > 5mm was 70.0% of the cases (n = 7). Lymphovascular invasion and perineural invasion were not present. Three patients received RT, and 8 patients underwent ND. There were 2 patients who consumed alcohol, and 2 patients who smoked tobacco. The results showed that histological differentiation had a significant relationship with the interval (p = 0.031). DLR, occurring more than 2years after the initial tumor resection surgery, is infrequent. Histological differentiation is associated with tumor recurrence intervals. Patients with a higher histological grading require more precise follow-up observation during the initial 2years after surgery.

Phase II Trial of Induction Chemotherapy for Advanced Sinonasal Squamous Cell Carcinoma.

Outcomes after primary surgery for advanced sinonasal squamous cell carcinoma (SCC) are poor. We tested whether induction chemotherapy (IC) can improve disease control or organ preservation. A phase II trial evaluated previously untreated patients with stage II-IV, M0 sinonasal SCC. Patients received IC with docetaxel, cisplatin, and fluorouracil, followed by chemoradiotherapy (CRT) for responders and surgery with adjuvant radiotherapy or CRT for non-responders. The primary endpoints were overall response rate (ORR) and locoregional control (LRC). Secondary endpoints included progression-free survival (PFS), overall survival (OS), organ preservation, and treatment toxicity. Of the 31 patients enrolled between 2008 and 2020, 28 were evaluated for efficacy. Disease was T4a, T4b, and N+ in 57%, 21%, and 36% of patients, respectively. The ORR was 82.1%; 17.9% of patients had stable disease, and 0% had progressive disease. Grade 3 and 4 adverse events (AE) occurred in 54% and 18% of patients, respectively; there were no Grade 5 AEs. The 2-year LRC and PFS rates were 64.3% (95% CI 40.4-77.6) and 52.4% (95% CI 32.3-69.0), respectively. The median PFS was 25.8 months. The median OS was 47.4 months, with a 2-year OS rate of 69.4% (95% CI 44.9-80.4). No survival difference was observed between surgery versus CRT (hazard ratio 1.07, 95% CI 0.9-3.84). Of patients alive at 2 years, 63% achieved organ preservation, avoiding maxillectomy (38%), craniotomy (13%), or orbital exenteration (38%). IC and response-directed treatment achieved promising disease control and added organ preservation for patients with advanced sinonasal SCC.

Challenges and Considerations in Diagnosing and Managing p16+-Related Oropharyngeal Squamous Cell Carcinoma (OPSCC) with Neck Metastasis: Implications of p16 Positivity, Tobacco Exposure, and De-Escalation Strategies

Background: The incidence of patients showing neck metastasis and no obvious primary tumor at the initial diagnostic evaluation or neck cancer of unknown primary (NCUP) is rising. It is estimated that a relevant part of these tumors arises in the tonsillar crypts or base of the tongue and are p16+-related. However, today, the detection rate of the primary tumor is suboptimal. Identifying the primary tumor and its biomolecular characterization is essential since it influences the treatment administered, possibly reducing radiation fields and providing de-escalation to primary surgical management. However, p16 IHC (immunohistochemistry) might not be sufficient to diagnose HPV-related OPSCC. The other subset of patients discussed are the HPV-positive patients who have a history of tobacco exposure and/or p53 mutations. Possible factors that could negatively influence the outcomes of these patients are investigated and discussed below. So, this paper aims to analyze the diagnostic, bio-molecular, clinico-radiological, morphological, prognostic and therapeutical aspects of p16-positive OPSCC, highlighting the possible bias that can occur during the diagnostic and prognostic process. Methods: A narrative review was conducted to investigate the biases in the diagnostic and therapeutic process of two groups of patients: those who are p16-positive but HPV-negative patients, and those who are p16-positive and HPV-positive with exposure to traditional risk factors and/or p53 mutations. The keywords used for the literature research included the following: NCUP, OPSCC, p16IHC, HPV testing, p16 positive HPV negative OPSCC, p16 positive HPV positive OPSCC, tonsillectomy, tobacco exposure, p53 mutations, cystic neck metastasis, extranodal extension (ENE), radiotherapy, de-escalation and neck neck dissection. Results: HPV-positive OPSCC has specific clinico-radiological features. Bilateral tonsillectomy should be considered for the identification of the primary tumor. P16 IHC alone is not sufficient for diagnosing HPV-related OPSCC; additional detection methods are required. The role of tobacco exposure and p53 mutations should be investigated especially in cases of HPV-positive tumors. Extranodal extension (ENE) must be taken into consideration in the prognostic staging of HPV-positive tumors. Surgical primary treatment involving neck dissection (ND) and bilateral tonsillectomy followed by adjuvant radiation may represent the most appropriate approach for N3 cases. Diagnosis, prognosis and therapeutical implications must be addressed considering clinical, biomolecular and morphological aspects. At least today, the numerous biases that are still present influencing the diagnostic and prognostic process do not permit considering de-escalation protocols. Conclusions: A precise and accurate diagnosis is required in order to adequately stage and manage p16+ OPSCC, particularly with neck metastasis. The role of tobacco exposure and/or p53 mutations must be considered not only in p16+ OPSCC but especially in HPV-positive OPSCC. Until a more accurate diagnosis is possible, ENE should be considered even in p16+HPV+ OPSCC. Primary surgery with unilateral ND and bilateral tonsillectomy might be the treatment of choice given the numerous diagnostic and prognostic pitfalls. Therefore, it is inappropriate and risky to propose de-escalation protocols in routine clinical practice due to the risk of undertreatment.

Anemia in patients ten years after bariatric surgery.

More than 10% of the global population has a BMI above 35. Bariatric surgery is an efficient way to treat this condition. Unfortunately, there is a risk of nutritional deficiencies. The number of studies after a longer time span is scarce. The aim of this study was to determine the occurrence of anaemia five and ten years after bariatric surgery and how it was related to substitution therapy. Registry data from individuals having primary bariatric surgery in the Scandinavian Obesity Surgery Registry (SOReg) from 2007 to 2022 and with a follow-up at five or ten years was retrieved. Demographic data including weight, as well as method of surgery, Hb levels, supplementation, PPI use and stomal ulcerations were recorded. In total, 39,992 individuals (mean age 41 years, range 18-74, 77% women) could be included. The majority, 78%, had undergone laparoscopic Roux-en-Y gastric bypass. After five years, 2838/13,944 women (20.3%) and 456/4049 men (11.2%) had anaemia. After ten years, 644/3400 women (18.9%) and 178/947 men (18.8%) had anaemia. The use of oral iron increased from 40 to 45%, and the need for parenteral iron intake increased from 5 to 11%. Anaemia is a significant but manageable condition five and ten years after bariatric surgery. Despite the prescription of oral iron supplements to 45% ten years after surgery, the Hb levels could still not be fully restored. Consequently, the importance of follow-up visits and continuous supplementation is emphasised.