Prior Abdominal Surgery Research Articles

Surgical outcomes of hysterectomy for endometriosis: Benefits of a minimally invasive approach

Introduction: We aimed to evaluate surgical outcomes of hysterectomy for endometriosis performed by general obstetricians and gynecologists (OB/GYNs) based on surgical approach. Methods: Using the 2016–2018 National Surgical Quality Improvement Program (NSQIP) database, we examined surgical outcomes including 30-day complication rates based on surgical approach in patients who underwent a hysterectomy for endometriosis by OB/GYNs. Results: From 2016 to 2018, 3641 hysterectomies were performed by OB/GYNs for endometriosis. 86.0% were performed via a minimally invasive (MIS) approach, with 2882 (79.2%) via a laparoscopic and 247 (6.8%) via a vaginal approach. Compared to MIS hysterectomies, those who underwent an abdominal hysterectomy included a higher proportion of African American and a lower proportion of non-Hispanic white patients, had heavier uteri, lower parity, and were more likely obese (all p < 0.05). There were no differences in age, American Society of Anesthesiologists class, comorbidities other than obesity, or a history of prior abdominal or pelvic surgery (all p > 0.05). Women undergoing hysterectomy for endometriosis experienced an overall 9.8% complication rate. Compared to abdominal approaches, MIS had a lower rate of overall complications (8.5% vs 17.8%) including wound (2.7% vs 7.2%) and major (4.4% vs 8.8%) complications (all p < 0.001). MIS had shorter operative time (129.2 ± 60.9 vs 143.8 ± 71.9), shorter length of stay (0.9 ± 1.6 vs 2.4 ± 1.8), and fewer readmissions (2.8% vs 5.5%) (all p < 0.001). Conclusion: While hysterectomy for endometriosis is a challenging procedure to perform, OB/GYNs are performing this procedure predominantly via a minimally invasive approach with fewer complications and more favorable surgical outcomes than an abdominal approach.

Perioperative and oncologic outcomes of open, laparoscopic, and robotic distal pancreatectomy for pancreatic adenocarcinoma.

The utilization of minimally invasive distal pancreatectomy (MIDP) is increasing, yet debate remains regarding its oncologic safety in the setting of pancreatic adenocarcinoma (PDAC). Herein we present our institutional experience with robotic (RDP), laparoscopic (LDP), and open distal pancreatectomy (ODP) in the setting of PDAC.Retrospective review of a prospectively collected single institutional database of patients undergoing consecutive ODP, LDP, and RDP for left-sided PDAC between January 2008 and December 2019 at the University of Pittsburgh Medical Center (UPMC) was done. Perioperative and postoperative outcomes were compared using non-parametric testing and Fischer exact or chi-squared testing. Kaplan-Meier survival curves for disease-free survival and overall survival were compared by Log-Ranksum test. Backward Cox-proportional hazard regression analysis was used to determine if the operative approach was an independent predictor of recurrence and overall survival.Over 12years, 146 consecutive distal pancreatectomies for PDAC were performed, of which 28.1% ODP, 60.3% RDP, and 11.6% LDP. There were no statistical differences in patients' baseline characteristics, including gender, comorbidities, prior abdominal surgeries, and AJCC8th stage (p > 0.05). Postoperatively, there was no difference in the frequency of major complications (p = 0.414), CR-POPF (p = 0.563), or DGE (p = 0.179). The median overall survival was 28.4months for ODP, 34.6months for RDP, and 32.5months for LDP (Log Rank p = 0.914). On multivariate Cox proportional hazard analysis, the surgical approach was not associated with overall survival. This comparative analysis suggests a non-inferiority of RDP platforms, compared to LDP and classic ODP. The merits of MIS pancreatic surgery in the setting of PDAC should be evaluated in future prospective studies with care to analyze RDP outcomes separately from LDP.

The Influence of Prior Abdominal Surgery on Robot-Assisted Partial Nephrectomy.

We evaluated the influence of prior abdominal surgery on perioperative outcomes in patients who underwent robot-assisted partial nephrectomy in initial Japanese series. We reviewed patients with small renal tumors who underwent robot-assisted partial nephrectomy from October 2011 to September 2020 at our institution. Patients with prior abdominal surgery were compared with those without prior surgery based on perioperative outcomes. The chi-square test and Mann-Whitney U test were used for statistical analyses of variables. Of 156 patients who underwent robot-assisted partial nephrectomy, 90 (58%) had no prior abdominal surgery, whereas 66 patients (42%) underwent prior abdominal surgery. No significant differences in perioperative outcomes were observed between with and without prior abdominal surgery groups. In transperitoneal approach robot-assisted partial nephrectomy, 31 patients (80.4%) had prior abdominal surgery. Trocar insertion time in the with prior abdominal surgery group took longer than the without prior abdominal surgery group (32 vs. 28.5 min, P = 0.031). No significant difference was observed in the conversion rate between the two groups (P = 0.556). Robot-assisted partial nephrectomy appears to be a safe approach for patients with prior abdominal surgery. In transperitoneal approach robot-assisted partial nephrectomy with prior abdominal surgery, trocar insertion time was longer, but no significant differences were found in other outcomes. Transperitoneal approach robot-assisted partial nephrectomy is thus considered a safe procedure for patients with prior abdominal surgery.

Panoramic colonoscopy in colorectal cancer screening - a randomized controlled trial.

IntroductionColonoscopy is considered the gold standard for colorectal cancer screening. Panoramic colonoscopy offers better visualization to decrease the adenoma miss rate.AimTo assess the influence of 330° panoramic view colonoscopy on adenoma and polyp detection rate, cecal intubation time, and examiner’s comfort.Material and methodsThe study enrolled 421 patients aged 18–80 years who were eligible for colonoscopy screening. Patients with prior abdominal surgery, inflammatory bowel disease or after colorectal resections were excluded from the study. Patients were randomized to either standard frontal view (SFV) (Olympus Evis Exera III 190 CF-HQ190L) or the panoramic view colonoscopy (PVC) (FUSE CDVL slim c38). The study was approved by the local bioethics committee and registered at ClinicalTrial.gov (NCT02929381).ResultsThere were 214 patients examined with SFV and 207 with PVC. The mean age of patients was 64 ±12.26 years. The two groups were comparable. The median cecal intubation time was 234 s with SFV vs. 311 s with PVC (p < 0.001). There were no significant differences in CIR or withdrawal time. PVC made it possible to discover more diverticula in the ascending colon (p = 0.009). PDR with SFV was 34.6% and 40.1% with PVC (p = 0.242). A higher number of polyps was found in the transverse colon in the PVC group (p = 0.006). ADR and advanced ADR (aADR) in both groups were similar (26.4% vs. 27.1% and 14, 2% vs. 13.9%).ConclusionsColonoscopy with wide-angle endoscopes lasts longer and allows for the detection of more polyps and diverticula without affecting ADR and aADR. Our study did not reveal the superiority of wide-angle colonoscopy in colorectal cancer screening

The Comprehensive Complication Index. Proposed modification to improve estimates of perioperative morbidity after radical cystectomy. A pilot study.

IntroductionThe aim of this article was to compare the 30-day morbidity after radical cystectomy comparing the prevalent Clavien-Dindo Classification (CDC) and the novel Comprehensive Complication Index (CCI). Additionally, we evaluated the correlation between particular clinical features and the severity of perioperative morbidity.Material and methodsA total of 42 patients were included into the study (33 men and 9 women) who underwent open radical cystectomy (RC) with bilateral lymphadenectomy for bladder cancer. The selection of complications was based on groundbreaking research on morbidity after RC. The assessment of perioperative complications was performed using the CDC and then the CCI.ResultsThe CCI was found to be a significant upgrade in capturing cumulative morbidity in comparison to the CDC when used as the only evaluational tool.ConclusionsUsing only the CDC may underestimate the severity of perioperative complications. Unfavorable clinical features e.g. older age, chronic kidney disease (CKD), persistent nodal (pN+) disease, prior abdominal and pelvic surgeries as well as smoking are of significant importance for the increase of the severity of perioperative complications.

Interstitial Cystitis/Bladder Pain Syndrome as Referred Pain From Injured T12/L1 Nerves: Symptomatic Improvement With Resection of Ilioinguinal and Iliohypogastric Nerves

To evaluate the specific contribution of ilioinguinal (II) and iliohypogastric (IH) nerve injury and referred pain to interstitial cystitis/bladder pain syndrome and patient-reported chronic pelvic pain, and to enumerate the effects of II and IH nerve resection on the pain and voiding symptoms in patients with IC/BPS. This was a prospective cohort study of 8 patients with ICS/BPS who had prior abdominal surgery. All patients received diagnostic image guided T12/L1 nerve blocks, followed by II and IH nerve resections. Validated O'Leary-Sant ICS symptom indices (OSPI) and pelvic pain and urgency/frequency patient symptoms scale (PUF) scores were collected at specified intervals pre- and post-operatively. Median scores at pre-operative (OSPI 13.9, PUF 20.4) and 1 week time points (OSPI 5.9, PUF 11), as well as differences between pre-operative and 10 month time points (OSPI 3.7, PUF 6) were all statistically significant (P=.008 and .009 at 1 week, and .007 and .008 at 10 months, for OSPI and PUF respectively). The mean difference in score from pre-operative to longest follow-up as measured by the OSPI was -14.4 (P < .001) and by PUF -10.3 (P < .001). All time points registered demonstrated improvement in pain scores. There were no surgical complications or adverse events. II and IH nerve resection may be an effective and durable treatment option for those with prior abdominal surgery who have referred interstitial cystitis/bladder pain syndrome pain from these injured nerves.

A Novel Abdominal Decompression Technique to Treat Compartment Syndrome After Burn Injury

BackgroundPrevalence of abdominal compartment syndrome (ACS) is estimated to be 4%-17% in severely burned patients. Although decompressive laparotomy can be lifesaving for ACS patients, severe complications are associated with this technique, especially in burn populations. This study outlines a new technique of releasing intraabdominal pressure without resorting to decompressive laparotomy. Materials and methodsTen fresh tissue cadavers were studied; none of whom had had prior abdominal surgery. Using Veress needles, abdomens were insufflated to 30 mm Hg and subsequently connected to arterial pressure transducers. Two techniques were then used to incise fascia. First, large skin flaps were raised from a midline incision (n = 5). Second, small 2 cm cutdowns at the proximal and distal extent of midaxillary, subcostal, and inguinal incisional sites were made, followed by tunneling a subfascial plane using an aortic clamp with fascial incisions made through the grooves of a tunneled vein stripper (n = 5). Pressures were recorded in the sequence of incisions mentioned previously. ResultsThe open midline flap technique decreased abdominal pressure from a mean pressure of 30 ± 1.8 mm Hg to 6.9 ± 5.0 mm Hg (P < 0.01). The minimally invasive technique decreased intraabdominal pressure from 30 ± 0.9 to 5.8 ± 5.2 mm Hg (P < 0.01). This technique significantly reduced intraabdominal pressure via extraperitoneal component separation and fascial release at the midaxillary, subxiphoid, and inguinal regions. ConclusionsThis technique offers the benefit of reducing the morbidity, mortality, and complications associated with an open abdomen, which may be beneficial in the burn injury population.

Postoperative Complications and Risk of Mortality after Laparotomy in a Resource-Limited Setting

BackgroundDespite increases in surgical capacity in Malawi, minimal data exist on postoperative complications. Identifying surgical management gaps and targeting quality improvement requires detailed, longitudinal complications, and outcome data that assess surgical safety and efficacy. MethodsWe conducted a 6-mo prospective, observational study of patients >12 y after laparotomy at a tertiary hospital in Lilongwe, Malawi. Outcomes included postoperative complications and mortality. The seniormost rounding physician determined complication diagnoses. Bivariate and Poisson regression analyses identified predictors of mortality. ResultsOnly patients undergoing emergent laparotomy (77.8%) died before discharge, so analysis excluded elective cases. Of 189 patients included, the median age was 33.5 y (IQR 22-50.5), 22 (12.2%) had prior abdominal surgery, and 11 (12.1%) were human immunodeficiency virus-positive. Gastrointestinal perforation was the most common diagnosis (35.5%). The most common procedures were primary gastrointestinal repair (24.9%), diverting ostomy (21.2%), and bowel resection with anastomosis (16.4%). Overall postoperative mortality was 14.8%. Intra-abdominal complication occurred in 17 (9.0%) patients, of whom 8 (47.1%) died. Older age (RR 1.05, 95% CI 1.02-1.08, P < 0.001) and intra-abdominal complication (RR 2.88, 95% CI 1.28-6.46, P = 0.01) increased the relative risk of mortality. Preoperative diagnosis, surgical intervention type, and symptom-to-surgery time did not increase the relative risk of mortality. ConclusionsThe incidence of complications and mortality after laparotomy at a large referral hospital in Malawi is high. Older age and intra-abdominal complications increase the risk of death. Strategies to improve operative mortality in Malawi should prioritize postoperative surveillance and management and continued outcomes reporting.

English

BACKGROUND Ectopic pregnancy is not only the gynaecologist’s most critical emergency but also one of the major problems because of its difficulties in diagnosis, increased risks of mortality, and its profound implications with regard to future reproductive performance. We wanted to study the types and accuracy of various diagnostic modalities, and effect of various management modalities of ectopic pregnancy. METHODS This study was conducted at Meenakshi Medical College Hospital and Research Institute, Kanchipuram, for a period of 32 months from May 2010 to October 2012. During the same period, there were 2602 reported pregnancies. RESULTS The incidence of ectopic pregnancy in the study is 15.3 / 1000 reported pregnancies. The incidence of ectopic pregnancy in patients with prior abdominal surgery was 86.6 %. Only 77.5 % patients gave history of typical amenorrhea. 22.5 % patients gave history suggestive of atypical amenorrhoea. It was noted that 55 % cases presented as tubal rupture, 7.5 % as tubal abortion, 35 % cases presented with intact tubal pregnancy and 2.5 % cases presented as ovarian pregnancy. The choice of management in our study included ipsilateral partial salpingectomy in 27.5 %, ipsilateral total salpingectomy in 45 %, ipsilateral salpingectomy with contralateral salpingo-oophorectomy in 5 % and bilateral salpingectomy in 22.5 % of cases. CONCLUSIONS Combination of accurate history, meticulous physical examination, ’Pregcolor’ urinary assay, culdocentesis and ultra-sonography will lead to early diagnosis. Transvaginal sonography is the best method of diagnosis in cases of ectopic pregnancy presenting in earlier weeks of gestation.\ KEYWORDS Culdocentesis, Ultra Sonography, Transvaginal Sonography, Ectopic Pregnancy

Laparoscopic Distal Pancreatectomy Following Prior Upper Abdominal Surgery (Pancreatectomy and Prior Surgery)

Background and PurposePrevious abdominal surgery can be a risk factor for perioperative complications in patients undergoing laparoscopic procedures. Today, distal pancreatectomy is increasingly performed laparoscopically. This study investigates the consequences of prior upper abdominal surgery (PUAS) for laparoscopic distal pancreatectomy (LDP). MethodsPatients who had undergone LDP from April 1997 to January 2020 were included. Based on the history and type of PUAS, these were categorized into three groups: minimally invasive (I), open (II), and no PUAS (III). To reduce possible confounding factors, the groups were matched in 1:2:4 fashion based on age, sex, body mass index (BMI) and American Society of Anesthesiology grade. ResultsAfter matching, 30, 60, and 120 patients were included in the minimally invasive, open and no PUAS groups, respectively. No statistically significant differences were found in terms of intraoperative outcomes. Postoperative morbidity, mortality and length of hospital stay were similar. Open PUAS was associated with higher Comprehensive Complication Index (33.7 vs 20.9 vs 26.2, p = 0.03) and greater proportion of patients with ≥ 2 complications (16.7 vs 0 vs 6.7%, p = 0.02) compared with minimally invasive and no PUAS. Male sex, overweight (BMI 25–29.9 kg/m2), diagnosis of neuroendocrine neoplasia, and open PUAS were risk factors for severe morbidity in the univariable analysis. Only open PUAS was statistically significant in the multivariable model. ConclusionsPUAS does not impair the feasibility and safety of LDP as its perioperative outcomes are largely comparable to those in patients without PUAS. However, open PUAS increases the burden and severity of postoperative complications.

Does Prior Abdominal Surgery Influence Peritoneal Transport Characteristics or Technique Survival of Peritoneal Dialysis Patients?

Introduction: Prior abdominal surgery may result in peritoneal membrane adhesions and fibrosis, compromising the success of peritoneal dialysis (PD). The impact of this factor on peritoneal membrane function and PD technique survival has not been adequately investigated. Methods: Following an observational, retrospective design, we studied 171 incident PD patients, with the main objective of analyzing the influence of prior abdominal surgical procedures (main study variable) on baseline and evolutionary peritoneal transport characteristics (main outcome) and PD patient and technique survival (secondary outcomes). Abdominal surgeries were categorized according to the degree of presumed injury to the peritoneal membrane. We also considered the additive effect of aggressions to the membrane during the first year on PD therapy. Results: All patients had a baseline peritoneal equilibration test with complete drainage at 60′, and 113 patients had a second study at the end of the first year. Sixty-one patients (35.7%) had a record of prior abdominal surgery, including 29 patients with at least one major intraperitoneal surgery, 22 having undergone minor intraperitoneal procedures, and 21 with a background of major abdominopelvic extraperitoneal surgery. We did not observe differences, at baseline or after 1 year, among patients with or without previous abdominal procedures regarding small solute transport, overall capacity of ultrafiltration, free water transport, small pore ultrafiltration, or peritoneal protein excretion. Stratified analysis, considering prior and first-year-on-PD peritoneal aggressions, did not reveal any differences, although in this case our analysis was hampered by a limited statistical power. Abdominal surgical events did not influence patient or PD technique survival. Conclusion: Prior abdominal surgical procedures do not appear to compromise peritoneal membrane function or technique survival in patients successfully started on PD.

Comparison of Differences in Patient Outcomes for Surgeries Performed By Fellowship-Trained Gynecologists Compared to Generalists

Study Objective To compare patient characteristics and surgical outcomes for surgeries performed by fellowship-trained gynecologic surgeons (MIGS) to OB/GYNs without additional training (Generalists). Design Literature review using PubMed/Medline. Setting Academic university and community hospitals. Patients or Participants Eight retrospective cohort studies including total of 8,888 patients undergoing minimally invasive surgery by MIGS and Generalists Interventions Compare patient BMI, uterine weight, and prior surgical history; evaluate difference in surgical complexity, operative times, blood loss, length of hospital stay, occurrence of complications, hospital costs. Measurements and Main Results Majority of studies included benign hysterectomies performed over an average of 3.75 years (range 1-9 years). Fellowship training included MIGS; only one study included gynecologic-oncologists and urogynecologists. Compared to Generalists, MIGS operated on patients with higher BMI (OR 2.030 for BMI 40+), greater uterine weight (649.9 g v. 320.7 g, p=0.01), and a history of prior abdominal surgeries (42.7% vs 17.2%; p=0.001). MIGS performed more difficult procedures related to resection of endometriosis (22.9% vs. 4.4%, p MIGS had significantly shorter operative times, lower blood loss during surgery, and decreased length of stay after surgery. Patient and hospital charges were lower for surgeries performed by MIGS (patient cost: $28,063 vs. $36,612, p Majority of the studies show a decrease or no difference in rate of total, postoperative or intraoperative complications with MIGS. Conclusion MIGS fellowship training is associated with improved perioperative outcomes, despite the increase in surgical complexity. This finding indicates that surgical volume is not the only determinant of outcomes. Unlike other surgical residencies, this higher level of technical ability is not consistently obtained in the current structure of OB-GYN residency, underlining the importance of additional training, which ultimately may be required for those who wish to practice gynecologic surgery in the future.

Factors Influencing Symptomatic and Nonsymptomatic Bulge Rates in the Abdominal Donor Site of Autologous Breast Reconstruction

INTRODUCTION: With continued demand for abdominal based breast reconstruction, it is important to understand all the factors influencing donor site morbidity. Previous studies mostly focus on type of flap and its associated donor site complications. However, we aim to assess other factors, including history of prior abdominal surgery, body mass index (BMI), and specific operative details such as the total area of muscle harvested, portion of the rectus muscle harvested, status of the anterior fascia after abdominal closure, use of mesh, and the status of abdominal wall nerves. METHODS: A retrospective chart review of patients undergoing autologous breast reconstruction from May 2012 to October of 2017 by 2 surgeons at a single institution was performed. Only patients with abdominal-based breast reconstruction were included in the study. Demographics, prior medical and surgical history, intraoperative data, and postoperative course were collected. Primary outcomes of interest were nonsymptomatic bulge found on physical exam and symptomatic bulge requiring surgical correction. RESULTS: One-hundred twenty women were identified with 39 undergoing unilateral and 81 undergoing bilateral breast reconstruction. Within the unilateral patient group, 30 patients underwent ms-Transversal Rectus Abdominis Muscle (TRAM) and 9 patients underwent deep inferior epigastric artery perforator (DIEP) reconstruction. The breakdown in the bilateral group is as follows: 39 bilateral ms-TRAM, 5 bilateral DIEP, 37 a combination of ms-TRAM and DIEP. The average follow-up was 2.01 years (range, 0.04–7.52 years). Thirteen (10.8%) patients developed nonsymptomatic bulge and 14 (11.7%) patients developed symptomatic bulge requiring surgical correction. Patient with BMI ≥ 30 were 3 times more likely to develop a symptomatic bulge (P = 0.029). Similarly, patients with prior abdominal surgery were 7.2 times more likely to develop a symptomatic bulge (P = 0.047). Patients with bilateral ms-TRAM reconstruction had higher rate of nonsymptomatic and symptomatic bulge compared with any other reconstruction type (P = 0.050). Size of muscle harvested did not have an effect on bulge development (P = 0.674). Higher percentage of patients with muscle harvested from the central portion of the rectus muscle developed non-symptomatic bulge (P = 0.008). In contrast, patients with muscle harvested from the medial or lateral portion of the rectus muscle had a 15% increased risk of developing symptomatic bulge (P = 0.023 and P = 0.021, respectively). The use of mesh, type of mesh, and location of mesh placement during abdominal wall reconstruction did not affect bulge development (P = 0.236, P = 0.285, P = 0.195, respectively). Whether the anterior rectus fascia was closed or left open at the end of the case did not influence the bulge rate (P = 0.122). Similarly, number of nerves severed did not influence the bulge rate (P = 0.575). CONCLUSION: High BMI and previous abdominal surgery significantly increase the risk of symptomatic bulge development. Location of muscle harvest from the rectus muscle influenced the rates of nonsymptomatic and symptomatic bulge development, with muscle from the central portion of the rectus muscle resulting in significantly higher rate of nonsymptomatic bulge, and muscle from medial or lateral portion of the rectus muscle resulting in higher rate of symptomatic bulge. Total muscle area harvested, use of mesh in abdominal reconstruction, or nerve preservation did not affect the rate of bulge development.

S1597 The Curious Case of a Missing Gallbladder: An Unusual Presentation of a Large Gallstone and Cholecystoduodenal Fistula

INTRODUCTION: Cholecystodudenal fistula is a rare complication of cholelithiasis. We present a unique endoscopically-treated case of a 5 cm gallstone that caused acute abdominal pain without gastric outlet obstruction in a middle-age female. CASE DESCRIPTION/METHODS: A 56-year-old woman with DM type II, hypertension, and BMI of 48 kg/m2 presented with acute right upper quadrant pain for 3 days. It was associated with nausea but no emesis, aggravating or alleviating factors. She had no prior abdominal surgeries. Vitals were normal. There was tenderness in the right upper quadrant but Murphy’s sign was negative. WBC, ALT, AST, total bilirubin and lipase were within normal limits. An ultrasound showed gallstones in a contracted gallbladder with no signs of cholecystitis. Robotic-assisted laparoscopic cholecystectomy was attempted, however, there was substantial amount of adhesions. Lysis of the adhesions was performed, then the duodenum and the stomach were found adhered to the gallbladder fossa. Thus, cholecystectomy was not deemed safe and the surgery was aborted. MRCP showed a minimal fluid collection in the gallbladder fossa but no evidence of bile duct stones or dilation. The gallbladder could not be identified. HIDA scan did not show it either. A CT scan of the abdomen revealed a cholecystoduodenal fistula along with air in a non-dilated biliary tree. EGD revealed a 5 cm golden-brown and hard stone and an inflamed and scarred fistulous opening in the bulb. The stone was too large to be retrieved through the pylorus. To prevent GI obstruction and to avoid a high-risk laparotomy, a large snare with a hard wire was used to break it down by forcefully pulling it against the plastic tip of the snare. The fragments were brought to the stomach for further fragmentation. The fragments were retrieved using stone baskets. Following the procedure, the symptoms improved. DISCUSSION: What was initially thought to be a classic case of symptomatic cholelithiasis was found to be a clinically, surgically, and endoscopically challenging cholecystoduodenal fistula. The fistula was not seen during an attempted cholecystectomy, nor was it seen on MRCP. Only CT then endoscopy revealed it. Large gallstones causing fistulas are very rare in the young. Laser, extracorporeal shockwave, and intracorporeal electrohydraulic lithotripsies have been used to treat large gallstones. Due to our limited resources, we performed mechanical fragmentation using the readily available stiff snares and stone baskets; a rarely reported approach.Figure 1.: Coronal oral and intravenous enhanced CT image of the abdomen demonstrates a large calculus (yellow arrow) with a few foci of air, as well as air within the biliary system (green arrow) suggesting choleduodenal fistula. A small amount of ascites surrounds the liver. There is also subcutaneous air within the right abdominal wall and adjacent to the gluteal muscles due to recent laparoscopy.Figure 2.: Endoscopic view of a large golden-brown, smooth and hard gallstone in the duodenal bulb. Erosion is seen on the wall of the duodenum.Figure 3.: Fragmentation of the large gallstone using a large-opening hard wire snare.

S2105 Isolated Cecal Varices: A Rare Cause of Hematochezia

INTRODUCTION: Ectopic varices (outside gastro-esophageal region) are uncommon in patients with portal hypertension (PH) and account for 5 % of all variceal bleeding cases. Isolated cecal varices (ICV) without pancolonic varices are extremely rare with only handful of cases reported so far. Here we present a case of bleeding from ICV in patient with alcoholic cirrhosis. CASE DESCRIPTION/METHODS: A 55-year-old male with history of alcoholic cirrhosis (last alcohol use 1 y ago), CKD3 was admitted with 1 day history of hematochezia and dizziness. Hemoglobin on admission was 5.8 gm/dL, platelet 126 b/L and INR 1.4. After initial resuscitation, he underwent EGD which revealed non-bleeding grade 2 esophageal varices which were banded. He continued to have hematochezia. He subsequently underwent colonoscopy which revealed a 4 cm area of granularity in cecum. This area was biopsied following which sudden spurting of blood was seen. He was sent for emergent abdominal CT angiography, which came back negative for active arterial bleeding. Retrospectively, the area of granularity in cecum was thought to represent an ICV. There was spontaneous cessation of bleeding and the patient was discharged in next few days. Two months later, he presented to our hospital for similar episodes of lower GI bleeding. EGD showed non-bleeding grade 1 esophageal varices. Due to suspected bleed from ICV, patient was taken for emergent TIPS. Mesenteric angiogram showed contrast extravasation from a large cecal varix. TIPS and coil embolization of cecal varix was performed resulting in hemostasis. DISCUSSION: Ectopic varices occur in the small intestine, biliary system, colon, rectum, and surgical ostomy sites and can develop in the setting of PH, prior abdominal surgery, vascular thrombosis, or anomalies of the venous outflow vessels. ICV without pancolonic involvement are extremely rare as less than 20 cases have been reported so far in English literature. Almost all the reported cases have presented with massive lower GI bleeding. Usually EGD is performed to rule out more common upper GI bleeding from esophageal varices. CT angiography may be obtained but extravasation may only be seen in the venous phase. No- bleeding ICV can be missed on colonoscopy as over-insufflation can cause the collapse of such varices. Exsanguinating ICV are usually treated by performing emergent TIPS with or without adjunctive variceal embolization.Figure 1.: Colonoscopy showing area of granularity in cecum representing cecal varix (left). Active bleeding seen when this area was mistakenly biopsied (right).Figure 2.: Abdominal angiogram showing large isolated cecal varix with extravasation of contrast.Figure 3.: Fluoroscopic image showing coil embolization of the cecal varix.

S2781 A Case of Clostridium difficile Enteritis

INTRODUCTION: Clostridium difficile (C. difficile) is the cause of 20–25% of antibiotic-associated diarrhea. Extracolonic manifestations of C. difficile are rare but include osteomyelitis and reactive arthritis. More rarely, the bacteria can colonize the small bowel and cause active small bowel enteritis with mortality reported as high as 25%. We present a case of C. difficile enteritis. CASE DESCRIPTION/METHODS: A 39-year-old woman with history of alcoholic liver cirrhosis and splenic embolization for thrombocytopenia one week prior to presentation was admitted for abdominal pain after paracentesis. Her labs were notable for leukocytosis, thrombocytopenia, elevated lactate and elevated INR. Computed-tomography of the abdomen revealed thickening of the proximal small bowel and right colon consistent with enterocolitis, splenomegaly and ascites. Ultrasound showed portal vein thrombosis. Her course was complicated by hepatic encephalopathy and spontaneous bacterial peritonitis. She was transferred to the intensive care unit and an indwelling intraperitoneal catheter was inserted to drain the ascites. The WBC of the peritoneal fluid peaked at 55,000/ml and cultures grew C. difficile. The serum WBC peaked at 66,500/ml and blood cultures also grew C. difficile. Stool was positive for toxigenic C. difficile PCR. Oral vancomycin, intravenous vancomycin and intravenous metronidazole were started. On the 10th day of admission, a donor liver became available and she was taken to the operating room (OR) for transplant. Multiple splenic and intra-abdominal abscesses were noted during the exploration phase of surgery and the surgery was cancelled. Decision was made to take the patient back to the OR for abdominal wash out and possible splenectomy. Unfortunately, she had cardiac arrest intraoperatively and expired after failed resuscitative efforts. DISCUSSION: The exact pathophysiology of C. difficile enteritis is not well-understood, especially in patients with intact small bowel. Majority of patients had prior gastrointestinal surgery such as colectomy. Our patient, however, had no prior abdominal surgeries or intervention. We presume that as a complication of her splenic embolization and raging peritonitis, she developed a portal vein thrombosis causing small bowel wall edema, allowing for translocation of C. difficile from her bloodstream into her small bowel and peritoneal cavity. There must be a high index of suspicion for C. difficile enteritis, as it is not a common entity and has a high mortality rate.

S1854 Endoscopic Retrograde Cholangiopancreatography in Patient With Roux-en-Y Gastric Bypass and High-Grade Duodenal Stricture Across Dual Lumen Apposing Metal Stents

INTRODUCTION: Endoscopic ultrasound-guided lumen-apposing metal stents (LAMS) is a minimally invasive modality that has not only been used for drainage of pancreatic fluid collection but also other off-label indications. We demonstrated a case with multiple applications of LAMS for management of both choledocholithiasis and enteric stricture in a patient with Roux-en-Y Gastric Bypass (RYGB) anatomy. CASE DESCRIPTION/METHODS: An 82-year-old woman with a history of RYGB, multiple abdominal surgeries and choledocholithiasis, which was treated with laparoscopic-assisted ERCP (LA-ERCP) and complicated by duodenal perforation and repaired by open surgery, was admitted for right upper quadrant abdominal pain. MRCP revealed choledocholithiasis with biliary dilatation. After discussion of various options for accessing biliary system, EDGE procedure was pursued. For the initial stage, LAMS was deployed to obtain access to gastric remnant under endosonographic and fluoroscopic guidance. The patient returned in 3 weeks after the tract was mature for ERCP. However, high-grade duodenal stricture, which is likely due to post-surgical scarring or peptic stricture, was unexpectedly found before reaching the biliary system. The stricture was treated with 20 mm by 10 mm LAMS placement under endosonographic and fluoroscopic guidance. She returned in 2 weeks for subsequent ERCP through dual transluminal connection consisted of gastrogastrostomy and duodenal LAMS. The duodenoscope was advanced through gastrogastrostomy and duodenal LAMS to the major papilla without difficulty. Biliary sphincterotomy and plastic biliary stent placement were performed. A large amount of sludge and stone was extracted. She was discharged the same day with improvement in symptoms. All stents were removed 6 weeks after the ERCP without complications. DISCUSSION: With application of LAMS, we described a novel case of EDGE procedure in patient with RYGB anatomy in conjunction with benign enteric stricture, which was performed through dual transluminal conduit comprised of gastrogastrostomy and duodenal LAMS. Other biliary access options were also considered. However, given the high likelihood of extensive adhesions from prior abdominal surgery, LA-ERCP posed a higher risk of complications, and balloon-assisted enteroscopy ERCP (BA-ERCP) has limited maneuverability which often leads to suboptimal success rates. This highly effective approach should be considered for situations where BA-ERCP is technically challenging, and when LA-ERCP is not feasible.

General surgery involvement with ventriculoperitoneal shunt insertions reduces revision rates

BackgroundVentriculoperitoneal shunts (VPS) are placed for a variety of etiologies. It is common for general surgery to assist with insertion of the distal portion in the peritoneum. ObjectiveTo determine if there is a difference in revision rates in patients undergoing VPS placement with general surgery as well as those undergoing laparoscopic insertion. MethodsA retrospective review of all consecutive patients undergoing VPS placements was performed in a three-year period (2017−2019). Those that underwent placement with general surgery were compared to those without general surgery. Additionally, patients undergoing distal placement via mini-laparotomy versus laparoscopy were compared. Multivariable logistic regression was used to examine risk factors for distal VPS failure. Results331 patients were included. 202 (61.0 %) underwent VPS placement with general surgery. 121 (36.6 %) patients underwent insertion via laparoscopic technique. General surgery involvement reduced operative times, decreased length of stay, and lowered overall revision rates with distal revision rates being most significant (1.5 % vs 8.5 %; p = 0.0034). Patients undergoing VPS placement via laparoscopic technique had decreased operative time, length of stay, in-hospital complications and revision rates, with significant decrease in shunt infection (1.7 % vs 7.1 %; p = 0.0366). A history of prior shunt or abdominal surgery (OR 3.826; p = 0.0282) and lack of general surgery involvement (OR 20.98; p = 0.0314) are independent risk factors for distal shunt revision in our cohort. ConclusionThe use of general surgeons in VPS insertion can be of benefit by decreasing operative time, length of stay, total revisions, and distal revision rates. Further prospective studies are warranted to determine true benefit.

S2306 Bad to the Bone: A Rare Case of Fistulizing Disease Extending to the Sacrum

INTRODUCTION: Fistula formation commonly occurs between intestines and other epithelial-lined hollow organs such as the bladder, skin, vagina, or other regions of the gastrointestinal tract. Infrequently, a connection can form between the bowel and the vertebral column and lead to vertebral osteomyelitis. We present the case of a young male with significant abdominal pathology found to have sacral osteomyelitis in the setting of fistula formation between the small bowel and sacrum. CASE DESCRIPTION/METHODS: A 27-year-old male with a history of opioid dependence and abdominal gunshot wound requiring subtotal colectomy with ileo-rectal anastomosis presented with progressive, bloody diarrhea and poor appetite. The patient reported history of previous colonoscopies with balloon dilations of strictures but never diagnosed with inflammatory bowel disease (IBD) or started on any therapies. On exam, the patient was emaciated with multiple clean abdominal scars and diffuse, mild abdominal tenderness. Labs showed microcytic anemia with hemoglobin of 8, elevated fecal calprotectin (402) and CRP (15.1) without leukocytosis, and negative tissue transglutaminase. His stool studies and gastrointestinal pathogen panel were negative for Clostridium difficile or other pathogens. Computed Tomography of the abdomen found enteritis and proctocolitis and concern for possible osteomyelitis of the sacrum and coccyx. Magnetic resonance enterography found multiple entero-colonic fistulas and active inflammatory disease of the small bowel, inflammation of the sacral nerve roots, and concern for fistulization between the small bowel and sacrum. Subsequent flexible sigmoidoscopy found ulcerated friable mucosa and pseudomembranes in the rectum. Pathology showed nonspecific chronic inflammation and was negative for Clostridium difficile. He was started on Rifaximin for empiric treatment of small intestinal bacterial overgrowth with improvement in diarrhea and is planned for further IBD workup to assess the status of his fistulizing disease. DISCUSSION: While most enteric fistulas occur due to prior abdominal surgery complications, 10-15% occur from inflammation and infection associated with Crohn’s disease. Rarely, fistulas can develop between bowel and vertebra, and osteomyelitis may result due to translocation of gut flora from the intestine to the spine via the fistula as seen in our patient. Ultimately, this uncommon presentation should prompt investigation into etiology and use imaging to guide aggressive management.Figure 1.: Rectal ulcer seen on flexible sigmoidoscopy.Figure 2.: MRE showing evidence of a fistula from the small bowel to the sacrum.

258. Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: a retrospective cohort study

258. Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: a retrospective cohort study