Prior Abdominal Surgery Research Articles

Prior infrarenal aortic surgery is not associated with increased risk of spinal cord ischemia after thoracic endovascular aortic repair and complex endovascular aortic repair

ObjectivePatients with prior infrarenal aortic intervention represent an increasing demographic of patients undergoing thoracic endovascular aortic repair (TEVAR) and/or complex EVAR. Studies have suggested that prior abdominal aortic surgery is a risk factor for spinal cord ischemia (SCI). However, these results were largely based on single-center experiences with limited multi-institutional and national data that had assessed the clinical outcomes for these patients. The objective of the present study was to evaluate the effect of prior infrarenal aortic surgery on the occurrence of SCI. MethodsThe Society for Vascular Surgery Vascular Quality Initiative database was retrospectively reviewed to identify all patients aged ≥18 years who had undergone TEVAR and/or complex EVAR from January 2012 to June 2020. Patients with previous thoracic or suprarenal aortic repair were excluded. The baseline and procedural characteristics and postoperative outcomes were compared between TEVAR and/or complex EVAR with and without previous infrarenal aortic repair. The primary outcome was postoperative SCI. The secondary outcomes included postoperative hospital length of stay, bowel ischemia, renal ischemia, and 30-day mortality. Multivariate regression was used to determine the independent predictors of postoperative SCI. Additional analysis was performed of the patients who had undergone isolated TEVAR. ResultsA total of 9506 patients met the inclusion criteria: 8691 (91.4%) had not undergone prior infrarenal aortic repair and 815 (8.6%) had undergone previous infrarenal aortic repair. Patients with previous infrarenal repair were older with an increased prevalence of chronic kidney disease (P = .001) and cardiovascular risk factors, including hypertension, chronic obstructive pulmonary disease, and positive smoking history (P < .001). These patients also presented with a larger maximal aortic diameter (6.06 ± 1.47 cm vs 5.15 ± 1.76 cm; P < .001) and required more stent-grafts (P < .001) with increased intraoperative blood transfusion requirements (P < .001), and longer procedure times (P < .001). Univariate analysis demonstrated no differences in postoperative SCI, postoperative hospital length of stay, bowel ischemia, or renal ischemia between the two groups. The 30-day mortality was significantly higher in patients with prior infrarenal repair (P = .001). On multivariate regression, prior infrarenal aortic repair was not a predictor of postoperative SCI. In contrast, aortic dissection (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.26-2.16; P < .001), number of stent-grafts deployed (OR, 1.45; 95% CI, 1.30-1.62; P < .001), and units of packed red blood cells transfused intraoperatively (OR, 1.33; 95% CI, 1.03-1.73; P = .032) were independent predictors of postoperative SCI. ConclusionsAlthough the patients in the TEVAR and/or complex EVAR group with prior infrarenal aortic repair constituted a sicker cohort with higher 30-day mortality, the rate of SCI was comparable to that of the patients without prior repair. Previous infrarenal repair was not associated with the risk of SCI.

Single incision laparoscopic lysis of adhesions

Minimally invasive approaches to surgery following open procedure are not often utilized due to known challenges of intra-operative visualization secondary to post-operative adhesions. In this case report we describe an innovative approach to the management of abdominal and thoracic post-operative adhesions via a single incision laparoscopic surgery (SILS) technique. Patient #1 is a 3-year-old boy with history of hepatoblastoma with pulmonary metastases status post serial thoracotomies who presented for resection of an enlarging chest wall nodule and small left upper lobe lesion. Patient #2 is a 21-year-old male with history of cerebral palsy, necrotizing enterocolitis, gastroesophageal reflux disease, with multiple prior abdominal surgeries presenting with symptomatic cholelithiasis. A single incision laparoscope with insertion of various instruments through the working port was successfully utilized to aid in adhesiolysis. Patient #1 had successful resection of his thoracic lesions without requiring repeat thoracotomy. Patient #2 had partial success in lysis of adhesions but requiring conversion to open due to inadequate visualization of the gallbladder anatomy. The single incision laparoscopic surgical technique is a novel and valuable minimally invasive tool for lysis of adhesions in recurrent surgical procedures. There remains a low threshold to convert open for completion of the surgical procedure when there is inadequate anatomic visualization. • Surgical procedures following laparotomy or thoracotomy are challenging due to post-operative adhesions. • A novel single-incision, single-port laparoscopic surgery technique can aid in adhesiolysis. • Single-incision laparoscopic lysis of adhesions can serve as a valuable tool in subsequent surgical procedures.

Impact of prior abdominal surgery on short-term outcomes following laparoscopic colorectal cancer surgery: a propensity score-matched analysis.

Whether laparoscopic surgery after prior abdominal surgery (PAS) is safe and feasible for colorectal cancer (CRC) remains controversial. The present study aimed to evaluate the impact of PAS on short-term outcomes following laparoscopic CRC surgery. We performed retrospective analysis used propensity score-matched analysis to reduce the possibility of selection bias. Participants comprised 1284 consecutive patients who underwent elective laparoscopic CRC surgery between 2010 and 2020. Patients were divided into two groups according to PAS. Patients with PAS were then matched to patients without these conditions. Short-term outcomes were evaluated between groups in the overall cohort and matched cohort, and risk factors for conversion to laparotomy and severe postoperative complications were analyzed. After propensity score matching, we enrolled 762 patients (n = 381 in each group). Before matching, significant group-dependent differences were observed in sex, age, primary tumor site, pathological (p) T stage, and type of procedure. No significant difference was found between groups in terms of rate of conversion to laparotomy, estimated blood loss, rate of extended resection, length of postoperative stay, and postoperative complications. After matching, estimated operative time was significantly longer in the PAS group (p = 0.01). Significant differences were found between groups in terms of reason for conversion to laparotomy. Multivariate analyses identified significant risk factors for conversion to laparotomy as pT stage ≥ 3 (odds ratio [OR] 2.36; 95% confidence interval [CI] 1.05-5.26) and body mass index ≥ 25kg/m2 (OR 3.56; 95% CI 1.07-11.7). Multivariate analyses identified rectum in the primary tumor site as the only significant risk factor for severe postoperative complications (OR 2.37; 95% CI 1.08-5.20). Laparoscopic CRC surgery after PAS showed acceptable short-term outcomes compared to Non-PAS. The laparoscopic approach appears safe and feasible for CRC regardless of whether the patient has a history of PAS.

Identifying Preoperative Predictors of Operative Time and Their Impact on Outcomes in Robot-Assisted Partial Nephrectomy.

Objective: To identify preoperative characteristics in patients with renal masses that influence operative time during robot-assisted partial nephrectomy (RAPN) and evaluate the relationship between operative time and length of stay (LOS), complication rates, and overall outcome. Materials and Methods: We queried our institutional database to identify a cohort of patients who underwent RAPN by two experienced robotic surgeons between 2012 and 2019. A multivariable regression model was developed to analyze operative time, LOS, and any grade complication within 30 days postoperatively using the bootstrap resampling technique. Results: A total of 392 patients were included. On multivariable analyses, prior abdominal surgery (p = 0.001) was associated with 22 minutes of increase in operating room time, as well as adhesive perirenal fat (22 minutes, p = 0.001). For each one unit increase in nephrometry score, there was a 4-minute increase in operating room time (p = 0.028), and for each one-cm increase in tumor size, there was an associated 12-minute increase in operating room time (p < 0.001). For each 1 year increase in age, there was an associated 0.024-day increase in LOS [odds ratio (OR) (0.013-0.035)]; in addition, for every one-cm increase in tumor size there was a 0.18-day associated increase in LOS [OR (0.070-0.28)]. Each 1-hour increase in operating room time was associated with a 0.25-day increased LOS [OR (0.092-0.41)]. Only tumor size was found to be associated with any grade complication. Conclusions: Patients with a history of abdominal surgery, larger complex tumors, and significant Gerota's fat undergoing robotic partial nephrectomy should anticipate longer operative times. Older patients with larger tumors and longer operative times can anticipate a longer LOS. Tumor size appears to be the common determinant of all three outcomes: operative time, LOS, and any grade Clavien complication.

EP.TU.193Omental band - A unusual cause of mechanical small bowel obstruction in a virgin abdomen

Abstract Introduction The small bowel obstruction in a non-operated abdomen is rare, and the most common causes are hernia and neoplasm. The complete mechanical small bowel obstruction due to an omental band in a patient with no previous abdominal surgery is rare, and less than five cases have been reported in the literature. Case presentation We report a 65 year old male patient presented to the emergency department with complaints of abdominal pain, distension, vomiting and obstipation for four days. On clinical examination, his abdomen was distended, diffusely tender, guarding. The blood investigations showed elevated White blood cells and neutrophils with normal CRP and the Serum lactate. The Abdominal X-ray was suggestive of SBO. The Computed tomography of the abdomen and pelvis showed marked dilatation of the jejunum, the ileum is entirely collapsed, the impression of a double beak sign in the mid-abdomen which would suggest closed-loop obstruction due to a possible internal hernia. We proceeded with emergency diagnostic laparoscopy converted to laparotomy, which showed omental band causing closed-loop proximal small bowel obstruction. The bowel loops appeared congested with the constriction band due to omental band. The omental band was divided, and the obstruction was relieved. Postoperatively patient recovered well and was discharged on day three post-op. Discussion The timely diagnosis and intervention could prevent complications like strangulation, ischemia and gangrene. Though the omental band is rare, it should still be suspected as an aetiology in patients without prior abdominal surgery.

Cervical Cancer Patient Reported Gastrointestinal Outcomes: Intensity/Volumetric Modulated vs. 3D Conformal Radiation Therapy

To evaluate gastrointestinal (GI) patient reported outcomes (PROs) in cervical cancer patients treated with definitive radiotherapy (RT), comparing 3D conformal RT (3DCRT) vs. intensity modulated /volumetric modulated arc therapy (IMRT/VMAT).A retrospective analysis of cervical cancer patients treated with curative intent RT between 2015-2018 was performed. GI PROs were collected at baseline, during RT (acute), ≤12 weeks after RT (subacute), and > 12 weeks after RT (late) using the Prospective Outcomes and Support Initiative (POSI) which includes validated questions from EPIC Bowel 2, PRO-CTAE, and EORTC QLQ CX24. GI PROs evaluated three symptom domains: bowel problems (BP), bowel bother (BB), and abdominal problems (AP).The cohort included 167 patients. The median age was 48 (27-86), 74% had squamous cell carcinoma, and 51% had FIGO stage I/II disease. All patients received brachytherapy, 99% received a 45Gy elective pelvic dose, 31% had para-aortic fields, and 97% received concurrent chemotherapy. 100 (60%) patients were treated with IMRT/VMAT and 67 (40%) with 3DCRT. The median follow-up was 24 (5-67) months. In the BP domain, mean changes in symptom scores compared to baseline for 3DCRT vs. IMRT/VMAT were +2.29 vs. +1.82 (P = 0.55) during RT, +0.9 vs. -1.15 (P = 0.01) ≤12 weeks after RT, and +0.72 vs. -0.82 (P = 0.01) > 12 weeks after RT. In the BB domain, mean changes in symptom scores compared to baseline for 3DCRT vs. IMRT/VMAT were +3.58 vs. +3.16 (P = 0.67) during RT, +2.18 vs. -0.10 (P = 0.02) ≤12 weeks after RT, and +1.98 vs. -0.03 (P = 0.01) > 12 weeks after RT. In the AP domain, mean changes in symptom scores compared to baseline for 3DCRT vs. IMRT/VMAT were +2.52 vs. +2.01 (P = 0.32) during RT, +1.41 vs. -0.38 (P = 0.02) ≤12 weeks after RT, and +1.29 vs. -0.31 (P = 0.01) > 12 weeks after RT. On multivariable analysis 3DCRT was associated with greater mean changes in subacute and late symptom scores in BP (subacute 0.29 (0.08-0.51), P = 0.01; late 0.22 (0.03-0.41), P = 0.02), BB (subacute 0.32 (0.04-0.61), P = 0.03; late 0.26 (0.03-0.48), P = 0.03), and AP (subacute 0.27 (0.05-0.48), P = 0.01; late 0.24 (0.08-0.40), P = 0.01) compared to IMRT/VMAT. Age, smoking status, prior abdominal surgery, FIGO stage, RT volume (pelvic vs. para-aortic), and use of external beam boost were not associated with symptom score changes (P > 0.05). Three-year estimates of overall survival, local control, and regional control were 87%, 97%, 86% in the IMRT/VMAT cohort and 91% (P = 0.32), 97% (P = 0.99), and 92% (P = 0.26) in the 3DCRT cohort, respectively.Cervical cancer patients treated with IMRT/VMAT had significantly less worsening of their GI PRO symptom scores compared to baseline in all three GI domains ≤12 weeks and > 12 weeks after RT. 3DCRT was associated with greater subacute and late patient reported GI toxicity.

Comparing Characteristics and Postoperative Outcomes of Hysterectomy for Endometriosis Versus Other Benign Indications: A NSQIP Study

<h3>Study Objective</h3> Endometriosis is known to cause mild to significant intra-abdominal adhesions, theoretically making surgical procedures more challenging. However, little comparative surgical outcomes data is available. <h3>Design</h3> The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was searched from 2018 to 2019 for all total hysterectomies. Hysterectomies for malignant conditions, emergent cases, and cases with pre-operative morbidity were excluded. Univariate comparisons were made between patients with hysterectomies for endometriosis vs other benign indications (abnormal bleeding, leiomyoma, prolapse, and pelvic pain). Unadjusted and adjusted logistic regression models were used to investigate the association between primary outcomes and hysterectomy indication, with covariates in the adjusted model including age, race, ethnicity and surgical route. <h3>Setting</h3> Within 30 days post operative. <h3>Patients or Participants</h3> Patients undergoing hysterectomy 18-55 years old. <h3>Interventions</h3> Hysterectomy. <h3>Measurements and Main Results</h3> A total of 29,742 women underwent hysterectomies, of which 3,596 (12.1%) were performed for endometriosis. Patients undergoing hysterectomy for endometriosis were statistically likely to be younger, predominately white, and had lower BMI. They were also more likely to have had prior abdominal surgery, prior pelvic surgery, undergo a laparoscopic approach, and undergo lysis of adhesions (all p<0.001). Overall length of stay (1.1 vs 1.2 days, p<0.001) and operative time (130.8 vs 136.8 minutes, p<0.001) were lower in patients undergoing hysterectomy for endometriosis. Examining primary outcomes, patients with endometriosis were more likely to experience major morbidity (AOR 1.25, p=0.033), with no difference in minor morbidity (p=0.87). There were two mortalities. Endometriosis patients were more likely to develop deep surgical site infection (SSI) (OR 1.42, p=0.004), and less likely to receive blood transfusion (OR 0.58, p<0.001). There was no significant difference in occurrence of superficial SSI, sepsis, venous thromboembolism, readmission or re-operation between groups. <h3>Conclusion</h3> Patients undergoing hysterectomy for endometriosis were more likely to experience major morbidity and deep surgical site infection compared to patients with other benign indications.

S3069 A Disease of Many Names: Sclerosing Mesenteritis

Introduction: Sclerosing mesenteritis (SM) refers to a spectrum of inflammatory disorders of the bowel mesentery adipose tissue whose pathogenesis is poorly understood, but has been associated with prior abdominal surgery, malignancy, and autoimmune disease. Patients can be asymptomatic or have non-specific abdominal complaints. Diagnosis can be made radiographically, but tissue is required for definitive evaluation. We present a case of severe constipation and abdominal distention due to sclerosing mesenteritis. Case Description/Methods: A 55-year-old male presented with two months of constipation, abdominal pain, and severe distention impairing ability to wear regular-sized clothing. Initial laboratory evaluation was normal, CTAP revealed no obstruction, and colonoscopy was normal. A trial of linaclotide briefly improved symptoms, however he re-presented to an ED with severe pain where CTAP showed an ovoid expansile region of mesenteric haziness within the central abdomen, encircling the mesenteric root vessels, reflecting SM with mass effect on the surrounding bowel (Figure 1A). PET/CT did not show evidence of malignancy. Laparoscopic mesenteric biopsy revealed areas of fat necrosis with associated lipid-laden macrophages; fibrosis was not identified, plasma cells were not prominent, and IgG4 positive cells were absent. Immunostains were negative. Laboratory evaluation was notable for: borderline ANA titer 1:80, positive fibrillarin antibody, and negative Scl-70. Systemic steroids were initiated with some improvement in symptoms, and tamoxifen was later added. Discussion: Sclerosing mesenteritis is a rare inflammatory, fibrotic disease of bowel mesentery fat tissue whose presentation ranges from asymptomatic to severe pain and bowel changes due to obstruction. While its exact pathogenesis is unclear, it may be related to prior surgery, underlying malignancy (eg. lymphoma) or an autoimmune etiology (due to association with conditions such as primary sclerosing cholangitis and retroperitoneal fibrosis). Diagnosis is challenging; CT scan is the most sensitive test, but histological analysis is necessary to evaluate for any underlying etiologies. There is no definitive therapy, but systemic steroids and antifibrotic agents such as tamoxifen have been studied; some patients require surgical resection.Figure 1.: CT-Abdomen and Pelvis: An ovoid expansile region of mesenteric haziness within the central abdomen, encircling the mesenteric root vessels, reflecting sclerosing mesenteritis with mass effect on the surrounding bowel loops.

S1786 A Rare Case of Bowel Obstruction: Cecal Bascule After Colonoscopy

Introduction: Cecal bascule is an exceedingly rare type of cecal volvulus in which a mobile cecum folds anteriorly and superiorly on to the ascending colon, causing partial obstruction. The following vignette highlights a case of cecal bascule following two unsuccessful colonoscopy attempts. Case Description/Methods: A 68-year-old male with history of advanced adenoma and no prior abdominal surgery was admitted for surveillance colonoscopy after inability to intubate the cecum on outpatient colonoscopy. Repeat double balloon assisted colonoscopy attempt failed to intubate the cecum , raising concern for cecal volvulus. While admitted, the patient complained of abdominal distention and discomfort despite ability to pass gas and stool. Abdominal x-ray showed a significantly dilated colon to 12 centimeters (Figure 1A). Computed tomography (CT) revealed upside down rotated cecum with ileocecal valve pointing laterally, dilatation of ascending colon to 10 centimeters without evidence of perforation, compatible with cecal volvulus (Figure 1B). A multi-disciplinary discussion between gastroenterology, radiology, and surgery resulted in exploratory laparotomy with right hemicolectomy and end ileostomy. Intraoperatively, a redundant colon was observed with severely dilated cecum and cecal bascule. He underwent a right hemicolectomy with ileal colonic anastomosis. The patient did well post-surgery without significant sequelae. Discussion: Cecal volvulus, a rare clinical entity, accounts for 1-2% of all large bowel obstructions. Cecal bascule, where the distended cecum folds anteriorly on the ascending colon without torsion, is the rarest type of cecal volvulus, accounting for 5-20% of all cases. It occurs secondary to congenital or acquired adhesions fixing the anterior wall of the cecum to that of the ascending colon. In our patient, the increased motility related to the colonoscopy preparation may have initiated the rotation of the cecum. The signs and symptoms of a cecal bascule are similar to that of a cecal volvulus. Plain X-ray usually reveals a distended cecum. CT of abdomen confirms the diagnosis in 90% of patients showing upward folding of the cecum, as in our patient. Treatment is primarily surgical. Due to high recurrence after simple reduction, cecopexy or resection and anastomosis are preferred approaches. In patients with recurrent or persistent abdominal pain and distension, cecal bascule should be considered in the differential diagnosis.Figure 1.: Abdominal X-ray and exploratory laparotomy findings.

Factors associated with successful response to neurolytic celiac plexus block in patients with upper abdominal cancer-related pain: a retrospective study.

BackgroundPrior studies have reported that 40%-90% of the patients with celiac plexus-mediated visceral pain benefit from the neurolytic celiac plexus block (NCPB), but the predictive factors of response to NCPB have not been evaluated extensively. This study aimed to identify the factors associated with the immediate analgesic effectiveness of NCPB in patients with intractable upper abdominal cancer-related pain.MethodsA retrospective review was performed of 513 patients who underwent NCPB for upper abdominal cancer-related pain. Response to the procedure was defined as (1) a decrease of ≥ 50% or ≥ 4 points on the numerical rating scale (NRS) in pain intensity from the baseline without an increase in opioid requirement, or (2) a decrease of ≥ 30% or ≥ 2 points on the NRS from the baseline with simultaneously reduced opioid consumption after NCPB. Logistic regression analysis was performed to determine the factors associated with successful responses to NCPB.ResultsAmong the 513 patients included in the analysis, 255 (49.8%) and 258 (50.2%) patients were in the non-responder and responder group after NCPB, respectively. Multivariable logistic regression analysis showed that diabetes (odds ratio [OR] = 0.644, P = 0.035), history of upper abdominal surgery (OR = 0.691, P = 0.040), and celiac metastasis (OR = 1.496, P = 0.039) were the independent factors associated with response to NCPB.ConclusionsCeliac plexus metastases, absence of diabetes, and absence of prior upper abdominal surgery may be independently associated with better response to NCPB for upper abdominal cancer-related pain.

S1713 Surgical Mesh Protrusion Through the Transverse Colon Masquerading as a Colonic Mass

Introduction: The differential diagnosis for abdominal pain in the setting of prior abdominal surgery is vast. Within general surgery, hernia repair is a frequently performed procedure and use of mesh has been shown to reduce the overall rate of recurrence. Unfortunately, mesh implantation is associated with many potential complications and risks. Having a high index of suspicion for the proper differential diagnosis is critical, so diagnosis is not delayed and the appropriate management can be started. We present the case of a female patient who presented with epigastric pain and was found to have surgical mesh from prior hernia repair perforating through the colon. Case Description/Methods: This is a 52 y/o female with PMH of pancreatic cancer, s/p Whipple procedure and abdominal hernia s/p repair presenting with complaints of dull epigastric pain exacerbated by eating and relieved by rest. She endorsed constipation but denied any fever, nausea, vomiting, diarrhea, melena or hematochezia. Physical exam was notable for moderate generalized pain and guarding, but no rebound tenderness. CMP revealed normal transaminases, mildly elevated Alk Phos 146 and normal T Bili 0.3 Rest of CMP and CBC were otherwise unremarkable. CT Abd/Pelv w/contrast revealed masslike diverticulitis in the mid-transverse colon concerning for a mass. Given these findings, colonoscopy was pursued which revealed nodularity, necrosis, irregular margins, and scarring in the mid-transverse colon compatible with protrusion of surgical mesh into the colon. Biopsies of this site were obtained, and pathology results were negative for malignancy. Patient has since been referred to surgery. Discussion: The differential diagnosis for abdominal pain is too numerous to count, and in the setting of prior abdominal surgery the task of obtaining the correct diagnosis is made even more difficult. Perforation of surgical mesh through the mid-transverse colon is an extremely rare phenomenon and the index of suspicion for such a complication must be high. In our case, though physical exam and laboratory studies were vague and nonspecific, CT Abd/Pelv findings increased our urgency for colonoscopy which resulted in subsequent appropriate referral and management of the patient. Unfortunately, literature search for abdominal pain in the setting of mesh protrusion through the colon has been heterogenous and scarce. Thus, more research must be done in this area.Figure 1.: Nodularity, necrosis, irregular margins, and scarring in the mid-transverse colon compatible with protrusion of surgical mesh into the colon.

Just Stick a Scope in: Laparoscopic Ventriculoperitoneal Shunt Placement in the Pediatric Reoperative Abdomen

Ventriculoperitoneal shunt (VPS) placement into the reoperative abdomen can be challenging due to intraperitoneal adhesions. Laparoscopic guidance may provide safe abdominal access and identify an area for optimal cerebrospinal fluid drainage. The study aim was to compare laparoscopic-assisted VPS placement to an "open" approach in patients with prior abdominal surgery. A retrospective review was performed of children undergoing VPS placement into a reoperative abdomen from 2009-2019. Clinical data were collected, and patients undergoing laparoscopy (LAP) were compared to those undergoing an open approach (OPEN). A total of 120 children underwent 169 VPS placements at a median age of 8 y (IQR 2-15 y), and a mean number of two prior abdominal operations (IQR 1-2). Laparoscopy was used in 24% of cases. Shunt-related complications within 30 d were lower in the LAP group (0% versus 19%, P=0.001), as were VPS-related postoperative emergency department visits (0% versus 13%, P=0.003) and readmissions (0% versus 13%, P=0.013). Shunt malfunction rates were higher (42% OPEN versus 25% LAP, P=0.03) and occurred sooner in the OPEN group (median 26 versus 78 wk, P=0.01). The LAP group demonstrated shorter operative times (63 versus 100 min, P < 0.0001), and the only bowel injury. Time to feeds, length of stay, and mortality were similar between groups. Laparoscopic guidance during VPS placement into the reoperative abdomen is associated with a decrease in shunt-related complications, longer shunt patency, and shorter operative times. Prospective study may clarify the potential benefits of laparoscopy in this setting.

Outcomes of Ureteroneocystostomy in Patients With Cancer

ObjectiveTo determine the durability of ureteroneocystostomy as well as pre- or post-operative factors that may be associated with failure to provide appropriate renal drainage. MethodsA total of 290 patients who underwent ureteral reimplantation to native bladder between 2003 and 2015 were identified. After excluding pediatric patients and those without any follow-up, 255 patients, 3 of whom had a subsequent contralateral reimplantation were included, for 258 observations. Kaplan-Meier method and univariate Cox models were used to assess whether factors such as radiation, prior abdominal surgery, age at re-implantation, gender and BMI are associated with re-implantation failure. ResultsAmong 258 observations, there were 27 failures. Median follow-up time was 1.1 years from re-implantation surgery among patients without a failure.1 and 5-year ureteral re-implantation failure is 7% (95% CI 4%, 12%) and 22% (95% CI 15%, 33%), respectively. On univariate analysis, post-operative radiation was found to be strongly associated with poorer ureteral re-implantation survival (HR: 6.62; CI 2.40, 18.29; P = .0003) No significant association between re-implantation failure-free survival and age at reimplantation, gender, BMI, previous abdominal surgery, preoperative radiation and adjuvant radiation was noted (all P > .4). ConclusionsUreteroneocystotomy in the malignant setting has reasonable success rates through five years. No preoperative factors were associated with re-implantation failure. While all patients need to be followed due to increasing rates of failure with time, patients receiving palliative or salvage radiation therapy appear to be more prone to failure requiring further intervention.

V11-10 ROBOTIC RETROPERITONEAL NEPHROURETECTOMY FOR UPPER TRACT UROTHELIAL CARCINOMA

You have accessJournal of UrologyRenal Oncology II (V11)1 Sep 2021V11-10 ROBOTIC RETROPERITONEAL NEPHROURETECTOMY FOR UPPER TRACT UROTHELIAL CARCINOMA Zachary McDowell, and James Porter Zachary McDowellZachary McDowell More articles by this author , and James PorterJames Porter More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002073.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephroureterectomy is the standard of care for high grade upper tract urothelial carcinoma (UTUC) or low grade UTUC when nephron-sparing surgery is not possible, and a retroperitoneal approach can be advantageous in the setting of previous abdominal surgeries. The patient in this case is a 67 year old female that was found to have high grade urothelial carcinoma of the left renal pelvis. She underwent 3 cycles of gemcitabine and cisplatin chemotherapy, and subsequent nephroureterectomy. A retroperitoneal approach was chosen for this patient because she had a history of multiple abdominal surgeries including exploratory laparotomy. This video will demonstrate the retroperitoneal approach for robotic nephroureterectomy as definitive surgical management of this patient's high grade UTUC. METHODS: The surgery was performed using the daVinci Xi robot. The patient was placed in full flank position and 4 robotic ports were placed in a line midway between the iliac crest and the 12th rib. A 12mm high-flow insufflator assistant port was placed near the anterior superior iliac spine. The retroperitoneal space was developed using balloon dilation. The initial step was mobilization of the ureter. Once the ureteral dissection was carried distally to the point of decreased range of motion for the robotic arms, the arms were undocked, the boom rotated 180 degrees, and the direction of dissection was into the pelvis. An additional 5mm assistant port was placed cephalad to the robotic ports near the 11th rib. After completion of the ureteral and bladder cuff dissection the robot was redocked and returned to the initial arm configuration. We then proceed to adrenal sparing radical nephrectomy with retroperitoneal lymph node dissection. RESULTS: We have experience with 3 robotic retroperitoneal nephroureterectomies. All patients had high grade transitional cell carcinoma of the kidney as the indication for surgery, and all had history of significant abdominal surgery. The mean age was 70 years, mean operative time was 251 mins, mean estimated blood loss was 42 cc, mean lymph nodes removed was 13, and mean length of stay of 2 days. There were no complications, readmissions, and recurrences. CONCLUSIONS: The retroperitoneal approach is a safe and effective technique for robotic assisted nephroureterectomy. This approach allows complete access to the kidney, ureter and bladder cuff and avoids adhesions in patients with prior abdominal surgery. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e860-e861 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zachary McDowell More articles by this author James Porter More articles by this author Expand All Advertisement Loading ...

Complications after transesophageal echocardiogram in pediatric patients with gastrostomy tube and/or Nissen fundoplication.

Transesophageal echocardiography (TEE) is frequently used in children with and without congenital heart disease when transthoracic echocardiography is inadequate for visualizing cardiac structures. Recent guidelines state relative contraindications of TEE include post-gastrostomy tube (GT) or Nissen fundoplication surgery. No data exist documenting the incidence of complications in this population after a TEE. Aim of this study was to document the incidence of abdominal complications after TEE in pediatric patients who previously had a GT or Nissen fundoplication. Single institution retrospective study was performed evaluating patients from 2013 through 2020. Patients were included if they had previously undergone a GT or Nissen procedure and subsequently underwent a TEE procedure. Baseline demographics were obtained. Major (esophageal/gastric perforation, oropharyngeal dysphagia, GT displacement, and Nissen breakdown) and minor (abdominal pain, feeding intolerance, and GT leakage) complications were recorded. Total of 34 patients underwent 48 TEE procedures. Age was 6.2±6.6 years (median 3.0 years, .4 - 23.0 years) and weight was 18.5±14.8 kgs (median 12.4 kgs, 4.2 - 57.5kg) at time of TEE. Twenty-nine patients had congenital heart disease. Five patients had a Nissen fundoplication, 14 patients had a GT, and 15 patients had both procedures prior to the TEE. No patient had a major abdominal complication after the TEE. One patient had abdominal pain (2.1%), one patient had feeding intolerance and leakage around the GT site (2.1%), and two patients had leakage around the GT site (4.2%) after the TEE. Patients that experienced complications were significantly younger (1.7±1.1 years vs. 6.6±6.7 years, P<.01) and weighed less (8.7±3.5kg vs. 20.1±15.5kg, P<.01) than those that had no complications. All minor complications resolved with minimal interventions required. In this study, major abdominal complications did not occur after a TEE procedure in pediatric patients that had previous abdominal surgeries. The incidence of minor complications was relatively low and was easily remedied in this patient population. Though a relative contraindication by guidelines, TEE imaging, including transgastric views, can be performed relatively safely in pediatric patients with prior abdominal surgeries if needed.

Peritoneal inclusion cysts as a diagnostic and treatment challenge.

Peritoneal inclusion cysts (PICs) are benign multilocular cysts that consist of fluid localized between intraperitoneal adhesions. They usually present in women in the third and fourth decades of life with a history of prior pelvic or abdominal surgery, especially months to 20 years ago. PICs have low mortality and the potential for high morbidity. Transvaginal ultrasound with color Doppler has an important role in the differential diagnosis. Also, a very important role is played by CA 125 plasma level or use of the ROMA algorithm. But thanks to laparoscopy and the possibility of biopsy from suspicious lesions the correct diagnosis can be established. Treatment of PICs depends individually on the patient's condition, symptoms, other diseases, and desire for procreation. Among other contemplated are hormonal oral contraceptive, an image-guided aspiration, minimally invasive or open surgery. The issue of diagnosis and treatment of PICs requires the continuation of multicentre, randomized clinical trials to find and standardize effective, personalized treatments for PICs.

Analysis of 300 Total Laparoscopic Hysterectomy Cases Performed by The Same Surgeon

Aim: This study aimed to evaluate the results of 300 cases of total laparoscopic hysterectomy (TLH) performed by the same surgeon.&#x0D; Material and methods: During the study period, a total of 300 TLH operations were performed between January 2017 and December 2018. Demographic characteristics, indications of hysterectomy, uterine weights, intra-operative and post-operative complications, duration of the operation, length of hospital stay, blood loss of patients, visual analogue scores and amount of analgesics needed were retrospectively evaluated. Complications were analysed and compared with literature.&#x0D; Results: Parameters analysed for 300 patients included in the study were as follows: mean age 47.82 ± 6.18 years, mean parity 3.4 ± 2.0 (0–11), BMI 27.41 ± 4.36 (kg/m²), mean uterine weight 367.67 ± 266.21 g (50–1600 g), mean operative time 89.07 ± 37.94 min (30–240 min), mean hospital stay 54.37 ± 21.95 h (24–168 h) and total complication rate 28 (9.3%). Conversion to open surgery was required in 29 (9.7%) patients. The level of technical difficulty and existence of prior abdominal surgery were associated with a higher risk of complications and conversions to laparotomy.&#x0D; Conclusion: Total laparoscopic hysterectomy is a well-designed surgical procedure for the management of benign gynaecological conditions, and after adequate training, it seems to be a safe and effective procedure for patients.

Prior Infrarenal Aortic Surgery Is Not Associated With Increased Risk of Spinal Cord Ischemia After Thoracic Endovascular Aortic Repair

Patients with prior infrarenal aortic intervention represent an increasing demographic of patients undergoing thoracic endovascular aortic repair (TEVAR). Studies have suggested that prior abdominal aortic surgery is a risk factor for spinal cord ischemia (SCI) after TEVAR. However, these Results were largely based on single-center experiences, and limited national data assessing the postoperative outcomes for these patients are available. The Objective of our study was to evaluate the effect of prior infrarenal aortic surgery on SCI after TEVAR.

Celiac Artery Aneurysms, a Case of Endovascular Management and a Systematic Review of Current Approaches

Celiac artery aneurysms (CAAs) compose an uncommon location for splanchnic artery aneurysms. Risk factors for acquiring a CAA include prior trauma, abdominal surgery, pancreatitis, or prior endovascular procedures. Strict guidelines for repair of CAA have yet to be delineated; however, many have advocated for prophylactic repair when dilation exceeds 2 cm. We present the case of a 6.8-cm CAA in a patient who presented with severe epigastric abdominal pain and a review of the literature.

Morbid obesity increases the failure rate of sentinel lymph node mapping for endometrial carcinoma

<h3>Objectives:</h3> Sentinel Lymph Node (SLN) mapping is recommended for patients with endometrial carcinoma to reduce the rate of full lymphadenectomy and its associated morbidity such as lymphedema. Obesity is a risk factor for endometrial carcinoma, and many patients are morbidly obese at the time of diagnosis. The goal of this study is to examine the impact of body mass index (BMI) on the success rate of SLN mapping using indocyanine green (ICG) and near-infrared imaging. <h3>Methods:</h3> A retrospective cohort study was performed of women with endometrial carcinoma undergoing robotic hysterectomy and SLN mapping with ICG between March 2016 and August 2019. Robotic surgery cases were identified from the hospital financial system that were coded with a primary diagnosis of Endometrial Cancer, a procedure of hysterectomy, and a cost code for indocyanine green. A total of 369 cases were identified. A total of 28 cases were excluded because no dye was used or SLN mapping was not attempted due to extent of disease. Preoperative patient characteristics and surgical outcomes including SLN mapping success rate were compared across World Health Organization BMI groups. <h3>Results:</h3> BMI was categorized as normal weight (BMI 18.5 - 24.9, 41 patients), pre-obesity (BMI 25.0 - 29.9, 48 patients), obesity class I (BMI 30.0 - 34.9, 71 patients), obesity class II (BMI 35.0 - 39.9, 70 patients), and obesity class III (BMI ≥40, 111 patients). Across BMI groups, patient age and ASA category were significantly different, with younger ages and higher ASA scores in the higher BMI groups. BMI groups did not differ in the number of prior abdominal surgeries or FIGO Grade. Uterine weight, diameter and procedure time were all significantly different across BMI groups, with higher weights, diameters and procedure times in the higher BMI groups. Estimated blood loss and depth of myometrial invasion were not significantly different. In the cohort, 85% had FIGO Stage 1 disease. For procedures with successful unilateral or bilateral SLN detection, the mean number of lymph nodes removed per side was not significantly different across BMI groups. The overall bilateral SLN mapping success rate for the cohort was 68.9%. However, the bilateral SLN mapping success rate was significantly lower in patients with obesity class III (54.1%) compared with patients who were less obese (76.1%, p<0.01). There was no difference in success rate between lower BMI categories. <h3>Conclusions:</h3> Patients with class III obesity (BMI > 40) have a significantly lower success rate for SLN mapping when compared with all other BMI categories (54.1% vs 76.1%, respectively, p<0.01).