Prior Repair Research Articles

Neonatal gastric perforation: Case report

Neonatal gastric perforation (NGP) is a life-threatening condition associated with high morbidity and mortality rates. Despite several proposed etiological theories, the causative principle is still unclear and controversial. A male neonate was born at 26 weeks 3 days gestation. The patient showed symptoms of acute respiratory failure and hypoxia and was admitted to the neonatal intensive care unit. On day of life (DOL) 2, a chest and abdominal radiography showed a large amount of free intraperitoneal air, for which exploratory laparotomy was performed. A small antimesenteric perforation in the distal ileum was found and repaired primarily. On DOL 7, a chest and abdominal radiography demonstrated recurrent pneumoperitoneum for which a repeat exploratory laparotomy was performed. The patient had global intestinal ischemia and a perforation in the anterior wall of the stomach, which was repaired. On DOL 12, a planned upper gastrointestinal water-soluble contrast study showed spillage of contrast into the anterior abdomen, for which the patient underwent a repeat exploratory laparotomy. We found a dehiscence of the prior gastric repair and closed it primarily. The remainder of the hospital course was uneventful and the patient reached full feedings on DOL 41. Premature neonates are at risk for gastric perforation. Gastric perforation should be in the differential diagnosis of a premature neonate who presents abdominal distension and pneumoperitoneum. Due to the fragility of the premature neonatal tissues, confirming the integrity of the gastric closure with a contrast study is recommended prior to initiating enteral feedings.

Aortic arch endovascular branch and fenestrated repair: Initial Canadian experience with novel technology

ObjectiveThe objective is to describe the initial Canadian experience using novel aortic arch branched endograft technologies. MethodsWe performed a retrospective consecutive case series of all patients undergoing aortic arch branched repair with newly available endograft technology since 2020 at our site. We describe the patient characteristics, treatment characteristics, and postoperative outcomes. ResultsEleven patients received arch branched endografts, indicated for penetrating aortic ulcer in seven patients (64%), arch degeneration after prior aortic dissection repair in three (27%), and acute aortobronchial fistula in one patient (9%). Their average age was 72 ± 7 years. Complete arch repair from zone 0 to 4 was performed in six cases (55%); the remaining repairs landed proximally in zones 1 or 2. Seven repairs used a single retrograde facing inner branch (thoracic branch endoprosthesis; W.L. Gore & Associates), three used double antegrade inner branch (Bolton Relay; Terumo Interventional Systems), and one emergent case used double in situ fenestrations. Seven repairs (64%) used an adjunctive extra-anatomic bypass to complete great vessel perfusion, two of which were created during a prior aortic repair. Inferior vena cava balloon inflow occlusion during deployment was used in all cases. No mortalities, transient or permanent spinal cord paralysis, myocardial infarction, dialysis dependence, venous thromboembolism, or bleeding requiring reintervention occurred. No patient undergoing elective arch branch repair experienced a stroke. The one patient undergoing emergent repair did suffer a stroke. The median length of stay was 5 days (interquartile range, 2-8 days). Two endoleaks developed: a type Ia endoleak successfully treated with a Palmaz stent (Cordis) during the index admission, and a type II endoleak with ongoing sac regression on postoperative follow-up. Postoperatively, one patient suffered a suspected aortic graft infection that was treated with lifelong antibiotics. During a mean radiographic follow-up of 7.2 months, no cases of branch vessel instability (ie, no migration, reintervention, arterial rupture, intraluminal thrombus, occlusion, stenosis, or kinking of the branch grafts) developed. Three patients experienced sac regression of >5 mm, and no patient experienced continued postoperative dilation. ConclusionsTo the best of our knowledge, this is the largest reported Canadian volume of aortic arch repair using novel branched or fenestrated technology. The series demonstrates that a multidisciplinary program and properly selected patients can yield excellent results using endovascular repair for complex aortic arch pathology.

Comparative outcomes of physician-modified fenestrated/branched endovascular aortic aneurysm repair in the setting of prior failed endovascular aneurysm repair

ObjectiveEndovascular treatment of aortic aneurysms involving renal-mesenteric arteries, especially in the setting of prior failed endovascular aneurysm repair (EVAR) typically requires fenestrated/branched endovascular aneurysm repair (F/BEVAR) with a custom-made device (CMD). CMDs are limited to select centers, and physician-modified endografts are an alternative treatment platform. Currently, there is no data on the outcomes of physician-modified F/BEVAR (PM-F/BEVAR) in the setting of failed prior EVAR. The purpose of this study was to evaluate the use of PM-F/BEVAR in patients with prior failed EVAR. MethodsA prospective database of consecutive patients treated at a single center with PM-F/BEVAR between March 2021 and November 2022 was retrospectively reviewed. The cohort was stratified by presence of a failed EVAR (type Ia endoleak or aneurysm development proximal to a prior EVAR) prior to PM-F/BEVAR. Demographics, operative details, and postoperative complications were compared between the groups using univariate analysis. One-year survival and freedom from reintervention were compared using the Kaplan-Meier method. ResultsA total of 103 patients underwent PM-F/BEVAR during the study period; 27 (26%) were in the setting of prior EVAR. Patients with prior failed EVAR had similar age (75.2 ± 7.7 vs 71.5 ± 8.8 years; P = .058), male gender (n = 24 ; 89% vs n = 57 ; 75%; P = .130), and comorbid conditions except higher incidence of moderate-to-severe chronic obstructive pulmonary disease (n = 7 ; 26% vs n = 7 ; 9%; P = .047). Overall, aneurysm diameter was 65.5 ± 13.9 mm with aneurysms categorized as juxta-/pararenal in 43% and thoracoabdominal in 57%, with no differences between the groups. Twelve patients (14%) presented with symptomatic/ruptured aneurysms. The average number of target arteries incorporated per patient was 3.8. Four different aortic devices were modified with a greater proportion of Terumo TREO devices used in the failed EVAR group (P = .03). There was no difference in procedure time, radiation dose, or iodinated contrast use between groups. Overall technical success was 99%. Rates of 30-day mortality (n = 0 ; 0% vs n = 3 ; 4%; P = .565) and major adverse events (n = 6 ; 22% vs n = 16 ; 21%; P = 1.0) were similar between groups. For the overall cohort, rates of type 1 or 3 endoleak, branch vessel stenosis/occlusion, and reintervention were 2%, 1%, and 8%, respectively, with no difference between groups. One-year survival (failed EVAR 94% vs no EVAR 82%; P = .756) was similar between groups. ConclusionsPM-F/BEVAR is a safe and effective treatment for patients with aneurysms involving the renal-mesenteric arteries in the setting of prior failed EVAR where additional technical challenges may be present. Additional follow-up is warranted to demonstrate long-term efficacy, but early results are encouraging and similar to those using CMDs.

Outcomes after dextranomer/hyaluronic acid bladder neck injection in patients with urethral incontinence following bladder neck repair

Many patients who undergo surgery for bladder neck (BN) incompetence may still experience incontinence postoperatively. Dextranomer/hyaluronic acid (Dx/HA) is widely used for endoscopic treatment of vesicoureteral reflux in children; however, few studies have reported its use in treating incontinence after BN surgery. The aim of this study was to evaluate outcomes after Dx/HA bladder neck injection in patients with persistent outlet incompetency following BN Repair. We retrospectively reviewed patients at a single pediatric tertiary care center with history of prior bladder neck surgery and reported persistent incontinence who then underwent endoscopic bladder neck Dx/HA injection from 2013 to 2018 and had subsequent follow-up post-injection. We described primary outcomes of reported incontinence as "wet" (leakage similar to before injection), "improved" (wet but leakage improved), and "dry" (no leakage). Our secondary outcome was need for a secondary procedure after Dx/HA injection, including Dx/HA injection or bladder neck closure (BNC). At first follow-up (median 2.3 months post-op), 7/19 were wet, 6/19 were improved, and 6/19 were dry. At last follow-up (median of 34.7 months), only three patients (16%) were dry. Only one patient who received a single surgery for Dx/HA injection was "dry", though nearly 2/3rds (12) were initially "improved" in their continence. Overall, seven patients had another intervention or surgery after first injection. Five patients had multiple Dx/HA injections after first procedure, which resulted in dryness by last assessment in two of these. Four patients (21%) in the overall cohort required subsequent BNC. Longer-term follow-up in our study demonstrated that only one patient who received a single procedure of Dx/HA injection remained dry. Several studies had follow up for greater than 1 year after initial bladder neck Dx/HA injection; rates of dryness after a single surgery for injection were variable and reported between 20 and 40% over follow-up times ranging from 1.5 to 7 years (Alova et al., 2012; DaJusta et al., 2013; Lottmann et al., 2006a; Lottmann et al., 2006b; Kitchens et al., 2007). Our st udy does have inherent limitations. This study was performed at a single institution in a retrospective manner, with a single surgeon reviewing the medical record to determine operative techniques and continence outcomes. The patient population is small, although relatively comparable to other previously reported studies. Outcomes were based on documentation of patient reports and are therefore lacking in objectivity. In patients with prior unsuccessful BN repair, long-lasting dryness after single Dx/HA BN injection is unlikely, although one-third may demonstrate relatively durable improvement in incontinence.

Predicting Outcomes Following Endovascular Abdominal Aortic Aneurysm Repair Using Machine Learning.

To develop machine learning (ML) models that predict outcomes following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). EVAR carries non-negligible perioperative risks; however, there are no widely used outcome prediction tools. The National Surgical Quality Improvement Program targeted database was used to identify patients who underwent EVAR for infrarenal AAA between 2011 and 2021. Input features included 36 preoperative variables. The primary outcome was 30-day major adverse cardiovascular event (composite of myocardial infarction, stroke, or death). Data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, 6 ML models were trained using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve. Model robustness was evaluated with calibration plot and Brier score. Subgroup analysis was performed to assess model performance based on age, sex, race, ethnicity, and prior AAA repair. Overall, 16,282 patients were included. The primary outcome of 30-day major adverse cardiovascular event occurred in 390 (2.4%) patients. Our best-performing prediction model was XGBoost, achieving an area under the receiver operating characteristic curve (95% CI) of 0.95 (0.94-0.96) compared with logistic regression [0.72 [0.70-0.74)]. The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.06. Model performance remained robust on all subgroup analyses. Our newer ML models accurately predict 30-day outcomes following EVAR using preoperative data and perform better than logistic regression. Our automated algorithms can guide risk mitigation strategies for patients being considered for EVAR.

Regenerative Therapy with Autologous Stromal Vascular Fraction Derived Mesenchymal Stem Cells and Platelet-Rich Plasma to Treat Complex Perianal Diseases

Abstract Background The high recurrence rate of surgically treated anal fistula remains a concern in proctology. Aims This study investigated the healing rate of complex anal fistula procedures supplemented by regenerative therapy with autologous stromal vascular fraction derived mesenchymal stem cells and platelet-rich plasma (SVF-PRP). Methods Consecutive patients with complex anal fistula were prospectively assessed by a validated incontinence questionnaire and MRI 4 and 12 months after surgery. Fistula were drained with setons prior to definitive surgery. SVF was harvested from subcutaneous abdominal fat and PRP from peripheral blood. Distal fistulectomy to the sphincter was performed and the wound left open, while the internal orifice was closed. SVF-PRP was injected around the fistula. Patients showered their excision wound until dry. Outcomes were reported as median & interquartile range (IQR). Results 40 patients (23 males : 17 females) were included from December 2019 to December 2022. Age was 40 years (IQR 30-53). Five patients (12.5%) suffered from perineal Crohn's disease and 3 had a rectovaginal fistula (7.5%). Patients had 2 prior fistula surgeries (IQR 1-3) and SVF-PRP fistula repair was performed 8 months (IQR 5-22.5) after initial diagnosis. Operation time was 82 minutes (IQR 73-95). Five patients were discharged on the day of surgery, 32 on postoperative day 1, and 3 on postoperative day 2. Follow up was 12 months (IQR 6-16). There was no deterioration in fecal continence. Two out of 40 patients (5%) experienced an early failure within 2 months of SVF PRP. All other patients were back to work and leisure. At 4 months of follow-up, 34/40 (85%) patients were clinically well with no active fistula. Of 30 patients who reached 12 months follow-up, 5 had an active fistula in MRI (16%) or on clinical ground. Conclusions SVF-PRP is a safe and promising addition to the broad armentarium of treatments for complex perianal fistula.

Architecture-Preserving Provable Repair of Deep Neural Networks

Deep neural networks (DNNs) are becoming increasingly important components of software, and are considered the state-of-the-art solution for a number of problems, such as image recognition. However, DNNs are far from infallible, and incorrect behavior of DNNs can have disastrous real-world consequences. This paper addresses the problem of architecture-preserving V-polytope provable repair of DNNs. A V-polytope defines a convex bounded polytope using its vertex representation. V-polytope provable repair guarantees that the repaired DNN satisfies the given specification on the infinite set of points in the given V-polytope. An architecture-preserving repair only modifies the parameters of the DNN, without modifying its architecture. The repair has the flexibility to modify multiple layers of the DNN, and runs in polynomial time. It supports DNNs with activation functions that have some linear pieces, as well as fully-connected, convolutional, pooling and residual layers. To the best our knowledge, this is the first provable repair approach that has all of these features. We implement our approach in a tool called APRNN. Using MNIST, ImageNet, and ACAS Xu DNNs, we show that it has better efficiency, scalability, and generalization compared to PRDNN and REASSURE, prior provable repair methods that are not architecture preserving.

Accurate anatomic repair of obstetric anal sphincter damage or rectovaginal fistula aided by prior ultrasonograghy: a cohort study.

A retrospective review of patients who underwent transvaginal surgical repair of RVF and ASD was undertaken. Patients were preoperatively assessed for pathology and incontinence degree. Anorectal ultrasonography was used to define ASD or RVF and the associated scar preoperatively. Repair of RVF or ASD entails total excision of the scar with accurate anatomical layers reconstruction of healthy tissues. There were 23 patients, 8 RVF with a mean (SD) age 29 (6.78) years and 17 ASD with a mean (SD) age 35.25 (15.90). Twenty followed obstetric trauma (6RVF, 14 ASD), 1 prior rectocoele repair (ASD), 2 rape (1RVF + 1 ASD) and 1 was idiopathic (RVF). All patients had 1 or more prior repairs except for idiopathic RVF. Operative technique entailed transvaginal complete excision of the fibrous scar and accurate anatomical reconstruction of healthy tissue layers. A colostomy was not routinely used. There were three significant postoperative complications: ASD breakdown from an infected haematoma; perianal abscess, later a sinus after drainage; and RVF repair dehiscence during early coitus. All patients had full continence after 8 months minimum follow-up. Complete excision of the fibrous scar and accurate anatomical tissue layers reconstruction of the obstetric RVF or ASD, aided by prior ultrasonography, yielded good results.

Thoracic endovascular aortic repair of metachronous thoracic aortic aneurysms following prior infrarenal abdominal aortic aneurysm repair

ObjectiveThoracic endovascular aortic repair (TEVAR) of metachronous thoracic aortic aneurysms (M-TAAs) following previous infrarenal abdominal aortic aneurysm (AAA) repair has been associated with higher spinal cord ischemia (SCI) risk compared with TEVAR of primary thoracic aortic aneurysms (TAAs). However, data on the impact of the type of prior infrarenal aortic repair on outcomes are scarce. In this study, we examined perioperative outcomes and long-term mortality following TEVAR M-TAA compared with primary TEVAR of TAA. MethodsWe identified all Vascular Quality Initiative (VQI) patients who underwent TEVAR of TAA in the descending thoracic aorta from 2013 to 2022. Only patients undergoing primary TEVAR or TEVAR following infrarenal open (OAR) or endovascular (EVAR) repair were included. We performed univariate analyses to identify differences in baseline and procedural characteristics, and multivariable analyses for perioperative outcomes and 5-year mortality using logistic and Cox regression, respectively. ResultsWe included 1493 patients who underwent primary TEVAR (81%) or TEVAR following prior OAR (9.0%) or prior EVAR (9.7%). Compared with primary TEVAR, patients undergoing TEVAR M-TAA were older, more commonly male, white, and had higher rates of hypertension, smoking, and renal dysfunction. Patients with M-TAA were more likely to be asymptomatic and have larger diameters at presentation but were exposed to greater contrast volume and procedural times relative to primary TEVAR patients. Following risk-adjustment, compared with primary TEVAR, TEVAR after prior EVAR was associated with higher perioperative mortality (9.7% vs 3.9%; odds ratio [OR], 5.3; 95% confidence interval [CI], 2.3-12; P < .001) and 5-year mortality (40% vs 24%; hazard ratio [HR], 2.1; 95% CI, 1.4-3.1; P = .001). Specifically, among octogenarians (n = 375; 25%), the perioperative and 5-year mortality differences were even more pronounced (perioperative mortality: 17% vs 8.4%; OR, 6.7; 95% CI, 2.2-21; P = .001; 5-year mortality: 50% vs 27%; HR, 3.0; 95% CI, 1.5-5.7; P = .010). However, in-hospital complications, including SCI (2.6% vs 2.8%; OR, 1.2; 95% CI, 0.33-3.3; P = .77), were not notably different. In contrast, TEVAR after previous OAR was associated with comparable perioperative mortality (4.4% vs 3.9%; OR, 1.2; 95% CI, 0.32-3.8; P = .73), 5-year mortality (28% vs 24%; HR, 1.3; 95% CI, 0.80-2.1; P = .54), and in-hospital complications, including SCI (2.6% vs 0.7%; OR, 0.21; 95% CI, 0.01-1.1; P = .16). ConclusionsPatients undergoing TEVAR of M-TAAs after prior EVAR, particularly octogenarians, have higher perioperative and 5-year mortality and therefore, represent a high-risk group. Future efforts should strive to discern the underlying factors leading to these poorer outcomes; meanwhile, these findings emphasize the need for careful patient selection and appropriate preoperative counseling in these high-risk individuals.

Thoracic Endovascular Aortic Repair for Metachronous Thoracic Aortic Aneurysms Following Prior Infrarenal Abdominal Aortic Aneurysm Repair

Thoracic endovascular aortic repair (TEVAR) for metachronous thoracic aortic aneurysms (M-TAA) after prior abdominal aortic aneurysm repair has been shown to be associated with higher risk of spinal cord ischemia compared with primary TEVAR. However, data regarding the impact of the type of prior repair on outcomes are scarce. In this study, we examined perioperative outcomes and long-term mortality after TEVAR for M-TAA compared with primary TEVAR for TAA. We identified all patients who underwent TEVAR for TAA of the descending thoracic aorta in the Vascular Quality Initiative from 2013 to 2022. Only patients undergoing primary TEVAR or TEVAR after infrarenal open (iOAR) or endovascular (EVAR) repair were included. We performed univariate analyses to identify differences in baseline and procedural characteristics, and multivariable analyses for perioperative outcomes and 5-year mortality using logistic and Cox regression models. We included 1493 patients who underwent primary TEVAR (n = 1213; 81%) or TEVAR after prior iOAR (n = 135; 9%) or prior EVAR (n = 145; 10%). Compared with primary TEVAR, patients undergoing TEVAR for metachronous aneurysms were older, more commonly male, White, and more frequently had a history of genetic disorders and other comorbidities. Patients with M-TAA were more often asymptomatic at repair, presented with larger diameters, and required higher contrast volume and longer procedural time, relative to patients undergoing primary TEVAR. After risk adjustment, compared with primary TEVAR, prior EVAR was associated with higher perioperative mortality (10% vs 3.9%; odds ratio [OR]: 4.5, 95% confidence interval [CI]: 2.0-9.9; P < .001) (Table) and 5-year mortality (40% vs 24%; hazard ratio: 1.9, 95% CI: 1.3-2; P = .001) (Fig), along with higher odds of acute kidney injury (10% vs 6.2%; OR: 2.0, 95% CI: 1.0-3.8; P = .04). However, other in-hospital complications including spinal cord ischemia were not notably different. On the other hand, TEVAR after prior iOAR was associated with similar perioperative mortality (4% vs 4%; OR: 0.8, 95% CI: 0.3-2.0; P = .75), 5-year mortality (28% vs 24%; hazard ratio: 1.2, 95% CI: 0.72-1.9; P = .54), and in-hospital complication and reintervention rates, relative to primary TEVAR. Type of prior repair has a significant impact on outcomes in patients undergoing intervention for M-TAA. Further efforts should aim to identify the reasons behind these differences in outcomes to help improve care of patients with M-TAA.TablePerioperative outcomes and 5-year mortality after primary TEVAR and TEVAR after prior iOAR or EVARPrimary TEVARPrior iOARPrior EVARPrimary TEVAR vs prior iOARPrimary TEVAR vs prior EVARUnadjusted event rates, %Odds ratio (95% CI)P valueOdds ratio (95% CI)P valuePerioperative mortality3.94.49.71.2 (0.32-3.7).754.5 (2.0-9.9)<.001Any complication1814230.92 (0.50-1.6).771.5 (0.89-2.3).13 AKI6.26.7101.3 (0.56-2.9).492.0 (1.0-3.8).04 Postoperative dialysis1.01.51.42.1 (0.24-1.2).461.4 (0.07-9.1).78 Spinal cord ischemia2.60.72.80.22 (0.01-1.2).161.3 (0.35-3.5).69 Leg ischemia1.90.72.11.2 (0.06-7.2).862.0 (0.42-7.0).33 Bowel ischemia0.501.4NANA3.0 (0.40-15).22 Stroke3.11.54.10.63 (0.10-2.3).541.3 (0.40-3.3).58 Pulmonary complication5.06.76.91.8 (0.72-4.0).181.9 (0.83-3.8).11 Cardiac complication2.53.02.81.7 (0.45-5.2).971.02 (0.23-3.2).97Reintervention4.93.76.21.2 (0.38-3.0).761.5 (0.64-3.3).30Unadjusted estimatesHazard ratio (95% CI)P valueHazard ratio (95% CI)P value5-year mortality2325401.2 (0.72-1.9).541.9 (1.3-2.8).001AKI, Acute kidney injury; CI, confidence interval; iOAR, infrarenal open aortic repair; TEVAR, thoracic endovascular aortic repair.Boldface P values represent significance P < .05.*Adjusted for age, gender, diameter, race, saccular, presentation, prior myocardial infarction, prior congestive heart failure, hypertension, diabetes, chronic obstructive pulmonary disease, smoking, renal dysfunction, prior medication use (aspirin, statin, and β-blocker), and genetic history. Open table in a new tab

(248) Utility of Fine-needle Vasography in Men with Obstructive Azoospermia

Abstract Introduction Obstructive azoospermia accounts for up to 14% of patients presenting for fertility evaluation. Fine-needle vasography (FNV) is a diagnostic procedure that can be performed to identify an obstruction proximal to the ejaculatory duct. Compared to traditional vasography, FNV utilizes a less-invasive method to perform imaging of the vas deferens and distal ejaculatory structures. Herein we report our experience performing FNV in a series of patients with suspected complete or near-complete obstruction. Objective To report our experience using FNV to identify a site of obstruction and determine candidacy for reconstructive procedures in patients presenting with suspected obstructive azoospermia or cryptozoospermia. Methods We report a multi-Institutional case series of patients with suspected complete or partial obstructive azoospermia. Patients that were included had azoospermia or severe oligoasthenospermia, presence of palpable vasa, testicles ≥12 ml, and FSH &amp;lt;7.6 IU/L. All patients underwent testicular biopsy prior to or at the time of FNV to confirm spermatogenesis. Fine-needle vasography was performed using a 25F angiocatheter, with radio-opaque dye visualized under fluoroscopy. Descriptive statistics are reported as median and interquartile range (IQR). Results A total of 16 patients underwent vasography between 2014 and 2022 with three surgeons. Twelve patients presented with azoospermia, and four with severe oligoasthenospermia. Median age at vasography was 35.0 (IQR 17) years. Median pre-vasography semen parameters were sperm concentration 0 million/mL (IQR 0.3), sperm motility 0% (IQR 1), semen volume 2.5 mL (IQR 2.5), and semen pH 8.0 (0.7). Median total testosterone was 445 ng/dL (IQR 433), and FSH 4.5 IU/L (IQR 3.6). Half of patients had a history of inguinal hernia repair, unilateral in two and bilateral in six cases. History of genitourinary infection was present in six (35.3%) patients. A total of 7 (44%) men were found to have distal obstruction on FNV, while 8 (50%) were offered epididymovasal reconstruction. Of the seven patients diagnosed with obstruction/atresia of the vas deferens within the inguinal canal and/or pelvis, only two were related to prior inguinal hernia repair. Of the eight men with prior inguinal hernia repairs, two were confirmed to have an obstruction at the level of the inguinal canal. Of the six patients with a history of genitourinary infection, four had an obstruction at the level of the epididymis (with normal FNV), while two had atresia of the vas deferens in the pelvis. Conclusions Fine-needle vasography is an effective, minimally-invasive way to identify the site of complete or partial obstruction in patients presenting with suspected obstructive azoospermia or severe oligoasthenospermia. It additionally permits identification of men who are candidates for epididymovasostomy reconstruction and helps to differentiate between ejaculatory duct obstruction and other causes of blockage. Disclosure No

P47 MITRAL VALVE RE–REPAIR THROUGH A RIGHT MINITHORACOTOMY

Abstract Objective Recurrent mitral valve regurgitation after prior repair is usually treated with re–repair or replacement through a median sternotomy. We report our small initial experience with mitral valve re–repair through a repeated minimally invasive approach. Methods From July 2018 to November 2021, 10 patients (median age 52 years IQR 49–68; male 90%) underwent isolated mitral valve re–repair with a right mini–thoracotomy approach with peripheral arterial and venous cannulation. Median Euroscore II was 2.05 (IQR 2.03–2.54). Results The median time from the original operation to redo surgery was 4.7 (3.5–8.1) years. Median cardiopulmonary bypass and cross–clamp times were 128 (IQR 109–134) and 99.5 (IQR 81–112) minutes, respectively. Failure of previous mitral valve repair was mainly due to Gore–Tex chordal rupture (3 patients), annular detachment (3 patients), native chordal rupture (2 patients), and posterior leaflet prolapse (2 patients). Concerning the surgical terchnique, a complete mitral valve ring Corcym Memo 3D or 4D was used in 8 patients while additional repair techniques were needed 5 patients (PTFE neochords implantation, cleft or commissure closure). No conversion to full sternotomy and no reoperation for bleeding was necessary. Median ICU and hospital stay were 2.0 (IQR 2.0–2.0) and 7.5 (7.0–9.0) days respectively. Median follow up time was 3.5 (2.8–3.9) years. Neither deaths nor major postoperative complications occurred in the follow–up period. Conclusions In our experience, mitral valve re–repair can be an attractive option for patients with failure of previous mitral valve surgery and can be safely performed through a minimally invasive approach with good outcomes. Main advantages seem to be the avoidance of extensive surgical dissection, optimal valve exposure, and low risk of surgical complications.

Mesh infection after umbilical hernia repair in a pregnant female

Introduction: Acute abdominal findings occur in about 1 in 500 pregnancies. Diagnosis of acute abdominal findings in pregnancy can be difficult due to the physiologic and anatomic changes that are intrinsic to pregnancy. In pregnancy, the presence or recurrence of umbilical hernia is common and should be included in the differential diagnosis for acute abdominal findings. Few cases have been reported of complications post-hernia repair during subsequent pregnancies. Case Report: We report the case of a 31-year-old female with a history of an umbilical hernia repair who presented with acute abdominal findings at 22 weeks gestation attributed to delayed infection of surgical mesh. Conclusion: This patient’s presentation of acute abdominal findings during pregnancy with a history of umbilical hernia repair one year prior required exclusion of both obstetric and non-obstetric causes to determine diagnosis. There is little published evidence to guide Ob/Gyn physicians in counseling patients on the impact of pregnancy on prior umbilical hernia mesh repair. This case emphasizes the need for surveillance for mesh related complications during subsequent pregnancies in women with a history of mesh umbilical hernia repair.

The gendered socioeconomic impact of the COVID-19 pandemic on women with fistula repair in Uganda

Public health mitigation strategies for SARS-COV-2 are effective in limiting the spread of COVID-19; however, these restrictions can create gendered socioeconomic impacts and further isolate marginalized communities from essential resources. Our qualitative study aimed to understand the gendered effects of the COVID-19 lockdown on a population of women in Uganda with a history of prior obstetric fistula repair, a group experiencing greater vulnerability and less support due to intersecting stigmatized identities. We conducted in-depth interviews among 30 women with prior genital fistula and corrective fistula repair surgery at 3 hospitals in Southern Uganda. We found that COVID-19 lockdown measures caused both financial and health-related impacts in this community such as inaccessibility of healthcare and loss of income. Understanding these experiences should inform strategies to ensure equitable, future pandemic responses.

OC-022 Quality and Quantity Matter - Incidence of Incisional Hernia Following Common Abdominal Surgeries by Abdominal Surgical History: A United States Population-based Analysis of 945,262 Patients

Abstract Objective Patients with prior abdominal surgery (prior-AS) may have increased risk of developing incisional hernia (IH) at the time of subsequent abdominal surgery (AS). We hypothesized that prior-AS history is associated with increased incisional hernia (IH) formation and that the risk is higher for prior IH repair (prior-IHR). Methods Patients undergoing common AS operations (bariatric, cholecystectomy, small/large bowel resection, prostatectomy, and gynecologic) were identified and followed-up for 1-year using Statewide Inpatient/Ambulatory Databases (2009–2016; FL, IA, NE, NY, UT). Prior-AS history was ascertained within 3-year period preceding the index operation. Risk-adjusted Cox regression examined the association of surgical history with IH. Results Of 945,262 patients, 8.55% had prior-AS. Median age was 49 years, most patients were female (68.95%), undergoing open (80.5%) elective (74.5%) AS. Risk-adjusted revealed increased IH risk by surgical history: prior-AS (HR 1.36 [95%CI 1.25–1.48]), multiple prior-AS (2.0 [1.67–2.46]), prior-IHR (3.4 [2.99–3.66]), and multiple prior-IHR (3.56 [2.5–4.28]; Figure). For every additional prior-AS and prior-IHR there was an increase in IH by 9.7% (95%CI 1%-18.6%) and 22.5% (15.6%-29.9%), respectively. Conclusion Both the type and number of previous AS are associated with increased risk for IH, particularly in patients with prior-IHR, and multiple prior operations. These findings demonstrate that reoperation through a previously-disrupted abdominal wall poses technical challenges that impact long-term morbidity, and underscore the need to consider preventive measures at the time of subsequent AS.

PO-05-029 VENTRICULAR PACING IS RELIABLE WITH A SINGLE LEFT VENTRICULAR QUADRIPOLAR LEAD AND A PLUGGED RIGHT VENTRICULAR PORT IN PATIENTS WITH TRICUSPID VALVE REPAIR OR REPLACEMENT

Transvenous ventricular pacing with a lead crossing a repaired or bioprosthetic tricuspid valve (TV) is undesirable due to the potential effect of permanent pacing leads on repaired or replaced TV function. One potential alternative is left ventricular (LV) pacing via the coronary sinus; however, LV pacing leads are associated with higher thresholds, potential for phrenic nerve stimulation, and lead instability requiring revision. While quadripolar LV leads offer improved lead stability and programmability from multiple electrode pair options, only Abbott CRT-P generators allow for sensing from an IS-4 lead without requiring an IS-1 lead plugged into the right ventricular (RV) port. Feasibility and outcomes with this pacing technique have not been previously reported. To study the reliability of LV-only pacing with a quadripolar lead and plugged RV port in patients with tricuspid valve repair or replacement. 10 consecutive patients with prior TV bioprosthesis or repair underwent quadripolar LV lead placement in CS branch veins with plugged RV port and were retrospectively analyzed. Patient demographics, procedure data, interrogation data and need for reprogramming or lead revision were collected over 16 months mean follow-up. Successful implantation an Abbott CRT-P device with LV quadripolar lead with a plugged RV port was achieved in all patients. 5/10 of these cases involved the concomitant extraction of an RV lead. The target branch vein selected was that which would provide the best perceived lead stability, which was the AIV in two patients and MCV in one patient. Implant LV lead thresholds ranged from 0.75V @ 0.4ms to 2.25V @ 0.4ms with little change in follow-up thresholds, which ranged from 0.5V @ 0.4s to 2.25V @ 0.4ms. No patient experienced undersensing or oversensing in follow-up and R waves were greater than 5 mV in all patients. No patients required lead revision and no patients developed a pacing induced cardiomyopathy (drop in LVEF ≤ 10%) with LV only pacing. Durable ventricular pacing utilizing a single quadripolar LV lead and CRT-P generator is feasible when a transvenous RV lead is undesirable. This can be achieved by utilizing a single manufacturer’s CRT-P generator with unique capability of ventricular sensing from the IS-4 port despite plugged RV IS-1 port. This technique is an attractive alternative to standard dual chamber pacing in patients with prior TV repair or bioprosthesis to reduce risk of future valve dysfunction.Tabled 1PatientAgeSexPacing IndicationRelative Contraindication for RV LeadLV Lead Implant VeinLV Sensing at ImplantLV Sensing at Follow-upLV Threshold at ImplantLV Threshold at Follow-upVP %Preimplant LVEFLast Follow-up LVEF169FSND / Paroxysmal AVBTricuspid Repair, annuloplastyMCV10.8mV>12mV[email protected][email protected]<1%60-65%60-65%233MParoxysmal AVBBioprosthetic Tricuspid ValvePosterolateral branch5.1mV7.2mV[email protected][email protected]2%50%64%342MComplete heart blockBioprosthetic Tricuspid ValvePosterior branch>12mV12mV[email protected][email protected]97%>55%>55%465FSinus node dysfunctionTricuspid Repair, annuloplastyAIV>12mV12mV[email protected][email protected]<1%35-40%35-40%526FComplete heart blockTricuspid Repair, annuloplastyAnterolateral branchNone at VVI 30None at VVI 30[email protected][email protected]92%50%51%669FComplete heart blockSevere TR, Anticipated Tricuspid ClipAIV11.4mV>12mV[email protected][email protected]98%>55%>55%765FSinus node dysfunctionTricuspid Repair, annuloplastyPosterolateral branch8.3mV7mV[email protected][email protected]4%55-60%58%831MComplete heart blockBioprosthetic Tricuspid ValvePosterior branchNone at VVI 30None at VVI 30[email protected][email protected]91%>55%58%957FComplete heart blockBioprosthetic Tricuspid ValveAnterolateral branch12mVNone at VVI 30[email protected][email protected]99%59%56%1057MComplete heart blockBioprosthetic Tricuspid ValvePosterolateral branchNone at VVI 30None at VVI 30[email protected][email protected]98%55-60%55-60% Open table in a new tab

Return to Sport and Patient-Reported Outcomes After Subpectoral Biceps Tenodesis for SLAP Tear in Collegiate Gymnasts.

The biceps superior labral complex is a known source of shoulder dysfunction in young, high-level athletes. Superior labral anterior-posterior (SLAP) repairs are often unsatisfactory for treating biceps-labral pathology in this demographic group, with high failure rates and poor return to sport (RTS). Minimal data have been published to demonstrate patient-reported outcomes (PROs) and RTS in gymnasts after treatment of SLAP pathologies. Gymnasts undergoing biceps tenodesis for SLAP pathologies would have satisfactory PROs and satisfactory RTS. Case series; Level of evidence, 4. Gymnasts aged ≤25 years who underwent open subpectoral biceps tenodesis for SLAP tears with or without biceps tendon pathology between August 20, 2014, and August 20, 2019, and who had minimum 2-year follow-up data were included in this study. Tenodesis was performed using a subpectoral technique with bicortical button fixation. The following PROs were included: RTS, postoperative activity level, 10-point visual analog scale for pain (VAS-Pain), American Shoulder and Elbow Surgeons (ASES), and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Of 16 shoulders in 14 gymnasts undergoing biceps tenodesis for SLAP tear during the study period, a follow-up was obtained for 13 of 16 shoulders (81%) at 4.3 ± 1.5 years. The mean age of patients at the time of surgery was 21.8 ± 2.2 years, with 12 (92%) male patients. Biceps tenodesis was performed as the primary procedure for the diagnosis of SLAP tear in 12 patients (92%) and for failed prior SLAP repair in 1 patient (8%). PROs were excellent at the follow-up, with VAS-Pain scores of 1.8 ± 1.7, ASES scores of 89.1 ± 9.1, and DASH scores of 2.4 ± 3.2. After surgery, 8 (62%) patients returned to their prior level of collegiate gymnastics. Three (60%) of 5 patients did not return to collegiate gymnastics because of the end of eligibility, and 2 (40%) patients did not return to collegiate gymnastics because of knee injuries. Significantly higher DASH scores were noted in the group that did not RTS (P = .04). No patients experienced postoperative complications or reoperation. Biceps tenodesis was an effective primary operation for high-level gymnasts with SLAP tears, with a satisfactory rate of return to the same level of sport and excellent PROs.

PC13. Abdominal Wall Reconstruction in Patients with Inflammatory Bowel Disease: A Single Center Experience

PURPOSE: Patients with inflammatory bowel disease (IBD) are at increased risk for postoperative complications due to prior surgical history, poor nutritional status, and immunomodulation. We investigate surgical outcomes after abdominal wall reconstruction (AWR) in patients with IBD. METHODS: A single-institution, retrospective review was performed of all patients with IBD undergoing abdominal wall reconstruction from 2016 to 2022. RESULTS: Fifty-eight patients were included, with 31 patients with Crohn’s disease and 27 patients with ulcerative colitis. The average age was 52.3 (±14.5) years and average BMI was 26.7 (±4.5) at time of surgery. Seventeen (29.3%) patients were on a steroid or immunomodulator prior to surgery. Patients had an average of 3.1 (±1.8) prior abdominal surgeries; 14 (24.1%) patients had prior hernia repair. The hernia breakdown was commonly midline 38 (65.5%) and parastomal 9 (15.5%). Biologic mesh was used in 7 (12.1%) cases. Postoperatively, 7 (12.1%) patients experienced major complications; 6 patients required takeback for abscess drainage (3), small bowel obstruction/perforation (2), or ileostomy revision (1), and 1 patient had sepsis and liver failure requiring prolonged care. Minor complications were seen in 19 (32.8%) patients, consisting of ileus or high ostomy output (13), superficial surgical site infection (3), and incisional breakdown or dehiscence (3). Patients were followed for an average of 314 (± 310.6) days. There were no instances of abdominal bulge and 1 patient with hernia recurrence. CONCLUSION: AWR in the IBD patient population can be performed with low complication rates. Most AWR were performed without mesh without compromising hernia recurrence rates.

A pilot study of implementation of endoscopic sleeve gastroplasty (ESG) in Norway

Background and aim Bariatric surgery is the most effective treatment for obesity but is invasive and associated with serious complications. Endoscopic sleeve gastroplasty (ESG) is a less invasive weight loss procedure to reduce the stomach volume by full-thickness sutures. ESG has been adopted in many countries, but implementation at Scandinavian centres has not yet been documented. We performed a clinical pilot trial at a Norwegian centre with the primary objective to assess the feasibility of the ESG procedure. Patients and methods We included the first 10 patients treated with ESG at a Norwegian centre in a single-arm pilot study. The eligibility criteria were either a body mass index (BMI) of 40–49.9 kg/m2, BMI 35–39.9 kg/m2 and at least one obesity-related comorbidity, or BMI 30–34.9 kg/m2 and type 2 diabetes. Patient follow-up resembled the scheme used for bariatric surgery at the center, including dietary plans and outpatient visits. Results All procedures were technically successful except for one patient who had adhesions between the stomach and anterior abdominal wall, related to a prior hernia repair, resulting in less-than-intended stomach volume reduction. Mean total body weight loss (TBWL) after 26 and 52 weeks was 12.2% (95% CI 8.1–16.2) and 9.1% (95% CI 3.3 − 15.0). One patient experienced a minor suture-induced diaphragmatic injury, which was successfully managed conservatively. Conclusions This first Scandinavian clinical trial of ESG, documenting the implementation of the procedure at a Norwegian center, demonstrated acceptable feasibility and safety, with large variations in individual weight loss during the 52-week follow-up period.

Outcomes of abdominal false lumen embolization for chronic aortic dissection after prior proximal repair with stent-graft.

Persistent false lumen (FL) perfusion with aneurysmal formation is common after thoracic endovascular aortic repair (TEVAR) for typical extended aortic dissection and is associated with poor outcomes. Endovascular FL embolization (FLE) has recently been tried for treatment of postdissection aortic aneurysm (PDAA). However, most reports address thoracic rather than abdominal FLE. In this study, we present the results of abdominal FLE in patients with residual patent abdominal FL following stent-graft repair for aortic dissection. Between 2015 and 2019, 24 patients (mean age: 56.7 ± 11.8 years, range: 40-84 years, 18 male) received endovascular abdominal FLE using vascular plugs, coils, or candy plugs as the main surgery (5 patients) or auxiliary procedure (19 patients) after earlier stent-graft repair for aortic dissection (Type A: 9, Type B: 15). The medical records were reviewed and aortic remodeling was examined comparing the preembolization computed tomography (CT) and the most recent CT before reintervention. Technical success was achieved without any intraoperative complications, early morbidity, or mortality. Median follow-up was 34.4 months (range: 12-71). Regarding thoracic FL, 15 patients exhibited complete thrombosis before the procedure and did not change status thereafter except for 1 patient with distal stent-graft-induced new entry. In the other 9 patients, 6 exhibited increased thrombosis. With regard to the abdominal aorta, increased FL thrombosis only occurred in 8 patients with 3 (12.5%) achieving complete thrombosis. The maximal thoracic aortic diameter did not change (1.4 ± 5.6 mm) statistically, but the abdominal diameter increased significantly (4.3 ± 3.7 mm, p < 0.005). From our results, abdominal FLE is a safe procedure. However, covering all the re-entry tears is complex and the possibility of complete FL thrombosis is low. The abdominal aortic diameter appears to become enlarged in these patients. Continuous follow-up is necessary after FLE.