Small-volume Center Research Articles

P.398: Evaluating post-liver transplantation outcomes in hepatorenal syndrome: Insights from a small volume center study.

P.398: Evaluating post-liver transplantation outcomes in hepatorenal syndrome: Insights from a small volume center study.

Simultaneous Pancreas and Kidney Transplantation: An Initial Experience in Southern India

Abstract Introduction: Simultaneous pancreas-kidney transplantation (SPKT) is a well-documented therapy for insulin-dependent diabetes mellitus (IDDM) with end-stage renal disease (ESRD). Here, we share the initial reports of SPKT conducted at our institution. Patients and Methods: We performed five SPKT procedures in patients with IDDM and ESRD between April 2021 and April 2023. All grafts were procured from healthy, in-house, brain-dead donors. Results: The recipients included three males and two females, with a mean age of 35 ± 11.2 years. The mean duration of diabetes mellitus and time on dialysis were 17 ± 9.7 years and 21 ± 8.7 months, respectively. Donors had a mean age and body mass index of 27 ± 5.8 years and 23 ± 2.7 kg/m2. The mean glycated hemoglobin (HbA1c) and creatinine levels of donors at the time of donation were 5.6% ±0.27% and 0.98 ± 0.4 mg/dL. One recipient underwent pancreas removal due to a duodenal leak, and one developed kidney acute tubular necrosis. All recipients were on proper follow-up for a median period of 12 (4–18) months, with 100% patient survival, 80% pancreas, and 100% kidney survival. Average HbA1c, fasting blood sugar, and serum creatinine on follow-up were 5.5% ±0.7%, 84 ± 9.9 mg/dL, and 1 ± 0.16 mg/dL, respectively. Conclusion: In our initial experience with SPKT, recipient outcomes were comparable to results published in the literature. With proper graft selection, SPKT can be established in small-volume centers. Meticulous surgical technique and postoperative management remain key to the success of the transplant program.

LMIC-25. EXPANDING THE PEDIATRIC NEURO-ONCOLOGY TELECONFERENCE EXPERIENCES, A LUXURY, OR A NECESSITY?

Abstract INTRODUCTION Videoteleconference in neurooncology is feasible and sustainable. The well-established 20 years’ Sickkids/KHCC teleconferencing is an example. Since 2018, several regional centers joined these meetings to discuss their patients’ management plans. We aimed to evaluate the impact of this experience. METHODS We retrospectively reviewed the 56 meetings’ minutes (9/2018-12/2023) and compared the pre-conference suggested plans with the post-conference recommendations. We recorded if the recommendations were implemented and the impact perceived. RESULTS In total, 251 patients were discussed: KHCC (137) and non-KHCC (114). Four of the regional participating oncologists had dedicated pediatric neuro-oncology training. Patients were selected for discussion due to challenges in their management (i.e. with relapsed tumors, rare diagnoses, unexpected tumor behavior). Main diagnoses were: Low-grade-glioma (28%), High-grade-glioma (21%), and Medulloblastoma (17%). Of the 227 patients where the local team suggested a care plan, the teleconference recommendations concurred with the proposed plan in 50% of the cases, agreed on but provided an alternative plan option in 18% and disagreed on in 32% of the cases. The difference in recommendations mostly affected the proposed treatment modality (15%). In 64% of the discordant plans and 50% of the alternative plans, the treating team applied the recommendations. Challenges to apply the recommendations were mainly linked to patients’ factors (53%, plan refusal, traveling abroad, clinical deterioration), local multidisciplinary team consensus on a different plan (29%) or logistic difficulties (18%, e.g. drug access). CONCLUSIONS Improvement in patients’ care was likely achieved with the continuous effort of the local teams to implement the recommendations. Participating oncologists valued the shared educational experience learned from each other’s case discussions, especially those related to molecular-testing and implications on treatment. Joining such regional teleconferences is of particular importance to small-volume centers or those lacking a pediatric neurooncologist. Regional and international collaborations are a necessity when it comes to improving the care of children with CNS tumors.

Applying the British Association of Oral and Maxillofacial Surgeons quality outcomes metrics to a regional Australian oncology and reconstructive service: benchmarking the data to audit clinical outcomes in emerging, regional, and small-volume centres

The traditional model of centralisation of care, whilst having many advantages, also requires adaptation and upscaling to meet the requirements of both regional areas and the increasing urban sprawl. However, to ensure comparable outcomes with current major centres, this transition, when required, must be delivered in a safe and effective manner. Our project, which utilised the British Association of Oral and Maxillofacial Surgeons (BAOMS) recently published outcome data from the Quality and Outcomes in Oral and Maxillofacial Surgery (QOMS) project to benchmark data prospectively collected from a small-volume, emerging centre in Northern Queensland, was the first of its kind in terms of validation studies. As expected, the small volume of our centre impacted the ability to derive powerful statistical models and comparators, an intrinsic limitation for small-volume centres whilst they are developing services. However, during this evolution project, the use of comparison metrics allowed for the detection of alert and alarm levels, which are invaluable to ensure patient safety and quality of outcome.Our paper demonstrated that, irrespective of size or volume, the utilisation of quality assurance metrics (national or international) provides for the safe and transparent upscaling of head and neck services in emerging, regional, and small-volume centres.

Outcomes of Neonatal Emergency Percutaneous Cardiac Interventions Performed in Rural India: Case Series

Background: Critical congenital heart diseases requiring emergency percutaneous interventions are associated with frequent complications and high mortality rates. Successful outcomes of the procedures require a well-established paediatric cardiac centre performing a large number of procedures. Our cardiac centre is situated in a rural region, and it is a small-volume centre for a paediatric cardiac unit. Case characteristics: Between April 2019 and July 2022, a total of nine neonatal emergency cardiac procedures were performed. This case series reviews the outcome of the study. Observation: Five newborns had no complications. Two neonates had minor complications. Major complications occurred in two neonates. Seven neonates were discharged. Two neonates died.

Liver Transplantation at a Small Volume Center—The Role of Network System

IntroductionLiver transplantation (LT) is typically performed at specialized, high-volume centers. However, some smaller centers also offer liver transplantation services, but their outcomes and safety have been a subject of debate. To overcome these difficulties, we tried to build a Catholic medical center (CMC) network to share our experiences and overcome the lack of volume. In this study, we reviewed the overall outcome of patients undergoing LT at a small-volume procedure center, with a focus on patient and graft survival rates. MethodsBetween July 2014 and September 2021, 60 adults underwent LT at Bucheon Saint Mary's Hospital. The overall outcomes were analyzed in terms of perioperative outcomes, complications, and overall survival rate. In addition, the patients were divided into a benign end-stage liver disease (ESLD) group (n =44) and a hepatocellular carcinoma (HCC) group (n = 16). The baseline characteristics, perioperative outcomes, complications, and overall survival rate were analyzed between the two groups. ResultsOf a total of 60 LT, living donor liver transplantation (LDLT) was 26, and deceased donor liver transplantation (DDLT) was 34. LDLT was 14 (31.8%) in the ESLD group and 12 (75.0%) in the HCC group. The overall 1-year, 3-year, 5-year survival rates were 86.7%, 79.7%, and 77.7%, respectively. The survival difference was not statistically significant (p=0.214) between the two groups. ConclusionWe suggests that with appropriate patient selection and adequate resources, LT can be safely performed at smaller centers, with the assistance of the CMC network, thus expanding access to this life-saving procedure.

P1039 RECtal OUtcomes in Paediatric Ulcerative Colitis (RECOUP-UC): An International Clinical Practice Survey of Paediatric Gastroenterologists

Abstract Background Ulcerative Colitis (UC) in childhood is associated with a higher risk of developing acute severe colitis and colectomy compared to adult populations. Following subtotal colectomy, the rectal remnant is typically oversewn and remains in-situ until ileal continuity surgery is undertaken. Access to such surgical expertise determines the timing of restorative surgery, which may range from months to years. There is a paucity of data regarding residual rectal activity during this interval, its medical management and clinical outcomes. Methods An electronic survey (SurveyMonkey) of clinical practice was disseminated to the paediatric inflammatory bowel disease (PIBD) community internationally. Data collected included treating centre demographics, local colectomy practices, expert opinion on rectal cuff assessment and management. Clinicians were asked to rank order the symptoms and signs considered most relevant to determining disease activity. They also ranked the clinical features they believed most important to patients. Descriptive statistics were used to present findings. Results Responses were collated from over 10 countries, including Ireland, Sweden, UK, Australia, Israel, Canada, Iran, Finland, UAE and Austria. Centre sizes were categorised based on total PIBD population. There was heterogeneity across centres - 16% of respondents were from small volume centres in the range of 0-100 patients, 45% were from medium sized centres (101-300), 25% were from large volume centres (301-500) and 12% treat >500 patients which we categorised as very large volume. Despite variation in centre volume majority of respondents (75%) diagnose >20 new cases of UC annually. Over 90% of respondents reported having no formal guideline for managing rectal disease. Most centres’ patients (60%) waited at least 3 months post-colectomy for restoration surgery. Mild intermittent symptoms were expected to continue by 60% of respondents. Of these symptoms, 45% ranked haematochezia as the most important in determining severity. There was no consensus on the best assessment tool to use; 30% use the PUCAI. Most (80%) use blood markers and endoscopy routinely to assess rectal activity. Favoured treatments include rectal therapy (80%) followed by oral steroids and surgical referral. All respondents agreed that additional research was needed. Conclusion International management of the rectum following subtotal colectomy in children is characterised by variable clinical practises, and a lack of guidelines or validated assessment tools. Additional research in the field is needed to address current literature deficits and improve care for children.

Advancing treatment for perihilar cholangiocarcinoma: role of hepatopancreaticoduodenectomy in small-volume centers.

Hepatopancreaticoduodenectomy (HPD) is a controversial surgical technique for the treatment of perihilar cholangiocarcinoma. This study aimed to clarify the mortality, morbidity, and survival outcomes in patients with perihilar cholangiocarcinoma who underwent HPD at a small-volume hepatobiliary-pancreatic center. This retrospective study included 78 patients with perihilar cholangiocarcinoma who underwent HPD (n = 18) or major liver resection with bile duct resection (n = 60) at our center between October 2013 and December 2022. The primary endpoints were the in-hospital morbidity and 90-day mortality rates. The secondary endpoints included the recurrence-free and overall survival rates in both groups. Major complications (Clavien-Dindo grade ≥3) were more common in the HPD group (Group 1, 61.1%) than in the major liver resection group (Group 2; 23.3%, p = 0.03). The 1-, 3- and 5-year overall survival rates for Groups 1 and 2 were 66.7%, 41.7%, and 27.8% and 79.9%, 44.5%, and 22.7%, respectively (p = 0.89). The 1-, 3-, and 5-year recurrence-free survival rates for Groups 1 and 2 were 64.2%, 53.5%, and 35.6% and 85.3%, 46.8%, and 25.0%, respectively (p = 0.41). Although morbidity and mortality after HPD are higher than those after other surgeries, our findings suggest that HPD is a feasible treatment option for perihilar cholangiocarcinoma, even in small-volume centers. However, meticulous pre- and perioperative evaluation of the patient's overall health status, quality of life, and prospective advantages are required.

A small-volume center experience of liver transplantation for the patients with hepatocellular carcinoma

A small-volume center experience of liver transplantation for the patients with hepatocellular carcinoma

EP06.05-13 Validation of the IASLC Grading System of Invasive Adenocarcinoma of the Lung in Small Volume Center

EP06.05-13 Validation of the IASLC Grading System of Invasive Adenocarcinoma of the Lung in Small Volume Center

How could we establish the laparoscopic donor hepatectomy at a small volume center?: Our early experiences

How could we establish the laparoscopic donor hepatectomy at a small volume center?: Our early experiences

Impact of COVID-19 lockdowns on postoperative morbidity after hepatectomy: A propensity-score matching study on a national French database

BackgroundThe impact of the SARS-CoV-2 pandemic on managing liver malignancies worldwide is unknown. This study aimed to determine the impact of lockdowns on patient clinical pathways and postoperative morbi-mortality. MethodsThis study evaluated all adults’ hospital stays for liver tumors between 2019 and 2021 from the national French discharge database. The primary outcome was the clinical pathway, especially surgical care and postoperative outcomes, between patients admitted during COVID-19 lockdown periods (lockdown group) and during the same periods of 2019 and 2021 (control groups). ResultsThe overall population included 58,508 patients: 18,907 patients in the lockdown group, 20,045 in the 2019 control group, and 19,556 in the 2021 control group. Surgical activity decreased by 11.6% during lockdowns, with 1,514 (8.0%) of patients in the lockdown group treated by surgery, 1,514 (8.6%) in the 2019 control group (P < .001), and 1,466 (7.4%) in the 2021 control group. Chemotherapy was considered more during the lockdowns (P < .001). More patients were operated in small-volume centers during the lockdowns (34% vs 32% vs 32%, P = .034), and fewer were hospitalized in highly populated regions (P < .001). Postoperative morbidity (47% vs 47% vs 47%, P = .90) and mortality (3.3% vs 3.6% vs 3.1%, P = .80) were comparable in the 3 periods, with no influence of lockdowns on morbidity (risk ratio = 0.94, 95% confidence interval = 0.81–1.09, P = .40) or mortality (odds ratio = 1.12, 95% confidence interval = 0.72–1.74, P = .6). Postoperative pulmonary (17% vs 13%, P = .024) and septic complications (20% vs 15%, P = .022) were significantly higher during the first lockdown compared to the second. ConclusionThis study provides a French overview of liver malignancy management during the COVID-19 pandemic. Moreover, surgical activity decreased by 11.6% in high-volume centers, with no impact on postoperative morbidity and mortality.

Pancreaticoduodenectomy in a Small Volume Center in North Macedonia

Pancreaticoduodenectomy in a Small Volume Center in North Macedonia

Feasibility of Peripherally Inserted Central Catheter Placement in COVID-19 Patients Isolated in the Intensive Care Unit of a Small Volume Center (291-Bed Hospital)

Purpose: Patients with coronavirus disease 2019 (COVID-19) should be isolated from others to prevent widespread infection. The purpose of this study was to evaluate the feasibility of performing peripherally inserted central catheter (PICC) placement in patients with COVID-19 isolated in the intensive care unit (ICU) of a small volume center hospital.Methods: This retrospective study included 79 patients who underwent PICC in 2 ICUs. There were 41 patients with COVID-19 who were isolated in an ICU (isolated ICU) and there were 38 patients who required ICU care who did not have COVID-19 (non-isolated ICU). Their medical records including PICC-related complications and clinical variables were compared.Results: PICC placement was performed to maintain long-term intravenous access for 78% of the COVID-19 group and 52.6% of the non-COVID-19 group (p = 0.017). The mean procedure time (minutes) was 15.2 ± 7.58 in the COVID-19 group and 12.6 ± 6.65 in the non-COVID-19 group (p = 0.109). When PICC tip locations were divided into three groups (optimal, suboptimal, and malpositioned), there was no significant difference between the two groups of patients. PICC-related complications in COVID-19 and non-COVID-19 groups included non-functioning catheter (0% vs. 5.3%, p = 0.137), occurrence of swelling or hematoma around PICC inserted site (2.4% vs. 0%, p = 0.333), and PICC-related infection.Conclusion: PICC placement for patients with COVID-19 isolated in the ICU of a small volume center hospital was feasible and safe.

Outcomes of Pure Laparoscopic Living Donor Right Hepatectomy at a Small-Volume Center.

Laparoscopic liver donor surgery is a technically difficult and demanding procedure. Our aim was toevaluate its feasibility at an established transplant center. Although our hospital is a small-volume center with <20 liver transplants per year, laparoscopic donor surgery has been performed regularly. In this study, we have reported our experiences with laparoscopic donor right hepa-tectomy and its outcomes. Between May 2014 and March 2021, 26 deceased donor liver transplants and 37 living donor liver transplants, approved by the Korean Network for Organ Sharing, were performed at out center. From these, we reviewed the medical records, including clinical and demographic characteristics and operative outcomes, of 3 living donors who under-went pure laparoscopic donor right hepatectomy and their recipients. Each of the 3 laparoscopic donor right hepatectomies took over 10 hours with the prolonged Pringle maneuver time and warm ischemic time. However, there were no significant events during surgery or critical postoperative complications. In the recipients, posttransplant complications included middle hepatic vein obstruction, postoperative bleeding, bile leak, septic shock, and primary nonfunction of the graft. We managed and resolved these complications using various approaches, including retransplant, and all 3 recipients recovered and survived. Laparoscopic donor right hepatectomy had a relatively long operative time at our small-volume center. We believe that successful laparoscopic donor hepatectomy is possible if the donor is selected appropriately according to the center's experiences and there are constant efforts to overcome the learning curve.

The outcomes of pure laparoscopic living donor hepatectomy at small volume center

The outcomes of pure laparoscopic living donor hepatectomy at small volume center

Does patient load affect clinical outcome of burn patients in specialized centers? An analysis of the German Burn Registry

Hospital volume has been identified as an independent outcome parameter for a number of medical fields and surgical procedures, and there is a tendency to increase required patient numbers for center verification. However, the existing literature does not support a clear correlation between patient load and clinical outcome in adult burn care and recent data from Germany does not exist. We therefore evaluated the effect of patient volume in German burn centers on clinical outcome. Patient data was extracted from the German Burn Registry from 2015 to 2018. For better inter-center comparability, solely burn patients with a TBSA ≥ 10% were included. Mortality, number of surgeries and length of stay (LOS) were evaluated with respect to burn center patient volume. Burn center volume was divided into two and three groups. A total of 2718 patients with a TBSA ≥ 10% were admitted to the participating 17 burn centers. Independent from the division of patient data into either 2 or 3 groups, the TBSA and ABSI score-related severity of burn injuries were comparable between groups. There was no significant difference in mortality due to center size. Nevertheless, patients treated in large volume burn centers showed a significantly increased LOS (+4.5 days, [1.9–7.2] CI, p = 0.001) and required significantly more surgeries (+0.5 surgeries [0.2–0.8] CI, p = 0.002) when compared to the small volume centers. A similar phenomenon regarding mortality and LOS (p 0.001) was observed after dividing the centers into two groups. Interestingly a division into three groups showed significant differences with the best outcome for patients in medium-volume centers. Nevertheless, mortality did not differ significantly. Therefore, our data demonstrates that in contrast to many other medical fields, outcome and mortality are not automatically improved in burn care by simply increasing the patient load, at least in centers treating 20–100 BICU patients/year.

Early Experience of Pure Robotic Right Hepatectomy for Liver Donors in a Small-Volume Center.

Living donor right hepatectomy has become the most common method of liver transplantation. With minimally invasive surgery, laparoscopic donor hepatectomy became possible, but with some limitations. Advancements in robotic technology made it possible to overcome these shortcomings and maximize the advantages of minimally invasive surgery in transplantation. For this reason, some centers have started robotic donor hepatectomy. Our study aimed to introduce our early experience of robotic donor right hepatectomy and investigate the feasibility of this surgery. This study included 10 (30%) living donors who underwent pure robotic donor right hepatectomy at Dong-A University Hospital from January 1, 2020 to December 31, 2021. The medical records were analyzed to determine the short-term outcomes of these patients. The total operation time and warm ischemic time were 396.6 min ± 62.7 min and 19.7 min± 5.6 min, respectively. Moreover, there was no transfusion during the operation and no other port use and open conversion. The average real graft volume was 590 mL ± 73.5 mL, and the mean hospital stay was 8.7 d ± 2.6 d. There have been no specific complications noted in the donor group. Based on our positive experience with pure robotic right hepatectomy for a liver donor, the robotic technique may be a new option for achieving minimally invasive surgery for a liver donor.

A Pilot Randomized Control Trial of Safety and Feasibility of a Delayed Rewarming Intervention for Infants Following Cardiopulmonary Bypass Surgery

Objective: Investigate safety and feasibility of a 12-hour delayed rewarming intervention on infants following congenital heart disease (CHD) surgery. Study Design: Pilot randomized control trial of infants &lt;6 months old with CHD undergoing cardiopulmonary bypass surgery. Infants were randomized 1:1 to standard of care (SOC) or to delayed rewarming intervention, accomplished by using a commercially available temperature regulating blanket set to gradually rewarm from 35°C to 36.5°C in the 12-hours following surgery. Safety was assessed by comparing the frequency of severe adverse events (SAE) for 48 hours after surgery. Feasibility was assessed by analysis of temperature data. Results: Twelve infants were randomized to SOC and 10 to the intervention group. Eight infants (36%) were female, 6 (27%) had Trisomy 21 and 7 (32%) had surgery in the first two weeks of life. Two SOC and one intervention infant had at least one SAE (p=0.57). Feasibility of the delayed rewarming intervention was demonstrated by a statistically significant difference in temperature over time between groups (p&lt;0.001). Heart rates for infants in the intervention group were slower during and after the intervention, without significant changes in blood pressure. Infants in the intervention group had no evidence of coagulopathy with lower, but not statistically significantly lower, chest tube output at alltime points. Conclusions: There were no differences in the number of SAEs for the delayed rewarming group and the temperature curve indicates that the intervention is feasible. The results of this small study, from a single, small volume center must be interpreted cautiously. (NCT03036072).

A Real-World Application of Liquid Biopsy in Metastatic Colorectal Cancer: The Poseidon Study.

Simple SummaryThe choice of first-line regimen represents a critical step in the therapeutic road for patients with metastatic colorectal cancer (mCRC) because the response to first-line treatment is the primary determinant of outcomes. The extended characterization of RAS and BRAF mutational status is one the key points to select the optimal first-line therapy. Despite the great strides, there are still many challenges in the decision-making regarding the upfront strategy in mCRC patients. RAS testing turnaround time and the unavailability of tissue are the factors most frequently cited by physicians for treating mCRC patients with unknown RAS status, particularly in small volume centers. An accurate blood-based RAS/BRAF mutation assay with fast turnaround time would help circumvent these hurdles. Our experience suggests that genotyping RAS/BRAF to guide therapy may be the first use of liquid biopsy in the daily care with mCRC patients, particularly in the urgent situation to define the first-line regimen.Background: First-line decision making is the key to the successful care of mCRC patients and RAS/BRAF status is crucial to select the best targeted agent. In hub centers, a relevant proportion of patients referred from small volume centers may not have standard tissue-based (STB) molecular results available at the time of the first visit (T0). Liquid biopsy (LB) may help circumvent these hurdles. Methods: A monoinstitutional prospective head-to-head comparison of LB versus (vs.) STB testing was performed in a real-world setting. Selection criteria included: mCRC diagnosis with unknown RAS/BRAF status at T0, tumoral tissue archived in external centers, no previous treatment with anti-EGFR. At T0, patients underwent plasma sampling for LB testing and procedure for tissue recovery. RAS/BRAF genotyping was carried out by droplet digital PCR on circulating-tumoral (ct) DNA. The primary endpoint was the comparison of time to LB (T1) vs. STB (T2) results using the Mann–Whitney U test. Secondary endpoints were the concordance between LB and STB defined as overall percent agreement and the accuracy of LB in terms of specificity, sensitivity, positive and negative predictive value. We also performed an exploratory analysis on urinary (u) ctDNA. Results: A total of 33 mCRC patients were included. Mean T1 and T2 was 7 and 22 days (d), respectively (p < 0.00001). T2 included a mean time for archival tissue recovery of 17 d. The overall percent agreement between LB and STB analysis was 83%. Compared to STB testing, LB specificity and sensitivity were 90% and 80%, respectively, with a positive predictive value of 94% and negative one of 69%. In detail, at STB and LB testing, RAS mutation was found in 45% and 42% of patients, respectively; BRAF mutation in 15%. LB results included one false positive and four false negative. False negative cases showed a significantly lower tumor burden at basal CT scan. Concordance between STB and uctDNA testing was 89%. Conclusions: Faster turnaround time, high concordance and accuracy are three key points supporting the adoption of LB in routinary mCRC care, in particular when decision on first-line therapy is urgent and tissue recovery from external centers may require a long time. Results should be interpreted with caution in LB wild-type cases with low tumor burden.