Cohort Of Surgery Research Articles

Nephron sparing surgery for renal hilar tumours: short-term follow-up of predominantly robot-assisted surgery cohort

BackgroundHilar tumours are the renal tumours, which abut the renal artery or vein. Nephron sparing surgery (NSS) is of proven benefit among those with small renal masses. Hilar tumours are usually offered radical surgery due to the presumed difficulty in dissection, upgrading to tumour stage, and risk of conversion to radical surgery. We present our results of patients with hilar tumour undergoing nephron sparing surgery.MethodsWe performed a retrospective analysis of patients who underwent NSS for renal hilar tumours in our tertiary referral institute from June 2017 to December 2022. The case sheets of all the patients who had undergone NSS were analysed and their radiology images reviewed. Those with hilar tumours were analysed based on demographic characters, perioperative and postoperative and follow-up details.ResultsAmong a total of 21 patients undergoing partial nephrectomy, ten had hilar tumours. The median age was 43 years. Nine patients had robot-assisted partial nephrectomy and one underwent open partial nephrectomy. Seven patients had incidentally detected tumours. One had Grade 3 chronic kidney disease. The mean operative time and robot console time were 225 and 125 min, respectively. Median warm ischaemia time (WIT) was 36 min (25–48 min). One patient had grade 2 complication and two had grade 3 complication. Eight had clear cell renal cell carcinoma and one had positive margin. None had recurrence at a median follow-up of 38 months.ConclusionNephron sparing surgery, especially with robot-assisted approach, is feasible in hilar tumours with prognosis and complications similar to non-hilar tumours in short-term follow-up.

Prognostic value of circulating tumor DNA (ctDNA) testing in patients (pts) with rectal cancer after neoadjuvant therapy (NAT) and surgery.

212 Background: ctDNA is a highly prognostic biomarker for pts with GI malignancies. However, its utility in perioperative treatment decision-making is not established. We evaluated the association of post-NAT and post-surgical ctDNA status with outcomes in rectal cancer pts. Methods: We analyzed 1,656 longitudinal plasma samples from 257 rectal cancer pts (clinical stages I: 7%; II: 23%; III: 65%; IV: 5%). A personalized, tumor-informed assay (Signatera, Natera, Inc.) was used for ctDNA detection and quantification. In this cohort, 169 (66%) pts received NAT followed by surgery, 26 (10%) received surgery alone, and 62 (24%) had nonoperative management (NOM) after NAT. NAT included total neoadjuvant therapy (N=183), chemoradiation (N=33), and chemotherapy (N=15). Post-NAT time point (tp) was taken after completion of NAT and before surgery (surgery cohort) or between 2-16 weeks post completion of NAT (NOM cohort). Event-free survival (EFS) was defined as the interval from end of NAT to the date of clinical progression (NOM cohort). Disease-free survival (DFS) was defined as the interval from surgery to radiological recurrence. Results: The median follow-up was 619 (0-2,535) days. Pre-treatment ctDNA results were available for 50/257 pts; 94% (47/50) of whom were ctDNA+. Post-NAT tp was available for 87 pts, of whom 29.9% (26/87) were ctDNA+ and were less likely to achieve a clinical response to NAT [complete response: 8% (ctDNA+) vs. 51% (ctDNA-), p=0.0017]. Of the 87 pts with post-NAT tp, 48 underwent surgery, 39.5% (19/48) of whom were ctDNA+ post NAT and had worse pathological response [TRG score >2 (ctDNA+) vs. 0-2 (ctDNA-), p<0.001]. The remaining 39/87 pts underwent NOM, of whom 21.9% (7/39) were ctDNA+ and had significantly worse EFS compared to ctDNA- pts (HR: 7.6, 95% CI: 1.9-31, p<0.001). Among the pts who underwent surgery + NAT (N=195), ctDNA was measured in the MRD window (2-12 weeks post-surgery, prior to adjuvant therapy) for 128. Of these, 14.8% (19/128) were ctDNA+ (MRD+). Clinical recurrence was observed in 79% (15/19) of MRD+ pts and in 11% (12/109) of MRD- pts. Notably, of the MRD- pts who clinically recurred, 83% (10/12) did convert to ctDNA+ on subsequent blood draws. MRD+ pts had significantly worse DFS compared to MRD- pts (HR: 18, 95% CI: 7.9-39, p<0.0001). Similar results were observed regardless of whether the pts received NAT (DFS; NAT: HR=13, 95% CI: 5.8-31, p<0.0001; no NAT: HR=12, 95% CI:5.29-7957, p<0.001). Conclusions: Post NAT ctDNA status is associated with clinical/pathological response and survival outcomes. As such, ctDNA can potentially guide treatment decision-making in rectal cancer pts. The post-NAT tp was prognostic of recurrence in pts who had NOM. In pts receiving surgery, ctDNA status in the MRD window was highly prognostic of outcomes. Further studies are warranted to evaluate ctDNA-guided management in the post NAT and NOM settings.

Socio-demographics, Causes of Injuries, and Rehabilitation Injury Categories in a Commercial Motorcycle Road-Related Orthopedics and Neurological Surgery Cohort in Eldoret, Kenya

Commercial motorcycle road related orthopedics and neurological injuries are one of the major causes of short- and long-term consequences requiring timely interdisciplinary referrals and in-patient physiotherapy rehabilitation together with out-patient follow-ups, to maintain and improve physical and functional level of patients. Spinal cord injuries and fractures of the vertebra and lower extremities remain one of the causes of mortality, impairments and disability to the riders, passengers and pedestrians. The objective of the study was to explore socio-demographic characteristics, causes of injuries, rehabilitation injury categories following commercial motorcycle road-related orthopedics and neurological surgery, Eldoret, Kenya. In this prospective cohort study, purposive sampling was adopted to select a sample size of 79 participants for a 6 months period of March 2021-July 2022 in 5 level hospitals, Eldoret, Kenya. The data was entered and analyzed with SPSS 20. The findings show that, from the patients’ bio-data during the study period, 79 out 150 were admitted with commercial motorcycle road-related orthopedics and neurological injuries for surgery with a prevalence rate 53%. All (100%) participants from socioeconmic backgrounds used commerical motorcycles as means of public transport. Male participants constituted to 62% and 38% females with a ratio of male to female of 4.9:3. Majority (94%) of participants were aged between 18 to 44 years with 62% aged between 18-34 years. Sixty-six per cent (66%) were admitted to orthopedics while 34% in neurological wards. All (100%) of the participants reported physical impairments and functional limitations with reduced independence level following commercial motorcycle road-related orthopedics and neurological injuries. All (100%) were referred for post-operative physiotherapy by orthopedics and neurological surgeons. More than half (62%) participants did not intend to continue with outpatient and follow-up physiotherapy rehabilitation. Majority (78%) paid their hospital health bills out of pocket with 51% coming from needy socio-economic class. However, 75% of the participants had requested for a waiver from a social worker. Based on the findings, the study concludes that interdisciplinary referral for post-operative physiotherapy by orthopedics and neurological surgeons were excellent. As a result, there is need for out-patient post-operative physiotherapy follow-ups and sensitization of NHIF registration and uptake by workers in informal sectors.

Does Anterior Cervical Spine Surgery Increase the Likelihood of Developing Obstructive Sleep Apnea? A Pearldiver Study

ObjectivesLiterature is sparse on the development of obstructive sleep apnea (OSA) after anterior cervical spine surgery and includes few case reports. Our objective is to evaluate the role of anterior cervical spine surgery as a risk factor for developing OSA. MethodsA retrospective cohort study was performed utilizing the M157 subset of the PearlDiver national database. Two matched cohorts of patients were identified based on anterior cervical spine surgery using CPT codes. ICD-9 and 10 was used to identify patients who developed OSA within one year time frame in both the cohorts. Relative risk of OSA was calculated for the study and risk factors for developing OSA in the cohort of anterior cervical surgery were evaluated using logistic regression. ResultsThe two cohorts contained 277475 patients each. The one-year incidence rate of OSA in those who undergo anterior cervical spine surgery is 3.5% and is 3.1% in the control group. The relative risk of OSA in the surgery group is 1.13 times compared to the control. Multilevel cervical spine surgery and surgery performed for spondylosis had a higher risk of developing OSA. ConclusionsAnterior cervical spine surgery is associated with an increased risk of developing OSA within one year of surgery. Timely diagnosis and management of OSA in patients who underwent anterior cervical spine surgery can help prevent morbidity and improve quality of life.

Cohort profile: the China surgery and anesthesia cohort (CSAC)

The China Surgery and Anaesthesia Cohort (CSAC) study was launched in July 2020 and is an ongoing prospective cohort study recruiting patients aged 40–65 years who underwent elective surgeries with general anaesthesia across four medical centres in China. The general objective of the CSAC study is to improve our understanding of the complex interaction between environmental and genetic components as well as to determine their effects on a wide range of interested surgery/anaesthesia-related outcomes. To achieve this goal, we collected enriched phenotypic data, e.g., sociodemographic characteristics, lifestyle factors, perioperative neuropsychological changes, anaesthesia- and surgery-related complications, and medical conditions, at recruitment, as well as through both active (at 1, 3, 7 days and 1, 3, 6, 12 months after surgery) and passive (for more than 1 year after surgery) follow-up assessments. We also obtained omics data from blood samples. In addition, COVID-19-related information was collected from all participants since January 2023, immediately after COVID-19 restrictions were eased in China. As of July 18, 2023, 12,766 participants (mean age = 52.40 years, 57.93% were female) completed baseline data collection (response rate = 94.68%), among which approximately 70% donated blood and hair samples. The follow-up rates within 12 months after surgery were > 92%. Our initial analyses have demonstrated the incidence of and risk factors for chronic postsurgical pain (CPSP) and postoperative cognitive dysfunction (POCD) among middle-aged Chinese individuals, which may prompt further mechanistic exploration and facilitate the development of effective interventions for preventing those conditions. Additional studies, such as genome-wide association analyses for identifying the genetic determinants of CPSP and POCD, are ongoing, and their findings will be released in the future.

Preliminary Development of a Program ABSITE Dashboard (PAD) to Guide Curriculum Innovation

Medical Knowledge for general surgery residents' is assessed by the American Board of Surgery In- Training Examination (ABSITE). ASBITE score reports contain many metrics residency directors can utilize to assess resident progress and perform program evaluation. The purpose of this study was to develop a framework to evaluate program effectiveness in teaching specific subtest and subtopic areas of the ABSITE, using ABSITE score reports as an indicator. The aim is to demonstrate the identification of topic areas of weakness in program-wide performance on the ABSITE to guide proposed modification of the general surgery residency program curriculum, and to initiate development of a data visualizing dashboard to communicate these metrics. A single institution retrospective study was performed utilizing ABSITE score reports from general surgery residents at a large academic training program from 2017 to 2020. ABSITE performance metrics from 320 unique records were entered into a database; statistical analysis for linear trends and variance were conducted for standard scores, subtest standard scores, and incorrect subtest topics. Deviation from national average scores were calculated by subtracting the national average score from each subtest score for each trainee. Data were displayed as medians or proportions and are displayed to optimize visualization as a proof-of-concept for the development of a program dashboard. Trends and variance in general surgery program and cohort performance on various elements of the ABSITE were visualized using figures and tables that represent a prototype for a program dashboard. Figure A1 demonstrates one example, in which a heatmap displays the median deviation from national average scores for each subtest by program year. Boxplots show the distribution of the deviation from national average, range for national average scores, and the recorded scores for each subtest by program year. Trends in median deviation from the national average scores are displayed for each program year paneled by subtest or for each exam year paneled by cohort. Median change in overall test scores from one program year to another in a cohort is visualized as a table. Bar graphs show the most often missed topics across all program years and heatmaps were generated showing the proportion of times each topic was missed for each subtest and exam year. We demonstrate use of ABSITE reports to identify specific thematic areas of opportunities for curriculum modification and innovation as an element of program evaluation. In this study we demonstrate, through data analysis and visualization, feasibility for the creation of a Program ABSITE Dashboard (PAD) that enhances the use of ABSITE reports for formative program evaluation and can guide modifications to surgery program curriculum and educational practices.

Application and validation of a surgical risk calculator in a liver surgery cohort of patients in Veracruz, Mexico

Application and validation of a surgical risk calculator in a liver surgery cohort of patients in Veracruz, Mexico

Cardiac arrest in vascular surgical patients receiving anaesthetic care: an analysis from the 7th National Audit Project (NAP7) of the Royal College of Anaesthetists.

The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest in the UK. We report the results of the vascular surgery cohort from the 12-month case registry, from 16 June 2021 to 15 June 2022. Anaesthesia for vascular surgery accounted for 2% of UK anaesthetic caseload and included 69 (8%) reported peri-operative cardiac arrests, giving an estimated incidence of 1 in 670 vascular anaesthetics (95%CI 1 in 520-830). The high-risk nature of the vascular population is reflected by the proportion of patients who were ASA physical status 4 (30, 43%) or 5 (19, 28%); the age of patients (80% aged > 65 y); and that most cardiac arrests (57, 83%) occurred during non-elective surgery. The most common vascular surgical procedures among patients who had a cardiac arrest were: aortic surgery (38, 55%); lower-limb revascularisation (13, 19%); and lower-limb amputation (8, 12%). Among patients having vascular surgery and who had a cardiac arrest, 28 (41%) presented with a ruptured abdominal aortic aneurysm. There were 48 (70%) patients who had died at the time of reporting to NAP7 and 11 (16%) were still in hospital, signifying poorer outcomes compared with the non-vascular surgical cohort. The most common cause of cardiac arrest was major haemorrhage (39, 57%), but multiple other causes reflected the critical illness of the patients and the complexity of surgery. This is the first analysis of the incidence, management and outcomes of peri-operative cardiac arrest during vascular anaesthesia in the UK.

Reproducibility and predictive value of three grading systems for intraoperative adverse events in a cohort of abdominal surgery.

Intraoperative adverse events (iAEs) are increasingly recognized for their impact on patient outcomes. The Kaafarani classification and Surgical Apgar Score (SAS) were developed to assess the intraoperative course, however, both have their drawbacks. ClassIntra® was validated for iAEs of any origin. This study compares the Kaafarani and SAS to ClassIntra® considering predictive value and interrater reliability in a cohort of abdominal surgery to support implementation of a classification in clinical practice. We made use of the LAParotomy or LAParoscopy and ADhesiolysis (LAPAD) study database of elective abdominal surgery. Detailed descriptions on iAEs were collected in real-time by a researcher. For the current research aim, all iAEs were graded according ClassIntra®, Kaafarani, and SAS (score ≤4). The predictive value was assessed using uni- and multivariable linear regression and the area under the receiver operating curve (AUROC). Two teams graded ClassIntra® and Kaafarani to assess the interrater reliability using Cohen's Kappa. A total of 755 surgeries were included, in which 335 (44%) iAEs were graded according to ClassIntra®, 228 (30%) to Kaafarani, and 130 (20%) to SAS. All classifications were significantly correlated to postoperative complications, with an AUROC of 0.67 (95% CI 0.62-0.72), 0.64 (0.59-0.70), and 0.71 (0.56-0.76), respectively. For the secondary endpoint, the interrater reliability of ClassIntra® with κ 0.87 (95% CI 0.84-0.90) and Kaafarani 0.90 (95% 0.87-0.93) was both strong. ClassIntra®, Kaafarani and SAS can be used for reporting of iAEs in abdominal surgery with good predictive value for postoperative complications, with strong reliability. ClassIntra®, compared with Kaafarani and SAS, included the most iAEs and has the most comprehensive definition suitable for uniform reporting of iAEs in clinical practice and research.

Benefit of Conversion Therapy in Patients with Unresectable Hepatocellular Carcinoma: A Propensity Score-Matched Study.

This study aimed to investigate the benefit of conversion therapy for patients with unresectable hepatocellular carcinoma (HCC). A retrospective cohort study was conducted involving 40 patients initially deemed unresectable HCC (uHCC). They received surgery following successful conversion therapy involving lenvatinib. The patients were matched in a 1:1 ratio to with a control group who underwent direct surgery, based on pre-treatment clinical data. The median recurrence-free survival (RFS) duration for the conversion therapy cohort was notably longer than that of the direct surgery cohort (25 months vs 11 months). Furthermore, the 1- and 2-year RFS rates were significantly higher in the conversion therapy group compared to the direct surgery group (1 year: 70.5% vs 40.1%; 2 years: 49.0% vs 19.1%). The survival curves indicated a statistically significantly longer RFS in the conversion therapy cohort compared to the direct surgery cohort (P = 0.007). While patients achieving good remission based on both RECIST 1.1 and mRECIST criteria showed superior median RFS, no significant disparity was observed in the survival curves. The subgroup analysis revealed significantly improved prognosis among patients in the conversion therapy group who were male, older, had a history of alcohol consumption, were non-smokers, had liver cirrhosis, possessed Child-Pugh A liver function, had a tumor diameter exceeding 5 cm, and had an AFP ≥ 400 ng/mL. Among the cohort of 40 patients, only 8 individuals encountered severe adverse reactions, which were managed through dose reduction. None of the patients experienced multiple severe adverse reactions concurrently. For patients with unresectable hepatocellular carcinoma, conversion therapy offers a significantly better prognosis than direct surgery for uHCC patients.

Evaluation of a tiered opioid prescription algorithm in an ERAS pathway: exploring opportunities for further refinement.

Opioid over-prescription is wasteful and contributes to the opioid crisis. We implemented a personalized tiered discharge opioid protocol and education on opioid disposal to minimize over-prescription. To evaluate the intervention by investigating opioid use post-discharge for women undergoing abdomino-pelvic surgery, and patient adherence to opioid disposal education. We analyzed post-discharge opioid consumption among 558 patients. Eligible patients included those who underwent elective gynecologic surgery, were not taking scheduled opioids pre-operatively, and received discharge opioids according to a tiered prescribing algorithm. A survey assessing discharge opioid consumption and disposal safety knowledge was distributed on post-discharge day 21. Over-prescription was defined as >20% of the original prescription left over. Descriptive statistics were used for analysis. The survey response rate was 61% and 59% in the minimally invasive surgery and open surgery cohorts, respectively. Overall, 42.8% of patients reported using no opioids after hospital discharge, 45.2% in the minimally invasive surgery and 38.6% in the open surgery cohort. Furthermore, 74.9% of respondents were over-prescribed, with median age being statistically significant for this group (p=0.004). Finally, 46.4% of respondents expressed no knowledge regarding safe disposal practices, with no statistically significant difference between groups (p>0.99). Despite implementation of the tiered discharge opioid algorithm aimed to personalize opioid prescriptions to estimated need, we still over-prescribed opioids. Additionally, despite targeted education, nearly half of all patients who completed the survey did not know how to dispose of their opioid tablets. Additional efforts are needed to further refine the algorithm to reduce over-prescription of opioids and improve disposal education.

Long-term oncological outcomes of transanal versus laparoscopic total mesorectal excision for mid-low rectal cancer: a retrospective analysis of 2502 patients.

Transanal total mesorectal resection (taTME) has recently emerged as a promising surgical approach for the treatment of mid-low rectal cancer. However, there is limited evidence on the long-term survival outcomes associated with taTME. This retrospective study aimed to compare the overall survival (OS), disease-free survival (DFS), and cancer-specific survival of taTME and laparoscopic TME (laTME) in patients with mid-low rectal cancer. From July 2014 to June 2022, a total of 3627 patients were identified from two prospective cohorts: the laparoscopic rectal surgery cohort and the CNTAES cohort. To balance the baseline characteristics between the taTME and laTME groups, propensity score matching (PSM) was performed. A total of 2502 patients were included in the study. Prior to PSM, the laTME group comprised 1853 patients, while the taTME group comprised 649 patients. The 5-year OS (82.9% vs. 80.4%, P =0.202) and 5-year DFS (74.4% vs. 72.5%, P =0.167) were comparable between the taTME and laTME groups. After PSM, the taTME group showed no statistically significant difference in the 5-year OS (83.1% vs. 79.2%, P =0.101) and 5-year DFS (74.8% vs. 72.1%, P =0.135) compared to the laTME group. Subgroup analysis further suggested that taTME may potentially reduce the risk of death [hazard ratio 0.652; (95% CI, 0.452-0.939)] and disease recurrence [hazard ratio 0.736; (95% CI, 0.562-0.965)] specifically in patients with low rectal cancer. In this study, taTME demonstrated comparable oncologic safety to laTME in patients with mid-low rectal cancer. Moreover, the results indicate that taTME may confer potential survival benefits for patients with low rectal cancer.

Diagnostic Accuracy of an Algorithm for Discriminating Presumed Solid and Gaseous Microembolic Signals During Transcranial Doppler Examinations.

The aim of the work described here was to assess the diagnostic accuracy of a new algorithm (SGA-a) for time-domain analysis of transcranial Doppler audio signals to discriminate presumed solid and gaseous microembolic signals and artifacts (SGAs). SGA-a was validated by human experts in an artifact cohort of 20 patients subjected to a 1-h transcranial Doppler exam before cardiac surgery (cohort 1). Emboli were validated in a cohort of 10 patients after aortic valve replacement in a 4-h monitoring period (cohort 2). The SGA misclassification rate was estimated by testing SGA-a on artifact-free test files of solid and gaseous emboli. In cohort 1 (n=24,429), artifacts were classified with an accuracy of 94.5%. In cohort 2 (n=12,328), the accuracy in discriminating solid/gaseous emboli from artifacts was 85.6%. The 95% limits of agreement for, respectively, the numbers of presumed solids and gaseous emboli, artifacts and microembolic signals of undetermined origin were [-10, 10], [-14, 7] and [-9, 16], and the intra-class correction coefficients were 0.99, 0.99 and 0.99, respectively. The rate of misclassification of solid test files was 2%, and the rate of misclassification of gaseous test files was 12%. SGA-a can detect presumed solid and gaseous microembolic signals and differentiate them from artifacts. SGA-a could be of value when both solid and gaseous emboli may jeopardize brain function such as seen during cardiac valve and/or aortic arch replacement procedures.

Thrombosis Rates and Use of Thromboprophylaxis after Discharge from Gynecologic Cancer-Related Surgery

Background: Cancer and major abdominopelvic surgeries pose significant thrombosis risks, making cancer-related surgery highly susceptible to venous thromboembolism (VTE) despite prophylaxis. Without post-operative thromboprophylaxis (TPX), VTE risk can reach 29% in the weeks following major surgeries. National Comprehensive Cancer Network (NCCN) guidelines recommend anticoagulation for up to 4 weeks after such surgeries, primarily using low molecular weight heparin (LMWH) for 28 days postoperatively. This study aimed to determine VTE rates linked to various gynecologic cancer-related surgeries and explore TPX utilization in a large cancer-center cohort. Additionally, we sought to further understand the necessity for post-discharge TPX in this setting. Methods: Patients (pts) diagnosed with gynecologic cancer between January 1st, 2012, through September 15th, 2022, at our institution were identified through our tumor registry. Using an in-house automated text search tool from our electronic medical record (Epic®), combined with natural language processing review, venous thromboembolism (VTE) events were identified, with secondary adjudication by the study leader (GAS). VTE was defined as either lower extremity deep vein thrombosis (DVT), or pulmonary embolism (PE) diagnosed from the day of surgery until 90 days after the first day of surgery. Logistic regression was performed on binary outcomes for the presence of VTE and TPX use at discharge. Kaplan-Meier curves and Cox regression were used for overall survival analysis. Results: 801 pts who underwent gynecologic cancer-related surgeries were identified. Patient demographics and surgery types are described in Table 1. VTE occurred in 1.9% (n=15) of the overall population but was unequally distributed. The number of VTE in those undergoing minimally invasive surgery (MIS), vulvovaginal surgery, and biopsies collectively was low (0.57%, n=3), even when considering that only 11.1% of those pts received TPX at discharge. VTE was more commonly diagnosed in patients who underwent open surgery (4.3%, n=12), with 5 pts (1.8%) diagnosed before discharge and 7 pts (2.5%) after discharge. In multivariable logistic regression analysis, during the full study period, open procedures were associated with a higher risk of thrombosis, (relative risk 7.5, p < 0.001) and higher use of post-discharge TBX (RR 4.55, p < 0.001). Notably, only 50% (139 of 279) of pts who underwent open surgery received TPX at the time of discharge. Within the open surgery cohort, the rate of post-discharge VTE correlated with the use of post-discharge TPX. Of pts on TPX, 0.7% (n=1) were diagnosed with VTE compared to 4.3% (n=6) of pts who did not receive TPX (RR=0.17, p= 0.12). There was no difference in overall survival in pts who received TPX and those who did not after open surgery up to 36 months after the surgery. Conclusions: Our findings suggest a tiered risk of post-operative VTE after gynecologic cancer surgery, with a clinically relevant risk observed only in women undergoing open surgery. Our gynecologic oncology practice already reflects this, as post-operative TPX is not routinely prescribed for lower-risk procedures. In patients who underwent open surgery, TPX at discharge showed a trend towards a protective effect, although this result did not reach statistical significance, probably due to sample size, it supports the need for a targeted prospective study. If this trend towards benefit holds in a prospective study, the number needed to treat to avoid one clinically detected post-operative VTE would be 28 pts. The relatively high fraction of post-op VTE events during the inpatient hospital stay also supports efforts for early TPX, as has been done with a prophylactic dose of pre-operative unfractionated heparin or LMWH in other high-risk cancer surgery settings (Selby et al, J Am Coll Surg. 2016). The limitations of this study include being conducted at a single institution, retrospective and non-randomized.

Multi-national observational study to assess quality of life and treatment preferences in patients with Crohn's perianal fistulas.

Patients with Crohn's disease (CD) are at risk of developing complications such as perianal fistulas. Patients with Crohn's perianal fistulas (CPF) are affected by fecal incontinence (FI), bleeding, pain, swelling, and purulent perianal discharge, and generally face a higher treatment burden than patients with CD without CPF. To gain insights into the burden of illness/quality of life in patients with CPF and their treatment preferences and satisfaction. This cross-sectional observational study was conducted in patients with CD aged 21-90 years via a web-enabled questionnaire in seven countries (April-August 2021). Patients were recruited into three cohorts: Cohort 1 included patients without perianal fistulas; cohort 2 included patients with perianal fistulas without fistula-related surgery; and cohort 3 included patients with perianal fistulas and fistula-related surgery. Validated patient-reported outcome measures were used to assess quality of life. Drivers of treatment preferences were measured using a discrete choice experiment (DCE). In total, 929 patients were recruited (cohort 1, n = 620; cohort 2, n = 174; cohort 3, n = 135). Short Inflammatory Bowel Disease Questionnaire scores were worse for patients with CPF (cohorts 2 and 3) than for those with CD without CPF (cohort 1): Mean score 3.8 and 3.7 vs 4.1, respectively, (P < 0.001). Similarly, mean Revised FI and FI Quality of Life scores were worse for patients with CPF than for those with CD without CPF. Quality of Life with Anal Fistula scores were similar in patients with CPF with or without CPF-related surgery (cohorts 2 and 3): Mean score 41 and 42, respectively. In the DCE, postoperative discomfort and fistula healing rate were the most important treatment attributes influencing treatment choice: Mean relative importance 35.7 and 24.7, respectively. The burden of illness in CD is significantly higher for patients with CPF and patients rate lower postoperative discomfort and higher healing rates as the most desirable treatment attributes.

Surgery for M1A Non-Small-Cell Lung Cancer With Additional Pulmonary Nodules in a Contralateral Lobe

IntroductionLimited consensus exists on the optimal treatment strategy for clinical M1a non-small-cell lung cancer (NSCLC) presenting as a primary tumor with additional intrapulmonary nodules in a contralateral lobe ("M1a-Contra"). This study sought to compare long-term survival of patients with M1a-Contra tumors receiving multimodal therapy with versus without thoracic surgery. MethodsOverall survival of patients with cT1-4, N0-3, M1a NSCLC with contralateral intrapulmonary nodules who received surgery as part of multimodal therapy (“Thoracic Surgery”) versus systemic therapy with or without radiation (“No Thoracic Surgery”) in the National Cancer Database from 2010 to 2015 was evaluated using Kaplan–Meier analysis, Cox proportional hazards modeling, and propensity score matching. ResultsOf the 5042 patients who satisfied study inclusion criteria, 357 (7.1%) received multimodal therapy including surgery. In multivariable-adjusted analysis, the Thoracic Surgery cohort had better overall survival than the No Thoracic Surgery cohort (HR: 0.66, 95% CI: 0.56-0.79, P < 0.001). In a propensity score-matched analysis of 386 patients, well-balanced on 12 common prognostic covariates, the Thoracic Surgery group had better 5-year overall survival than the No Thoracic Surgery group (P = 0.020). In propensity score-matched analyses stratified by clinical N status, Thoracic Surgery was associated with better overall survival than No Thoracic Surgery for patients with cN0 disease and cN1-2 disease. ConclusionsIn this national analysis, multimodal treatment including surgery was associated with better overall survival than systemic therapy with or without radiation without surgery for patients with M1a-Contra tumors. These preliminary findings highlight the importance of further evaluation of surgery in a multidisciplinary treatment setting for M1a-Contra tumors.

Robotic Vaginal Cuff Closure During Radical Hysterectomy for Early-Stage Cervical Cancer: The Bruges Method.

The only randomized trial (LACC trial, Laparoscopic Approach to Cervical Cancer), published in 2018, comparing the oncologic outcomes of minimally invasive and open surgery in early-stage cervical cancer, has shown inferior disease-free and overall survival for minimally invasive surgery. Subsequent large retrospective cohort studies of centers with long-standing experience in minimally invasive surgery and large nationwide cohort studies have shown that both the laparoscopic and robotic approaches have similar survival outcomes as the open surgery group in the LACC trial. Important protective measures to avoid tumor spillage in the peritoneal cavity during colpotomy were the closure of the vaginal cuff and avoiding the use of a uterine manipulator. Several methods have been described to close the vaginal cuff, mainly by a vaginal approach. Here we describe with a video a new technique of vaginal cuff closure during a robotic-assisted radical hysterectomy. During the robotic procedure, a purse string barbed suture is placed through the vaginal walls in order to close the vagina prior to colpotomy. The technique is a feasible, relatively fast, and easy-to-learn addition to the robotic radical hysterectomy procedure in early-stage cervical cancer.

EGS P29 Evaluating Compliance and Identifying Barriers to Timely Cholecystectomy in Gallstone Pancreatitis: A Retrospective Study

Abstract Background Gallstone pancreatitis is a common cause of acute pancreatitis. Timely cholecystectomy within two weeks of admission is recommended by the UK Pancreatitis Guidelines and NCEPOD to prevent recurrent pancreatitis and associated complications. This study aimed to evaluate compliance with these guidelines at a District General Hospital. Methods A retrospective analysis was conducted on all patients (n=92) admitted with acute pancreatitis between July 1st 2022, and January 31st 2023. Patient demographics, diagnostic methods, time to surgery, and relevant laboratory values (median amylase, median CRP) were collected and analysed. Results 35% (n=32) of patients had gallstone pancreatitis. 26 were fit for cholecystectomy. 35% (n=9) were operated on within 2 weeks. Median time to surgery was 7 days and median CRP 133. There were no readmissions within 6 months. The delayed surgery cohort (n=17) had a median time to surgery of &amp;gt;60 days, median CRP 29 and a 59% (n=10) readmission rate . 1 patient had three readmissions. Reasons for delay were: 2 pancreatic necrosis, 1 pregnancy, 1 pneumonia, 1 delirium, 2 bed pressure, and 10 no clinical reason. 5 patients are still waiting for surgery at the time of analysis &amp;gt;6months. Conclusions Prior to the COVID-19 pandemic, compliance with UK pancreatitis and NCEPOD guideline was excellent (GIRFT) at our institution. Our findings are that most patients with gallstone pancreatitis are not being operated upon within two weeks. Delays result in hospital readmissions increasing resource use. Most delays were organisational rather than clinical. Patients who were ambulated for operative management within 2 weeks rarely were operated upon within this timeframe. Trust initiatives aimed at COVID-19 recovery prioritised early discharge and repurposed emergency ‘hot lists’ to reduce elective waiting lists. Interventions to increase emergency operating capacity are most likely to improve matters.

Preoperative psychological symptoms and chronic postsurgical pain: analysis of the prospective China Surgery and Anaesthesia Cohort study

BackgroundBoth preoperative psychological symptoms and chronic postsurgical pain (CPSP) are prevalent conditions and major concerns among surgery patients, with inconclusive associations. MethodsBased on the China Surgery and Anaesthesia Cohort (CSAC), we recruited 8350 surgery patients (40–65 yr old) from two medical centres between July 2020 and March 2023. Patients with preoperative psychological symptoms (i.e. anxiety, depression, stress reaction, and poor sleep quality) were identified using corresponding well-established scales. We then examined the associations of individual preoperative psychological symptoms and major patterns of preoperative psychological symptoms (identified by k-means clustering analysis) with CPSP, and different pain trajectories within 3 months. Lastly, mediation analyses were conducted to elucidate the mediating role of surgery/anaesthesia-related factors and the presence of 1-month postoperative psychological symptoms on the studied associations. ResultsWe included 1302 (1302/8350, 15.6%) CPSP patients. When analysed separately, all studied preoperative psychological symptoms were associated with increased CPSP risk, with the most pronounced odds ratio noted for anxiety (1.52, 95% confidence interval [CI] 1.23–1.86). Compared with patients clustered in the minor symptom group, excess risk of CPSP and experiencing an increasing pain trajectory was increased among patients with preoperative psychological symptoms featured by sleep disturbances (odds ratio=1.46, 95% CI 1.25–1.70 for CPSP and 1.58, 95% CI 1.20–2.08 for increasing pain trajectory) and multiple psychological symptoms (1.84 [95% CI 1.48–2.28] and 4.34 [95% CI 3.20–5.88]). Mediation analyses revealed acute/subacute postsurgical pain and psychological symptoms existing 1 month after surgery as notable mediators of the observed associations. ConclusionsThe presence of preoperative psychological symptoms might individually or jointly increase the risk of chronic postsurgical pain or experiencing deterioration in pain trajectory. Interventions for managing acute/subacute postsurgical pain and psychological symptoms at 1 month after surgery might help reduce such risk. Clinical trial registrationChiCTR2000034039.

SURG-24. FACTORS PREDICTING REMISSION AND RECURRENCE AFTER SURGICAL TREATMENT OF ACTH SECRETING PITUITARY ADENOMAS - CUSHING’S DISEASE

Abstract Despite recent advances in management, disease persistence and recurrences are common in patients with ACTH secreting pituitary adenomas-Cushing’s disease (CD). The study aims to determine clinical, biochemical, radiological, histological factors that correlate with persistence and recurrence in patients with CD, and also aims to understand the clinico-pathological significance of EGFR-MAPK, NF-kB, SHH pathway activation. Clinical data of 167 patients who underwent surgical treatment (n = 174 surgeries) for CD was ambispectively analysed with median follow-up of 8.1years(1-13.29 years). Among the 174 surgeries performed, 140 were primary, 22 were redo, 24 were for paediatric patients and 12 surgeries were performed in Nelson syndrome. In the primary surgery cohort, 74.3% were females and the average age was 28.73years(SD = 10.15). 75% of patients experienced remission after primary surgery compared to 47.4% in redo surgery. The remission rate in paediatric patients was 55.5%. Post-operative day-1 plasma cortisol (p &amp;lt; 0.001;AUC = 0.8894[0.8087-0.9701]) and ACTH (p &amp;lt; 0.001;AUC 0.9[0.7386-1]) levels were seen to be strong independent predictors of remission in primary surgery cohort. Remission rates after endoscopic trans-sphenoidal surgery- TSS were more than those after microscopic TSS, in patients undergoing primary surgery (81.08%vs57.14%;p = 0.008). Presence of adenoma on histopathological examination(HPE) was also strong predictor of disease remission (p = 0.020). On categorising based on surgical approach and HPE, microscopically operated patients without histopathological evidence of adenoma had significantly higher odds of non-remission (OR 38.1;95%CI-4.2-348.3) compared to endoscopically operated patients with adenoma on HPE. Lower immune reactivity score (IRS) of NR4A1 was found to correlate with higher remission rates (p = 0.074). However, none of the molecular markers studied - NR4A1, c-Fos, c-Jun, GLI1, pMEK, p44 showed a significant correlation with the preoperative cortisol values. Post-operative day-1 serum cortisol and ACTH are reliable predictors of remission. Additionally, endoscopic approach and histopathological evidence of adenoma are associated with higher remission rate, with both features together raising the odds significantly.