Time Of Surgery Research Articles

The effective duration of systemic therapy and the neutrophil-to-lymphocyte ratio predict the surgical advantage of primary tumor resection in patients with de novo stage IV breast cancer: a retrospective study

BackgroundThe primary tumor resection (PTR) of de novo stage IV breast cancer (DnIV BC) is controversial, and previous studies have suggested that the neutrophil-to-lymphocyte ratio (NLR) could be a poor-prognosis factor for BC. We investigated PTR’s surgical advantage related to clinical outcomes, the surgery timing in responders to systemic therapy, and whether the NLR can predict the benefit of surgery for DnIV BC.Patients and methodsWe retrospectively analyzed the cases of the DnIV BC patients who received systemic therapies and/or underwent PTR at our institution between January 2004 and December 2022. Blood tests and NLR measurement were performed before and after each systematic therapy and/or surgery.ResultsSixty patients had undergone PTR local surgery (Surgery group); 81 patients had not undergone surgical treatment (Non-surgery group). In both groups, systemic treatment was performed as chemotherapy (95%) and/or endocrine therapy (92.5%) (p < 0.0001). The groups’ respective median progression-free survival (PFS) durations were 88 and 30.3 months (p = 0.004); their overall survival (OS) durations were 100.1 and 31.8 months (p = 0.0002). The Surgery-group responders to systemic therapy lasting > 8.1-months showed significantly longer OS (p = 0.044). The PFS and OS were significantly associated with the use of postoperative systemic therapy (p = 0.0012) and the NLR (p = 0.018). A low NLR (≤ 3) was associated with significantly better prognoses (PFS and OS; p < 0.0001).ConclusionsA longer effective duration of systemic therapy (> 8.1 months) and a low pre-surgery NLR (≤ 3.0) could predict PTR’s surgical advantage for DnIV BC. These variables may help guide decisions regarding the timing of surgery for DnIV BC.

Temporal trends in the utilization, costs, and outcomes of concomitant left atrial appendage closure across a statewide collaborative

ObjectiveWith the rising incidence of atrial fibrillation, left atrial appendage closure (LAAC) at the time of cardiac surgery remains an important adjunct. The present study characterized trends, associated resource utilization, and potential disparities in the use of left atrial appendage exclusion. MethodsUsing a Society of Thoracic Surgeons regional academic collaborative database, we queried all adult patients undergoing coronary and valve procedures with concomitant LAAC between 2015 and 2021. Trends in LAAC, as well as the technique for closure, were evaluated. Multilevel hierarchical logistic modeling was applied to delineate factors associated with LAAC, accounting for patient and operative characteristics. Generalized linear models were developed to perform risk-adjusted incremental cost analysis. ResultsOf the 8699 patients who met the study criteria, 1377 underwent left atrial appendage closure. Over the study period, the annual rate of LAAC increased from 16.7% to 30.8% (P < .001). LAAC patients were older, but less commonly insulin-dependent diabetics or on dialysis. Female sex, redo, and urgent operative status had lower risk-adjusted odds of LAAC. Although LAAC was associated with longer bypass time, there was no significant association with 30-day mortality or 30-day readmission. LAAC was associated with an incremental increase in adjusted costs by $10,602 (95% confidence interval, $4078-$17,126). ConclusionsRates of LAAC are increasing but less common among female patients, as well as those requiring urgent/emergent interventions. LAAC did not significantly impact short-term mortality. Our results suggest that LAAC may be a high-value intervention among patient populations that have the greatest potential to derive its benefits.

Satisfactory Clinical Outcomes After Latissimus Dorsi Tendon Transfer for Irreparable Posterosuperior Massive Rotator Cuff Tears: A 10- to 20-Year Follow-up

Background: Latissimus dorsi tendon transfer (LDTT) leads to good clinical outcomes and recovery of function. A previous study have evaluated the outcomes of LDTT at a minimum 10-year follow-up and found durable improvements in shoulder function and pain relief but observed that shoulders with fatty infiltration of the teres minor muscle and insufficiency of the subscapularis muscle tended to have inferior results. Purpose: To evaluate the outcomes of LDTT with a minimum follow-up of 10 years in a sizeable cohort for the treatment of irreparable posterosuperior massive rotator cuff tears (mRCTs). Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent LDTT for irreparable mRCTs between 2004 and 2013, performed by the same senior surgeon, were included in this study. All intraoperative and postoperative complications, as well as whether patients required conversion to reverse shoulder arthroplasty (RSA), were noted. At a minimum follow-up of 10 years, an independent observer collected range of motion measurements and clinical scores, including those for the Constant score, the Subjective Shoulder Value, and a visual analog scale for pain; the subacromial space was also assessed. Results: A total of 143 patients (147 shoulders) that underwent LDTT, with a minimum follow-up of 10 years, were included; of these, 24 patients (24 shoulders, 16%) were lost to follow-up, 1 patient (1 shoulder, 0.7%) died 9 years after the index procedure for reasons unrelated to shoulder surgery, and 18 patients (18 shoulders, 12%) required conversion to RSA, of which 6 underwent conversion at ≥6 years after LDTT. The remaining 101 patients (104 shoulders), including 3 patients who were scheduled to undergo RSA, were assessed at a mean time of 12.3 ± 2.2 years (range, 10-20 years) after index LDTT, comprised 52 men (53 shoulders) and 49 women (51 women) and had a mean age of 61.6 ± 8.0 years (range, 39-81 years) at the time of index surgery. Complications were noted in 14 shoulders, of which 4 required a reoperation. The Constant score improved by 34.2 ± 11.7 points, the adjusted Constant score by 43.5 ± 15.3 points, and the Subjective Shoulder Value score by 50.4 ± 16.4 points. The subacromial space decreased by 0.3 ± 2.0 mm. Conclusion: At a minimum follow-up of 10 years, LDTT for the treatment of irreparable posterosuperior mRCTs led to satisfactory clinical scores. Of the 147 shoulders that underwent LDTT, 18 (12%) required conversion to RSA.

Treatment of Pink Pulseless Hand Following Supracondylar Fractures of the Humerus in Children.

Background: Supracondylar humerus fractures (SCHF) in children are common and can lead to serious complications, including neurovascular injury. The optimal management of children with a 'pink pulseless' hand following such a fracture is unclear. This study aimed to ascertain an appropriate therapeutic approach for children with SCHF and a pink pulseless hand. Methods: A retrospective analysis of medical records from paediatric patients under 16 years old with SCHF and clinically perfused but pulseless hands between 1 January 2016 and 30 June 2021 was conducted. Clinical characteristics, imaging, treatment processes and follow-up results were analysed to predict arterial injuries requiring vascular repair and determine the optimal timing for exploratory surgery. Results: The study included 88 patients, predominantly male (58%) with an average age of 6 years. Most fractures resulted from falls onto outstretched arms. Satisfactory outcomes, indicated by the return of the pulse following closed reduction and percutaneous pinning (CRPP) alone, were seen in 66% of patients, negating the necessity for vascular exploration. Amongst patients with a persistently absent radial pulse 72 hours after CRPP, 83% were diagnosed with brachial artery injuries, with all such patients experiencing recurrent pulse loss after surgery. Conclusions: Urgent reduction and CRPP are effective initial treatments for children with SCHF and a pink pulseless hand. Immediate vascular exploration is generally not necessary in these patients. Further research is needed to determine the optimal management for persistent pulselessness and recurrent pulse loss. Level of Evidence: Level IV (Therapeutic).

The Influence of Timing of Surgery on Postoperative Length of Hospital Stay in Closed Ankle Fractures

The Influence of Timing of Surgery on Postoperative Length of Hospital Stay in Closed Ankle Fractures

BS SO14 - Is there a correlation between preoperative HbA1c changes and long-term weight loss plus glycemic control in patients with type 2 diabetes undergoing metabolic surgery?

Abstract Background Optimization of patients with type 2 diabetes mellitus (T2DM) prior to metabolic surgery aims to achieve tight glycemic control by the time of surgery. Little is known about the influence of altering preoperative HbA1c on postoperative weight loss and glycemic control. The aim of this study was to determine whether a change in HbA1c during the preoperative period correlated with long term weight maintenance and HbA1c in patients undergoing metabolic surgery. The proportion of glucose-lowering medication used following surgery was also examined. Method Retrospective analysis was conducted of patients with T2DM who underwent metabolic surgery between 2013 – 2017. Preoperative HbA1c change was measured as change in glycemic control during the 1-year pre-surgery. Primary outcomes were % excess weight loss (EWL) and HbA1c at 5 years post-surgery. Secondary outcomes were % EWL and HbA1c at 1-year post-surgery and the use of glucose-lowering medications post-surgery. The Pearson correlation coefficient (r) was used to determine the relationship between the pre-surgery HbA1c change and postoperative % EWL and HbA1c. Chi-squared test was used to calculate the statistical impact of change in medication use post-surgery Results Sixty-nine patients with complete data were included in the study. The mean change in HbA1c in the 1-year pre-surgery, the 1-year post-surgery and 5-years post-surgery was -0.9% (± 1.5), -0.7% (± 1.2) and 0% (± 1.8), respectively. The change in HbA1c in the 1-year pre-surgery did not correlate with % EWL at 1-year and 5-years post-surgery or with HbA1c at 1-year and 5-years post-surgery. There was a significant decrease in the proportion of patients requiring glucose-lowering medications at 1-year and 5 years post-surgery (p&amp;lt;0.05). Conclusion This study demonstrated a significant reduction in the proportion of glucose-lowering medication required long-term following metabolic surgery. Altering pre-operative glycemic control was not associated with long term weight maintenance or glycemic control.

Dorsolateral Transdural Surgical Management of Spontaneous Intracranial Hypotension From Ventral Dural Cerebrospinal Fluid Leaks: Case Series and Technical Report

BACKGROUND and OBJECTIVES: Spontaneous intracranial hypotension is an uncommon but debilitating condition that commonly involves positional headaches and vertigo. One cause is cerebrospinal fluid (CSF) leakage from ventral dural defects from calcified spinal discs. Patients can undergo epidural blood or fibrin glue patches as treatment; however, in cases where the leak does not resolve, surgical repair of the dural tear may be warranted. We aim to describe a case series and technical notes for these patients. METHODS: Patients with spontaneous intracranial hypotension because of myelography-confirmed ventral dural defect from calcified thoracic disc, who were treated surgically between June 2020 and March 2024, were included in the study cohort. Demographic information, clinical course, and postoperative outcomes were collected. The surgical technique was also described based on an illustrative case. RESULTS: Twelve consecutive patients underwent surgery between June 2020 and March 2024 with postoperative records. The median age at the time of surgery was 41.5 years (range: 28-58 years). Male patients comprised 50% of the cohort. Dural defects were spread throughout the thoracic spine in the cohort. While all patients reported positional headaches, other symptoms included vertigo, pulsatile tinnitus, and neck pain. Median length of follow-up time was 6.5 weeks. There were no surgical complications or permanent neurologic deficits. All patients had radiologic cure of their leaks with absence of extradural CSF on postoperative MR imaging. Ten patients (83.3%) had complete resolution of spontaneous intracranial hypotension-related symptoms. Two patients did suffer from rebound headaches postoperatively. CONCLUSION: The dorsolateral transdural surgical approach is a safe and effective method to repair type 1 CSF leaks caused by ventral dural defects. Our case series of 12 patients did not involve any surgical or immediate postoperative complications, and all patients had radiologic resolution of their leaks with relief of positional headaches. Two patients experienced continued headaches after treatment.

A02 - BS Ethnic and Social Deprivation Influence Weight Regain Following Roux En-Y Gastric Bypass

Abstract Background Weight regain is a prevalent issue following Roux-En-Y Gastric Bypass (RYGB) surgery for obesity. This study aims to assess the impact of ethnicity and social deprivation on the likelihood of weight regain post-RYGB. Method We analysed data from Luton &amp; Dunstable Hospital. Key variables included patient demographics such as sex, age, ethnicity, social deprivation (Indices of Multiple Deprivation – IMD), American Society of Anesthesiologists (ASA) classification, and weight and Body Mass Index (BMI) at the time of surgery. Weight regain was defined as the regaining of more than 25% of the Total Body Weight Loss (TBWL) achieved after RYGB. Results Out of 1,346 patients who underwent RYGB, 80% were female. The median age was 48 years (IQR: 39-55), and the median BMI was 44.7 kg/m^2 (IQR: 40.6-50.1). At a median follow-up of 39 months, 20.7% experienced weight regain. Multivariable analysis showed that patients from Black (HR: 1.63, 95% CI: 1.33-1.81, p=0.009) and Asian (HR: 1.40, 95% CI: 1.23-1.71, p=0.011) ethnic groups, as well as those from more socially deprived backgrounds (HR: 2.39, 95% CI: 1.99 – 3.13, p&amp;lt;0.001), were more likely to experience weight regain compared to their White and more affluent counterparts. Conclusion Ethnicity and social deprivation significantly influence the likelihood of weight regain following RYGB. The factors contributing to these disparities are likely multifaceted, encompassing genetic, social, and educational elements. Early identification of patients at increased risk of weight regain and the provision of tailored resources can help mitigate this risk and enhance surgical outcomes.

HPB SO20 - Evaluating the Impact of Enhanced Recovery After Surgery Protocols Post Hepatectomy in Patients with Chronic Liver Disease: A Meta-Analysis

Abstract Background Defined criteria for the resectability of liver disease continue to be refined. In the era of enhanced recovery after surgery (ERAS), data regarding its safety and efficacy in specific patient populations is required. Patients with liver cirrhosis are particularly vulnerable, owing to both operative and peri-operative risk. However, the application of ERAS in cirrhotic patients undergoing hepatectomy is absent from the most recent ERAS Society Group recommendations from 2022. We present a meta-analysis assessing outcomes after liver resection in patients with cirrhosis following an ERAS protocol compared to standard post-operative care. Method A systematic literature search was performed using PubMed, Embase and Web of Science. Studies were included if comparing ERAS protocols versus standard post-operative care in patients undergoing liver resection in which more than 50% of the patient population had cirrhosis at time of surgery. The primary outcome analysed was overall complication rates with secondary outcomes of post-operative mortality, estimated blood loss, operation time, post-operative incidence of liver failure, readmission and reoperation rates. Statistical analysis was performed using Review Manager by the Cochrane Collaboration. Results 930 records were screened for eligibility. Five articles were eligible for inclusion(ERAS n = 425 vs control group n = 423 patients). Cirrhotic patients enrolled in an ERAS program post-hepatectomy had a significantly reduced risk of overall complications (OR 0.45, 95% CI 0.33, 0.61, p&amp;lt;0.00001) and a shorter hospital stay when compared to standard post-operative care by 1.8 days (mean difference -1.83, 95% CI -2.22, -1.45, p&amp;lt;0.00001). No significant differences were noted in post-operative mortality, estimated blood loss, operation time, post-operative incidence of liver failure, readmission or reoperation rates between the ERAS group and control. Conclusion Application of an ERAS protocol for patients undergoing liver resection is safe and feasible in cirrhotic patients. ERAS protocols were successful in significantly reducing overall complication rates and length of inpatient hospital stay, and did not negatively impact secondary post-operative outcomes or mortality. ERAS protocols should be reflected in future guidelines, specifically for cirrhotic patients undergoing hepatectomy, and additional research on the utility of ERAS in higher risk patients is encouraged.

HPB SO19 - Comparison of perioperative outcomes of open (CUSA) versus laparoscopic (LOTUS) major hepatectomy – revisited. First evaluation of efficacy and safety of AEONTM stapler

Abstract Background In 2019, preliminary data matching 40 cases demonstrated improved outcomes of laparoscopic major liver resections using the BOWA-LOTUSTM liver blade (Devon, UK). An updated and expanded comparison between open and laparoscopic major hepatectomies is presented as well as evaluating of an endovascular stapler AEON™ (Lexington Medical, Massachusetts, USA). Method January 2020 to June 2023 patients were identified from a prospectively maintained database. Propensity score matching analysis used R statistical tool in SPSS (IBM, New York, USA) to isolate matched open and laparoscopic cases. LOTUSTM ultrasonic energy device was used for parenchymal transection in laparoscopic cases and CUSA (Valleylab, Colorado, USA) in open procedures. AEONTM endovascular stapler was used from early 2021. Results 86 patients constitute the study population after applying propensity score matching analysis in a 1:1 ratio. The median (range) age in the matched sample was 63 (27-83) yrs. Hospital stay (mean 7.8 v 14.7 days; p=0.025) and blood transfusion requirement (0 v 4 units; p=0.035) were all significantly improved when comparing laparoscopic to open. Comparison of the AEONTM stapler with Endo-GIA (Medtronic, MN, USA) showed no significant difference in any outcome measure, although AEONTM demonstrated (non-significantly) a reduced trend in operating time comparing all cases (56 v 69 mins; p=0.300) and laparoscopic (56 v 71 min; p=0.295). Conclusion The LOTUS liver blade continues to be associated with acceptable outcomes in laparoscopic liver resections. The AEONTM endovascular stapler was equivalent to other staplers with a trend towards a shorter operating time in liver transectional surgery.

Factors influencing operative time for mini-endoscopic combined intrarenal surgery for renal stones

Mini-endoscopic combined intrarenal surgery (ECIRS) offers improved advantages in the treatment of renal stones. However, the factors influencing the operative time remain poorly understood. This study aimed to identify the factors that enhance treatment planning and minimize complications. Clinical data from consecutive patients who underwent mini-ECIRS for renal stones and achieved a stone-free status between 2015 and 2021 at three high-volume centers in Japan were analyzed. The final treatment outcome was evaluated by computed tomography imaging at postoperative 1 month, and a successful outcome was defined as complete stone-free or residual stone fragments < 4 mm. Logistic and linear regression models were used to predict the operative duration of mini-ECIRS. An operative time of ≥ 120 min was significantly associated with punctured pole and body mass index (BMI), and septic shock was only observed in patients with operative times of ≥ 120 min. The multivariate model for the operative time for mini-ECIRS identified five clinical factors: punctured pole, number of stones, number of involved calyces, BMI, and preoperative nephrostomy. We believe these findings will help surgeons and patients plan suitable treatment strategies, predict the additional need for a second mini-ECIRS or retrograde intrarenal surgery alone, and avoid severe complications.

HPB SO53 - Implementation of High Volume-Low Complexity 'GIRFT' lists for laparoscopic cholecystectomy

Abstract Background Waiting times for elective surgery have risen steadily since 2010, with particularly sharp increases after the Covid pandemic. There have been several initiatives to improve theatre productivity and increase operative numbers and these are broadly encompassed within GIRFT standards and the development of the concept of a High Volume-Low Complexity list. Current GIRFT standards recommend six laparoscopic cholecystectomies on an all-day operating list. This study aimed to describe the development and implementation of these lists within out district general hospital setting and outline the key barriers and solutions for other units to learn from. Method All patients on the waiting list for laparoscopic cholecystectomy were assessed and screened by a panel of consultant surgeons to assess suitability for a HVLC list. Theatre staff, anaesthetists and surgeons were widely consulted within local focus groups and a novel method of remuneration for additional work was developed: a 'cost-per-case (CPC)' remuneration structure was introduced (in contrast to standard remuneration by session time) to ensure productivity and high quality surgery. Operations were carried out on weekend lists in a dedicated accredited Elective Surgical Hub and staff were able to finish the day when all operations were completed. Results CPC lists took place from August 2023 to May 2024. All lists had six laparoscopic cholecystectomies or eight hernia repairs (or a combination) in line with GIRFT standards. Overall 124 cholecystectomies were performed and 119 were completed on a day case basis. The remaining 5 patients had a single night stay. There were no returns-to-theatre or major morbidity. All lists had started by 830AM and the latest finish time throughout the study period was 1525PM. The utilisation of CPC lists contributed to waiting times falling dramatically from over 52 weeks to 28 weeks by the end of the study period. Conclusion By utilising a novel form of remuneration, based on volume of work completed rather than time, we were able to maximise productivity without compromising safety whilst developing employment conditions that encouraged colleagues to perform additional work. Key facets to successful implementation include appropriate screening of cases, allowing staff to leave when the work is completed (rather than have to wait till the end of the day) and standardising equipment and kit to reduce wastage and turnaround time between cases. These lessons can be implemented in any surgical unit to improve productivity and increase volume of cases performed.

BN SO23 - From referral to resolution, impact of acute biliary pathway on patients care

Abstract Background At our trust, we introduced acute biliary pathway to efficiently manage patients presenting with acute biliary pathology. This pathway begins with a referral form containing relevant patient information for triage. A triage team reviews these forms and classifies patients into three categories based on specific criteria. Method Patients are triaged into three categories:Red: Patients needing emergency surgery during the same admission.Amber: Patients requiring urgent but non-emergency care, scheduled for an outpatient (OP) appointment for consent, followed by a laparoscopic cholecystectomy within 2-3 weeks or 6-8 weeks, based on the pathology.Green: Patients who do not meet the criteria for red or amber are referred for further outpatient assessment before definitive management. Results Over four months , 202 referrals were received. Approximately 50% (102 patients) were referred to the outpatient department. Of the remainder, 45% were categorised as red and had IP cholecystectomy, with a mean length of stay of 1.5 days post-surgery across 30 operations. The remaining patients were managed as amber, resulting in 22 operations. The total complication rate was low, with only 2 cases managed conservatively, and 4 patients required re-admission before definitive treatment. The average wait time for a clinic appointment was 2 weeks, while the average wait time for surgery was 8 weeks, with a total of 6 cancellations. Conclusion The acute biliary pathway demonstrates effectiveness through a low complication rate and timely management of patients. This approach improves the efficiency of patient care and reduces the need for emergency re-admissions. More importantly, this model is straightforward enough to be implemented in any high-volume centre with a sufficient level of expertise in treating biliary patients.

Accuracy of adult height predictions in patients with axial leg deviations using the Modified and the Abbreviated Modified Fels Knee System.

The accurate estimation of residual growth is crucial for the appropriate timing of growth-guiding surgery in patients with axial leg deviations. Skeletal age methods such as the Modified and the Abbreviated Modified Fels Knee System were developed on historical patient cohorts and the applicability to the modern pediatric population with axial leg deviation has not yet been evaluated. Are both final adult height prediction methods (the Modified Fels Knee System (FKS) and the Abbreviated Modified Fels Knee System (aFKS)) accurate to determine SA and the final adult height on long leg radiographs in patients with axial leg deviations?Which multiplier table shows highest association between predicted and true final adult body height?Do FKS- and aFKS- skeletal age determination methods improve final adult body height prediction accuracy compared to the simple use of chronological age? A single center, retrospective study of 31 patients who underwent temporary hemiepiphysiodesis due to axial leg deviations in the frontal plane between 2018 and 2020 was conducted. Skeletal age at the time of surgery was determined on an anterior-posterior long leg X-ray using FKS and aFKS. Adult height predictions were calculated using three different multiplier tables (Paley et al., Sanders-Greulich and Pyle (SGP), Sanders-Peak Height Velocity (PHV)). The accuracy of adult height prediction was determined by comparing the mean differences and mean absolute differences between predicted and true adult height. All adult height predictions overestimated the true adult height. The final height prediction using aFKS and the SGP multiplier showed the lowest overestimation (mean 3.2 cm, SD 5.5 cm). The PHV multiplier table showed the highest correlation between predicted and true adult height (FHPRE_FKS_PHV: r = 0.913, p < 0.001 and FHPRE_aFKS_PHV: r = 0.862, p < 0.001). The simple use of chronological age at the time of surgical intervention (CASI) with the Paley multiplier table showed the highest median delta absolute values and lowest correlations with true adult height (median 7.4 cm, 25%-75% percentile: 3.5-10.0 cm, r = 0.838, p < 0.001). Nevertheless, no significant differences in delta absolute values between various adult height predictions methods could be shown. Overall, the results of the present retrospective cohort study show that there was no significant improvement in final height prediction accuracy when using the FKS or the aFKS method compared to the simple use of chronological age. One reason could be that patients with varus/valgus malalignment have specific growth characteristics that are not accounted for in multiplier tables or the FKS and aFKS method. Since there is no significant difference in prediction accuracy between the methods, the choice of method may depend on other factors, such as clinical preference or availability of resources. However, due to the small sample size, the study cannot definitively rule out potential differences between the prediction methods, and larger studies are required to validate these findings.

Abstract 4115801: Assessing Prevalence of Cardiac Amyloidosis at the Time of Spinal Laminectomy for Spinal Stenosis

Introduction: Cardiac amyloidosis (CA) involves deposition of amyloid fibrils within cardiac myocardium, resulting in heart failure. Recent studies have shown an association between amyloid deposition in the ligamentum flavum (LF) and development of CA. Our study aims to investigate the prevalence of CA in patients identified with amyloid deposition in their LF at the time of spinal laminectomy for spinal stenosis, employing a comprehensive approach integrating multi-modality imaging and laboratory testing. Methods: This is a retrospective study of patients age &gt;50 years old who underwent spinal laminectomy for non-congenital spinal stenosis or spondyloarthropathy. LF tissue samples obtained during surgery were examined histologically for amyloid deposition. Patients with positive findings underwent testing, including serum markers, echocardiography, and 99mtechnetium pyrophosphate (99mTcPYP) scintigraphy. Additionally, cardiac magnetic resonance imaging (cMRI) was obtained when clinically appropriate to assess for CA. Results: Among the 197 enrolled patients, 39 (19.3%) exhibited amyloid deposition in LF tissue. Patient demographics and clinical characteristics did not significantly differ between the positive and negative groups (Table 1). Of the 39 amyloid positive specimens, subtyping using mass spectrometry identified 1 (3%) light-chain, 28 (72%) transthyretin (TTR), and 10 (25%) were unable to be subtyped. Of the 28 TTR positive patients, 8 were of the wild type genotype. Furthermore, 18 of the 28 TTR patients underwent 99mTcPYP scintigraphy, of which none had cardiac uptake consistent with TTR amyloidosis; the other 10 declined work up. Of the 10 untyped patients, 6 had 99mTcPYP scintigraphy with none of the patients having cardiac uptake. Adjunctive cMRI in select positive patients showed findings inconsistent with amyloid deposition. Serum NT-proBNP, Troponin T, and serum pre-albumin levels were similar between groups. Conclusion: Amyloid deposition in LF tissue did not correlate with cardiac manifestations of amyloidosis at the time of surgery. Longitudinal investigation is ongoing to better understand the relationship between amyloid deposition in LF tissue and the development of CA over time.

Abstract 4138282: Effect of cardiopulmonary exercise testing parameters and global longitudinal strain on survival after surgery for severe primary mitral regurgitation

Background: Optimum timing of surgery for severe primary mitral regurgitation (MR) particularly in the absence of significant symptoms or echo evidence of LV impairment remains unclear. Other modalities of assessment include cardiopulmonary exercise testing (CPET) and novel echo measurements, such as LV global longitudinal strain (LVGLS). We sought to evaluate whether pre-op CPET or LVGLS are associated with survival after surgery. Methods: We identified consecutive patients who had surgery for severe primary MR between 2007 and 2017 and had pre-op CPET. Clinical and mortality data were collected from chart review and our institutional database. LVGLS was retrospectively collected by a single person blinded to patient outcomes. Primary outcome was post surgery all cause death, and we used univariable analysis to identify variables associated with all cause death. Results: We included 176 patients with median age 63 (IQR 51, 71) years, 63 patients (35.8%) were female and 31 patients (14.8%) had a history of atrial fibrillation. 165 patients (93.8%) had mitral repair, 18 (10.2%) had concomitant CABG, 22 (12.5%) had concomitant ablation procedure and 14 (8.0%) had concomitant tricuspid procedure. 114 patients (64.8%) were in NYHA Class I and 56 (31.8%) were in NYHA Class II. There was no operative mortality. Median % predicted peak VO2 (ppVO2) was 89 (74, 101), median ventilatory equivalent of carbon dioxide (VE/VCO2) was 28.0 (25.7, 31.0) l/min/l/min and median respiratory exchange ratio was 1.2 (1.1, 1.2). 73 patients (41.5%) had abnormal CPET (defined as ppVO2&lt;85%). Median LVEF was 65 (60, 68) %, median LVESD was 35 (32, 38) mm and median LVGLS was 18.5 (16.6, 20.3) %. 45 patients (25.9%) had abnormal LVEF (defined as ≤ 60%), 11 patients (6.7%) had abnormal LVESD (defined as ≥45mm) and 35 patients (20.8%) had abnormal LVGLS (defined as &lt;16%). At a median follow up of 10.2 (6.8, 13.2) years, there were 19 (10.8%) deaths. In the univariate analysis, age at surgery (HR 1.12, p&lt;0.001), LVESD (HR 1.11, p=0.009), LVGLS (HR 1.11, p=0.013) and VE/VCO2 (HR 1.08, p=0.044) were associated with all cause mortality. Conclusion: A significant proportion of patients with no or mild symptoms exhibit echocardiographic evidence of LV impairment when having surgery for severe primary MR. CPET parameters such as VE/VCO2 and novel echocardiographic measurements such as LVGLS may predict risk of long term mortality and potentially inform timing of surgery in these patients.

Abstract 4141445: Long-Term Predictive Value of 4D Flow MRI in Bicuspid Aortic Valve Patients: A 10-Year Assessment for Aortic Surgery Risk

Introduction: Bicuspid aortic valve (BAV) is associated with progressive ascending aorta (AAo) dilation, often leading to aneurysms, dissections, and ruptures. Thus, current guidelines recommend preventive surgery for AAo dilation. Recent 4D flow MRI studies show that BAV morphology causes abnormal transvalvular flow patterns, increasing wall shear stress (WSS), a trigger of aortic growth. Further studies have delineated areas of abnormally high WSS by comparing to estimates of matched controls, and show promise in detecting risk for aortic growth. However, since the long-term prognostic significance of this marker is unclear, we aimed to quantify WSS in BAV patients to assess its value in predicting the need for aortic surgery up to 10 years post-4D flow MRI acquisition. Methods: BAV patients without prior surgical intervention scanned before April 1, 2014 were identified. Using medical records, patients were categorized as ‘operated’ if they underwent aortic surgery post-scan and ‘non-operated’ if they were surgery-free for at least 10 years post-scan. 4D flow MRIs were processed with an AI pipeline, including 3D segmentation of the aorta, followed by peak velocity (PV) and WSS quantification in the AAo (Fig. 1A-C). Patient-specific WSS heatmaps were computed relative to a map based on the WSS of 10 or more sex and age-matched controls. Relative areas of elevated WSS in the AAo were then calculated (Fig. 1D-F). Results: 115 patients were included, with 73 non-operated (age: 42.5±11.5y, 49M) and 42 operated patients (age: 53.5±12.1y, 34M). The mean baseline mid-AAo diameters for non-operated and operated patients were 3.8±0.6 cm and 4.1±0.5 cm, respectively. Among operated patients, the mean scan to surgery time was 5.7±3.3y. All three 4D flow metrics were significantly higher in operated compared to non-operated patients: PV: 2.6±0.6 vs. 1.7±0.4 m/s (p&lt;0.01); WSS: 2.2±0.5 vs. 1.6±0.4 Pa (p&lt;0.01); relative area of high WSS on heatmaps: 31±12 vs. 15±13% (p&lt;0.01). Conclusions: 4D flow MRI parameters provide long-term predictive value in BAV patients, as elevated peak velocity, wall shear stress, and relative area of high wall shear stress on heatmaps are associated with subsequent aortic surgery within 10 years post-scan.

Long Term Outcomes in Patients With Differences in Sex Development in Lucknow, India.

The long term outcomes for individuals with a difference in sex development (DSD) are influenced by ethnic, socio-cultural and economic factors, besides the medical issues. Data from India on these aspects are sparse. We report on gender identity, patients' opinion regarding timing of genitalia surgery, suicidal thoughts, romantic inclination, and quality of life (QOL, SF36 scale), in 31 young adults with a DSD. Median (IQR) age was 23 (19-27) years; 16 raised male, 15 female. Age at first surgery was 6.0 (2.0-16.25) years. Gender identity in 30 patients remained identical with sex of rearing. Majority (27) thought the timing of genital surgery should be in childhood. Six of 31 patients had attempted suicide at least once. Four patients reported sexual abuse in the past. Twelve patients reported romantic relationships, rates similar to reports from India, with seven reporting sexual intercourse. Eleven of 31 patients reported aversion to and fear of sexual activity, due to fear of rejection. Heterosexual orientation was reported by 25 of 29 patients. QOL scores were not different between patients and 46 healthy controls or 43 people with type 1 diabetes. Mental QOL scores were lower for those with history of teasing (37.10 ± 16.01 vs. 47.76 ± 9.4 in those without, p = 0.04) and with suicidal thoughts (33.9 ± 14.51 vs. 45.65 ± 13.2 for those without, p = 0.04). The absence of prominent gender dysphoria in our young adults was noteworthy, as was their preference for early genital surgery. Lack of adequate mental health support is a high alert for our teams involved in the care of DSD and as well as for policy-makers.

CTNI-62. EVALUATION OF SAFER-SEQS CTDNA ASSAY OPTIMIZED FOR DETECTING LOW CTDNA COUNTS FROM CSF AND PLASMA: ASSESSING SENSITIVITY AND FEASIBILITY FOR CLINICAL IMPLEMENTATION

Abstract BACKGROUND Gliomas with BRAF alterations are often difficult to treat in the recurrent setting due to emergent resistance to FDA-approved targeted therapies. Additionally, it is difficult to assess response to therapy given the limitations of radiographic techniques and the infeasibility of serial tissue sampling. This protocol will serve as a prototype for determining the feasibility of using CSF and plasma circulating tumor DNA (ctDNA) as biomarkers for response to a novel-BRAF inhibitor, plixorafenib. Plixorafenib is a small-molecule selective inhibitor of Class 1 and 2 BRAF mutations that does not induce paradoxical reactivation of MAPK signaling. METHODS This clinical trial is designed as a single institution, signal-finding study to demonstrate the feasibility and sensitivity of detecting ctDNA at baseline and after one month of treatment with plixorafenib (primary endpoint). In addition, we will evaluate the correlation of ctDNA with disease status over time and response rate to plixorafenib. Patients aged 18 years or older with measurable recurrent BRAF-V600 mutant glioma (by RANO 2.0), who have received prior BRAF and/or MEK inhibitor therapy will be screened and consented for the study prior to surgery. Leptomeningeal disease allowed. A total of 12 evaluable patients will be enrolled. Patients will undergo clinically-indicated resection or biopsy for confirmation of disease progression and characterization of putative resistance alterations. All patients will have a ventricular reservoir placed at time of surgery with CSF and plasma sampling. Patients will initiate the study drug (oral plixorafenib 900mg daily with cobicistat 150mg daily) when clinically recovered from surgery. Patients will take the drug continuously for 28-day cycles. MRI, CSF, and plasma assessments will occur approximately every two months to evaluate disease status. Enrollment is planned to begin November, 2024.

NIMG-39. THE “RESECTABILITY INDEX” AS A NOVEL OBJECTIVE PREDICTOR OF SURVIVAL FOR PATIENTS WITH ADULT-TYPE DIFFUSE GLIOMAS

Abstract Extent of resection (EOR) is a strong prognostic factor for patients with adult-type diffuse gliomas. Whole brain tractography (WBT) allows visualization of tumors in relation to functional subcortical white matter tracts connecting eloquent cortex. We developed a preoperative metric, the resectability index (RI), to estimate tumor resectability based on pre-resection volume (PRV) and unresectable tumor volume (UTV). We explore if RI predicts progression-free survival (PFS) and overall survival (OS). We retrospectively reviewed the charts of consecutive patients with adult-type diffuse gliomas resected from 2013-2020. Only patients with pre-operative DTI MRIs were included. UTV was the total overlapping volume of tumor with functionally significant tracts (corticospinal, arcuate, optic, fornix) and deep structures (basal ganglia, thalamus, brainstem). RI was (PRV-UTV)/PRV. Seventy-nine patients were included with an average age of 56 years at time of surgery. Glioblastoma was the most common histology (68%). Tumors were located in the left hemisphere (LH) (48%), right hemisphere (RH) (39%), and bilateral hemispheres or midline (BHM) (13%). EOR for LH, RH, and BHM tumors was 0.8, 0.91, and 0.29, respectively (P = 0.1^7). RI for LH, RH, and BHM tumors was 0.86, 0.912, and 0.44, respectively (P = 0.00021). Cox regression was used to model PFS and OS based on age, preoperative KPS, WHO grade, EOR, and RI. Age, recurrent status, bilaterality, residual tumor volume (RTV) and UTV predicted PFS (CI = 1.01 – 1.06, P = 0.002). For OS, UTV and RI were more strongly predictive than RTV or EOR. In a Cox regression model consisting only of preoperative variables, RI was independently predictive of OS. RI is a novel metric with potential efficacy for preoperative survival prognostication in patients with diffuse gliomas. RI may enable neurosurgeons to provide HGG patients with more accurate information about expected benefits of surgical intervention than is currently possible. RI will also enable more valid comparisons of HGG patient cohorts treated at different institutions.