742 INITIAL RESULTS OF THE ‘TUBELESS’ OESOPHAGUECTOMY: LESS IS MORE

Abstract Oesophageal cancer surgery is a complex procedure with high morbidity and mortality rate. High volume centres, complete multidisciplinary support and clear clinical guidelines are required to obtain adequate results. One of the objectives of multimodal rehabilitation programs in this field is to reduce surgical aggression. Initial experience with the tubeless oesophagectomy technique is described. Methods Description of the technique and perioperative management of tubeless oesophagectomy. We performed a 3-stage esophagectomy with a minimally invasive approach, without NGT placement or any type of drainage. The procedure includes the so-called phantom jejunostomy, which require of fixing the first jejunal loop to the parietal peritoneum in order to position a percutaneous catheter if necessary. All patients were extubated at the end of the surgery, remaining in the ICU with high-flow glasses for the first 24–48 hours. Also in the first 2 days, the urinary catheter and the epidural catheter were removed, sitting and fluid tolerance began. Results Beteween June–November 2020 6 patients were operated on. Median age was 60 years (range: 52–70), 83.3% were squamous cell carcinoma located in the middle oesophagus, 4 patients received neoadjuvant CROSS treatment. No intraoperative complications reported and a median stay of 7 days (range: 6–28). There was no anastomotic leak, nor need to place a jejunostomy, nor need to place a nasogastric tube and neither reoperation. A thoracic tube was necessary for chylothorax and another for pneumothorax (in a patient with acute respiratory distress). There was no mortality at 30 and 90 days after the procedure. Conclusion Tubeless oesophagectomy is a feasible concept that can improve postoperative recovery in selected cases, reducing pain associated with drains and tubes, facilitating early mobilization and correct performance of respiratory physiotherapy exercises. Improving functional recovery and quality of life during the postoperative period. Studies with a greater number of cases and well designed are necessary to strongly evaluate this type of procedure.

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Esophageal resection in Austria—preparing a national registry

European Surgery ◽

10.1007/s10353-021-00734-8 ◽

2021 ◽

Author(s):

Matthias Paireder ◽

Reza Asari ◽

Wolfgang Radlspöck ◽

Anna Fabbri ◽

Andreas Tschoner ◽

...

Keyword(s):

Improve Patient Safety ◽

High Volume ◽

Esophageal Resection ◽

National Registry ◽

Outcome Data ◽

Esophageal Surgery ◽

High Morbidity ◽

Term Outcome ◽

Long Term Outcome ◽

Invasive Approach

Summary Background Esophageal resection is a technically challenging procedure. Despite improvements in perioperative management and outcome, it is still associated with considerably high morbidity and mortality rates even if performed in high-volume centers. This study aimed to shed light on the results of routine patient care in three representative referral centers concerning caseload and surgical and oncological outcomes. Methods This study is a retrospective, multicenter, national-wide analysis of a newly established database including perioperative and long-term outcome data from three referral centers in Austria. Results In a 6-year study period (2013–2018), 411 patients were eligible for analysis. The indication for esophageal resection was esophageal adenocarcinoma in 299 (72.7%) patients and esophageal squamous cell carcinoma in 90 (21.9%) patients. The abdominothoracic approach (70.1%) was the most common operation, followed by transhiatal extended gastrectomy (14.8%) and a thoracic-abdominal-cervical approach (8.5%). Most patients (77.9%) underwent neoadjuvant therapy (chemotherapy 45.3%, radiochemotherapy in 32.6%). A minimally invasive approach was chosen in 25.3%. Major complications and mortality were seen in 21.7% and 2.9%, respectively. The 1‑year survival rate was 84%, 3‑year survival 60%, and 5‑year survival was 52%. The pooled overall median survival was 110 months (95% CI 33.97–186.03). Conclusion This first publication of the Austrian Society of Esophageal Surgery shows that the outcome of esophageal surgery for cancer in Austria compares well with that of renowned international centers. However, a more comprehensive approach including as many national centers as possible will improve outcome research, offer quality management, and improve patient safety. The study group invites all Austrian institutions performing esophagectomy to participate in the initiative.

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When less is more: a daring conservative approach to postpneumonectomy oesophago-pleural fistula

Interactive CardioVascular and Thoracic Surgery ◽

10.1093/icvts/ivz240 ◽

2019 ◽

Vol 30 (1) ◽

pp. 146-148

Author(s):

Lara Girelli ◽

Elena Prisciandaro ◽

Niccolò Filippi ◽

Lorenzo Spaggiari

Keyword(s):

Clinical Presentation ◽

Clinical Status ◽

High Morbidity ◽

Conservative Approach ◽

Chronic Fistula ◽

Less Is More ◽

Primary Surgery ◽

History Of ◽

Uncommon Complication

Abstract Oesophago-pleural fistula is an uncommon complication after pneumonectomy, usually related to high morbidity and mortality. Due to its rarity and heterogeneous clinical presentation, its diagnosis and management are challenging issues. Here, we report the case of a patient with a history of pneumonectomy for a tracheal tumour, who developed an asymptomatic oesophago-pleural fistula 7 years after primary surgery. In consideration of the patient’s good clinical status and after verifying the preservation of respiratory and digestive functions, a bold conservative approach was adopted. Five-year follow-up computed tomography did not disclose any sign of recurrence of disease and showed a stable, chronic fistula.

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Outcomes of nonagenarians with acute coronary syndrome

European Heart Journal ◽

10.1093/ehjci/ehaa946.3232 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J Echarte Morales ◽

P.L Cepas Guillen ◽

G Caldentey ◽

E Martinez Gomez ◽

J Borrego-Rodriguez ◽

...

Keyword(s):

Myocardial Infarction ◽

High Risk Population ◽

High Morbidity ◽

Baseline Characteristic ◽

Invasive Approach ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment ◽

All Cause Mortality

Abstract Background Myocardial infarction (MI) in nonagenarians is associated with high morbidity and mortality. Nonetheless, this population has typically been underrepresented in cardiovascular clinical trials. Objective The aim of this study was to evaluate outcomes of nonagenarian patients presenting with MI who underwent either conservative or invasive management. Methods We retrospectively included all consecutive patients equal to or older than 90yo admitted with non-ST segment elevation (NSTEMI) or ST segment elevation MI (STEMI) in four tertiary care centers between 2005 and 2018. Patients with type 2 myocardial infarction were excluded. We collected patients' baseline characteristic and procedural data. In-hospital and at 1-year follow-up all-cause mortality and major adverse cardiovascular events were assessed. Results 523 patients (mean age 92.6±2 years; 60% females) were analyzed. Overall, 184 patients (35.2%) underwent percutaneous coronary intervention (PCI), increasing over the years, mostly in STEMI group (from 16% of patients in 2005 to 75% in 2018). PCI was preferred in those subjects with less prevalence of disability for activities of daily living (p<0.01). The use of a radial access (76.6%) and bare metal stents (52.7%) was predominant. No significant differences were found in the incidence of major bleeding events or MI-related mechanical complications between both strategies. During index hospitalization, 99 (18.9%) patients died. Whereas no differences were found in the NSTEMI group (p=0.61), a significant lower in-hospital mortality was observed in STEMI group treated with PCI (p<0.01). At one-year follow up, 203 (38.8%) patients died, most of them due to a cardiovascular cause (60.6%). PCI was related to a lower all-cause mortality in either NSTEMI (p<0.01) or STEMI groups (p<0.01) however, lower cardiovascular mortality was only found in STEMI group (p=0.03). Conclusion An invasive approach was performed in over a third of nonagenarian patients, carrying prognostic implications and with a few numbers of complications. PCI seems to be the preferred strategy for STEMI in this high-risk population in spite of age. Figure 1 Funding Acknowledgement Type of funding source: None

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Robotic Central Hepatectomy for the Treatment of Gallbladder Carcinoma. Outcomes of Minimally Invasive Approach

The American Surgeon ◽

10.1177/00031348211047457 ◽

2021 ◽

pp. 000313482110474

Author(s):

Iswanto Sucandy ◽

Furrukh Jabbar ◽

Cameron Syblis ◽

Kaitlyn Crespo ◽

Sharona Ross ◽

...

Keyword(s):

Gallbladder Carcinoma ◽

Intraoperative Complications ◽

Bile Leak ◽

Robotic Approach ◽

Robotic Technology ◽

Minimally Invasive Approach ◽

Invasive Approach ◽

Operative Duration ◽

Estimated Blood Loss ◽

Central Hepatectomy

Gallbladder cancer (GBC) is an uncommon but very aggressive malignancy with poor prognosis. Concerns for oncological inferiority related to the technical difficulties in performing laparoscopic portal lymphadenectomy discourage many surgeons to undertake this operation minimally invasively. With wide application of robotic technology to solve limitations of conventional laparoscopy, we describe our initial outcomes of robotic central hepatectomy and portal lymphadenectomy for gallbladder carcinoma in 15 consecutive patients. Data were presented as median (mean ± SD). Patients were 70 (73 ± 10.9) years old with BMI of 26 (26 ± 3.6) kg/m2. Tumor size was 3(4 ± 1.9) cm. Operative duration was 222 (237 ± 85.7) minutes and estimated blood loss was 200 (222 ± 135.4) mL. There were no intraoperative complications and complete resection (R0) was obtained in nearly all patients. Postoperative complications were seen in two patients (bile leak (n = 1) and respiratory failure (n = 1)). Length of stay was 3 (4 ± 4.0) days without 30-day mortality. Robotic approach is safe and effective for the treatment of GBC.

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Image-guided intervention in the management of chronic patellar tendinopathy with calcification: a three-pronged approach

BMJ Case Reports ◽

10.1136/bcr-2020-240553 ◽

2021 ◽

Vol 14 (6) ◽

pp. e240553

Author(s):

Aqeel Butt ◽

Neelan Umaskanth ◽

Ajay Sahu

Keyword(s):

High Volume ◽

Patellar Tendinopathy ◽

Dry Needling ◽

Positive Research ◽

Invasive Approach ◽

Image Guided ◽

Reduced Dose ◽

Image Guided Intervention ◽

Patient Reported ◽

Research Findings

Patellar tendinopathy is a common cause of knee pain and functional impairment in athletes. It is commonly managed using conservative measures such as physiotherapy, but cases that are refractory to such treatment may require a more invasive approach. Various forms of image-guided injection therapy have been described in the literature. We present a case of successful treatment of chronic patellar tendinopathy with calcification with the first reported use of a three-pronged image-guided approach, consisting of dry needling, high volume image-guided injection (but at a reduced dose) and barbotage applied in a single sitting. The patient reported resolution of symptoms persisting to 1 year postprocedure. We suggest that this management option, if supported by further positive research findings, could be used in the future in the management of certain cases of patellar tendinopathy with calcification where conservative measures have failed.

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Abstract 14956: Improved Operative Efficiency for Minimally Invasive Mitral Valve Surgery at a Low-volume Center

Circulation ◽

10.1161/circ.142.suppl_3.14956 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Monica Fowler ◽

Jeffrey B MacLeod ◽

christie aguiar ◽

Alexandra M Yip ◽

zlatko pozeg ◽

...

Keyword(s):

Cardiac Surgery ◽

Mitral Valve ◽

Minimally Invasive ◽

High Volume ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Entire Study ◽

Invasive Approach ◽

Low Volume ◽

Skin To Skin

Introduction: When implementing a minimally invasive cardiac surgery program, increased surgical times may serve as a deterrent. Results demonstrating parity in operative times between minimally invasive (MIMVR) and conventional mitral valve replacement/repair (CMVR) have been limited to high-volume centers. The purpose of this study was to examine operative efficiency for MIMVR in a low-volume center. Methods: All patients having undergone non-emergent, isolated MIMVR or CMVR at the New Brunswick Heart Centre from 2011-2017 were considered. Detailed peri-operative data, including cross clamp (XC), cardiopulmonary bypass (CPB), skin-to-skin (SS) and total operative (TO) times, were collected. Patients were assigned to one of 3 eras: 2011-2013, 2014-2015, 2016-2017. Unadjusted comparisons were made between MIMVR and CMVR over the entire study period and within each era. Results: A total of 168 patients were included (MIMVR: 64; CMVR: 104). There was an increase in the number of MIMVR cases over time (2011-2013: 19; 2014-2015: 17; 2016-2017: 28). Patients undergoing MIMVR were less likely to be ≥70years (29.7% vs. 47.1%, p=0.04) and to have had NYHA-IV symptoms (17.2% vs. 41.3%, p=0.002), previous cardiac surgery (4.7% vs. 23.1%, p=0.003) or urgent presentation (12.5% vs. 35.6%, p=0.002). Intra-operatively, MIMVR patients were more likely to have undergone a mitral valve repair (65.1% vs. 29.1%, p<0.0001). No differences were noted in rates of in-hospital mortality (0.0% vs. 5.1%, p=0.29). Median operative times were uniformly longer among MIMVR patients between 2011-2013. However, in 2014-2015 and 2016-2017, these times improved to the point where no significant differences in operative efficiency were noted (Figure). Conclusions: Improved operative efficiency may be safely achieved for MIMVR in a low-volume center. The results of this study should encourage low-volume centers to adopt a minimally invasive approach to isolated mitral valve surgery.

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P119 SURGICAL OUTCOMES AFTER ESOPHAGECTOMY IN THE ELDERLY POPULATION - A SINGLE CENTER COHORT STUDY

Diseases of the Esophagus ◽

10.1093/dote/doz092.119 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

Söderström Henna ◽

Ilonen Ilkka ◽

Andersson Saana ◽

Kauppi Juha ◽

Räsänen Jari

Keyword(s):

Elderly Patients ◽

Neoadjuvant Treatment ◽

Hybrid Approach ◽

High Volume ◽

Good Health ◽

The Elderly ◽

Pulmonary Complications ◽

Long Term Results ◽

High Morbidity ◽

Survival Times

Abstract Aim To evaluate morbidity and mortality after esophagectomy among elderly patients Background & Methods Esophagectomy is associated with significant morbidity1, and with the aging population we are faced with an increasing number of elderly patients eligible for surgery. In this retrospective study we analyzed both minor and major postoperative complications (Clavidien-Dindo II-V), in-hospital and 90-day mortality, and overall survival in all carcinoma patients ≥75 yo undergoing esophagectomy for cancer between 2009 and 2018 at a high-volume center. Results 47 patients underwent esophagectomy during the 10-yr. period, 95,7% either minimally invasively or with a hybrid approach. Median age was 77, and the oldest patient 85 yo. The majority were in otherwise good health, 39 had an ASA score of 1-2, and all but one was ECOG 0. 70% had adenocarcinomas, and 70% received neoadjuvant treatment. 68,1% of the patients suffered some sort of complication. 19 patients (40,4%) had a C-D III-IV complication, 9 of which were pulmonary requiring a median of 5 days in the ICU. Only 4 patients (8,5%) had anastomotic leakage requiring an intervention, 2 were managed endoscopically, 1 early dehiscence was sutured and one required a revision and LD plasty. One patient had non-fatal gastric tube necrosis that was excised. Atrial fibrillation (34%) was the most common but easily managed issue, followed by pulmonary complications (C-D II 5pts /10,6%, C-D III-IV 10 pts / 21,3%). We had 3 re-operations for bowl herniation, and one for bleeding. Our in-hospital and 90-day mortality were 0%, in spite of the high complication rate. 63,8% were discharged home. Mean and median survival times 68,2 mo. and 47 mo., respectively. At time of follow up, 28 patients (59,6%) were still alive. Conclusion Esophagectomy comes with high morbidity, but with acceptable long term results it should be considered for elderly patients otherwise fit for surgery. Our results show that in select cases age is just a number 1. Low DE, Kuppusamy MK, Alderson D, Cecconello I, Chang AC, Darling G, Davies A, D'Journo XB, Gisbertz SS, Griffin SM, Hardwick R, Hoelscher A, et al. Benchmarking Complications Associated with Esophagectomy. Ann Surg 2017;:1.

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Should the laparoscopic approach be the norm for appendicectomy in the third trimester of pregnancy?

BMJ Case Reports ◽

10.1136/bcr-2018-228192 ◽

2019 ◽

Vol 12 (4) ◽

pp. e228192

Author(s):

Hashviniya Sekar ◽

Nisha Rajesh Thamaran ◽

David Stoker ◽

Sayantana Das ◽

Wai Yoong

Keyword(s):

Acute Appendicitis ◽

Laparoscopic Approach ◽

Postoperative Recovery ◽

Laparoscopic Appendicectomy ◽

Third Trimester ◽

Invasive Approach ◽

Suspected Appendicitis ◽

The Third ◽

Trocar Placement ◽

Theoretical Risk

Our case describes a pregnant woman with acute appendicitis who presented in the third trimester and underwent a laparoscopic appendicectomy. She made a rapid postoperative recovery and the pregnancy was otherwise uncomplicated, ending with a spontaneous vaginal birth at 41 weeks. The diagnosis of acute appendicitis can be unclear in pregnancy. Difficulty in establishing diagnosis due to atypical presentation often leads to delay in surgery, resulting in significant maternal and fetal morbidity and mortality. Surgical intervention should be prompt in cases of suspected appendicitis and the laparoscopic approach is advocated in the first two trimesters. In the third trimester (after 28 weeks), laparotomy is often performed due to the size of the uterus and the theoretical risk of inadvertent perforation with trocar placement. More recently, several authors have described successful outcomes following laparoscopic appendicectomy after 28 weeks and with increasing reassuring data, we suggest that this minimally invasive approach should be considered in managing appendicitis in the third trimester.

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Bilateral tubular minimally invasive approach for decompression, reduction and fixation in lumbosacral lythic spondylolisthesis

Neurosurgical FOCUS ◽

10.3171/2013.v2.focus13196 ◽

2013 ◽

Vol 35 (v2supplement) ◽

pp. Video9 ◽

Cited By ~ 5

Author(s):

Giuseppe M.V. Barbagallo ◽

Francesco Certo ◽

Giovanni Sciacca ◽

Vincenzo Albanese

Keyword(s):

Minimally Invasive ◽

Postoperative Recovery ◽

Pedicle Screw Fixation ◽

Invasive Technique ◽

Surgical Morbidity ◽

Nerve Roots ◽

Invasive Approach ◽

Minimally Invasive Surgical ◽

Pull Out ◽

Mini Open

This video demonstrates the minimally invasive surgical technique used in a 56-year-old woman suffering from L-5 spondylolysis and grade 2 L5–S1 spondylolisthesis. The first author used expandable tubular retractors bilaterally to perform neural decompression, mini-open TLIF, spondylolysthesis reduction and L5–S1 pedicle screw fixation. L-5 cement augmentation was performed through cannulated and fenestrated screws to enhance resistance to screw pull-out secondary to reduction maneuvers.Sequential surgical steps related to microsurgery, spondylolysthesis reduction and instrumentation are shown and commented.We submit that in cases of lythic spondylolisthesis a bilateral traversing and exiting nerve roots decompression is a safer option prior to performing the deformity reduction and fixation; the proposed minimally invasive technique may help in reducing surgical morbidity and improving postoperative recovery.The video can be found here: http://youtu.be/G4Qdg-A-Y3M.

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Variation in the surgical management of locally advanced pancreatic cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.4122 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. 4122-4122

Author(s):

Bradley Norman Reames ◽

Alex Blair ◽

Robert Wallace Krell ◽

James Padussis ◽

Sarah P. Thayer ◽

...

Keyword(s):

Pancreatic Cancer ◽

Neoadjuvant Therapy ◽

Surgical Management ◽

Locally Advanced ◽

Advanced Pancreatic Cancer ◽

High Volume ◽

Response To Therapy ◽

Locally Advanced Pancreatic Cancer ◽

Invasive Approach ◽

Clinical Vignettes

4122 Background: Recent reports suggest patients with locally advanced pancreatic cancer (LAPC) may become candidates for curative resection following neoadjuvant therapy, with encouraging survival outcomes. Yet the optimal management approach for LAPC remains unclear. We sought to investigate surgeon preferences for the management of patients with LAPC. Methods: An extensive electronic survey was systematically distributed by email to an international cohort of pancreas surgeons. Data collected included surgeon practice characteristics, preferences for staging and management, and 6 clinical vignettes (with detailed videos of post-neoadjuvant arterial and venous imaging) to assess attitudes regarding eligibility for surgical exploration. Results: A total of 150 eligible responses were received from 4 continents. Median duration in practice was 12 years (IQR 6-20) and 75% respondents work in a university setting. Most (84%) are considered high volume, 33% offer a minimally-invasive approach, and 48% offer arterial resection in selected patients. A majority (70%) always recommend neoadjuvant chemotherapy, and 62% prefer FOLFIRINOX. Preferences for duration of neoadjuvant therapy varied widely: 39% prefer ≥2 months, 41% prefer ≥4 months, and 11% prefer 6 months or more. Forty-one percent frequently recommend neoadjuvant radiation, and 51% prefer standard chemoradiotherapy. Age ≥80 years and CA 19-9 of ≥1000 U/mL were commonly considered contraindications to exploration. In 5 clinical vignettes of LAPC, the proportion of respondents that would offer exploration following neoadjuvant varied extensively, from 15% to 54%. In a vignette of oligometastatic pancreatic liver metastases, 32% would offer exploration if a favorable biochemical and imaging response to therapy is observed. Conclusions: In an international cohort of high volume pancreas surgeons, there is substantial variation in attitudes regarding staging preferences and surgical management of LAPC. These results underscore the importance of coordinated multi-disciplinary care, and suggest an evolving concept of “resectability.” Patients and their oncologists should have a low threshold to consider a second opinion for the surgical management of LAPC, if desired.

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