Chimney Graft Technique Combined With Embolization for Treating Ruptured Aortic Arch Lesions

Background: This study aimed to share the experience in applying the chimney graft technique combined with embolization for treating aortic arch rupture under emergency conditions and evaluating early-term results in these patients.Methods: This study retrospectively included patients with ruptured aortic arch lesions who received the chimney graft technique combined with embolization between March 2016 and March 2021. The primary endpoint was a technical success, deemed as successful stent graft deployment to the planned location, patency of the target branch vessel, and absence of significant type I endoleak. The secondary endpoint was clinical success defined with the size of false lumen in follow-up remaining unchanged or decreasing over time, 30-day mortality, complication, and primary patency of chimney graft.Results: This study included 12 patients (age, 61 ± 12 years; male, 83%). Five patients (42%) received single chimney, one patient (8%) received double chimney, and six patients (50%) received triple chimney. Intraoperative type I endoleak occurred in six patients (50%) who underwent endovascular embolization in the primary operation. Post-operative type I endoleak, evaluated by computed tomography angiography examination following the primary operation, occurred in seven patients (58%), including one patient who received endovascular embolization two times. All patients with post-operative type I endoleak were successfully re-treated using coil and Onyx glue within 1 week, and the median length of stay was 22 ± 11 days (range: 7–44 days). Overall technical success was 100%. Eleven patients had completed their follow-up (median, 12 months, range: 1–34 months), and one patient was out of contact. The 30-day mortality was 9% (1/11, post-operative death of a patient with cerebral hemorrhage). No major complications and no chimney compression, migration, occlusion, or stenosis were recorded during follow-up. Seven patients (58%) have ≥6 months of clinical follow-up time with appropriate imaging. In four (57%) of these patients, diameter stabilization was detected, whereas three (43%) experienced significant reduction (≥5 mm).Conclusion: The patients in this study had satisfactory early-term outcomes. The chimney graft technique combined with coil and Onyx glue embolization may be a safe and effective treatment for ruptured aortic arch lesions under emergency conditions.

EP.TH.855Hartmanns reversal - Laparoscopic Vs Open, UHNM experience over the last 3 years

Aim Reversal of hartmanns is still an operation associated with significant morbidity. Although various studies have tried to assess the best time for attempting reversal after the primary operation, there is still no consensus. The aim of our study was to look at our experience over the last three years to find any possible factors which determine the duration between primary operation and reversal and compare laparoscopic vs open approach. Methods Prospective cohort including consisting of patients who underwent hartmanns reversal in 3 years was analysed (January-2017 to December-2019). Data was collected retrospectively from clinical notes. Results Among the patients (n = 50) there was equal distribution of males (52%) and females (48%). Although the initial operation was open in 74% patients, reversal was attempted laparoscopically in 46% with a conversion rate of 43.4%. Median duration between initial operation and reversal was 433 days. There was no significant association between duration before reversal and patient comorbidities or the indication for the index procedure. Also there was no statistical difference in postoperative hospital stay or immediate postoperative morbidity between laparoscopic and open hartmanns reversal. Conclusion There was no difference in immediate postoperative outcomes between patients who had laparoscopic or open hartmanns reversal. There was no determining factor which made the surgeon prefer laparoscopic over open approach nor was there a difference in duration between primary operation and reversal based of patient factors or method of approach. Hence timing of hartmanns reversal and the method of approach still depends on surgeon preference and experience.

Re-operation for recurrent intracranial meningioma – is it worth it?

Aims Meningioma is the commonest primary brain tumour. Despite surgery, meningiomas can recur. Surgery is usually the first line treatment for recurrent meningioma. The aim was to determine the risk factors associated with clinical outcomes (performance status, morbidity, mortality, recurrence) following re-operation for recurrence of intracranial meningioma. Method Retrospective cohort study (1998-2018). Eligible patients had re-operation for local recurrence of a previously operated meningioma. Collected data included baseline clinical and imaging characteristic. Primary outcome measure was performance status after each re-operation. Secondary outcome measures were medical and surgical morbidity, recurrence-free survival (RFS) and overall survival (OS). Results Fifty-eight patients were eligible (38 female, mean age at 1st re-operation 56 years (SD=11.4)). Eleven patients (18.9%) had 2 re-operations and 3 patients (3.4%) had 3 re-operations. Median follow up was 125.5 months (IQR 73-191.5). Median time to 1st recurrence and 1st re-operation were 36.5 (IQR 24.2–79.1) and 43.8 months (IQR 22.9–102.7), respectively. Fifteen patients (25.9%) had worse performance status after 1st re-operation, compared to 6.9% (n=4) after the primary operation (Figure 1). Complication rate was 32.8% (n=19) after the primary operation compared to 46.6% (n=27) after 1st re-operation. At primary operation, there were 29 (50%) grade 1, 26 (44.8%) grade 2, and 1 (1.7%) grade 3 tumours. Median RFS after first re-operation was 68 months (95% CI 45.5-90.5) (figure 2). Median OS was 312 months (95% CI 236.9-387.1) (Figure 3). Post-operative complications were a risk factor for worsened performance status following re-operation (OR 4.91, 95% CI 1.3-18.4). Conclusion Re-operation is associated with a worse performance status and increased risk of complications. Re-operating meningiomas for radiological recurrence without symptoms increases patient morbidity. Shared-care management decision should be made with patients when considering operating for radiological recurrence only.

Suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery: a case report

Background Suture granuloma with hydronephrosis after abdominal surgery is extremely rare. We herein report a successfully treated case of suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery. Case presentation A 63-year-old male underwent laparoscopic low anterior resection with covering ileostomy. Two months after primary operation, ileostomy closure was performed with two layered hand-sewn suture (Albert–Lembert method) using absorbable suture. In that operation, marginal blood vessels in the mesentery were ligated with silk suture. The patient had remained in remission with no evidence of tumor recurrence, however, 2 years and 5 months after primary surgery, a contrast-enhanced computed tomography (CT) scan showed a mass-forming lesion on the right external iliac artery (43 × 26 mm) and hydronephrosis. Positron emission tomography/computed tomography (PET/CT) showed a mass-forming lesion without high accumulation, which obstructed the right ureter. Recurrence could not be ruled out due to the rapid appearance of tumor and hydronephrosis in the short-term period. Thus, the patient underwent laparotomy. The tumor located in the mesentery near the anastomosis of ileostomy closure and it was strongly adherent to the retroperitoneum, which obstructed the right ureter. The adhesion between the tumor and ureter was carefully dissected and tumor resection with partial small bowel resection was then performed with preservation of the ureter using ureteral stents. Pathological examination of the tumor revealed fibrous proliferation of foreign body granuloma. In the resected tumor, sutures with foreign giant cells were found. Therefore, we diagnosed the tumor as silk suture granuloma, which was caused by the silk suture used to ligate blood vessels of the mesentery at the ileostomy closure. The patient remained well with no evidence of tumor recurrence as 5 years after the primary operation of rectal cancer. Conclusions Suture granuloma is a rare surgery-related complication in the postoperative surveillance of patients with colorectal cancer. If suture granuloma mimicking local recurrence is a differential diagnosis, it would be important to consider to avoid unnecessary extended resection.

Novel Energy Trading System Based on Deep-Reinforcement Learning in Microgrids

Inefficiencies in energy trading systems of microgrids are mainly caused by uncertainty in non-stationary operating environments. The problem of uncertainty can be mitigated by analyzing patterns of primary operation parameters and their corresponding actions. In this paper, a novel energy trading system based on a double deep Q-networks (DDQN) algorithm and a double Kelly strategy is proposed for improving profits while reducing dependence on the main grid in the microgrid systems. The DDQN algorithm is proposed in order to select optimized action for improving energy transactions. Additionally, the double Kelly strategy is employed to control the microgrid’s energy trading quantity for producing long-term profits. From the simulation results, it is confirmed that the proposed strategies can achieve a significant improvement in the total profits and independence from the main grid via optimized energy transactions.

P14.66 Re-operation for recurrent meningioma - are we helping patients?

BACKGROUND Meningioma is the commonest primary brain tumour. Despite surgery, meningiomas can recur. Surgery is usually the first line treatment for recurrent meningioma. The aim was to determine the risk factors associated with clinical outcomes (performance status, morbidity, mortality, recurrence) following re-operation for recurrence of intracranial meningioma. MATERIAL AND METHODS Retrospective cohort study (1998–2018). Eligible patients had reoperation for local recurrence of a previously operated meningioma. Collected data included baseline clinical and imaging characteristic. Primary outcome measure was performance status after each reoperation. Secondary outcome measures were medical and surgical morbidity, recurrence-free survival (RFS) and overall survival (OS). RESULTS Fifty-eight patients were eligible (37 female, mean age at 1st re-operation 56.1 years (SD=11.6)). Eleven patients (19.6%) had 2 re-operations and 3 patients (5.4%) had 3 re-operations. Median follow up was 128.5 months (IQR=73–194.5). Median time to 1st recurrence and 1st re-operation were 36.5 (IQR=24.3–81.0) and 43.8 months (IQR=20.3–103.4), respectively. Fifteen patients (26.8%) had worse performance status after 1st reoperation, compared to 5.4% (n=3) after the primary operation. Complication rate was 32.1% (n=18) after the primary operation compared to 48.2% (n=27) after 1st reoperation. At primary operation, there were 29 (51.8%) grade 1, 24 (42.9%) grade 2, and 1 (1.8%) grade 3 tumours. Median RFS after first re-operation was 36.5 months (95% CI 29.3–43.9). Median OS was 312 months (95 % CI 257.8–366.2). Increased number of post-operative complications were a risk factor for worsened performance status following reoperation (OR 2.2 [95% CI 1.1–4.6], P=0.029). CONCLUSION Re-operation is associated with a worse performance status and increased risk of complications. Re-operating meningiomas for radiological recurrence without symptoms increases patient morbidity. Shared-care management decision should be made with patients when considering operating for radiological recurrence only.

A comparison of comorbidity measures for predicting mortality after elective hip and knee replacement: A cohort study of data from the National Joint Registry in England and Wales

Background The risk of mortality following elective total hip (THR) and knee replacements (KR) may be influenced by patients’ pre-existing comorbidities. There are a variety of scores derived from individual comorbidities that can be used in an attempt to quantify this. The aims of this study were to a) identify which comorbidity score best predicts risk of mortality within 90 days or b) determine which comorbidity score best predicts risk of mortality at other relevant timepoints (30, 45, 120 and 365 days). Patients and methods We linked data from the National Joint Registry (NJR) on primary elective hip and knee replacements performed between 2011–2015 with pre-existing conditions recorded in the Hospital Episodes Statistics. We derived comorbidity scores (Charlson Comorbidity Index—CCI, Elixhauser, Hospital Frailty Risk Score—HFRS). We used binary logistic regression models of all-cause mortality within 90-days and within 30, 45, 120 and 365-days of the primary operation using, adjusted for age and gender. We compared the performance of these models in predicting all-cause mortality using the area under the Receiver-operator characteristics curve (AUROC) and the Index of Prediction Accuracy (IPA). Results We included 276,594 elective primary THRs and 338,287 elective primary KRs for any indication. Mortality within 90-days was 0.34% (N = 939) after THR and 0.26% (N = 865) after KR. The AUROC for the CCI and Elixhauser scores in models of mortality ranged from 0.78–0.81 after THR and KR, which slightly outperformed models with ASA grade (AUROC = 0.77–0.78). HFRS performed similarly to ASA grade (AUROC = 0.76–0.78). The inclusion of comorbidities prior to the primary operation offers no improvement beyond models with comorbidities at the time of the primary. The discriminative ability of all prediction models was best for mortality within 30 days and worst for mortality within 365 days. Conclusions Comorbidity scores add little improvement beyond simpler models with age, gender and ASA grade for predicting mortality within one year after elective hip or knee replacement. The additional patient-specific information required to construct comorbidity scores must be balanced against their prediction gain when considering their utility.

Failed preoperative vacuum bell therapy does not affect outcomes following minimally invasive repair of pectus excavatum

Purpose It is unknown if failed preoperative vacuum bell (VB) treatment in patients undergoing minimally invasive repair of pectus excavatum (MIRPE), delays repair and/or affects postoperative outcomes. Methods A retrospective data analysis including all consecutive patients treated at one single institution undergoing MIRPE was performed between 2000 and 2016. Patients were stratified into preoperative VB therapy versus no previous VB therapy. Results In total, 127 patients were included. Twenty-seven (21.3%) patients had preoperative VB treatment for 17 months (median, IQR 8–34). All 27 patients stopped VB treatment due to the lack of treatment effect. Eight (47.1%) of 17 assessed VB patients showed signs of skin irritation or hematoma. VB treatment had no effect on length of hospital stay (p = 0.385), postoperative complications (p = 1.0), bar dislocations (p = 1.0), and duration of bar treatment (p = 0.174). Time spent in intensive care unit was shorter in patients with VB therapy (p = 0.007). Long-term perception of treatment including rating of primary operation (p = 0.113), pain during primary operation (p = 0.838), own perspective of look of chest (p = 0.545), satisfaction with the procedure (p = 0.409), and intention of doing surgery again (p = 1.0) were not different between groups. Conclusions Failed preoperative VB therapy had no or minimal effect on short-term outcomes and long-term perceptions following MIRPE.