A study of efficacy and feasibility of laparoscopic surgery in a tertiary care center, Pokhara, Nepal

Introduction: Laparoscopic surgery is the gold standard technique for most of the gastrointestinal surgeries in developed countries. However, challenges in developing countries, apart from cost of instrumentation, include lack of awareness. Therefore, the aim of this study is to determine the efficacy and feasibility of laparoscopic surgeries in our part of the world. Methods: Retrospective, cross-sectional study was carried out from January 1, 2018 to June 30, 2019. Patient’s information on demographic details, type of laparoscopic surgery, operation time, length of hospital stay, reasons for conversion to open surgery, and intra-operative and post-operative complication details were retrieved from the operation log book and patient’s chart. Results: A total of 380 patients that underwent laparoscopic surgeries were included in the study. Out of 193 patients that underwent laparoscopic cholecystectomy, there were 144 (74.61%) females and 49 (25.38%) males with conversion rate of 4.66% and post-operative complication rate of 8.80%. Similarly, among 136 patients that underwent laparoscopic appendectomy, there were 68 (50%) females and 68 (50%) males with conversion rate of 4.41% and post-operative complication rate of 14.70%. Finally, amid 51 patients who underwent trans-abdominal pre-peritoneal approach, post-operative seroma collection was seen in three cases and port site hematoma formation was seen in two cases only. Conclusions: Our results were comparable with various literature demonstrating that laparoscopic surgeries are safe and effective. However, evolution of laparoscopic surgery in developing countries is still slow. Therefore, effective training and availability of required instruments is needed.

The Impact of Multidisciplinary Team Approach on Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis

Background: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS–HIPEC) is a therapeutic approach used to achieve curative treatment in intra-abdominal malignancy with peritoneal carcinomatosis (PC). However, it is a complicated procedure with high post-operative complication rates. Thus, we analyzed our preliminary data to establish whether multidisciplinary teamwork (MDT) implementation is beneficial for CRS–HIPEC outcomes. Method: A series of 132 consecutive patients with synchronous or recurrent PC secondary to gastrointestinal or gynecologic cancer who received CRS–HIPEC operation between May 2015 and September 2017 were included. Ninety-nine patients were categorized into the MDT group, with the 33 other patients into the non-MDT group. Results: The mean PCI score was 16.3 ± 8.8. Patients in the MDT group more often presented a higher PCI score (p value = 0.038). Regarding CRS completeness (CCR 0–1), it was distributed 81.8% and 57.6% in the MDT and the non-MDT group, respectively (p value = 0.005). Although post-operative complications were common (n = 62, 47.0%), post-operative complication rates did not differ between the two groups. The cumulative OS survival rate at the first year was 75.5%. Older age (p = 0.030, HR = 4.58, 95% CI = 1.16–18.10), ECOG 2 (p = 0.030, HR = 6.41, 95% CI = 1.20–34.14), and incomplete cytoreduction (p = 0.048, HR = 2.79, 95% CI = 1.04–8.27) were independent prognostic factors for survival. Conclusions: Our experience suggests that the CRS–HIPEC performed under MDT cooperation may result in higher complete cytoreduction rates without increasing post-operative complications and hospital mortalities.

P-BN14 Differences in rate of complications between emergency and elective laparoscopic cholecystectomy at district general hospital

Background Current NICE guidelines recommend healthy low risk patients who present with acute biliary disease should be offered laparoscopic cholecystectomy on the same index admission. The increased complexity of the acute operations may impact on the operative complication rates; hence the aim of this study is to evaluate and compare the operative complication rates between elective and emergency laparoscopic cholecystectomies and additionally to assess the difference in surgical techniques comparing complete cholecystectomy versus subtotal versus open procedures. Methods Retrospectively, data was collected from emergency and elective Laparoscopic Cholecystectomies completed in the period 01/01/2021-01/06/2021 at the Queen Elizabeth Hospital Gateshead. The data set was gathered from an electronic theatre database and the individual cases were sub-analyzed further by delving into the electronic patient records database. Statistical analysis done by using Excel 2010. Results The average age of both groups was 50 years. There wasn’t a statistical significance on the rate of complication between the elective Vs emergency cholecystectomies (Elective 2%, Emergency 9% P = 0.17). Out of 42 Elective procedures, 4 had Sub-total cholecystectomy Vs 3 out of 42 patients on the emergency group who had Subtotal cholecystectomy (9% Vs 7%), implying there was no significant difference noted between the two groups. Average hospital stays was 5.6 days for the acute presentation with biliary disease Vs 0.14 days on the planned elective group. 2% of the elective group were noted to have a surgical drain inserted during the operation; whilst the emergency cohort had a slightly higher rate at 5%. Conclusions Overall there was no significant difference noted between the surgical complications arising in emergency cholecystectomy compared to planned surgeries. In addition to this the data also suggests that there is negligible difference in the rates of sub-total cholecystectomies in both cohorts.

EP.FRI.16 Use of Pulsed Lavage Reduces the Rate of Surgical Site Infection After Laparotomy

Aims Surgical site infections (SSIs) are a preventable and common post-operative complication within general surgery. Intra-operative irrigation of surgical incisions is an inexpensive method to reduce post-operative SSI rates, however its use is currently limited to orthopaedic surgery. We aimed to assess the effects of pulsed lavage (PL) irrigation on SSI rates following elective and emergency laparotomies. Methods Elective and emergency patients who underwent a laparotomy between 2018 and 2019 were included. Relevant demographic and peri-operative risk factors collected retrospectively, following STROBE criteria. The primary outcome was rate of superficial SSIs within 30 days of the operation. Independent risk factors were assessed via multivariate logistic regression analysis. Results 176 patients were identified, with an average age of 60.7 ±19.1 years. 82.4% (145/176) were emergencies and the mean ASA grade was 2.8. Fifty two patients (29.5%) had PL used during their operation. Thirty seven patients (29.8%, 37/124) in the control group developed a SSI, compared to seven patients (13.5%, 7/52) in the PL group (p = 0.022). At multi-variate analysis, the use PL conferring an Odds Ratio 0.36 (CI 0.12-0.94, p = 0.047) for developing a SSI. Conclusions PL appears to significantly reduced the rate of SSI following laparotomy. There remains scope to reduce the incidence of this common and expensive post-operative complication, and PL could provide a potential cost-effective means to deliver improved outcomes. Future prospective randomised trials are essential to fully assess its benefits and wider use within general surgery.

TP7.2.13 Clinical characteristics and outcomes of acute pancreatitis following spinal surgery: a systematic review

Aims Acute pancreatitis (AP) is a rare post-operative complication of spinal surgery. This study reviews the current evidence on clinical characteristics and outcome of AP following spinal surgery. Methods A systematic search was performed on English articles published up to May 2020 using PubMed, Scopus, EMBASE, LILACS and Cochrane databases. Data on clinical characteristics, risk factors and outcomes were extracted and analysed. Results Eleven papers meeting the inclusion criteria which included a total of 306 (23.02%) patients developing AP out of 1,329 patients undergoing spinal surgery were included (mean age= 14.17 years). Of the 11 studies that specified symptoms (n = 55 patients) abdominal pain (43.6%), nausea and vomiting (32.7%) and abdominal distension (7.27%) were the commonest symptoms. The mean duration from surgery to onset of symptoms was 6.15 days (range:1-7). Almost all (n = 10, 90.9%) were treated non-operatively. Of the complications mentioned (n = 306 patients), glucose intolerance (25%), peritonitis (2%), pseudocyst (2%), and fluid collection (2%) were the commonest. Of the studies mentioning associated factors (n = 22 patients) prolonged fasting time (13.6%), intra-operative blood loss (9.09%), gastroesophageal reflux disease (9.09%), age >14 years (9.09 %), low BMI (9.09 %), and anterior/combined approach (9.09%) were the commonest associated factors for AP. A total of 2 deaths (n = 2/306, 0.65%) were reported. Conclusion Although uncommon, AP remains an important post-operative complication of spinal surgery due to its associated morbidity and mortality. Avoiding major risk factors including prolong fasting and minimizing intra-operative blood loss may help reduce the incidence of AP in patients undergoing spinal surgery.

Impact of surgical delays on pre-operative complications in primary GBM patients- a 5-year study

Aims Glioblastoma Multiforme (GBM) is one of the most aggressive primary brain tumors with poor prognosis (median survival 18 months) and no cure. Management strategies often involve maximum safe resection followed by chemoradiotherapy. There has been a move from managing such patients electively rather than the traditional model of treating them as an emergency. While this may have advantages, this can delay the time from presentation to operation. This delay has recently been further compounded by the current COVID-19 pandemic. There is no data available as to whether the surgical delays that are currently occurring have an impact on patient care, and may outweigh the benefits of elective management on health services. We aimed to conduct a single centre observational study to assess how long patients should be waiting prior to surgery. We hypothesised that the longer the wait, the higher the pre-operative complication rate and worse the outcomes. Method 698 patients in a GBM database over a 5-year period (29/10/14- 8/11/19) were studied. All patient data was accessed via electronic patient records Surgical delay was defined as the interval between date of being put on the waiting list (the date seen in the neuro-oncology clinic) to date of surgery. Primary outcome measure was preoperative complications, which was categorised into transient neurological decline, stroke, seizures, diabetes/erratic blood sugars, emergency admission, others (e.g., cardiovascular compromise, steroid complications, blood disorders) Inclusion criteria included: First presentation supratentorial WHO Grade 4 GBM confirmed on histology (this included histological variants such as Gliosarcoma and Epithelioid Glioblastoma), and all patients who had been seen in the neuro-oncology clinic prior to surgery. Exclusion criteria included all patients who were not thought to have a GBM or high-grade glioma on initial imaging, those admitted as an emergency without being seen in a neuro-oncology clinic, recurrent or secondary GBMs. Results 460 patients met the inclusion criteria in this study. There was a pre-operative complication rate of 14.6% (67/460). 55% of complications were due to a transient neurological decline (37/67) with 16.4 % (11/67) of patients presenting with seizures. For those with surgical delays ≤7 days pre-operative complication rates were 2.2 % vs 15.9% in those with delays >7 days, p value 0.012, Odds ratio 8.53 (95% CI 1.48- 88.09). Results were statistically significant in those with delays greater than 10 and 14 days (p values 0.0026 and 0.0004 respectively) ROC Curve analysis revealed an AUC of 0.66 with sensitivities of 99%, 90% and 76% at surgical delays of 7,10 and 14 days respectively. The median length of hospital admission in both groups of patients was 5 days (p= 0.2065) All statistical analysis was carried out using Prism 9 and SPSS Conclusion In spite of unchanged length of hospital stay, we note a significant increase in pre-operative complication rates as a result of surgical delays greater than 7,10 and 14 days, which introduces an interesting debate in the merit of delaying operations for further assessment in clinic. Our objectives would be to minimize complication rate, therefore a high sensitivity i.e. true positive rate would be most desirable. The 99% levels achieved at 7 days In the ROC analysis lends weight to introducing policy to fast-track admissions for primary GBM patients. Further directions could include assessing the impact reduced surgical services and redeployment might have had on complications rates and length of hospital stay on patients admitted over the COVID 19 pandemic.

EP.WE.385A retrospective audit reviewing current practice on managing the incidence of anaemia and iron deficiency in pre-operative oesophagogastric resection patients

Aims NICE guidelines state patients with anaemia should be offered iron therapy before and after surgery. An audit was undertaken at a tertiary care centre to assess compliance in patients undergoing oesophagogastric resection. Methods Retrospective audit looking at oesophagogastric resections over a period 12 months at a tertiary care centre. Data is being gathered from ORSOS and ICE to record pre, peri and post-operative haemoglobin and MCV, amongst other metrics, including whether iron therapy was prescribed. Data is also being gathered on post-operative outcomes. An intervention aiming to increase pre-operative haemoglobin levels will be implemented and then a repeat audit cycle will be carried out. Results Preliminary results from cycle 1 suggest that despite 71% of patients undergoing oesophagogastric resection having a haemoglobin<130g/l in men and <120g/l in women, only 6.7% are receiving preoperative iron therapy of any kind (i.e. oral or intravenous). 42.8% of all patients included suffered a post-operative complication. We predict implementation of changes in pre-operatively will reduce the post-operative complication rate. Conclusions The majority of patients undergoing oesophagogastric resection are not receiving adequate iron therapy prior to surgery and are being put at an increased risk of post-operative complications. Ongoing auditing will highlight the scope of the problem and reduce the risk of post-operative complications. Data is preliminary at this stage but due to the novelty of the audit (only one relevant paper was returned upon completing a structured literature search) we are submitting this abstract now as we believe it to be of clinical significance.