EP.WE.739Antibiotics Prescriptions in Elective Laparoscopic Cholecystectomy

Aim To assess our compliance to the trust and national guidelines for antibiotic usage and prescription in elective laparoscopic cholecystectomy and to assess whether prophylactic antibiotics are prescribed appropriately and identify areas of improvement. Method Medical records for patients who underwent laparoscopic cholecystectomy over 3 months were collected (May – July 2019). Urgent laparoscopic cholecystectomies were excluded, and medical records were reviewed retrospectively for operative note details, patient risk factors, antibiotic prescribed, concomitant procedure, and complications. Results Appropriate antibiotic prescription represented 50% (Patient had at least one risk factor and prescribed antibiotic or no risk factors and wasn't prescribed antibiotics) and inappropriate prescription 50% (Patient had no risk factors and prescribed antibiotic or had risk factors and wasn't prescribed antibiotics). In the group with risk factors and wasn't prescribed antibiotics, Age was a risk factor in 17 patients, BMI in 25, Bile spillage in 10, and Diabetes in 3. Conclusion We are not compliant with the current guidelines for antibiotic prophylaxis in elective laparoscopic cholecystectomy, some patient with no risk factors received antibiotics while other with risk factors did not. We plan to disseminate this information in the governance meeting and print guidelines posters in theatres and then re-audit in 3 months’ time to assess progress.

Outcomes of Septal Myectomy beyond 65 Years, with and without Concomitant Procedures

Introduction and objectives: Septal myectomy remains the first septal reduction therapy for hypertrophic obstructive cardiomyopathy in young patients and those requiring concomitant procedures. Its role in advanced ages is questioned due to perceived increased risk. We assess the outcomes of surgical relief of obstruction in patients beyond 65 years old. Methods: A single-center retrospective review of patients ≥ 65 years old undergoing septal myectomy through median sternotomy between April 2015 and February 2020. Results: We identified 52 patients. Mean age was 71.8 ± 4.9 years; 36 (69.2%) were females. All were symptomatic. Mean highest LVOT gradient was 90 ± 39 mmHg. All patients had systolic anterior motion (SAM) of the mitral valve and 36 (69.2%) ≥ moderate mitral regurgitation. Additional LVOT interventions beyond myectomy were performed in 34 (65.4%). At least one other cardiac concomitant procedure was performed 44 (84.6%). No perioperative mortality in elective surgery occurred. One patient (1.9%) developed atrio-ventricular block. Postoperative mean gradient was 4.3 ± 1.9 mmHg, with 46 (88.4%) achieving complete resolution of obstruction. Mitral regurgitation was reduced to grade ≤ I in 46 (88.5%). Mean follow-up time was 2.3 ± 1.2 years and 82% of patients were in NYHA I. Survival at 2 years was 98%. Conclusion: Septal myectomy in the elderly is a safe and effective operation despite the need for concomitant procedures. LVOT interventions beyond septal myectomy to relieve obstruction are common in this advanced cohort of hypertrophic cardiomyopathy patients. This operation carried at experienced centers seems an unmatched therapeutic option.

Personalised external aortic root support for elective treatment of aortic root dilation in 200 patients

Background and objectivesIn personalised external aortic root support (PEARS), a custom-made, macroporous mesh is used to stabilise a dilated aortic root and prevent dissection, primarily in patients with genetically driven aortopathies. Data are needed on the safety and postoperative incidence of aortic events.MethodsWe present a multicentre cohort study evaluating the first 200 consecutive patients (median age 33 years) undergoing surgery with an intention to perform PEARS for aortic root dilatation in 23 centres between 2004 and 2019. Perioperative outcomes were collected prospectively while clinical follow-up was retrieved retrospectively. Median follow-up was 21.2 months.ResultsThe main indication was Marfan syndrome (73.5%) and the most frequent concomitant procedure was mitral valve repair (10%). An intervention for myocardial ischaemia or coronary injury was needed in 11 patients, 1 case resulting in perioperative death. No ascending aortic dissections were observed in 596 documented postoperative patient years. Late reoperation was performed in 3 patients for operator failure to achieve complete mesh coverage. Among patients with at least mild aortic regurgitation (AR) preoperatively, 68% had no or trivial AR at follow-up.ConclusionsThis study represents the clinical history of the first 200 patients to undergo PEARS. To date, aortic dissection has not been observed in the restrained part of the aorta, yet long-term follow-up is needed to confirm the potential of PEARS to prevent dissection. While operative mortality is low, the reported coronary complications reflect the learning curve of aortic root surgery in patients with connective tissue disease. PEARS may stabilise or reduce aortic regurgitation.

Trends in Lateral Retinacular Release from 2010 to 2017

Historically, lateral retinacular release (LRR) procedures have been utilized in the treatment of a variety of patellofemoral disorders, including lateral patellar instability. However, in the past decade, there has been an increasing awareness of the importance of the lateral stabilizers in patellar stability, as well as the complications of LRR, such as recurrent medial patellar instability. The purpose of this study was to investigate current trends in LRR procedures from 2010 through 2017 using a large national database. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for arthroscopic LRR procedures (the Current Procedural Terminology [CPT] code, 29873) from 2010 to 2017. The number and incidence of lateral release procedures, both isolated and nonisolated, were analyzed and separated into cohorts for analysis. Age and gender of the LRR cohort was investigated and compared with all other orthopaedic procedures during the same time period in the NSQIP database. In addition, concomitant procedures and associated International Classification of Disease-9th Revision (ICD-9) and ICD-10th Revision (ICD-10) codes were analyzed over time and between LRR groups. From 2010 to 2017, 3,117 arthroscopic LRRs were performed. The incidence for LRR was 481.9 per 100,000 orthopaedic surgeries in 2010 and significantly decreased to 186.9 per 100,000 orthopaedic surgeries in 2017 (p < 0.01). LRR was more commonly performed in females (66%) and 58% of patients were under 44 years of age. In addition, LRR was most commonly performed with a concomitant meniscectomy (36%), synovectomy (19%), or microfracture (13%), and for a diagnosis of pain (22%). The overall incidence of LRR procedures significantly decreased from 2010 to 2017. LRRs were more commonly performed in younger, female patients for a diagnosis of pain with the most common concomitant procedure being meniscectomy, synovectomy, or microfracture.

A Simple Way to Fix a Lateral Meniscal Root Tear

Background: Meniscal posterior root tears, which are often associated with anterior cruciate ligament (ACL) injury, lead to the loss of normal biomechanical and kinematic behavior of menisci. Several arthroscopic techniques have been introduced to address this kind of injury. In this video, a simple all-inside technique to repair posterior lateral root tear (PLRT) is presented. Indications: To repair type 1, type 2, and type 4 PLRT. Technique: The torn lateral meniscus root is sutured to the medial fibers of the posterior cruciate ligament (PCL), with an arthroscopic all-inside repair system, with the purpose of reproducing the stabilizing function of the meniscofemoral ligaments. Results: This procedure allows restoration of the correct position of the detached horn, and restores meniscal stability with satisfactory clinical outcomes. Discussion/Conclusion: The technique described represents a simple and fast arthroscopic all-inside procedure to repair PLRT in association with concomitant procedure, such as ACL reconstruction. However, outcome reports of this technique are still lacking in the literature, and further studies are needed to confirm the authors’ results.

Outcomes of 207 totally extraperitoneal hernia repairs using self-fixation mesh

Inguinal hernia (IH) repair is one of the most common procedures in general surgery around the world. Minimizing postoperative acute and chronic pain without increasing recurrence has been a critical point, giving place to different strategies like self-fixation mesh. The current study aimed to describe a group of patients who underwent IH repair by Totally Extraperitoneal (TEP) technique with self-gripping mesh at a fourth level hospital between 2012 and 2019. Retrospective review of a prospectively collected database including patients who underwent laparoscopic TEP approach with self-fixation mesh for IH repair. Follow up data was obtained at 12, 24, 36, 48, and 60 months post surgical intervention. 207 hernia repairs were performed in 142 patients, with a total of 66 patients with bilateral IH. 10.6% required hospitalization due to either concomitant procedure performed or cardiovascular comorbidities, with a mean hospital stay of 1.6 days. Median and late follow up was up to 5 years. 88.9% of patients complete a year, 86% two years, and 36.7% with a 5 year follow-up. IH repair using the TEP technique and self-fixation mesh showed to be an excellent approach, demonstrating satisfactory results in follow up and complications.

The safety and feasibility of the simultaneous use of 180-W GreenLight laser for prostate vaporization during concomitant surgery

Objectives: To explore the safety and feasibility of photo-selective vaporization of the prostate (PVP) with GreenLight XPS 180 Watt laser (GL-180- W XPS) combined with other surgical procedures. Material and methods: Data on patients in whom GL-180-W XPS was performed to relieve lower urinary tract symptoms/ benign prostatic hyperplasia (LUTS/BPH) symptoms were extracted from a multi-institutional database (2011-2016). Patients were stratified into two groups. In the first all patients who had GL-180-W XPS with a concomitant procedure during the same surgical session were included as cases while those who underwent GL-180-W XPS PVP only were included as control. Results: A total of 487 patients were included. Fifty-eight (11.9%) patients underwent concomitant procedures. Multivariable linear regression models failed to find an association between concomitant procedures and longer laser time (p = 0.4). Similarly, multivariable linear regression models failed to find an association between concomitant procedures and laser time even when the analyses were repeated and stratified into endoscopic (p = 0.6) and open/laparoscopic (p = 0.4) procedures. Multivariable logistic regression models failed to demonstrate any association between concomitant procedures and early complications (OR:1.39, CI: 0.379-2.44, p = 0.2), late complications (OR:1.84, CI:0.78-3.98; p = 0.1) and acute urinary retention (OR:1.84, CI:0.78-3.98; p = 0.1). When the analyses were repeated and the concomitant procedures stratified into endoscopic and open/laparoscopic ones, they yielded virtually the same results. Conclusions: GL-180-W XPS PVP could be safely performed in concomitant endoscopic or open/laparoscopic surgery. These results should be taken into consideration in the counseling of the patient who might choose to undergo simultaneous procedures.

Abstract 15556: Clinical Outcomes After Routine Cox-MAZE IV and Appendectomy and Aggressive Left Atrial Plication Added to Mitral Valve Repair for Atrial Functional Mitral Regurgitation

Introduction: Atrial functional mitral regurgitation (AFMR) is one of the significant factors to worsen the outcomes in heart failure. The optimal therapy for AFMR is still controversial. Previous studies reported AFMR patients underwent mitral valve repair alone frequently had heart failure re-hospitalization or stroke after surgery. New guidelines recommend adding surgical ablation as a concomitant procedure for class I indications. However, many surgeons avoid concomitant procedure especially in patients with extremely enlarged left atrium (LA) and long atrial fibrillation (AF) duration. Hypothesis: Routine strategy of adding surgical ablation and appendectomy and aggressive LA plication to mitral valve repair might improve the outcomes with keeping sinus rhythm and without stroke events in AFMR patients. Methods and Results: We investigated 35 consecutive patients with severe AFMR who underwent surgery in our institute between 2014 and 2018. Our strategy was Cox-maze IV and appendectomy for all patients and if LA volume was more than 200 ml by echocardiography, we added LA plication. In addition to clinical data and conventional echocardiographic assessment (Table), left ventricular (LV) function was evaluated using 2D speckle tracking echocardiography. MR grade improved in all patients. Despite enlarged LA, 76% of patients regained sinus rhythm and atrial kick was detected by pulse doppler method (mean value: 55 ± 19 cm/s). After 2-year follow-up, LV global longitudinal strain and LA peak strain were significantly improved (Table). During 4.1 ± 1.3 years observation, no patient experienced heart failure re-hospitalization and stroke. Conclusions: Majority of AFMR patients had long duration of AF and severely enlarged LA. The routine Cox-maze IV, appendectomy and aggressive LA plication in enlarged LA patients improved LV and LA function. This strategy may contribute to the better long-term outcomes of AFMR compared to mitral valve repair alone.

A Prospective Assessment of Great Toe Fusion Outcomes: The Effect of Concomitant Procedures

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Great toe fusion is the standard of care for severe hallux rigidus and other great toe pathology requiring definitive surgical management. Great toe fusion has proven an effective surgical treatment when correctly performed on appropriate patients. This study aimed to prospectively assess the clinical results of great toe fusion surgery in isolation compared to great toe fusion surgery combined with concomitant procedures. Methods: All patients undergoing a 1st metatarsophalangeal joint fusion from January 1st 2017 through June 30th 2018 were prospectively studied. Patients completed the Foot and Ankle Outcome Score (FAOS) and Veterans RAND 12 (VR-12) patient- reported outcome measures (PROMs) on the day of surgery (T0) and 12 months post-surgery (T1). Surgeons were surveyed regarding surgical details and patient characteristics. 204 patients underwent a great toe fusion during the study period. There were 67 enrollment failures (2 patient refusals, 63 incomplete T0 patient surveys, 2 incomplete surgeon surveys). Of the 137 patients completing the initial PROMs at T0, 100 patients (73%) also completed the PROMs at T1. Within this study group, 54 patients underwent an isolated great toe fusion and 46 underwent one or more concomitant procedures including hammertoe correction (30); MTP joint capsulotomy (22); Weil osteotomy (19); bunionette (2); metatarsal head resection (3); and other (12). Results: The study group consisted of 80 females and 20 males with age = 63.3 +/-8.5 and BMI = 28.3 +/-6.0. Indications for surgery included: hallux rigidus (26%), hallux valgus (35%), hallux varus (7%), arthritic bunions (30%) and other (2%). Fixation constructs included: a plate and a lag screw (82%), a plate alone (15%), and lag screws alone (3%). Patients undergoing isolated great toe fusions and those undergoing concomitant procedures both improved at one year (Table 1). Multivariable analysis demonstrated that after controlling for confounding variables, patients undergoing an isolated great toe fusion when compared to those also undergoing a concomitant procedure had higher odds for improvement in: FAOS pain (odds Ratio = 0.34, p=0.011); FAOS QoL (Odds Ratio=0.38, p=0.022); and VR-12 PCS (Odds Ratio=0.58, p=0.162). Conclusion: A great toe fusion can lead to substantial improvement in pain, quality of life, and overall physical function. However, this study demonstrates that the addition of a concomitant procedure such as a claw toe correction or a Weil osteotomy leads to an inferior outcome with respect to pain and quality of life when compared to an isolated great toe fusion. [Table: see text]

Is Intensive Care Unit Admission Necessary After Removal of Mandibular Distraction Devices in Infants With Robin Sequence?

Objective: Intensive care unit (ICU) care is routinely required after the operation to initiate mandibular distraction osteogenesis (MDO) in infants with Robin sequence (RS). Many patients are also managed in the ICU after subsequent device removal. It is uncertain if ICU care, which is expensive and limited, is necessary after this second operation. The objective of this study was to evaluate the incidence of respiratory events following device removal. We hypothesized that respiratory events would be infrequent and non-ICU inpatient monitoring would be adequate. Design: This is a retrospective study of patients with RS from 2013 to 2018. Patients: Patients were included if they had MDO and distractor removal during the first year of life. Patients were excluded if they had a tracheostomy or remained intubated after distractor removal. Main Outcome Measure: Postoperative respiratory events. Results: Twenty-five (60% male) patients were included. Mean age and weight at distractor removal were 142 ± 79 days of life and 5.5 ± 1.1 kg. Mean apnea–hypopnea index after completion of distraction was 1.1 ± 1.5 events/hour. Two (8%) patients experienced postoperative respiratory events that required intervention. In 1 (4% of sample) of these, the event was deemed to have benefited from ICU-level care. Two variables were significantly associated with these events: congenital heart disease ( P = .020) and concomitant procedure performed during the same operation ( P = .020). Conclusions: Intensive care unit–level care is rarely needed after distractor removal in infants with RS. Intensive care unit admission should be considered in patients with congenital cardiac disease and when having multiple operations during the same anesthetic.