P-EGS24 Surgical case series of incarcerated diaphragmatic hernias following oesophagectomy for oesophageal cancer. Single centre experience

Background Incarcerated post-oesophagectomy diaphragmatic hernia (IPODH) is a recognised surgical emergency and potentially hazardous event. Information regarding the natural course for this emergency and guidelines regarding the management were not described clearly in literature. This case series aim to review patients who presented as emergency with IPODH Methods This observation study is conducted at Salford Royal Hospital that has one of the largest oesophago-gastric unit in United Kingdom. A 7-year period (April 2013 - April 2020) retrospective data collection is performed using prospectively maintained database. We reviewed the presentation and management course for all patients who presented as emergency with IPODH. Results We identified 341 patients who underwent oesophagectomies over the seven-year period. Seven patients (2%) developed IPODH which required emergency surgery. All these patients underwent 2 stage oesophagectomies. Out of these, 5 patients had laparoscopic assisted procedure (hybrid), 1 patient had minimally invasive procedure and another patient had open operation. Mean time interval from esophagectomy to the acute incarcerated hernia presentation was 23 months. Only 1 patient developed acute diaphragmatic hernia on day 4 post-oesophagectomy. The incarcerated hernia contents were reported as small bowels (4 patients), gastric conduit (2 patients) and colon (1 patient). Dealing with these acute emergency cases can be difficult as the hernia contents are threatened. Therefore, most of these patients underwent emergency laparotomy, only 1 patient had laparoscopic procedure to repair the incarcerated hernia. Collagen mesh used to repair the defect only in 2 patients, whereas the rest of the patients had the defect repaired with primary sutures only. Conclusions Minimally invasive techniques were associated with a higher incidence of post-oesophagectomy diaphragmatic hernia compared with open techniques. These hernias can lead to a significant and serious risk when they present with incarceration. The risk of the acute manifestation and significant post-repair morbidity support long-term surveillance for post-oesophagectomy diaphragmatic hernia and elective surgical treatment. Laparoscopic repair of non-complicated diaphragmatic hernia is feasible and effective in high-volume centres.

Full-Endoscopic Transforaminal Ventral Decompression for Symptomatic Thoracic Disc Herniation with or without Calcification: Technical Notes and Case Series

Background. Symptomatic thoracic disc herniation is a challenge in spinal surgery, especially for cases with calcification. Traditional open operation has a high complication rate. The authors introduced a modified full-endoscopic transforaminal ventral decompression technique in this study and evaluated its imaging and clinical outcomes. Materials and Methods. Eleven patients with symptomatic thoracic disc herniation who underwent full-endoscopic transforaminal ventral decompression in a single medical center were enrolled. The surgical technique was performed as described in detail. Dilator sliding punching, endoscope-monitored foraminoplasty, and base cutting through the “safe triangle zone” are the key points of the technique. Clinical outcomes were assessed by the modified Japanese Orthopedic Association (mJOA) score for neurological improvement and the visual analogy score (VAS) for thoracic and leg pain. The operation time, hospital stay, and complications were also analyzed. Results. Postoperative magnetic resonance imaging (MRI) revealed good decompression of the spinal cord. The mJOA improved from 7.4 (range: 5–10) to 10.2 (range: 9–11). Axial thoracic pain improved in 8 of 9 patients. Leg pain and thoracic radicular pain improved in all patients. No complications were observed. The average operation time was 136 minutes (range: 70–180 minutes). The average length of hospital stay was 5.3 days (range: 2–8 days). Conclusion. Minimally invasive full-endoscopic transforaminal ventral decompression for the treatment of symptomatic thoracic disc herniation with or without calcification is feasible and may be another option for this challenging spine disease.

P052 EARLY OPERATIVE OUTCOMES OF ENHANCED-VIEW TOTALLY EXTRA PERITONEAL REPAIR(ETEP) FOR VENTRAL HERNIAS

Aim Early operative outcomes of enhanced-view totally extraperitoneal repair (eTEP) for ventral hernias Material and Methods We have retrospectively analysed the date of 41 patients who underwent an eTEP procedure on between November 2018 and April 2021 by a single surgeon and monitored until May 2021. Results During the study period, 29 endoscopic transversus abdominis muscle release and 12 endoscopic Rives-Stoppa techniques were performed to repair incisional (30), umbilical (6), epigastric (3), and spigelian, and parastomal hernias occurred in 1 patient each. The mean age was 68.0 years, mean BMI was 26.4 kg/m2. The hernial orifice centers were as follows: M2 in 7, M3 in 23, M4 in 5, L2 in 4, L4 in 1, and M2 and L2 (2 orifices) in 1 patient. Nine cases of large incisional hernia (width ≥10cm) were included. An average mesh area of 624cm2 was used for an average defect area of 57cm2. Mean operative time, blood loss, and length of hospital stay were 278 min, 5 ml, 6 days, respectively. Only one case was converted to an open operation due to presence of severe adhesions. Postoperative complication consisted of hematoma (n = 1) and a small bowel obstruction due to a tear of the posterior sheath (n = 1). There was no hernia recurrence at mean follow-up of 448 days. No patient reported significant pain at the surgical site at the first postoperative follow up. Conclusions Judging from our short-term results, eTEP approach for ventral hernias can be an attractive option for selected cases.

Spectrum of Complications of Patients with Chronic Kidney Disease on Maintenance Continuous Ambulatory Peritoneal Dialysis: An Experience of Tertiary Nephrology Center in Najaf City-Iraq

BACKGROUND: Chronic kidney disease (CKD), also called chronic kidney failure, is described as gradual loss of kidney function. CKD can progress to end-stage kidney failure, which is fatal without artificial filtering (dialysis) or kidney transplant. Peritoneal dialysis (PD) has a widespread renal replacement therapy with great acceptance because of simplicity, flexibility, and independence. AIM: The aim of this study was to evaluate the complications of continuous ambulatory PD (CAPD) in patients with CKD. METHODS: A cross-sectional study, involved 140 patients, aged between 18 and 80 years old and suffered from CKD under maintenance CAPD in the dialysis unit of the renal center. All data regarding the sociodemographic profile of the patient, vitals, etiological diagnosis, frequency and duration of dialysis, and dialysis-related complications were taken. RESULTS: In the current study, there is a significant difference in the distribution of complications among gender where the female patients had a higher incidence of both infectious and non-infectious complications. The study also reported that there is much lower rate of complications among patients on laparoscope operation in compared with the open operation. In addition, patients with open abdomen PD developed the complications earlier than those with laparoscope maintenance CAPD. CONCLUSION: Peritoneal infection is the most prevalent complication among the other complications in the current study. There is much lower rate of complications among patients on PD in compared with hemodialysis and on laparoscope in compared with the open operation.

TP10.2.1Lessons Learnt in the Management of Acute Appendicitis During the Sars Covid-19 [Cv 19] First Wave

Aims To evaluate the impact of CV19 on surgical technique and patient outcome in management of acute appendicitis during the 1st wave. Method Data was collected on patients presenting with appendicitis to ED. Group A: Jan-March 2020, pre COVID and Group B: April-June 2020: peri COVID Results There was no difference in sex, age and length of stay between groups. In group A [n = 194], 88% had lap appendicectomy vs Group B [n = 98], 97% had an open operation. Group A had a complication rate of 6% [wound infection] with no readmissions. Group B had 31% complication rate [intra-abdominal collection, bleeding, and ileus] requiring readmission. 685 surgical patients attended ED in the first half of 2020 of which 4 % had an appendicectomy. However the method of surgical access in the 1st wave significantly impacted on patient outcome, resource and re-admission rates. Conclusion In our study open appendicectomy undertaken due to concerns around COVID transmission during laparoscopic surgery during the 1st wave, increased rates of complications and readmission thus raising hospital costs and chances of COVID 19 infection in these patients. As a result of this and due to greater confidence in laparoscopic surgery as a whole we have returned to undertaking laparoscopic appendicectomy in the current wave. Further analysis is underway assessing the impact of COVID on all emergency operations undertaken in the 1st wave.

TP6.1.8 Meta-analysis and trial sequential analysis of three-port versus four-port laparoscopic cholecystectomy (Level 1 Evidence)

Aims to compare the outcomes of three-port and four-port laparoscopic cholecystectomy. Methods In compliance with PRISMA statement standards, electronic databases were searched to identify all comparative studies investigating outcomes of three-port versus four-port laparoscopic cholecystectomy. Two techniques were compared using direct comparison meta-analysis model. The risks of type 1 or type 2 error in the meta-analysis model were assessed using trial sequential analysis model. The certainty of the available evidence was assessed using GRADE system. Random effects modelling was applied to calculate pooled outcome data. Results Analysis of 2524 patients from 17 studies showed that three-port and four-port laparoscopic cholecystectomy techniques were comparable in terms of operative time (MD:-0.13,P=0.88), conversion to open operation (OR:0.80,P=0.43), gallbladder perforation (OR:1.43,P=0.13), bleeding from gallbladder bed (OR: 0.81, P = 0.34), bile duct injury (RD: 0.00, P = 0.97), iatrogenic visceral injury (RD:-0.00,P=0.81), bile or stone spillage (OR:1.67,P=0.08), port site infection (OR:0.90,P=0.76) and need for reoperation (RD:-0.00,P=0.94). However, the three-port technique was associated with lower VAS pain score at 12 hours (MD:-0.66,P<0.00001) and 24 hours (MD:-0.54,P<0.00001) postoperatively, shorter length of hospital stay (MD: -0.09, P = 0.41), and shorter time to return to normal activities (MD:-0.79,P=0.02). Conclusions Robust evidence (Level 1 with high certainty) suggests that in an elective setting with uncomplicated cholelithiasis as indication for cholecystectomy, three-port laparoscopic cholecystectomy is comparable with the four-port technique in terms of procedural and morbidity outcomes and may be associated with less postoperative pain, shorter length of hospital stay and shorter time to return to normal activities.

Primary extraskeletal osteosarcoma of sigmoid mesocolon: a case report and a review of the literature

Background Extraskeletal osteosarcoma (ESOS) is a rare mesenchymal malignancy, which produces osteoid, bone, or chondroid material and is located in the soft tissue without attachment to skeletal bones and periosteum. One of the things that ESOS originated from mesentery is much rarer. Case presentation A 75-year female had a history of pain in the left lower abdomen for more than 4 months. Abdominal computerized tomography (CT) and magnetic resonance imaging revealed a large, irregular, and solid-cystic mass (largest diameter was 11.5 cm). The tumor was radically removed during an open operation. It was composed of abundant osteoid and polyhedral-shaped tumor cells with high atypia and high mitotic activity microscopically. The final pathological diagnosis was osteoblastic osteosarcoma, arising from the sigmoid mesocolon with negative margins. A 9-month follow-up by CT exhibited signs of peritoneal metastasis. Conclusions Given the rarity of cases of mesenteric ESOS, diagnosis mainly depended on pathology findings or should be taken into consideration when the mesenteric mass was found. Its most effective treatment had not been determined, with surgical excision being generally accepted. Ensuring negative surgical margins may be an important factor affecting prognosis.

Trends and Factors Impacting Healthcare Charges and Length of Stay for Cholecystectomies: A New York State Population-based Analysis

Background: Gallbladder disease confers a significant economic toll on the United States healthcare system. This study aims to characterize current trends and features of the cholecystectomy population and identify factors that influence the length of stay and total charges. Methods: Case information was extracted for laparoscopic and open cholecystectomies from 2013-2016 using the New York Statewide Planning and Research Cooperative System (SPARCS) database. Descriptive, comparative, and multivariable linear regression analysis was conducted on 58,141 cases assessing age group, race, gender, admission presentation, surgical technique, insurance status, year of operation and severity of illness by the length of stay and total charges. Results: Of all procedures, 91.6% were laparoscopic, and 79.4% were emergent on admission. Total procedures trended down, while laparoscopic and emergent cases steadily increased (p<0.0001). Total charges increased during the study period, while the length of stay decreased (p<0.0001). Open and emergent procedures were associated with a higher cost and longer inpatient stays (p<0.0001). Open procedures were proportionally more common among elderly, male patients, and elective cases (p<0.0001). Emergent presentation was more common in females, non-whites, and younger patients (p<0.0001). Regression model showed that male gender, open operation, Black race, and emergent presentation were independent predictors for a longer stay and greater total charges (p<0.0001). Medicare insurance predicted lower total charges but longer length of stay (p<0.0001). Conclusion: Race, insurance, procedure type, and patient presentation influence hospital charges and stays following cholecystectomy. Understanding these trends will allow policymakers and providers to limit the healthcare burden of cholecystectomy.

Short-term clinical and oncological outcomes after single-incision plus one-port laparoscopic surgery for rectosigmoid cancer: a retrospective clinical analysis of 30 cases

Objective To evaluate the safety and feasibility of single-incision laparoscopic surgery+1 (SILS+1) radical resection of sigmoid and upper rectal cancer. Methods The clinical data of 30 consecutive patients with sigmoid and upper rectal cancer who underwent SILS+1 radical resection between October 2018 and January 2020 in our hospital were retrospectively analyzed. An initial 5-cm periumbilical transverse incision was made. Then, a multiport device was placed in the umbilical incision. Two 10-mm ports were used for laparoscope insertion, and the other two ports were used for laparoscope device insertion. A 12-mm trocar was placed in the right lower abdominal quadrant under laparoscopic view and served as the surgeon’s dominant operating channel. Results All operations were performed successfully without conversion to conventional laparoscopic surgery or open operation. Three patients developed postoperative complications: one patient developed ileus, one developed postoperative bleeding, and one developed wound infection. There were no perioperative deaths. Conclusions The safety and feasibility of SILS+1 radical resection of sigmoid and upper rectal cancer was established by experienced surgeons in our study. However, further studies are needed to demonstrate the advantages of this procedure compared with the benefits of conventional laparoscopic surgery.