Preoperative Ultrasonography in the Evaluation of Suspected Familial Non-Medullary Thyroid Cancer: Are We Able to Predict Multifocality and Extrathyroidal Extension?

Family history of thyroid cancer increases the risk of harboring thyroid malignancies that end up having extrathyroidal extension (ETE) and multifocality on histology; some authors suggest a more aggressive surgical approach. Their pre-operative identification could allow more conservative surgical procedures if none of these features are suspected. Our aim was to assess if neck ultrasonography could identify or exclude multifocality or ETE in these patients to tailor the extent of surgery. This retrospective study included patients with previous thyroid surgery, ≥1 first-grade relative with thyroid cancer, and who had undergone pre-surgical ultrasound. ETE was suspected in the case of thyroid border interruption or gross invasion of perithyroidal tissues. Multiple suspicious nodules were defined as suspicion of multifocal cancer. The cohort consisted of 45 patients (median age 49 years, 40 with thyroid cancer, 30 females). The positive predictive value of ultrasonography in predicting multifocality and ETE was 57.14% (25.25–84.03) and 41.67% (21.5–65.1%), respectively, while the negative predictive values were 63.2% (56.4–69.4%) and 72.7% (63.3–80.5%). Pre-operative ultrasound examination is unable to reliably identify or exclude multifocal disease or extrathyroidal extension. In patients scheduled for surgery and with a first-degree relative affected by DTC, a “negative” pre-operative US report does not exclude the potential finding of multifocality and ETE at final histopathology.

TP5.2.4 Patency of radiocephalic versus brachiocephalic arteriovenous fistula in a major tertiary hospital

Introduction The patency of brachiocephalic fistulae is generally considered to be superior to radiocephalic fistulae. We have explored this in a major tertiary hospital. Method This was a retrospective review of fistulae created between 1st January 2015 and 31st July 2020. Index cases were identified from a prospectively maintained vascular access database. Patient demographics, procedure details and subsequent interventions are described. Results There were 915 fistulae created on 813 patients (528 males and 285 females). There were 388 radiocephalic fistulae created on 374 patients and 363 brachiocephalic fistulae were formed on 301 patients. Both groups had 315 fistulae with patency data available. Age and a diagnosis of diabetes were comparable. There were significantly fewer female patients in the radiocephalic cohort (p = 0.004). Primary patency at 3 months, 1 year and 3 years were 84.6%, 58.1% and 37.9% for radiocephalic and 87.9%, 63.1% and 37.0% for brachiocephalic fistula (p = 0.273). Primary assisted patency at 3 months, 1 year and 3 years were 92.3%, 87.0%, 77.4% for radiocephalic and 96.1%, 88.6%, 79.9% for brachiocephalic fistulas (p = 0.295). Secondary patency at 3 months, 1 year and 3 years were 93.3%, 88.3% and 81.5% for radiocephalic fistulas and 97.4%, 90.6% and 85.7% for brachiocephalic fistulas (p = 0.134). Conclusion We have demonstrated similar primary, primary-assisted and secondary patency for radiocephalic and brachiocephalic fistulae. Pre-operative ultrasound vein mapping, selective ultrasound surveillance, surgical expertise and careful patient selection may contribute to the high secondary patency and absence of difference between the groups.

EP.FRI.229 The Role of Ultrasound in the Diagnosis of Paediatric Appendicitis

Background Acute appendicitis remains the most common acute surgical presentation among children and adults. Ultrasonography is a commonly used investigation for patients with right iliac fossa pain were the diagnosis is unclear, however in a district general hospital (DGH), appropriate radiologists are not often readily available. The aim of this study was to determine the value of ultrasonography in the diagnosis of appendicitis in children. Methods A retrospective review was carried out of all paediatric patients (aged 5-16), who underwent an appendicectomy in a single acute surgical unit, over a 6 month period. An institutional database and up to date electronic care records were used to record preoperative ultrasound results, intraoperative findings and histopathology results. Results A total of 59 patients were admitted with possible appendicitis within the audit window, 31 of which underwent an appendicectomy, 58% performed laparoscopically. 38.7% underwent pre- operative ultrasound, 33.3% of which identified an acutely inflamed appendix. The remaining patients who did not proceed to theatre were successfully discharged with no re-attendance following a period of observation. Following histopathological confirmation, ultrasonography was found to have a sensitivity and specificity of 100%. Negative appendicectomy rate returned at 6.7%. Conclusion Ultrasonography is a low cost, highly sensitive diagnostic tool in appendicitis, where provisions are in place to do so. Visualising the appendix on ultrasound can reduce negative pathology rates. This is a small study within a DGH and access to ultrasound is limited. Better utilisation or the development of a protected ultrasound slot should be sought.

TP9.2.5Routine ultrasound in paediatric appendicitis is highly accurate and substantially reduces negative appendicectomy rate

Aims Our centre routinely uses ultrasound in adults to confirm diagnosis of appendicitis. This study investigated its use in the diagnosis of suspected appendicitis in children and its impact on management. Methods Retrospective cohort study of children (5-16 years) managed by general surgeons with suspected appendicitis during 2019. Primary outcomes were ultrasound use. Secondary outcomes were diagnosis, length of stay, complications and negative appendicectomy rate. Results A total of 193 children were admitted with suspected appendicitis. The majority underwent an ultrasound scan (169/193 [88%]) which identified an inflammed appendix or secondary-inflammation in nearly all cases of appendicitis (65/71 [91%] and 5/71 [7%] respectively). A normal appendix was identified in more than half of children not diagnosed with appendicitis (53/95 [56%]), with the rest showing an ovarian pathology (3/95 [3%]) or normal scan (39/95 [41%]). Ultrasound had high sensitivity (92% [CI 83-97%]) and specificity (100% [CI 96-100%]) for appendicitis. The majority of children diagnosed with appendicitis were treated with laparoscopic appendicectomy (75/85 [88%]) and a minority medically-managed (10/75 [12%]). One appendix mass was medically-managed, and two Meckels Diverticulitis underwent a laparoscopic small bowel resection. Negative appendicectomy rate was extremely low (2/77 [2.5%]). Post-operative complication rate was low (6%). Median length of stay was short for appendicitis and all other diagnoses (2days [IQR 2.2] and 1day [IQR 0] respectively). Discussion The majority of children with suspected appendicitis underwent pre-operative ultrasound, which was highly sensitive and specific for appendicitis. Negative appendicectomy rate was extremely low, and likely related to routine pre-operative imaging.

966 Comparison of Lord and Jaboulay Procedure for Hydrocele Repair

Aim Hydrocele is a common surgical pathology with a variety of operative techniques described, including Lord plication and Jaboulay procedure. Whilst current evidence suggests no difference in the recurrence rate between different techniques, the Lord’s procedure is described as having the lowest complication rate. NICE guidelines state all men aged 20 - 40 should receive a pre-operative ultrasound scan. We aimed to audit the complication rate between the two procedures as well as the rate of pre-operative ultrasound assessment. Method A retrospective review of all elective hydrocele repairs was performed within one health board over a 17-month period. All elective patients over the age of twelve and three-quarters were included, with emergency repairs excluded. Patient records were accessed, and data collected including hydrocele side and size, procedure performed, co-morbidities, medication, pre-operative ultrasound, and incidence of immediate and late complications. Results 83 cases were identified. All men aged 20 - 40 received pre-operative ultrasound assessment. 27 (33%) repairs utilised Lord’s technique, whilst 56 (67%) used Jaboulay’s technique. There was no statistical difference in complication rate for all complications (10% vs. 16% p = 0.48), haematoma (3.4% vs. 12% p = 0.16), infection (1.7% vs. 12% p = 0.08) or reoccurrence (1.7% vs 0% p = 1.0) between Jaboulay’s and Lord’s respectfully. Conclusions Analysis in this series showed the complication rate is higher for Lord’s procedure versus Jaboulay’s, however this was not found to be statistically significant. All patients aged 20-40 within our analysis received pre-operative ultrasound assessment.

Risk Factors and Outcomes Following Septostomy during Fetoscopic Surgery for Twin-to-Twin Transfusion Syndrome

Fetoscopic laser photocoagulation (FLP) of placental anastomoses is the preferred treatment for twin-to-twin transfusion syndrome (TTTS). Iatrogenic septostomy (IOS) during FLP is associated with increased risk of neonatal morbidity and mortality. We sought to identify risk factors for IOS and quantify the resultant outcomes. This is a secondary analysis of prospectively collected cases of TTTS in monochorionic diamniotic twins following FLP at a single center. Pre-operative ultrasound characteristics and operative technique (i.e., cannula size, total energy used) were compared between cases with vs. without IOS. Pregnancy and neonatal outcomes were also compared. Of 475 patients that had FLP, 33 (7%) were complicated by IOS. There was no association between operative technique and IOS. IOS was more common with later diagnosis, but less likely when selective fetal growth restriction (sFGR) was present. Survival was similar between groups (76% vs. 76% dual survivors, p = 0.95); however, IOS was associated with earlier delivery (29.7 vs. 32.0 wks, p < 0.01) and greater composite neonatal morbidity (25% vs. 8% in both twins, p = 0.02). Risks of IOS at greater gestational ages without sFGR may be related to a larger collapsed intervening membrane area and the resulting increased risk of puncture on entry.

Validation of Automated Ultrasound-based Registration for Navigated Scaphoid Fixation

Fractures of the scaphoid bone may be treated in a minimally-invasive fashion. Conventionally, fluoroscopy is required to guide the placement of an osteosynthesis screw. In this work, an alternative method based on volumetric ultrasound is validated. Methods: The fully automatic and fast image processing pipeline involves two machine learning architectures for segmentation and registration. A pre-operatively acquired 3D bone model is registered to the 3D bone surface segmented from the intra-operative ultrasound. Screw positioning is planned in an automated fashion and evaluated in an in-vitro setting: Volumetric ultrasound images of a 3D-printed phantom of a human wrist are acquired for 22 different probe poses. For 220 test runs with different initial displacements, the resulting screw placement within a defined safe zone is evaluated. If the screw lies within the safe zone, its placement is assumed to be successful. Results: An isolated analysis of the registration results in a surface distance error of the registered meshes of 0.49 ± 0.01mm, with successful screw placement in all of the evaluated 220 test runs. The full pipeline, combining segmentation and registration, achieves a mean surface distance error of 0.79 ± 0.37mm, leading to successful screw placements for 149 out of 220 test runs. Poses not suited for the registration could be determined. Excluding these from the analysis, 139 out of 160 test runs are successful. Conclusion: The method proves to be promising when evaluating the registration alone, even given the challenging setup of sub-optimal probe positions. The experiments also demonstrate that further improvement regarding the segmentation is necessary.

Technical standardization of ICG near-infrared fluorescence (NIRF) laparoscopic partial nephrectomy for duplex kidney in pediatric patients

Purpose This study aimed to standardize the operative technique of indocyanine green (ICG) near-infrared fluorescence (NIRF) laparoscopic partial nephrectomy (LPN) and compare it with the standard technique. Methods In the last 4 years, we performed 22 LPN (14 right-sided, 8 left-sided) in children with non-functioning moiety of duplex kidney. Patients included 12 girls and 10 boys with a median age of 3.9 years (range 1–10). Patients were grouped according to the use of ICG-NIRF: G1 included 12 patients operated using ICG-NIRF and G2 included 10 patients receiving the standard technique. We standardized the technique of injection of ICG in three different steps. Results The median operative time was significantly lower in G1 [87 min (range 68–110)] compared with G2 [140 min (range 70–220)] (p = 0.001). One intra-operative complication occurred in G2. At post-operative ultrasound (US), the residual moiety was normal in all patients. An asymptomatic renal cyst related to the site of surgery was visualized at US in 8/22 (36%), with a significantly higher incidence in G2 (6/10, 60%) compared with G1 (2/12, 16.6%) (p = 0.001). Renogram demonstrated no loss of function of residual moiety. No allergic reactions to ICG occurred. Conclusion ICG-NIRF LPN is technically easier, quicker, and safer compared with the standard technique. The main advantages of using ICG-NIRF during LPN are the clear identification of normal ureter, vasculature of non-functioning pole, and demarcation line between the avascular and the perfused pole. The main limitation of ICG technology remains the need for specific laparoscopic equipment that is not always available.