EP.WE.555Impact of COVID 19 on Renal access surgery

Aims To assess the impact of COVID -19 on renal access surgery. Methods Electronic patient records and renal ware were accessed to obtain data of all renal access activity during the COVID period. Results There as a shutdown of all elective activity which affected the renal access surgery as well. No new Arterio venous fistulas (AVFs) were created in the time period 14 March to 05th May 2020. No pre-fistula mapping scans were performed. All new starters started with a tunneled dialysis line. In the recovery phase special theatre sessions were asked for and procedures carried out in Day surgery and in independent sector (n-18). A total of 203 new AVF’s were created compared to 272 the year before a fall of 25%. There were 48 patients admitted with blocked access, 70% of whom underwent radiological intervention compared to 52% in 2019. Surgical intervention was offered to just 4% compared to 25% in 2019. The number of access abandoned was 27% in 2020 vs 19% in 2019. Conclusion COVID-19 adversely affected the renal access population and none of the British Renal access surgery targets were met for 2020.

Combined Surgical/Interventional-Radiological Cytoreduction in a Patient with Disseminated Highly Differentiated Neuroendocrine Ileal Tumor

A combined approach to cytoreduction in a patient with a neuroendocrine tumor G1 the ileum with multiple bilobar metastases G2 in the liver, originally considered as a candidate only for drug therapy, has been demonstrated. The first stage was laparoscopic resection of the ileocecal segment of the intestine, followed by interventional radiological intervention — a two-stage selective transarterial oil chemoembolization of the liver with bleomycin. As a result, 90 % cytoreduction, suppression of clinical manifestations, normalization of chromogranin A and serotonin were achieved. The patient continues to be observed without signs of progression for more than 4 years from the moment of diagnosis. It is shown that multidisciplinary treatment of patient with timely inclusion of interventional-radiological interventions allows achieving long-term favorable results in patients with advanced stage of disease.

778 Management of Colorectal Anastomotic leaks: The East of England Experience

Introduction Colorectal anastomotic leaks (AL) are an unfortunate occurrence and are associated with a high mortality. The aim of this multi-centre study is to explore the different management strategies used and compare outcomes in the management of AL. Method All patients who had an AL were included at seven hospitals across the East of England. Morbidity, mortality, and survival were compared across the different management strategies. Results A total of 247 consecutive patients were included of which 60.3% were male and the median age was 68 (IQR 57-77). Half of patients were initially managed conservatively, a further 10.5% had a radiological procedure. 39.7% required surgery as an initial treatment. Of those who initially did not have a surgical intervention (n = 149), 10.7% (n = 16/149) eventually required laparotomy. Ultimately, 42.7% (n = 106/248) required a laparotomy. The 30- and 90-day across the entire population mortality were 3.6% and 4.9% respectively. There were no significant differences in mortality or long-terms survival between the different initial treatment modalities. Conclusions Despite initial conservative, antibiotic and radiological intervention being successful in the majority of patients, two out of five patients will still require a laparotomy. A consensus approach is required to standardise management in these difficult scenarios.

697 An Evaluation of Patient Outcomes Following Percutaneous Cholecystostomy (PC) For Acute Cholecystitis (AC) At Our Health Board Between 2011-2020

Introduction PC is a radiological intervention used in the management of high-risk patients with AC. Method A retrospective study of outcomes following PC, including success rates, complications, AC resolution, readmissions, and subsequent cholecystectomy. Results Our database identified 28 patients (14M:14F), median age 73 (range 40-93). 82% were ASA III/IV. Median follow-up was 2 (range 0-8) years. Imaging suggested AC in 61% and empyema in 39%. 86% were calculous. All procedures were USS-guided with 100% success. AC resolution occurred in 89.3%. Of three unresolved, there was 1 death day-1 post-PC (non-procedure related), 1 index cholecystectomy, 1 chronic complicated cholecystitis. 28.6% developed complications, 2 major (1 late biliary peritonitis and 1 cholecystocutaneous fistula with abdominal wall abscess), 17.9% dislodged drain, 10.7% other. 20 patients had bile cultures (70% positive, mainly gram-negative). 17.9% patients were readmitted with AC, 1 had repeat PC. 21.4% had subsequent ERCP. 32.1% underwent subsequent cholecystectomy, 1 laparoscopic cholecystectomy(LC) index, 4 elective (3 LC, 1 open), 4 emergency (2 LC, 1 LC subtotal, 1 failed open with drain insertion). Conclusions PC is both safe and effective with significant procedural success rates and resolution rates. There are few major complications but significant morbidities, mainly dislodged drains. One-third of patients have subsequent cholecystectomy.

Early dynamic changes in circulating tumor cells and prognostic relevance following interventional radiological treatments in patients with hepatocellular carcinoma

The aim of this study was to investigate the dynamic changes of circulating tumor cells (CTCs) in patients with hepatocellular carcinoma (HCC) before and immediately after conducting a microwave ablation (MWA) and conventional transarterial chemoembolization (C-TACE). Additionally, the CTCs short-term dynamics were compared with the clinical course of the HCC-patients. Blood samples from 17 patients with HCC who underwent MWA (n = 10) or C-TACE (n = 7) were analyzed. Venous blood was taken before and immediately after the radiological interventions to isolate and quantify CTCs using flow cytometry. CTCs were identified as CD45- and positive for the markers ASGPR, CD146 and CD274 (PD-L1). Patients were followed of up to 2.2 years after the radiological intervention. CTCs were detected in 13 HCC patients (76%) prior to the radiological interventions. The rate of CTCs was significantly decreased after the intervention in patients treated with MWA (0.4 CTCs/mL of blood, p = 0.031). However, no significant differences were observed in patients who received C-TACE (0.3 CTCs/mL of blood, p = 0.300). Overall, no correlation was found between the CTCs rate before and after the radiological intervention and recurrence rate of HCC. This preliminary data could confirm the tumoricidal effects of MWA in patients with HCC by significantly decreasing CTCs rate. In our study, we were able to detect CTCs in HCC patients using 3 different tumor markers. This preliminary data shows significant lower CTCs detected in response to MWA. However, large-scale randomized clinical trials are needed to determine the future role and the prognostic relevance of CTCs following this treatment.

Complete embolisation of the proper hepatic artery for delayed haemorrhage after pancreaticoduodenectomy: a case report

Postpancreatectomy haemorrhage (PPH) is a rare and life-threatening complication that can occur after pancreaticoduodenectomy (PD). Recently, radiological intervention has become a first-line approach for the diagnosis and treatment of late PPH in haemodynamically stable patients. Surgical intervention should be performed in haemodynamically unstable patients. We report the case of a 54-year-old man who underwent PD for ampullary carcinoma. On postoperative day (POD) 20, he developed a late PPH in the context of pancreatic fistula that was accompanied by hypotension and tachycardia. Therefore, emergency relaparotomy was performed, but the bleeding site was not detected due to severe adhesions in the surgical field. Thus, urgent angiography was performed immediately, and active bleeding was detected from the distal part of the proper hepatic artery. Coil embolisation of the proper hepatic artery trunk was successfully performed. No intrahepatic abscess or liver failure was subsequently observed, and the patient left our hospital on POD 27. This case shows that radiological intervention is a first choice for the diagnosis and treatment of haemodynamically stable late PPH and that it also might still be a first choice and also be safer and more effective than surgical intervention even with unstable haemodynamics.

COVID patients encountered by a general surgeon- 6 unique scenarios.

Background and Objectives :With rising demand of surgical interventions post lockdown due to Corona Virus Infectious Disease(COVID)-19, surgeons need to restart their surgical practice shortly. To increase caution and safety, six scenarios in which a surgeon may encounter COVID patients are hereby highlighted in the present study.Patients and Methods:A hospital based case series analysis of eight surgical patients admitted in past two months was done. Clinical and radiological records of these patients were studied separately and concluded consensually by two surgeons.Results:Six unique scenarios were identified:1. COVID positive patient, with concurrent surgical pathology.2. COVID positive patient incidentally diagnosed with additional surgical pathology.3. A solely surgical patient mimicking COVID positive symptomatology.4. A COVID negative surgical patient acquiring nosocomial COVID infection postoperatively.5. COVID positive surgical patient with false negative COVID report.6. COVID suspected by intraoperative COVID specific intestinal findings and then getting postoperative COVID test positive for the patient.Interpretations:· Deferrable surgeries to be avoided· A stringent institutional protocol for all patients is the essence of current surgical practice.· Minimal surgical or radiological intervention should be sought whenever possible.· The bias towards COVID, should not let us miss a surgical pathology in patients mimicking COVID clinically.· The possibility of a false negative COVID test, should be kept in mind in patients with typical COVID like symptomatology.· Immunocompromised surgical patients susceptible to nosocomial COVID infections should be dealed with extra caution and precaution.

Hepaticojejunostomy for Benign Disease: Long-Term Stricture Rate and Management

The objective of the study was to determine the long-term stricture rate of hepaticojejunostiomy (HJ) performed for benign disease, to compare stricture rates for transplant patients and non-transplant patients, and to compare the success rates of procedural and surgical treatment options. Hospital charts of 135 consecutive patients undergoing HJ between 1998 and 2016 were analyzed retrospectively. The primary outcome was stricture formation. Secondary outcomes were time to stricture diagnosis and success rates of various interventions. The anastomotic stricture rate was 13.3 per cent (18). The mean follow-up period was 4.3 years. The mean time to stricture diagnosis was 2.3 years. Stricture rates were similar between the transplant (19.2%) and nontransplant, non-Whipple group (13%). Strictures were treated with radiological intervention with a 44.4 per cent success rate; each required multiple interventions. Mortality from liver disease after failure of nonoperative management of HJ strictures reached 30 per cent (3). Five of ten patients who failed radiological intervention underwent HJ revision; the success rate was 80 per cent. Anastomotic strictures of HJ performed for benign disease occur in 13 per cent of patients and typically develop within 2.5 years postoperatively. Yet, given the dangerous sequelae of chronic biliary obstruction and potential delay in presentation, a follow-up is recommended for up to 10 years. When strictures occur, HJ revision should be considered early, after two failed radiological interventions.