Initial Experience of Self-Expanding Metal Ureteral Stent in Recurrent Ureteral Stricture After Ureteroplasty

Background: The aim of this prospective study was to assess the safety and effectiveness of self-expanding metal ureteral stent (MUS) for the treatment of recurrent ureteral stricture after ureteroplasty.Methods: We prospectively included 24 patients who underwent MUS implantation between February 2019 and August 2020. The inclusion criteria for the procedure were recurrent ureteral strictures after ureteroplasty. A paired T test was used to compare continuous variables before and after surgery.Results: A total of 24 patients were finally included in this study. The stricture site was most common on the proximal ureter 19 (79.2%), followed by distal ureter 4 (16.7%) and middle ureter 1 (4.2%). The median length of ureteral stricture is 2.5 (range 1–18) cm. The median operative time was 51.5 min, and the median hospital stay time after surgery was 3 days. Post-operative complication included pain 1 (4.2%), urinary tract infection 2 (8.3%) and hematuria 2 (8.3%). After a median follow-up of 12 months, 19/24 (83.3%) patients were clinically and radiologically successful. We endoscopically adjusted or exchanged the failed stents. The volume of hydronephrosis (124.7 ± 132.5 vs. 66.4 ± 73.2 cm3, P = 0.015), blood creatinine level (104.5 ± 45.4 vs. 80.1 ± 23.2 μmol/L, P = 0.044) and urea nitrogen level (6.9 ± 2.4 vs. 4.8 ± 1.5 mmol/L, P = 0.003) decreased significantly after a median follow-up of 12 months.Conclusions: MUS is a safe and effective way to manage recurrent ureteral strictures after ureteroplasty. This technique provides a new choice for the treatment of recurrent stricture.

P-O17 The Royal Stoke Green Pathway: a method to undertake safe UGI surgery during the COVID pandemic

Background During the first wave of the COVID pandemic surgical services we paralysed globally, with cancellation of an estimated 28-million operations during the first 12 weeks. Worryingly, surgical patient with COVID were reported to have unacceptably high peri-operative mortality, approaching 25%. However, there was an urgent clinical need to progress with category 1 and 2 operations, to prevent disease progression and avoidable morbidity and mortality from non-COVID pathologies. During the second and subsequent waves of the pandemic it was vital to protect patients from peri-operative COVID whilst undertaking urgent surgery safely. Methods Our centre developed a ring-fenced 'Green Pathway' for category 1 and 2 patients requiring surgery. Patients were treated in physically separate area of the hospital, with no interaction between COVID and non-COVID patients, healthcare staff or facilities. Patients self-isolated for 14-days prior to admission, and had pre- and peri-operative COVID RT-PCR tests. We assessed outcomes for patients immediately prior to the introduction of the Green Pathway (1/10/2020) and following implementation (31/12/2020) to assess safety. Textbook outcomes for pancreatoduodenectomy were compared to assess safety and quality. Other data suggests that UGI surgery couldn't continue in other hospitals from December 2020. Results There were 47 admissions to surgical HDU following category 1 and 2 upper GI operations during the study; 31 pre-pathway (PP) implementation, and 16 green pathway (GP) patients. Median age 66-years (43-78 range) PP vs 65-years (range 42-74) GP, median ASA 3 vs 2. Median HDU length of stay (LOS) 5-days vs 7-days, and median hospital LOS 11.5-days vs 9-days for PP vs GP respectively. There were 6 cases of peri-operative COVID in PP cohort, and 1 in GP (contract following discharge). There was no mortality within either cohort. For the subgroup of patients undergoing PD: 10 patients PP, 6 patients GP, textbook outcomes were achieved in 90% vs 67% PP vs GP. Conclusions The implementation of the Green Pathway at our institution enabled continuation of surgery for patients with category 1 and 2 operations during the COVID pandemic with a significant reduction in peri-operative COVID infection, no mortality and no increase in length of stay. The TO rate was lower with the GP (not statistically significant), but our 4-year institution TO rate is 70.3%, comparing favourably to other studies. This pathway has enabled safe continuation of urgent surgery during the pandemic and could be a model for adoption in other centres especially if there is resurgence of COVID cases during the coming winter.

Comparison of Staging Laparoscopy for Peritoneal Metastases with or without Pressurized Intra-Peritoneal Aerosol Chemotherapy (PIPAC)

Background Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has been introduced for palliative treatment of peritoneal cancer (PC) and is currently tested also in the neoadjuvant and prophylactic setting. The aim was therefore to compare safety and tolerance of staging laparoscopy with or without PIPAC. Methods This retrospective analysis compared consecutive patients undergoing staging laparoscopy alone for oesogastric cancer with patients having PIPAC for suspected PC of various origins from January 2015 until January 2020. Safety was assessed by use of the Clavien classification for complications and CTCAE for capturing of adverse events. Pain and nausea were documented by use of a visual analogue scale (VAS: 0-10: maximal intensity). Results Overall, 25 PIPAC procedures were compared to 24 in the laparoscopy group. PIPAC procedures took a median of 35 min (IQR: 25-67) longer. Four patients experienced at least one complication in either (p=0.741). No differences were noted for postoperative nausea (p=0.961) and pain levels (p=0.156). Median hospital stay was 2 (IQR: 1-3) for PIPAC and 1 (IQR: 1-2) for the laparoscopy group (p=0.104). Conclusions The addition of PIPAC did not jeopardize safety and postoperative outcomes of staging laparoscopy alone. Further studies need to clarify its oncological benefits.

Abstract 13658: Characterization of Acute Respiratory Distress Syndrome in Post-Cardiac Arrest Patients

Introduction: Acute respiratory distress syndrome (ARDS) may be precipitated by cardiac arrest, but the incidence and epidemiology of post-arrest ARDS is not well characterized in the in-hospital cardiac arrest (IHCA) setting. This study aimed to describe the incidence of ARDS after IHCA and ARDS-associated IHCA outcomes. Methods: This was a single-center retrospective study of adult patients admitted to the hospital between 2017-2018 who suffered IHCA, were resuscitated, and were intubated within 2 hours of arrest. Patients who died or were extubated on the day of resuscitation and those with pre-arrest ARDS were excluded. Post-IHCA ARDS was defined as meeting the Berlin criteria in the first 3 days after the cardiac arrest. Outcomes included hospital length-of-stay and hospital mortality. Results: Of the 105 patients included, 78 (74.3%) developed ARDS within 3 days of arrest. The mean PaO2:FiO2 ratio was 222 (SD 105). Of those with ARDS, most had mild (32%) or moderate (41%) disease. Patients with ARDS had a median hospital and ICU length of stay of 17 (IQR: 8, 31) and 7.5 (IQR: 3, 16) days compared to patients without ARDS, who had a median hospital and ICU length of stay of 10 (IQR: 7, 19) and 5 (IQR: 3, 11) days (p>0.1 for both comparisons). There was a higher use of midazolam in patients with ARDS (18% vs 4%), but this was not statistically significant (p=0.1). Conclusion: There is a high incidence (74%) of post-arrest ARDS in IHCA patients. This compares to recent estimates suggesting a post-arrest ARDS incidence of approximately 50% in the out-of-hospital arrest population. While there was no statistically significant difference in outcomes, this study was limited by a small sample size. Future studies should further investigate these relationships in a larger cohort.

Epidemiology and Predictors of Readmission in CAR T-Cell Therapy Recipients

Background: CAR (chimeric antigen receptor) T-cell therapy is a novel form of immunotherapy that utilizes genetically altered autologous T cells to target cancer cells. Since the first FDA (Food and Drug Administration) approval in August 2017, several CAR T-cell products have been approved for the treatment of various malignancies. Due to the recent approval, large-scale epidemiologic data are lacking. This study aims to characterize the epidemiology of hospitalizations for CAR T-cell therapy, readmissions, and factors associated with all-cause-30-day readmission. Methods: We performed a retrospective cohort study using the Nationwide Readmissions Database (NRD) for 2017 & 2018 to identify hospitalizations with CAR T-cell therapy administration utilizing the ICD-10-PCS (International Classification of Diseases, Tenth Revision, Procedure Coding System) codes XW033C3 & XW043C3. These admissions were further categorized into non-Hodgkin's lymphoma, leukemia, and multiple myeloma. Descriptive analysis was performed to compare demographics, hospital characteristics, various comorbid conditions, and complications between these groups. We identified primary diagnoses at readmission and all-cause 30-day readmission rate after excluding index admissions from December and deaths during index admissions. Multivariable logistic regression was used to elucidate factors associated with all-cause-30-day readmission. The analysis was carried out to produce national estimates after applying weights, and the methodology provided by the HCUP (Healthcare Cost and Utilization Project) was utilized. Results: Out of 1,322 CAR T-cell therapy admissions in 2017-2018, 909 had a diagnosis of non-Hodgkin's lymphoma, 154 had multiple myeloma, and 128 had leukemia. The median age of those with leukemia was lowest at 26 (10-42) years, followed by multiple myeloma and non-Hodgkin's at 59 (57-61) years and 63 (61-64) years, respectively (p<0.001). The majority of CAR T-cell recipients were males (63%), admitted to teaching hospitals (97.96%), had private insurance (53.01%), and belonged to the highest income communities (34.95%). The median length of stay was longest for leukemia, followed by multiple myeloma and non-Hodgkin's (18 days vs. 16 days vs. 15 days; p<0.001). Median hospital charges were highest for non-Hodgkin's, followed by leukemia and multiple myeloma ($702,484 vs. $313,366 vs. $185,854; p<0.001). Overall mortality during index hospitalization was 2.98%. The complete baseline characters are described in table 1. A total of 316 hospitalizations (25%) were readmitted within 30 days. The median time to readmission was 9 days, the median length of stay during readmission was 5 days, and crude in-hospital mortality during readmission was 3%. Readmission incurred an additional median hospital charge of $58,568. The top five diagnoses at readmission were malignancy & therapy-related (23%), sepsis or infection (19%), neurologic events (19%), neutropenia or pancytopenia (13%), and fever or hypotension (8%) (figure1). On multivariable logistic regression for predictors of 30-day readmission, admission to public hospital (aOR {adjusted odds ratio} 2.01, p 0.027), transfer to a skilled nursing facility or intermediate care facility at discharge (aOR 2.59, p 0.001), and chronic renal disease (aOR 1.47 p 0.027) were associated with higher odds of readmission. Admission to a large metro hospital (aOR 0.63 p 0.047) and teaching hospital (aOR 0.59 p 0.012) were associated with reduced odds of readmission (figure2). Conclusion: As CAR T-cell therapy has recently been added to the cancer treatment arsenal, we describe that it is associated with strikingly high hospital charges, and a quarter of recipients are readmitted within the first 30 days. Figure 1 Figure 1. Disclosures Deol: Kite, a Gilead Company: Consultancy.

613. Clinical Outcomes Following Dalbavancin Administration during Outpatient Parenteral Antimicrobial Therapy

Background Dalbavancin, a lipoglycopeptide with prolonged half-life targeting Gram-positive organisms, is approved for treatment of acute bacterial skin and soft tissue infection. It reduces hospital duration in patients with barriers to short-term rehabilitation or outpatient parenteral antimicrobial therapy (OPAT). Increasing evidence supports the off-label use of dalbavancin to treat other types of infection. We conducted a quality improvement study to evaluate outcomes following dalbavancin administration. Methods We performed a cohort study of recipients of ≥1 dose of dalbavancin from 1/31/2016-1/31/2021 at the Veterans Affairs Connecticut Healthcare System. Demographic, comorbidity, microbiological, antibiotic duration prior to dalbavancin, indication for dalbavancin, and type of infection data were collected. Outcomes included 1) lab abnormalities: hepatotoxicity within 2 weeks of dalbavancin; 2) clinical cure: resolution of symptoms of infection within 90 days; 3) all-cause readmission within 90 days; and 4) all-cause mortality within 90 days. Results 42 patients met criteria. Median age was 69 years (range, 32-91), 100% were male, 55% (n=23) had diabetes, 31% (n=13) had liver disease, 36% (n=15) had other immunosuppressive conditions, and 12% (n=5) had substance use disorder (SUD). All received their first dose as inpatients. Median hospital duration was 8 days (range, 1-32). 4 (10%) required critical care. Median antibiotic duration prior to dalbavancin was 7 days (range, 1-42). Indications included ineligibility for OPAT (n=21, 50%), pharmacologic reasons (n=10, 24%), ineligibility for peripherally inserted central catheter (n=6, 14%), or SUD (n=5, 12%). Common microorganisms were Staphylococcus spp. (n=22, 52%), polymicrobial (n=13, 31%), and Corynebacterium spp. (n=10, 24%). 93% (n=39) had clinical cure of infection; readmissions and mortality were rare (Table 1). Conclusion Dalbavancin was associated with clinical cure for diverse infections with low rates of adverse events, readmission and mortality in patients ineligible for traditional OPAT. Although confirmatory data are needed from larger studies, dalbavancin appears to be a versatile therapeutic agent for Gram-positive infections. Disclosures All Authors: No reported disclosures

617. Long Acting Lipoglycopeptide Use in Veterans for Serious Gram-Positive Infections in the COVID Era

Background Dalbavancin and Oritavancin are semisynthetic lipoglycopeptides (LGP) that are FDA-approved for treatment of skin and soft tissue infections, but emerging data supports LGP use for other serious gram positive (GP) infections. We describe our experience with LGP during the COVID-19 pandemic. Methods We initiated a quality improvement project to assess the use of LGP for label and off-label indications at the Atlanta Veterans Affairs Health Care System. We define serious GP infections as infective endocarditis, osteomyelitis, joint infections, or bacteremia. Patients with serious GP infections that receivedLGP were selected at the treating physician's discretion. We reviewed medical records of all patients receiving at least one dose of long-acting LGP from March 1, 2020 - May 31, 2021. We described patient demographics, clinical information,and outcomes (90-day readmission). Results Nineteen patients with GP infections received LGP (table). Overall, the most common infection was cellulitis 7 (35%); 14 patients received LGPs for serious GP infections. All patients received at least one other non-LGP antibiotic for at least 2 days, majority vancomycin (60%) and cefazolin (30%). Overall, the median hospital stay among patients who received LGP was 8.5 days (range: 2-45 days), for those with serious GP infections the median hospital stay was 15 days (range: 4-45). 90% of patientswho received LGP were discharged home. Number of LGP doses ranged from 1 to 6 doses total, based on type of infection. Sixteen veterans (80%) followed up in outpatient clinicfollowing discharge within 2 weeks, two patients were discharged to home hospice due to complications of underlying malignancies and two patients were lost to follow up. Noadverse drug events were reported, and none with serious GP infections required rehospitalization at 90 days. Conclusion Our experience suggests that long-acting LGP may be valuable tools to treat serious gram-positive infections by optimizing theduration of hospitalization and preventing unnecessary admissions to acute care and nursing facilities for daily antibiotic infusions. These aspects of LGP use are especially important during the COVID-19 pandemic where nosocomial transmission has been documented. Disclosures All Authors: No reported disclosures

Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies

Purpose The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies. Methods A prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series. Results Twenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured. Conclusion Ligation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.

Lactate based Scoring System in the diagnosis of necrotizing fasciitis

Introduction Necrotizing fasciitis (NF) is a rare and quickly progressing infection and leads to 100% mortality if untreated. Quick diagnosis and an early and radical surgical treatment are essential for stopping bacterial progression. Unfortunately, the absence of clear clinical signs makes the diagnosis often challenging. Therefore, we searched for easy determinable predictive laboratory markers for NF. This is the first study which includes lactate values in a new score. Material and Methods A retrospective analysis of patients with NF (n = 44) and patients with erysipelas (n = 150) was performed. Lactate values, patients` demographics, clinical presentations, site of infection, comorbidities, microbiological and laboratory findings, antibiotic therapies and LRINEC and modified LRINEC Scores were analyzed. Logistic regression analysis was used to derive adjusted weights, and final simple point score was assessed with a ROC curve analysis. Results Patients with NF had a mean age of 57 years, patients with erysipelas 65 years. The median hospital length of stay was 8 and 49 days in patients with erysipelas and NF, respectively. While only one patient (0.7 %) in the group of erysipelas died, the mortality rate of patients with NF was 9/44 (20.5 %). The lactate values were statistically significant higher in the NF group 4.1 vs. 2.0 mmol/l (p < 0.001). The new created CologNe-FaDe-Score shows the highest AUC-value with 0.907. Conclusion With the help of lactate values the CologNe-FaDe-Score consists of easily practicable and highly available parameters, which could sensitize diagnosis.

Radical Hemiscrotectomy and En Bloc Orchidectomy: Surgical Technique and Perioperative and Oncologic Outcomes of a Supra-Regional UK Referral Centre

Background and Purpose Hemiscrotectomy with en bloc orchidectomy represents a radical primary, completion, or salvage option in men with inguinoscrotal cancers. We describe our surgical technique and peri-operative and oncological outcomes. Patients and Methods Retrospective cohort study of 16 men treated at a supra-regional referral centre with open radical hemiscrotectomy with or without en bloc orchidectomy between 2010 and 2020. Peri-operative and survival outcomes were analysed. Results Radical hemiscrotectomy with or without en bloc orchidectomy was performed on 16 patients comprising 7 well-differentiated liposarcomas, 4 dedifferentiated liposarcomas, 2 leiomyosarcomas, 1 mesothelioma, 1 rhabdomyosarcoma and 1 mammary type myofibroblastoma. Primary hemiscrotectomy was performed in four, completion hemiscrotectomy in nine and salvage hemiscrotectomy in three. The median hospital stay was 2 days [interquartile range (IQR) 2–4]. Four patients (25%) had post-operative complications including wound infection or haematoma. During a median follow-up of 18 months (IQR 2–66), one patient (6%) died following a recurrence in the pelvis and retroperitoneum. Discussion and Conclusions If careful dissection is performed, radical hemiscrotectomy and en bloc orchidectomy is a radical but safe procedure with a short hospital stay. Haematoma and infection represent the main complications, and within limited follow-up most men showed no recurrence.