P-BN26 The effect of cholecystectomy on unplanned admissions following endoscopic sphincterotomy and bile duct stone removal

Background Choledocholithiasis is common, with patients usually treated with ERCP and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focussed on recurrent CBD stones, negating the risks of cholecystectomy. Methods Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James’s University Hospital January 2015 - December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated. Results 844 patients received ERCP and CBD clearance with 3.9 years follow up. 209 patients underwent cholecystectomy with 15% requiring complex surgery. 373 patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive. Conclusions The majority of patients do not require readmission following ERCP for CBD stones and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but difficult biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.

Cancer follow-up supported by patient-reported outcomes in patients undergoing intended curative complex surgery for advanced cancer

Background and aim Patient activation (PA) and Patient Involvement (PI) are considered elements in good survivorship. We aimed to evaluate the effect of a follow-up supported by electronic patient-reported outcomes (ePRO) on PA and PI. Method From February 2017 to January 2019, we conducted an explorative interventional study. We included 187 patients followed after intended curative complex surgery for advanced cancer at two different Departments at a University Hospital. Prior to each follow-up consultation, patients used the ePRO to screen themselves for clinical important symptoms, function and needs. The ePRO was graphically presented to the clinician during the follow-up, aiming to facilitate patient activation and involvement in each follow-up. PA was measured by the Patient Activation Measurement (PAM), while PI was measured by five indicator questions. PAM and PI data compared between (− ePRO) and interventional (+ ePRO) consultations. PAM data were analysed using a linear mixed effect regression model with intervention (yes/no) and time along with the interaction between them as categorical fixed effects. The analyses were further adjusted for time (days) since surgery. Results According to our data, ePRO supported consultations did not improve PA. The average mean difference in PAM score between + ePRO and − ePRO consultations were − 0.2 (95% confidence interval − 2.6; 2.2, p = 0.9). There was no statistically significant improvement in PAM scores over time in neither + ePRO nor − ePRO group (p = 0.5). Based on the five PI-indicator questions, the majority of all consultations were evaluated as “some, much or very much” involved in consultation; providing a wider scope of dialogue, encouraged patients to ask questions and share their experiences and concerns. Nevertheless, another few patients reported not to be involved at all in the consultations. Conclusion We did not demonstrate evidence for ePRO supported consultations to improve patient activation, and patient activation did not improve over time. Our results generate the hypotheses that factors related to ePRO supported consultation had the potential to support PI by offering a wider scope of dialogue, and encourage patients to ask questions and share their experiences and concerns during follow-up.

P078 SURGICAL PLANNING WITH 3D TECHNOLOGY UN PATIENT WITH MORGAGNI HERNIA AND INGUINAL HERNIA

Aim The use of 3D technology is increasingly used for surgical planning in cases of complex surgery. In the case of the abdominal wall, its use is not very widespread. In this video we present the case of a patient with inguinal hernia and Morgagni hernia in which 3D planning provided us with multiple benefits Material and Methods 71-year-old patient awaiting intervention for right inguinal hernia, presenting progressive dyspnea, abdominal pain and vomiting. A thoraco-abdominal CT scan was performed, which reported a Morgagni hernia containing the transverse colon and omentum. Due to 3D planning, we were able to obtain the abdominal and hernial sac volumes, evaluate the hernial orifice and its relationship with the adjacent structures. Results Laparoscopic repair of the Morgagni hernia was performed by reducing the hernial content, placement of visceral contact mesh fixed with resorbable tackers. In the same surgical act, an inguinal hernioplasty was performed via TAPP. The postoperative period was correct, without complications, and the patient was discharged after 3 days. Two years after the intervention, the patient remains asymptomatic. Conclusions The use of 3D technology for surgical planning facilitates the repair of complex hernias, helping us to assess the surgical indication, hernial volumes and hernial content. Good surgical planning facilitates the performance of the intervention through minimally invasive surgery, in this case two hernias were repaired in the same surgical procedure and with the same incisions, which facilitated the recovery of the patient.

A new model of inexpensive portable homemade PERC Mentor (IPHOM) and its validation

Background Percutaneous nephrolithotomy (PCNL) is a complex surgery and has a flat learning curve. Due to this and the ethical issues, trainees do not get enough hands on exposure. Virtual simulator is very expensive and bulky. Animal model requires legal clearance. This inexpensive portable homemade PERC Mentor (IPHOM) teaches all the major aspects of PCNL surgery. This article has shown the way to make this model and its validation study. Methods IPHOM can be made at home with carton box, ball bearings, LED torch and some hospital wastes. After a short demonstration of IPHOM, 14 residents and 4 urologists were given 8 tasks to perform on it followed by 15-min supervised practice exercise on day 0 and day 1. Their performance was reassessed on day 2 and 3. Response to 17 feedback points was recorded on a seven-point Likert scale. Results There was significant difference between the performance of expert and novice on day 0. Expert completed all the tasks in less time and no. of attempts. The time for tract dilatation and duration of radiation exposure were significantly less in the expert group. The performance of both expert and novice improved on day 2 and 3, but the improvement was significantly more in novice. Response to the feedback points showed no difference between expert and novice (p > .05). Conclusions We have found that training on IPHOM has improved the concept and skills of PCNL in residents. The simplicity and low cost of the model make it constructible at home.

SP6.1.1 Cholecystectomy or expectant management after endoscopic sphincterotomy and bile duct stone removal?

Aims Following ERCP, NICE guidance suggests that surgically fit patients undergo cholecystectomy to prevent recurrence of choledocholithiasis and its complications. However, for many patients who are deemed unfit or who choose not to have surgery, ERCP is their definitive management. This study examines the clinical outcomes and costs of expectant management (EM) or cholecystectomy following ERCP. Methods All patients that underwent ERCP, sphincterotomy and common bile duct (CBD) clearance at St James’s University Hospital between January 2015 and December 2018 were identified from a prospectively maintained ERCP database. The clinical outcomes for patients that had undergone an ERCP, sphincterotomy and CBD clearance for gallstones were identified from their electronic patient record. A cost analysis for the complete patient pathway was performed. Results 820 patients underwent ERCP and CBD clearance for gallstones with a median 3.9 year follow up. 222 patients had undergone a cholecystectomy prior to ERCP and were excluded from analysis. 203 patients underwent planned cholecystectomy with 15% (31 patients) requiring complex surgery and 12% (24 patients) needing readmission. 395 patients received expectant management (EM). 9 (2.3%) patients returned with CBD stone symptoms, 6 (1.5%) went on to laparoscopic cholecystectomy (LC). The readmission rate in the EM group was 9%. The average cost per patient in the expectant management group was £7,487 and in the cholecystectomy group was £10,584. Conclusion The results from this study suggest that the need for cholecystectomy following ERCP is uncertain, with similar rates of biliary re-admissions in both groups.

Restorative Proctocolectomy: When to Propose and When to Avoid

Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) is a surgical procedure performed when excising the entire colon and rectum is need and reconstitution of the intestinal transit through an ileal pouch is made with anastomosis to the anus. It is mainly used to treat patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC). It is a complex surgery with potential complications, and the functional outcomes can be worse over time. So, it is essential to select the appropriate patient, proceed to a correct surgical technique, and know-how to deal with and solve the main ileal pouch complications. This chapter intends to be a reflection on this subject.

Injectable Hydrogels in Repairing Central Nervous System Injuries

The injured central nervous system (CNS) can hardly regenerate. In vitro engineering of brain tissue hits technical bottlenecks. Also, the compaction and complexity of anatomical structure defy the accurate positioning for lesion sites in intracranial injuries. Therefore, repairing injured CNS remains a significant clinical challenge. Various recent in vivo and in vitro experiments have demonstrated the excellent effect of tissue engineering on repairing central nerve cells and tissues through implanting new materials and engineered cells. Except for porous three-dimensional structures able to pad lesions in various shapes and simulate the natural extracellular matrix with nutrients for cell proliferation, hydrogels incorporate high biocompatibility. Injectable hydrogels with the merits of avoiding complex surgery on large wounds, filling irregular gaps, delivering drugs, and others, are of growing interest. This review focuses on the experimental studies regarding injectable hydrogels, especially applying various injectable hydrogels to repair brain damage.

Predicting Surgical Factors for Unplanned Overnight Admission in Ambulatory Arthroscopic Surgery of the Knee: A Prospective Cohort in 184 patients

Background: Unplanned overnight admission (UOA) is an important indicator for quality of care with ambulatory knee arthroscopic surgery (AKAS). However, few studies have explored the factors related to the UOA and how to predict UOA after AKAS. This study aimed to evaluate the effectiveness of a standardized perioperative protocol for the AKAS with UOA and identify whether a correlation exists between the perioperative surgical factors and UOA in the patients undergoing AKAS. Methods: A prospective cohort study was conducted, between October 2017 and March 2021, in 184 patients. All patients operated on standard AKAS protocol. The UOA was defined as overnight hospitalization of a patient undergoing AKAS. Demographic and perioperative data were recorded, and the procedure was categorized based on the surgical invasiveness based on less invasive (n = 65) and more complex surgery (n = 119). The clinical risk factors for UOA were identified and analyzed with multivariate logistic regression analysis. Results: The incidence of UOA in the more complex group (17 cases, 14.3%) was significantly higher than in the less invasive group (3 cases, 4.6%) (p = 0.049), with the incidence of readmission as 0%. The perioperative factors significantly associated with UOA were age, more complex surgery, and tourniquet time (p < 0.10 all). However, the multivariate regression analysis revealed that tourniquet time was the only significant predictor for UOA (odds ratio = 1.045, 95% confidence interval = 1.022 to 1.067, p = 0.0001). The optimal cut-off points of tourniquet time for predicting UOA with the highest Youden index in the less invasive and more complex groups were 56 minutes and 107 minutes, respectively. Conclusion: The UOA after AKAS is more common in more complex surgery compared to less invasive surgery. Many factors—such as patient factors, surgical invasiveness, and tourniquet time—were also significantly associated with the unplanned admission. However, the results from this study showed that, under strict perioperative management protocol, tourniquet time is the only independent predictor for UOA.

Application of the Konno procedure for infective endocarditis in native bicuspid aortic valve with annular abscess extending into the interventricular septum

Annular abscess is a serious complication of infective endocarditis, which often requires complex surgery and has a very high post-operative mortality rate. The Konno procedure involves valve annuloplasty for a narrow aortic annulus or left ventricular outflow tract stenosis in children; it is also performed for various cardiac conditions in adults. Here, we report a case of the Konno procedure performed in a patient with aortic valve infective endocarditis, with an annular abscess extending into the interventricular septum (IVS). A 58-year-old man who presented to our hospital with fever was diagnosed with aortic valve infective endocarditis caused by Streptococcus saccharolyticus. On echocardiography, an annular abscess in the direction of the IVS was detected, and surgery was planned. The Konno procedure was performed to secure an adequate surgical field and to debride and reconstruct the cavity created by the interventricular septal abscess. The patient was discharged uneventfully 29 days after surgery.