P-OGC73 Effect of pyloroplasty on the need for endoscopic intervention for delayed gastric emptying post oesophagectomy

Background Delayed gastric emptying (DGE) is a common complication following oesophagectomy, affecting 15-39% of patients. Controversy remains regarding the role of pyloric drainage procedures during oesophagectomy with gastric conduit reconstruction in reducing DGE. This study investigated the effect of pyloroplasty at the time of oesophagectomy on the need for endoscopic pyloric intervention post-operatively. Methods We performed a retrospective analysis of all oesophagectomies performed in a single tertiary centre over a 10-year study period between 1 January 2010 and 31 December 2019. Electronic records were reviewed to analyse patient demographics, operative details and post-operative outcomes, as well as the need for endoscopic procedures after surgery. Patients were dichotomized into two groups, with those who had pyloroplasty performed at oesophagectomy compared to those who did not. Patients who died ≤30 days after oesophagectomy were excluded from analysis. Patients were followed up for a median of 32 months (IQR 19-60). Results 298 patients were eligible for the study, of whom 80/298 (26.8%) had a pyloroplasty performed. Demographics were evenly matched between the two groups. Patients undergoing Ivor-Lewis oesophagectomy were significantly more likely to have had pyloroplasty performed (90.0% vs. 24.3%; p < 0.001). Pyloroplasty had no significant effect on post-operative complication rates, ICU admission, need for re-operation or length of hospital stay. Patients without a pyloroplasty were significantly more likely to require endoscopic pyloric balloon dilatation (43.1% vs. 12.4%, p < 0.001) or pyloric botox injection (12.4% vs. 3.8%, p = 0.029) after oesophagectomy. Conclusions In this study, patients who had a pyloroplasty at the time of oesophagectomy were significantly less likely to require endoscopic pyloric balloon dilatation and/or pyloric botox injection post-operatively. This has significant long-term implications for both patients’ quality of life post-operatively and demands on over-stretched endoscopic services.

V-OG05 Robotic Hellers Myotomy

Background Achalasia is a rare condition affecting less than 1:100,000 patients. Treatment for this rare condition include balloon dilation, botox injection, endoscopic myotomy (POEMS) or surgical myotomy. Laparoscopic surgical myotomy is the “go to” approach for most surgeons; it is tried and tested, can be performed safely and quickly with a low complication rate, minimal pain and a short length of stay. Methods This video presents the technique adopted for robotic oesophageal myotomy in a patient with type II achalasia. A 4 arm technique was adopted with arm 4 on the patients left. The Davinci X system was used in this case. A Nathensen liver retractor was used to retract the liver; robotic instruments included the hook and cadiere forceps x2. Results The procedure was successfully performed; the operative time was 53 minutes, LOS was <24 hours. Check endoscopy revealed a wide open gastro-oesophageal junction and a long myotomy. The patient noted an improvement in symptoms with 24 hours and has had no significant reflux. Conclusion The enhanced magnified 3D view on the robotic platform allows better visualisation of the hiatal structures, vagal nerves and muscle fibres when performing the myotomy. Using the 4th arm to retract the lateral edge of the oesophageal muscle provides a very safe and stable platform to perform a long myotomy. I think the robotic system should be adopted as the standard approach for a hellers myotomy.

P028 COMBINING SEVEN ITEMS OF THE TOOLBOX TO TREAT A LARGE INCISIONAL HERNIA WITH HETEROTOPIC OSSIFICATION: A CASE REPORT

Aim We present our approach of treating a W3 (EHS-Classification) incisional hernia with heterotopic ossification in the abdominal wall. Material and Methods a 62-years-old female patient presented with a hernia in her inverted-T incision (midline and transverse) after undergoing multiple laparotomies. The CT-scan showed calcified structures within the abdominal wall. We planned the extensive reconstruction after preoperative Botox injections. Results The 20x25 cm hernial sack contained parts of the stomach and colon. The dissection of the midline and transverse scars was challenging with the needed removal of scattered pieces of heterotopic bone tissues. After dissecting the retro-muscular space, the fascial edges were 25 cm apart. With bilateral transversus abdominis release (TAR), It was reduced to 20 cm. The posterior fascia was approximated, leaving a central 12 cm defect, and a smaller lateral defect, which we covered using open-IPOM and underlay techniques respectively. A 30x40 cm mesh in sublay position was placed and fascial traction was applied on the anterior fascia. With the resulting defect of 16 cm, a tension-free closure was still not possible, and we bridged the gap with a mesh in inlay position. Conclusions Despite combining pre-operative Botox injection and fascial traction with TAR, complete closure of the fascia was not possible. IPOM, sublay, underlay and inlay bridging were needed. Specialized hernia surgeons should be familiar with a wide range of different techniques to deal with such cases.

Intractable Muscle Tension Dysphonia Treated by Injection Laryngoplasty and Lidocaine Injection

Muscle tension dysphonia (MTD) is a voice disorder characterized by excessive tension of the laryngeal muscles during phonation. Voice therapy is the gold standard of treatment for MTD. However, patients with MTD do not always respond to voice therapy. Multidisciplinary approaches have been attempted to treat intractable MTD such as lidocaine instillation, lidocaine injection to recurrent laryngeal nerve, botox injection and excision of false ventricle using CO2 laser. Recently, injection laryngoplasty is suggested that assists in more efficient phonation and voice therapy to MTD patients. A patient with intractable MTD underwent lidocaine injection and injection laryngoplasty showed improved voice quality and remained stable until postoperative 3 months without any complications.

Surface Electromyography for Identification of Pre-Phonatory Activity

Surface electrode EMG is an established method for studying biomechanical activity. It has not been well studied in detecting laryngeal biomechanical activity of pre-phonatory onset. Our aims were to compare the sensitivity of surface EMG in identifying pre-phonatory laryngeal activity to needle electrode laryngeal EMG and to compare the pre-phonatory period in patients with adductor laryngeal dystonia (ADLD) with that in controls. ADLD patients (n = 10) undergoing needle LEMG prior to Botox injection and participants with normal voices (n = 6) were recruited. Surface EMG electrodes were placed over the cricoid ring and thyrohyoid membrane. Needle EMG electrodes were inserted into the thyroarytenoid muscle. EMG and auditory output samples were collected during phonation onset. Tracings were de-identified and evaluated. Measurements of time from onset in change of the amplitude and motor unit frequency on the interference pattern to onset of phonation were calculated by two blinded raters. 42 of 71 patient and 40 of 50 control tracings were available for analysis. Correlation for pre-phonatory time between electrode configuration was 0.70 for patients, 0.64 for controls and 0.79 for all the data combined. Inter-rater correlation was 0.97 for needle and 0.96 for surface electrodes. ADLD patients had a longer pre-phonatory time than control subjects by 169.48ms with surface electrode and 140.23ms with needle electrode (p < 0.001). Surface EMG demonstrates equal reliability as Needle EMG in detecting pre-phonatory activity in controls and subjects. Patients with ADLD have a significantly prolonged pre-phonatory period when compared with controls.

A ROLE OF AYURVEDIC MANAEGEMENT IN BLEPHAROSPASM w.s.r. NIMESHA - A CASE STUDY

Ayurveda can provide effective and harmless relief for certain diseases which sometimes can’t be cured with modern medicine. Nimesha is a condition, pertaining to Shalakya Tantra in which eye lids starts blinking involun- tary due to influence of Vata Dosha. In this condition patients can’t be able to focus things properly and having lots of discomfort. It can be correlated to blepharospasm i.e., an abnormal contraction of eye lid muscles, which is also refers to benign essential blepharospasm. It is thought to be rare, affecting about 16–133 cases per million. There is no cure for blepharospasm in modern practice. Generally, doctors inject botox injection into eyelid mus- cles which need to get injected in every 4-6 month, rather than permanent benefits it has lots of side effects like diplopia ectropion etc. Ayurveda can be useful in the treatment of blepharospasm and its complication that it is a Vataj Vyadhi all Vatashamak therapies could be effective for its treatment. A 61 years old male patient known case of bilateral blepharospasm was visited in OPD of Government Autonomous Dhanwantari Ayurveda Hospi- tal, Ujjain. He had complained of excessive blinking with tired eye muscles, heaviness around eyes, headache, anxiety and irritation etc. for 3 years. He was on regular allopathic medicine along with botox injection around each eye which is repeated in every 6 months, but after few shots of treatment pt. didn’t receive any benefits.Therefore, he came to us and after Ayurvedic treatment patient showed marked improvement in symptomatology, with limited abnormal eye lid movement and with negligible side effects. Here was 70% relief after Ayurvedic treatment. Keyword: Ayurveda, Nimesha, Blepharospasm, Botox

Outcome Using Either Intradermal Botox Injection or Endoscopic Thoracic Sympathectomy for Patients with Primary Palmar Hyperhidrosis: A Comparative Study

Hyperhidrosis, or excessive sweating, negatively impacts patients both physically and psychologically. It may be primary or secondary: the primary form is a benign condition, with its growing prevalence reaching 5% recently. Its medical treatments are transitory. Objectives: Comparison of the outcomes of patients with primary palmar hyperhidrosis (PPH) after intradermal Botox injection (IBI) versus endoscopic thoracic sympathectomy (ETS). Methods: Forty patients were randomly divided into two equal groups. Patients in the IBI group received an intradermal injection of a botulinum toxin A. Patients in the EST group received endoscopic electrocautery of the sympathetic chain. The patients were evaluated biweekly for 12 weeks, and patient satisfaction by outcome was evaluated using a 4-point satisfaction score. Results: At 12 weeks, 60% of the IBI group patients had maintained an improvement. Meanwhile, 40% of the patients were improved compared to pre-intervention scores, despite deterioration after remarkable improvement. On the other hand, 80% of ETS group patients maintained their Hyperhidrosis Disease Severity Scale (HDSS) up until the end of follow-up. Patient satisfaction scores were significantly higher for the IBI group compared to the ETS group. Conclusions: Intradermal Botox injection is a simple, safe, non-invasive, and effective therapeutic modality for PPH and achieved higher patient satisfaction compared to ETS.