84.20 Ventral hernia repair and mesh infection survey.

Posted on January 26, 2017

L. Knaapen1, O. Buyne1, S. Feaman4, P. Frisella4, N. Slater2, B. Matthews3, H. Van Goor1  1Radboud University Medical Center,Department Of Surgery,Nijmegen, GELDERLAND, Netherlands 2Radboud University Medical Center,Department Of Plastic And Reconstructive Surgery,Nijmegen, , Netherlands 3Carolinas Hernia Institute,Charlotte, SOUTH CAROLINA, USA 4Washington University,Department Of Surgery, Section Of Minimally Invasive Surgery,St. Louis, MISSOURI, USA

Introduction:
Choice of mesh and surgical technique in ventral hernia repair represent major surgical challenge, especially under contaminated conditions. Aim of this survey was to present international overview of current practice concerning ventral hernia repair in clean or contaminated condition.

Methods:
A survey (2013-2015) was send to surgeons worldwide performing ventral hernia repair. This survey was designed to compare differences in ventral hernia repair concerning life style/pre-operative work-up, antibiotic prophylaxis, hernia repair in clean/contaminated environment, recurrence and mesh infection. 

Results:
Responders (n=417) were male (92%;n=381), aged 36-65 (84%;n=351) and practicing inNorth- America (56%;n=234). Open repair was performed by 99% (20% expert level). Laparoscopic repair by 77% (15% expert level).
The majority agrees on benefit of pre-operative work-up/lifestyle changes like smoking cessation (80%;n=319) and weight-loss (64%;n=254)). Not reaching target(s) does not change decision on whether to operate or not.
Common practice is administer antibiotics at least one hour preoperatively (71%;n=295).
Synthetic (43%;n=180) and biologic (42%;n=175) mesh are used as often in contaminated primary hernia repair.
Concerning recurrent hernia repair, synthetic mesh (87%;n=359) is used in clean environment, biological (53%;n=215) or no mesh (28%;n=112) in contaminated environment. American surgeons prefer biologic mesh over  synthetic mesh in contaminated environment. 
Generally, percutaneous drainage and antibiotics is the first step regarding mesh abscess, independent of type of repair or mesh used. Concerning synthetic mesh infection with sepsis most explant the mesh and repair with biologic mesh (54%;n=217). There is no agreement on mesh infection without sepsis on when to explant  and how to repair.

Conclusion:
The majority agrees on the benefit of pre-operative work-up however not always with consequences. Both synthetic and biologic meshes are used for primary hernia repair in contaminated environment. Concerning recurrent hernia repair, synthetic mesh is used in clean environment and biologic mesh or no mesh in contaminated environment. 

79.18 Biliary Excretion of Diclofenac Metabolites Leads to Increased Rates of Anastomotic Leakage in Rats

Posted on January 26, 2017

S. Yauw1, R. Lomme1, P. Van Den Broek2, R. Greupink2, F. Russel2, H. Van Goor1  1Radboudumc,Department Of Surgery,Nijmegen, GELDERLAND, Netherlands 2Radboudumc,Department Of Pharmacology And Toxicology,Nijmegen, GELDERLAND, Netherlands

Introduction:
Nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with anastomotic leakage in humans and animals, but underlying mechanisms are unknown. Some studies suggest an increase of bile toxicity by specific NSAIDs, causing small intestinal damage. In this experiment we determined the relevance of biliary diclofenac excretion in anastomotic leakage.

Methods:
Randomized controlled blinded experiment assessing anastomotic leakage, leak severity and anastomotic strength in 138 male Wistar rats, using bile duct and duodenal catheterization techniques and 72 rats as bile donors. It was studied if administration of ‘diclofenac bile’ induces leakage in control rats and, in turn, if diversion or replacement of bile reduces leakage in diclofenac (oral or intramuscular) treated rats. Diclofenac biliary metabolites and plasma levels were determined with HLPC and LCMS.

Results:
Leak rate was 28% after administration of ‘diclofenac bile’ compared to 6% (p=0.089) after control bile. Following oral diclofenac administration 76% leaked compared to 47% (p=0.127) when bile was replaced with control bile. After intramuscular administration 67% leaked and 50% if the rat’s own bile was diverted and returned, compared to 25% (p=0.060) when bile was drained or 20% (p=0.117) when replaced with control bile, respectively. Grading according to an Anastomotic Complication Score revealed signs of leakage were significantly more severe in ‘diclofenac bile’ groups; (p=0.006 versus control bile in control groups; p=0.016 versus control bile in oral diclofenac groups; p=0.025 versus bile drainage in intramuscular diclofenac groups; p=0.283 versus control bile in intramuscular diclofenac groups. Anastomotic strength results grossly supported macroscopic findings. Bile analysis showed diclofenac metabolite levels peak within two hours after administration, with diclofenac-acyl-glucuronide and unchanged diclofenac as main metabolites. Plasma levels of diclofenac did not change following exchange of ‘diclofenac bile’ by ‘control bile‘, or vice versa, and could not explain the different leak rates.

Conclusion:
Altered bile composition aggravates ileal anastomotic leakage in rats treated with diclofenac, which may result from biliary excretion of diclofenac metabolites. This is a newly identified pathway in the pathophysiology of anastomotic leakage and its exact mechanism and clinical relevance should be clarified by further research.
 

79.17 Beta-glucuronidase Inhibitor Reduces Diclofenac Induced Anastomotic Leakage

Posted on January 26, 2017

S. Yauw1, M. Arron1, R. Lomme1, P. Van Den Broek2, R. Greupink2, A. Bhatt3, M. Redinbo3, H. Van Goor1  1Radboudumc,Department Of Surgery,Nijmegen, GELDERLAND, Netherlands 2Radboudumc,Department Of Pharmacology And Toxicology,Nijmegen, GELDERLAND, Netherlands 3University Of North Carolina At Chapel Hill,Department Of Biochemistry And Microbiology,Chapel Hill, NORTH CAROLINA, USA

Introduction:
Use of diclofenac in colorectal surgery has been associated with increased rates of anastomotic leakage. Previous experiments suggest drug metabolites in bile play a role in this process. Cleavage of the diclofenac-acyl-glucuronide metabolite by bacterial glucuronidase in the gut releases a harmful aglycone, which causes small intestinal mucosal damage in mice. Administration of a beta-glucuronidase inhibitor (Inh1) prevents this. It was studied if inhibition of glucuronidase prevents the development of diclofenac-induced anastomotic leakage in rats.

Methods:
In one hundred and eight male Wistar rats an anastomosis of the ileum was constructed. Animals were allocated to six groups, three with diclofenac and three without diclofenac. For the diclofenac groups, group Dic received diclofenac only and the groups Dic-Inh1-low and Dic-Inh1-high received diclofenac and beta-glucuronidase inhibitor in either a low (800ug/kg/d) or high dose (4000ug/kg/d) orally. For the non-diclofenac groups, animals received either low dose beta-glucuronidase inhibitor (group Inh1-low), vehicle (methylcellulose; group Veh) or no solution (group Neg). All solutions were given from the day of surgery until sacrifice on day three. Plasma levels of diclofenac were determined to rule out a systemic effect. Outcomes were anastomotic leakage, leak severity score, bursting pressure and breaking strength.

Results:
Anastomotic leak rates were 67% in group Dic, 33% in group Dic-Inh1-low (p=0.094) and 50% in group Dic-Inh1-high (p=0.500). Leak severity was reduced in group Dic-Inh1-low (p=0.029), but not in the high dose group (p=0.293). In non-diclofenac cohort rates were 0% in group Neg, 17% in group Inh1-low (0.230), 17% in group Veh (p=0.227). Bursting pressure and breaking strength were not significantly different. Plasma levels of diclofenac were not changed by Inh-1.

Conclusion:
Beta-glucuronidase inhibitor reduces anastomotic leakage when given in low doses, suggesting a toxic effect of diclofenac metabolite on anastomotic healing. The absent effect in the high dose might be due to an intrinsic toxicity of the inhibitor or clumping of the substance. These findings improve our understanding of the pathogenesis of anastomotic leakage.
 

64.02 Learning curve of minimally invasive Ivor-Lewis esophagectomy

Posted on January 26, 2017

F. Van Workum1, G. H. Berkelman3, A. E. Slaman4, M. Stenstra1, M. I. Van Berge Henegouwen4, S. S. Gisbertz4, F. J. Van Den Wildenberg5, F. Polat5, M. Nilsson2, T. Irino2, G. A. Nieuwenhuijzen3, M. D. Luyer3, C. Rosman1  1Radboudumc,Surgery,Nijmegen, GELDERLAND, Netherlands 2Karolinska Institutet,Surgery,Stockholm, -, Sweden 3Catharina Hospital,Surgery,Eindhoven, BRABANT, Netherlands 4AMC,Surgery,Amsterdam, NOORD HOLLAND, Netherlands 5Canisius-Wilhelmina Ziekenhuis,Surgery,Nijmegen, GELDERLAND, Netherlands

Introduction: Totally minimally invasive Ivor-Lewis esophagectomy (TMIE-IL) has a learning curve but the length of the learning curve and the extent of learning curve associated morbidity for surgeons experienced in TMIE-McKeown is unknown.

Methods: This study was performed in 4 high volume European esophageal cancer centers from December 2010 until April 2016. Surgeons experienced in TMIE-McKeown changed operative technique to TMIE-IL. All consecutive patients with esophageal carcinoma undergoing TMIE-IL with curative intent were included. Baseline, surgical and outcome parameters were analyzed in quintiles and were plotted in order to explore the learning curve. Textbook outcome (the percentage of patients in which the process from surgery until discharge was <21 days and uneventful in terms of complications, interventions, mortality and oncological aspects) was also analyzed. CUSUM analysis was performed in order to determine after how many cases proficiency was reached. An area under the curve analysis was performed to calculate the learning associated anastomotic leakage and costs.

Results: Four hundred and sixty eight patients were included. In one hospital, ASA classification was significantly higher in quintile 2 and 3 (p=0.01) and in one hospital, more distal esophageal tumors were operated in quintile 4 and 5 (p=0.01). In the pooled curve analysis, anastomotic leakage decreased from 26% at introduction of MIE-IL to 8% at the plateau phase which occurred after 121 cases. Textbook outcome increased from 39% to 60% and the plateau phase occurred after 128 cases. Learning curve associated anastomotic leakage occurred in 42 patients and this excess morbidity was associated with more than € 2 million in healthcare costs.

Conclusion: TMIE-IL has a significant learning curve. Learning curve associated morbidity and costs are substantial, even for surgeons experienced in TMIE-McKeown. The length of the learning curve was more than 100 operations.

 

55.16 Continuous Monitoring of Vital Signs on the General Ward

Posted on January 26, 2017

M. Weenk1, S. Bredie2, L. Engelen3, T. Van De Belt3, H. Van Goor1  1Radboudumc,Surgery,Nijmegen, GELDERLAND, Netherlands 2Radboudumc,Internal Medicine,Nijmegen, GELDERLAND, Netherlands 3Radboudumc,Radboud REshape Innovation Center,Nijmegen, GELDERLAND, Netherlands

Introduction: Measurement of vital signs in hospitalized patients is necessary to assess the clinical situation of the patient. Early warning scores (EWS), such as the Modified Early Warning Score (MEWS) are generally measured three to four times a day and may not capture early deterioration. A delay in diagnosing  deterioration is associated with increased mortality and costs. Clinical deterioration might be detected earlier by wearable devices continuously monitoring vital signs, which allows clinicians to take corrective interventions. Further these devices potentially reduce patient discomfort and work load of nurses. In this pilot study, reliability of continuous monitoring using the ViSi Mobile (VM; Sotera; HR, RR, saturation, BP, skin temperature) and HealthPatch (HP; Vital Connect; HR, RR, skin temperature) was tested and experiences of patients and nurses were collected.

Methods: Twenty patients, 10 at the surgical and 10 at the internal medicine ward, were monitored with both devices simultaneously for 2-3 days and data were compared with MEWS measurements taken as reference method. Artifacts in continuous data were registered and analyzed. Patient and nurse experiences were obtained by semi-structured interviews.

Results: Eighty-six MEWS measurements were compared with VM and HP measurements. Almost all VM vital signs (mean difference HR -0.09 bpm; RR 1.00 breaths/min; saturation 0.19%; temperature 0.00 ?C; BP systolic 1.33 mmHg) and all HP vital signs (HR -2.10 bpm; RR -0.58 breaths/min; temperature 0.00 ?C) were in range of accepted discrepancies, although wide limits of agreement were found. The largest discrepancy in mean difference was found for VM diastolic blood pressure (-8.33 mmHg) probably due to inaccuracy of measurement by nurses. Predominant VM artifact (70%) was a connection failure. Over 50% of all HP artifacts had unknown cause, were self limiting and took less than one hour. The majority of patients, family members, and nurses were positive about VM and HP, e.g. increased feelings of safety, better sleep and more comfort for patient and nurses. Devices did not restrict patients’ daily activities. Disadvantage were the cables (showering) and the short battery life of the VM device.

Conclusion: Both VM and HP have potential for continuously measuring vital signs in hospitalized patients. The devices were well received and comfortable for most patients. A further study focuses on the different effects of VM or HP compared to routine MEWS on patient comfort and safety and nurse workload, and on early detection of deterioration.

 

45.16 Training Surgeons in Shared Decision-Making with Older Cancer Patients: Shared Benefits within Reach

Posted on January 26, 2017

N. Geessink1, Y. Schoon1, M. Olde Rikkert1, H. Van Goor1  1Radboud University Medical Center,Nijmegen, , Netherlands

Introduction: The number of cancer patients aged 65 years or older presenting for major abdominal surgery such as colorectal (CRC) and pancreatic cancer (PC) resections is rising. In frail older patients such procedures are highly associated with negative outcomes that threaten patients’ quality of life and functioning. Shared decision-making (SDM) and goal-oriented communication are widely recommended to improve treatment decision-making, deliver patient-preferred care, and improve overall outcomes. SDM is particularly applicable for surgical disorders such as rectal and pancreatic cancer where alternatives for a major operation are available. This study aimed to evaluate the EASYcare in Geriatric Onco-surgery (EASY-GO) intervention; an intervention designed to improve the SDM process in older CRC/PC patients.

Methods: The EASY-GO intervention comprised a training for surgeons in frailty assessment and SDM. After training, the EASY-GO working method was implemented by screening all patients on frailty and applying SDM. Adherence to the intervention was stimulated by training-on-the-job: surgeons received feedback post-consultation about the SDM process by a geriatric specialist. Consecutive patients aged ≥65 years with newly diagnosed CRC/PC were included at the surgical department of the Radboud university medical center, the Netherlands. Primary outcomes were patient-reported level of SDM (SDM-Q-9), satisfaction (VAS-S), involvement in decision-making (VAS-I), and decisional regret (DRS). Patient involvement was also rated by surgeons (VAS-I).

Results:Eleven surgeons were trained of whom 4 were eligible for complete evaluation since they consulted patients both before and after implementation in the study’s time frame (11 months). The 4 surgeons consulted 38 patients; 19 (15 PC,4 CRC) before and 19 (13 PC,6 CRC) after implementation. SDM-Q-9 scores increased with 3.9 special symbol2.6 (before 72.8 special symbol11.2,after 76.7 special symbol19.6;p=0.72), VAS-S with 0.8 special symbol1.3 (before 8.0 special symbol0.4,after 8.7 special symbol1.2;p=0.27), and VAS-I with 0.7 special symbol2.6 (before 6.9 special symbol2.8,after 7.6 special symbol1.6;p=0.72). DRS decreased with 7.4 special symbol17.9 (before 27.3 special symbol8.6,after 19.9 special symbol14.0;p=0.47). Surgeons’ VAS-I increased with 0.3 special symbol2.1 (before 7.4 special symbol1.5,after 7.6 special symbol0.7;p=0.47). SDM-Q-9 scores increased both in CRC (before 69.4 special symbol25.8,after 74.7 special symbol18.4;p=0.56) and PC patients (before 76.1 special symbol29.2,after 88.0 special symbol12.3;p=0.52).

Conclusions:Although statistical significance was not realized due to the small sample size, the consistent change in scores in the direction of improved decision-making strongly suggests a positive effect on SDM in this vulnerable onco-surgical patient group. The higher scores of PC patients may be explained by differences in number and duration of consultation and outcome perspective. The promising results suggest that clinically relevant improvements in patient-centeredness of this complex onco-surgery may be realized by ongoing training of surgeons in SDM. The results warrant further study on implementation of the EASY-GO intervention.

43.08 Lobectomy, Segmentectomy or Wedge Resection for T1a NSCLC: a Systematic Review and Meta-analysis

Posted on January 25, 2017

M. A. IJsseldijk1,2, M. Shoni3, C. Siegert5, J. Seegers2, T. Van Engelenburg2,5, T. Tsai3, A. Lebenthal3,4,5, R. Ten Broek1,2  1Radboud University Medical Center,General Surgery,Nijmegen, GELDERLAND, Netherlands 2Slingeland Hospital,Surgery,Doetinchem, GELDERLAND, Netherlands 3Brigham And Women’s Hospital,Surgery,Boston, MA, USA 4Harvard School Of Medicine,Brookline, MA, USA 5VA Boston Healthcare System,West Roxbury, MA, USA

Introduction:
The optimal treatment of small (T1a) non-small cell lung cancer (NSCLC) remains subject to debate. Lobar resection is considered the standard of care. However, recent studies indicate sublobar resection (segmentectomy or wedge resection) as a promising, parenchymal sparing treatment yielding comparable oncological outcomes. We conducted a systematic review and meta-analysis to compare oncological outcomes after lobar resections and parenchymal sparing resections in T1a NSCLC.

Methods:
We searched MEDLINE, PubMed, EMBASE, Web of Knowledge and CENTRAL to identify studies reporting overall survival (OS) or disease-free survival (DFS) following lobar resection or parenchymal sparing resections in early-stage NSCLC. Two researchers independently identified  studies and extracted data. Oncological outcomes after lobar resection and parenchymal sparing resections were compared using the Mantel-Haenszel method and outcomes were pooled for each surgical modality using the inverse variance method. 

Results:
A total of 8781 studies were identified, from which 24 articles were included. There was no difference in 5-year OS in pT1a tumors when lobar resection was compared to a lung parenchymal sparing resection (Relative Risk=0.90 (95%CI 0.80-1.02)). Moreover, there was no difference in 5-year DFS for pT1a tumors or 5-year OS for cT1a tumors between lobar surgery and a lung parenchymal sparing resection. Strikingly, there was a minor difference in 5-year DFS favoring a parenchymal sparing resection over lobar surgery for cT1a tumors.
The point estimates of 5-year OS of both comparative and non-comparative studies for pT1a tumors were 86% (95% CI: 84-89%) following lobar resection (n=1538), 83% (95%CI: 75- 91%) following segmentectomy (n = 402) and 71% (95% CI: 65 – 76%) following wedge resection (n = 65). There were no differences in pooled estimates for 5-year OS in cT1a tumors and 5-year DFS for pT1a tumors.

Conclusion:
This systematic review and meta-analysis shows that parenchymal sparing surgery in the form of segmentectomy yields equivocal results in terms of 5-year OS or DFS compared to lobar surgery for T1a NSCLC tumors. However, nodal upstaging is present in approximately 10% of patients.

 

42.20 Development of Hepatic Injury Model in Rats for Testing Hemostatic Patches

Posted on January 25, 2017

E. Roozen1, R. Lomme1, H. Van Goor1  1RadboudUMC,General Surgery,Nijmegen, GELDERLAND, Netherlands

Introduction:
Intra-operative or traumatic bleeding are common problems in surgery causing significant morbidity and mortality. Hemostatic products are increasingly recognized as an important measure to control bleeding. There is a need for safe, synthetic, cheap and effective alternatives for the already available hemostatic products. Preclinical testing of these products is predominantly performed in pig liver injury models. We develop hepatic injury models in small animals in order to replace the pig model. These models are our first step to ultimately create ex vivo perfusion models in order to reduce, refine and replace (3R’s) animals.  Aim of this study is to explore the consistency in creating a significant bleeding defect of the rat liver to discriminate between different hemostatic patches in terms of efficacy.

Methods:
Two models were evaluated, a liver biopsy punch model and a partial liver resection model . It is known that punch biopsies are reproducible because the surface area and depth have the same dimensions and can be controlled for. Resection models vary more, but have more clinical relevance. Thirty rats were used, in each rat 2 defects were created. In experiment 1, different punch diameters and depths were used to obtain a reproducible and significant bleeding (punch model). In another set of animals partial-lobe resection was performed (resection model). Rats were randomized for either model, receiving an active patch (A1) or a control non-active patch (P1) on both defects. In experiment 2 the feasibility of folding the patch around the edges of the resected area was explored using 2 active patches (A2 and A3).
Outcome for consistency were the severity of bleeding, amount of bloodloss (BL,weight absorbed blood), the surface area of the defect (photodigital planimetry), and the weight of the resected specimen. Outcome for efficacy were time to hemostasis (TTH) and BL after patch application, prior to hemostasis.

Results:
A punch diameter of 8x3mm and the resection created consistent bleedings. 37/60 defects were evaluable for efficacy. There was no difference in TTH (p=0,715) and BL (p=0,440) between the A1 and P1 in the punch model, whereas A1 significantly decreased TTH (p=0,003) and BL (p=0,001) compared to P1 in the resection model. Non-folding was better feasible than folding the patches without differences in TTH and BL. A2 and A3 patches differed in TTH (p:0,02) and BL in both the folding (TTH: p=0,02; BL: p=0.049) and non-folding (TTH: p=0,000 ; BL: p=0.005) application.

Conclusion:
In rats a consistent and easy to operate, partial liver resection model can be created that discriminates between well and worse performing hemostatic products using easy to measure and clinically relevant outcomes.
 

42.04 Characteristics Affecting Virtual Reality Distraction for Pain

Posted on January 25, 2017

J. Harder1, M. De Vries1, H. Van Goor1  1RadboudUMC,Nijmegen, GELDERLAND, Netherlands

Introduction:
Post-surgical pain (PSP) is a difficult to treat condition that requires alternative means to improve patient comfort, physical functioning and quality of life. Virtual reality (VR) has shown to be an distraction tool that can reduce pain perception and expectation and anxiety to suffer from pain. Most studies investigating VR distraction included mostly young patients and did not explore patient or VR characteristics. Our goal was to investigate the effects of two applications (passive or interactive) of VR distraction and their association with personal characteristics such as age, gender, visualisation, imagination, immersion in the virtual world and previous gaming or VR experience.

Methods:
Fifty healthy volunteers (25 M, 25 F, 19 – 66 years of age, mean age 40.9 years) underwent electrical and monofilament tactile perception tests while undergoing three study conditions (control (black screen, no audio), passive VR, interactive VR) in a randomized order using a placebo-controlled, three-way, crossover design. The in-house developed passive and interactive VR applications consisted of the same journey through a river-like landscape, but differed only by a cognitive task (shooting at various targets using head movements) in the interactive VR. Personal characteristics and immersion in the virtual world were gathered using a questionnaire with a 5-point Likert scale design.

Results:
A difference in overall mean of electrical detection threshold and monofilament threshold was observed between each study condition (F(2, 76) = 6.340, p = 0.003 | F(2, 76) = 20.174, p < 0.0005). Interactive VR showed a significant greater beneficial effect as a distraction tool compared to passive VR (p = 0.012). No gender effect was found. There was a positive correlation between age and interactive VR distraction (r = 0.333, p = 0.018). The amount of self-reported immersion in the virtual world showed a positive correlation with an increased effect of distraction by VR (r = 0.352, p = 0.012). Other personal characteristics and previous gaming or VR experience did not affect VR distraction (p > 0.1).

Conclusion:
Passive and interactive VR both distract from pain and tactile sensation, with interactive VR having the largest effect, independent of age and gender. Self reported presence in the VR world enlarged the distraction effect. Previous gaming/VR experience did not affect VR distraction. Future research focuses on personalizing VR applications for a maximum distraction effect to be used as an adjunct to painkillers for post-surgical pain treatment.
 

27.05 A Shared Decision Approach to Chronic Abdominal Pain Based on Cine-MRI

Posted on January 25, 2017

B. A. Van Den Beukel1, S. Van Leuven1, M. Stommel1, C. Strik1, M. A. IJsseldijk1, F. Joosten2, H. Van Goor1, R. P. Ten Broek1  1Radboud University Medical Center,General Surgery,Nijmegen, GELDERLAND, Netherlands 2Rijnstate Hospital,Department Of Radiology,Arnhem, GELDERLAND, Netherlands

Introduction:
Chronic abdominal pain develops in 18-40% of patients who have undergone abdominal surgery. Adhesions are associated with chronic post-operative pain; however, diagnosis and treatment is controversial.  In this study we evaluate long-term pain and healthcare utilization in a prospective cohort of patients who underwent adhesion mapping by cine-MRI, with subsequent treatment determined through a shared decision-making approach. 

Methods:
Patients with chronic post-operative abdominal pain with suspicion for causative adhesions underwent evaluation with cine-MRI. When adhesions were present on cine-MRI, individualized risks and benefits of adhesiolysis were discussed in a shared-decision making process. Patients who elected to undergo adhesiolysis received an anti-adhesion barrier. Pain and healthcare utilization were evaluated by questionnaire at follow up.

Results:
106 patients were recruited, with a median of 19 (range 6-47) months’ follow-up. 79 patients had adhesions on cine-MRI, 45 underwent an operation, while 34 patients elected not to pursue surgical intervention. 27 patients had no adhesions on cine-MRI, five choose to proceed with diagnostic laparoscopy. Response rate to follow-up questionnaire was 86?8%. In the operative group (Group 1), 80?0% of 45 responders reported long-term improvements in pain, compared to 42?9% (difference 37·1%; 95% confidence interval (CI): 14·4%-55·9%) in patients with adhesions on cine-MRI who declined surgery (28 responders, group 2), and 26?3% (difference 53·7%; 95%CI: 27·3%-70·8%) in patients with no adhesions on cine-MRI who declined laparoscopy (19 responders, group 3). Consultation of medical specialists was significantly lower in group 1 compared to groups 2 and 3 (35?7% vs. 65?2% vs. 58.8%; P=0?023). 

Conclusion:
We demonstrate long-term pain relief in two-thirds of patients with chronic pain caused by adhesions, using cine-MRI and a shared decision making process. Long-term improvement of pain was achieved in 80% of patients who underwent surgery with concurrent application of an anti-adhesion barrier. 
 

26.03 Health Care Consumption and Sick Leave for Persistent Abdominal Pain after Cholecystectomy

Posted on January 25, 2017

S. Z. Wennmacker1, M. G. Dijkgraaf4, G. P. Westert3, J. P. Drenth2, C. J. Van Laarhoven1, P. R. De Reuver1  1Radboud University Medical Center,Surgery,Nijmegen, , Netherlands 2Radboud Univeristy Medical Center,Gastroenterology And Hepatology,Nijmegen, , Netherlands 3Radboud University Medical Center,Scientific Institute For Quality Of Healthcare (IQ Healthcare),Nijmegen, , Netherlands 4Academic Medical Center,Clinical Research Unit,Amsterdam, , Netherlands

Introduction: Annually, 800.000 cholecystectomies are performed in the United States and 22.000 in the Netherlands. Estimated costs of a cholecystectomy in the Netherlands are around 4000 euro’s. Gallbladder removal for symptomatic gallstones appears to be ineffective in terms of pain relief, in up to 40% of patients. Although several studies have reported on persistent abdominal pain after cholecystectomy, there is no literature on the actual burden of persistent pain to the health care system. The aim of this study is to determine health care consumption and the related costs in patients with persistent abdominal pain after cholecystectomy.

Methods: All 146 patients of a previous prospective multicenter cohort study who reported persistent abdominal pain 24 weeks after cholecystectomy between June 2012 and June 2014 were included in this study. Health care consumption was assessed in February 2016 using Patients experience of surgery questionnaire (PESQ), Medical Consumption Questionnaire (iMCQ) and patients’ medical records. Sick leave and productivity loss of (un)paid work were assessed by the Productivity Cost Questionnaire (iPCQ). Costs were calculated according the Dutch “Guideline for performing economic evaluations in health care” and reported in euro's.

Results: The response rate was 85% (124/146 patients), after a mean follow-up of 31.0 months after surgery (SD 6.5). A total of 55.6% (n=69) of patients had additional care for persistent abdominal pain after cholecystectomy; 30.6% received primary care, 37.1% received secondary care, 16% were admitted in the emergency department, and 8.9% of the patients were admitted to hospital. Diagnostic procedures were performed in 33.9% (n=42) of the patients, which revealed gallstone or surgery related causes in nine patients. In 20 patients another diagnosis was found. Additional treatment included use of medication in 17.7% (n= 22) of the patients (10% uses analgetics, 9.6% uses proton pomp inhibitors ). Additional interventions were performed in 7 patients (5.6%). Estimated mean medical costs for persistent abdominal pain since cholecystectomy were €1,239 (SD €3,573) per patient. Subsequent mean costs of sick leave and productivity loss of (un)paid work were €727 (SD €2,163) per patient.

Conclusion: Due to persistent abdominal pain after cholecystectomy, 55% of the patients needed additional health care, and one third of the patients underwent additional diagnostic procedures. Postoperative medical costs and costs of sick leave and productivity loss in patients with persistent abdominal pain are up to 50% of the initial costs of the cholecystectomy.

 

18.15 Interactive Online Course on Perioperative Management in the Elderly.

Posted on January 25, 2017

E. Ozturk1, M. Van Iersel5, K. Van Loon2, C. Den Rooyen2, J. Klaasse4, R. De Lind Van Wijngaarden3, H. Van Goor1  1Radboud University Nijmegen Medical Center,General Surgery,Nijmegen, GELDERLAND, Netherlands 2KNMG,Utrecht, UTRECHT, Netherlands 3Hart Long Centrum Leiden,Cardiothoracic Surgery,Leiden, ZUID-HOLLAND, Netherlands 4Medisch Spectrum Twente,Enschede, OVERIJSSEL, Netherlands 5Radboud University Nijmegen Medical Center,Geriatrics,NIjmegen, GELDERLAND, Netherlands

Introduction: Surgical specialists and those in training lack knowledge to adequately diagnose and treat the frail older patient before, during and after the operation.As part of a national initiative to increase competency of residents to deal with the elderly perioperatively, a six weeks open interactive online course was developed and broadly promoted among physicians (in training) involved in operations of elderly patients.The aim of this study was to evaluate the attitude, self confidence and knowledge after taking this course. 

Methods: Multiple educators followed the participants in their process and supported them in the discussions.Attitude (Ageing Semantic Differential, ASD), self confidence (validated questionnaire of self-perceived knowledge) and knowledge in 5 different domains (multiple choice exam) were obtained before and after the course.Correlations between these three outcomes and with demographics e.g. profession,gender,experience were explored. Participants gave written consent for using the data for research before start of the course . 

Results:260 physicians applied for the course.206 (79%) actually started and in 174 (67%) participants ASD and self confidence were available for analysis.Complete knowledge scores were available in 125 participants (60%).Professions with the highest percentage of participants were (residents in), anesthesiology (23.1%),gynecology (22.3%) and surgery (21.5%).Of these, 81.7%,60.3% and 46.4% were residents.Mean age was 35 years and 68% were women.Dropout for the knowledge exams was 40 percent,in the majority these were surgical interns and emergency department physicians.Knowledge in 5 different categories improved significantly, mean scores of correct answers increased from 49 to 65 percent (p<0.005).Participants of surgery and gynecology felt more secure (p=0.012 and p=0.01) in the treatment of the older patient after completing the course.Gynecologists (in training) also had a better attitude after the six-week course (p=0.036).A significant correlation was found between the ASD and the total knowledge score for surgeons (in training) (p=0.02).Discussions and exchange of best practices were many via the forum included in the course.

Conclusion:An interactive open online course on peri-operative care for the elderly increases knowledge in a mix group of surgeons,anesthetists,gynecologists and other physicians involved in the perioperative care of elderly.Thereby selfconfidence increases in surgeons and gynecologists and trainees in these specialties, with a significant attitude improvement in gynecologists (in training).More knowledge improves attitude, although this was only apparent for the surgical specialty.Drop out is high, however, the 60% completion rate is high compared to a 10% completion rate of massive open online courses in general.The next research steps are to measure the retention in knowledge and to explore the value of this courses for daily practice in the participating departments.

18.04 Are We Asking Too Much? Integrating Technical and Non-Technical Skills Training in Trauma Surgery

Posted on January 25, 2017

A. Alken1, M. Weenk1, J. Luursema1, C. Fluit2, H. Van Goor1  1Radboud University Nijmegen Medical Center,Surgery,Nijmegen, GLD, Netherlands 2Radboud University Nijmegen Medical Center,Health Academy,Nijmegen, GLD, Netherlands

Introduction:

Shortcomings in non-technical skills are important contributors to errors in the operating room which emphasizes the importance of training these skills in simulation. Non-technical skills can be trained separately or combined with technical skills. Previous research of a highly demanding emergency surgery integrated skills training showed that surgical educators predominantly coached on technical and hardly on non-technical skills. This study aims to investigate whether priming educators could increase the amount of non-technical skills coaching during such training and whether this is dependent of the trainee level.

Methods:

We conducted a randomized controlled trial. Data were collected during the hands-on part of the Definitive Surgical and Anesthetic Trauma Care course, a highly realistic emergency surgery integrated skills training on anesthetized porcine models. 12 surgical teams participated, each with 1 surgical educator coaching 2 surgical trainees, 1 scrub nurse and an anesthetic team. All educators were Advanced Trauma Life Support certified teachers who finished non-technical skills training. 8 final year residents, 8 junior (0-5 years of experience) and 8 senior surgeons (>5 years of experience) participated as trainees. 6 surgical educators were primed on non-technical skills teaching. 6 others received no priming.
All coaching was recorded, reviewed and scored as technical, non-technical or other. For the primed and non-primed educators the amount of non-technical skills coaching was calculated as a percentage of the total amount of coaching. Per team we collected all non-technical skills coaching utterances, added the same amount of technical skills coaching utterances and sorted out to which trainee level each utterance was directed. We than calculated per trainee level what percentage was non-technical and analyzed how much this deviated from 50%.

Results:

Primed educators did not coach more often on non-technical skills than non-primed educators (4.4%; sd=3.2 vs. 4.4%; sd=4.3; Mann-Whitney U test, P= .71). Within the resident trainee level group 51.2% (+1.2) of the coaching was non-technical. For junior and senior surgeon trainees this was 50.6% (+0.6) and 50% (0) respectively. Differences between trainee levels were not statistically different (Kruskal-Wallis test, P= .37).

Conclusions:

Primed educators did not coach more often on non-technical skills than non-primed educators. We found no differences in the amount of non-technical skills coaching per trainee level. The intervention might have been too weak to cause an effect on coaching. Another explanation is that an emergency surgery integrated skills training on porcine models is too complex and ‘chaotic’ for combined technical and non-technical skills coaching. Our findings are a valuable contribution to the debate on whether non-technical skills training should happen independent from or combined with technical skills training in such simulation.