79.06 Validation of the American Association for the Surgery of Trauma Grade for Mesenteric Ischemia

Posted on January 31, 2019

M. C. Hernandez1, H. Saleem1, E. J. Finnesgard1, N. Prabhakar1, J. M. Aho1, A. K. Knight1, D. Stephens1, K. B. Wise1, M. D. Sawyer1, H. J. Schiller1, M. D. Zielinski1  1Mayo Clinic,Surgery,Rochester, MN, USA

Introduction:

 

Acute mesenteric ischemia (AMI) is a lethal and variable disease without uniform severity reporting. The American Association for the Surgery of Trauma (AAST) developed an Emergency General Surgery (EGS) grading system for AMI where grade I represents low disease severity and grade V severe in order to standardize risk assessment. We aimed to validate this system by stratifying patients using the AAST EGS grade hypothesizing that disease severity would correspond with clinical outcomes.

Methods:

 

Retrospective, single-institution review of adults with AMI was performed (2013-2017). Preoperative, procedural, and postoperative data were abstracted. Univariate comparisons of imaging and operative grades and covariates were performed and a multivariate analysis evaluated for factors independently associated with 30-day mortality (odd ratios ±95% confidence intervals).

Results:

 

There were 230 patients; 137 (60%) were female. AMI etiologies included: hypovolemia (137, 60%), thrombosis/atherosclerosis (68, 30%), and embolism (25, 10%). The imaging AAST EGS grades were I (108, 47%), II (38, 17%), III (53, 23%), IV (24, 10%), V (7, 3%). Compared to patients who received an operation, patients managed non-operatively (91, 40%) demonstrated a lesser imaging grade (1 [1-2] vs 2 [1-3]) and the etiology was more commonly (75% vs 50%;both p<0.05). Increased imaging grade was associated with diminished systolic blood pressure and increased serum lactate concentrations but not with other physiologic or demographic covariates (Table 1). The type of operation (laparotomy, laparoscopy, conversion to open), need for multiple operations, open abdomen therapy, bowel resection, intensive care management, and 30-day mortality were associated with increasing imaging grade (Table 1). After adjustment for age, sex, AAST EGS grade, operation type, qSOFA score, and etiology, the following factors were independently associated with 30-day mortality: age 1.02 (95%CI 1.0-1.05). imaging grade I (reference), grade II 2.6 (1.01-6.9), grade III 3.1 (1.3-7.4), grade IV 6.4 (1.9-12.2) and grade V 16.6 (2.4-21.3) and increasing qSOFA 2.9 (1.9-4.5). Operative AAST EGS grade was similar to preoperative imaging AAST EGS grade, Spearman correlation 0.88 (p=0.0001).

Conclusion:

 

The AAST EGS grade, used as a surrogate for AMI disease severity, incrementally demonstrated greater odds of 30-day mortality. Decreasing blood pressure and increasing lactate correlated with increasing AAST EGS grade. Operative approach was also associated with AAST EGS grade with few patients receiving vascular interventions at higher grades. The AAST EGS grade for AMI is valid and may be used as a benchmarking tool on these disease severity definitions.

 

79.01 The Impact of Prehospital Whole Blood on Arrival Physiology, Shock, and Transfusion Requirements

Posted on January 31, 2019

N. Merutka1, J. Williams1, C. E. Wade1, B. A. Cotton1  1McGovern Medical School at UT Health,Acute Care Surgery,Houston, TEXAS, USA

Introduction: Several US trauma centers have begun incorporating uncrossmatched, group O whole blood into civilian trauma resuscitation. Our hospital has recently added this product to our aeromedical transport services. We hypothesized that patients receiving whole blood in the field would arrive to the emergency department with more improved vital signs, improved lactate and base deficit, and would receive less transfusions following arrival when compared to those patients receiving pre-hospital component transfusions. 

Methods: In Novemeber 2017, we added low-titer group O whole blood (WB) to each of our helicopters, alongside that of existing RBCs and plasma. We collected information on all trauma patients receiving prehospital uncrossed, emergency release blood products between 11/01/17 and 07/31/18. Patients were divided into those who received any prehospital WB and those who received only RBC and or plasma (COMP). Initial field vital signs, arrival vital signs, arrival lbaoratory values, and ED and post-ED blood products were captured. Statistical analysis was performed using STATA 12.1. Continuous data are presented as medians (25th-75th IQR) with comparisons performed using Wilcoxon ranksum. Categorical data are reported as proportions and tested for significance using Fisher’s exact test. Following univariate analyses, a multivariate model was created to evaluate post-arrival blood products, controlling injury severity score, field vital signs, and age. 

Results: 174 patients met criteria, with 98 receiving prehospital WB and 63 receiving COMP therapy. 116 WB units were transfused in the prehospital setting. Of those receiving WB prehospital, 84 (82%) received 1 U, 14 (12%) received 2U. There was no difference in age, sex, race, or injury severity scores between the two groups. While field pulse was similar (WB: median 117 vs. COMP: 114; p=0.649), WB patients had lower field systolic pressures (median 101 vs. 125; p=0.026) and were more likely to have positive field FAST exam (37% vs. 20%; p=0.053). On arrival, however, WB patients had lower pulse and higher systolic pressures than COMP patients (TABLE). There was no difference in arrival base excess and lactate values (TABLE). However, WB patients had less ED and post-ED blood transfusions than the COMP group. A multivariate linear regression model demonstrated that field WB was associated with a reduction in ED blood transfusions (corr. coef. -10.8, 95% C.I. -19.0 to -2.5; p=0.018).

Conclusion: Prehospital WB transfusion is associated with improved arrival physiology with similar degrees of shock compared to COMP treated pateints. More importantly, WB pateints received less transfusions after arrival than their COMP counterparts. 

76.08 Some is Not Better Than None: A Meta-Analysis of Total and Proximal Gastrectomy for Gastric Cancer.

Posted on January 31, 2019

B. P. Stahl1, J. B. Rose1, C. M. Contreras1, M. J. Heslin1, T. N. Wang1, S. Reddy1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction: Surgical resection is a mainstay for treating gastric cancer. There is significant controversy surrounding the appropriate operation to maximize oncological benefit and functional outcome for proximal gastric cancer. Some advocate total gastrectomy (TG) with roux-en Y esophagojejunostomy reconstruction claiming that this operation provides optimal lymph node staging for this disease and eliminates post-operative reflux.  Others favor proximal gastrectomy (PG) with esophagogastric reconstruction hoping that the residual gastric reservoir will improve nutrition. We sought to address this question by reviewing oncological, perioperative, and functional outcomes of patients undergoing these two operations for proximal gastric cancer.

Methods: We performed a systematic review and meta-analysis of patients undergoing TG and PG for gastric cancer using PubMed, Embase, and the Cochrane Library from 2007 to 2018 with the MeSH terms “proximal”; “total”; and “gastrectomy” in English-language publications. We identified 659 results; 359 remained after duplicates were purged. From this dataset, 23 articles were selected for the present study. Studies were evaluated for quality with the Newcastle-Ottawa scale for non-randomized evaluations and via the Jadad scale for randomized-control trials.

Results: 23 articles were included in the quantitative synthesis (17 retrospective and 6 prospective studies) with 3227 patients (1984 TG and 1243 PG).  Most of the studies originated from Asia (Japan 13, Korea 5, China 2, Italy 1, India 1, United States 1) with patients cared for from 1990-2012. Most of the patients (96%) had Stage I or II gastric cancer. 30% (6/20) of the studies used perioperative chemotherapy. Median follow up was reported in 19/23 studies (range 17-60 months). TG retrieved a larger number of lymph nodes (OR 13.11, P<0.00001; FIGURE A), had fewer anastomotic stenoses (OR 3.13, P=0.0004; FIGURE B), and had less post-operative reflux symptoms (OR 2.72, P=0.01; FIGURE C) compared to PG.  The two operations had similar complication (FIGURE D) and 5-year overall survival rates (FIGURE E).  Mortality was similar between the two operations (PG 3.5% vs. TG 1.3%, P=0.66).

Conclusion: Although TG obtains a greater number of lymph nodes, both operations offer similar long-term overall survival—raising the question of whether these additional distal gastric resected lymph nodes are important in early stage proximal gastric cancer. PG is a safe and effective operation for early stage proximal gastric cancer if surgeons are willing to accept postoperative gastric reflux and anastomotic stenosis. These findings will need to be evaluated in advanced gastric cancer.

75.03 NQO1 Expression Predicts OS and Response to Preoperative Chemotherapy in Colorectal Liver Metastasis

Posted on January 31, 2019

Y. Hirose1, J. Sakata1, T. Kobayashi1, K. Takizawa1, K. Miura1, T. Katada1, M. Nagahashi1, Y. Shimada1, H. Ichikawa1, T. Hanyu1, H. Kameyama1, T. Wakai1  1Niigata University Graduate School of Medical and Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan

Introduction:  NAD (P) H: quinone oxidoreductase – 1 (NQO1) protects human cells against redox cycling and oxidative stress. We hypothesized that immunohistochemical expression of NQO1 in the resected specimen of colorectal liver metastasis (CRLM) has impact on the response to preoperative chemotherapy for CRLM and survival after liver resection in patients with CRLM.

Methods:  A retrospective analysis was conducted of 88 consecutive patients who underwent initial liver resection for CRLM from January 2005 through December 2016 in Niigata university medical and dental hospital. The median follow-up time was 65.4 months. Immunohistochemistry was conducted for the resected specimen using a monoclonal anti-NQO1 antibody. According to the NQO1 expression in tumor cells of CRLM, the patients were classified into two groups: the NQO1 positive group and the loss of NQO1 group. According to the NQO1 expression in non-neoplastic epithelial cells of the large intrahepatic bile ducts, the patients were classified into two groups: the NQO1 non-polymorphism group, which had NQO1 expression in those cells, and the NQO1 polymorphism group, which had no NQO1 expression in those cells. Overall survival (OS) after liver resection for CRLM were evaluated by univariate and multivariate analyses taking into consideration 15 other clinicopathological factors. Among 30 patients who received preoperative chemotherapy for CRLM, association between response to preoperative chemotherapy for CRLM and NQO1 status of those patients was evaluated. Response to preoperative chemotherapy was determined according to pathologic response and RECIST criteria using multidetector row CT. All tests were two-sided and P < 0.05 were considered statistically significant.

Results: Of the 88 patients, 61 were classified as the NQO1 positive group and 27 as the loss of NQO1 group, whereas 21 were classified as the NQO1 non-polymorphism group and 67 as the NQO1 polymorphism group. The loss of NQO1 group was associated with a lower prehepatectomy serum CEA level. The NQO1 polymorphism group was associated with higher frequency of bilobar metastases. The loss of NQO1 group had significantly better OS than the NQO1 positive group (cumulative 5-year OS rate: 90.9% vs 66.5%, P = 0.026), and loss of NQO1 expression was an independent favorable prognostic factor in multivariate analysis (relative risk: 0.139, P = 0.001). Regarding association between the response to preoperative chemotherapy for CRLM and NQO1 status, the presence of NQO1 polymorphism was significantly associated with a better response to preoperative chemotherapy in RECIST (P = 0.004). The absence or presence of NQO1 expression in CRLM was not associated with response to preoperative chemotherapy for CRLM.

Conclusion: Loss of NQO1 expression indicates favorable prognosis for patients with CRLM. The presence of NQO1 polymorphism may predict a good response to preoperative chemotherapy for CRLM.

 

71.06 Prevalence of Thymic Parathyroids in Primary Hyperparathyroidism during Radioguided Parathyroidectomy

Posted on January 31, 2019

S. Dream1, B. Lindeman1, H. Chen1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:

Radioguided surgery has been an effective tool for identifying hyperfunctioning parathyroid glands, including both adenomas and hyperplastic glands during routine parathyroidectomy for hyperparathyroidism.  The purpose of this study was to examine the role of radioguided surgery for the identification of intrathymic adenomatous and hyperplastic parathyroid glands.

Methods:
Between March 2001 to February 2018, 2291 patients underwent parathyroidectomy by one surgeon for primary hyperparathyroidism.  Of these patients 158 (7%) were identified to have an ectopic intrathymic parathyroid gland. All patients underwent radioguided parathyroidectomy with preoperative injection of 10 mci of TC-99m sestamibi.  Ex vivo radionuclide counts were used to confirm parathyroid excision with specimen radioactivity of >20% of the background level.

Results:
The mean age was 56 ±1 years with 74% of the patients being female.  Preoperatively, 122 patients underwent sestamibi scan with the scan correctly identifying the the affected gland 61% of the time.  Mean preoperative calcium was 10.7± 0.1 mg/dL and the mean preoperative parathyroid hormone(PTH) was 112 ± 6 pg/mL. Mean background radionuclide count was 208 +/-7, mean ex vivo radionuclide count was 127 ± 9, with ex vivo counts of removed glands were >20% in all patients.  Thymectomy was performed in 140 of the patients. Mean postoperative calcium was 9.3 ± 0.1 mg/dL and the mean postoperative PTH was 46 ± 3 pg/mL.

All ectopic parathyroid glands were successfully identified using gamma probe.  Ex vivo counts found to be significantly higher in patients with adenomas. Patients with parathyroid adenomas also were older in age and had higher preoperative calcium levels (see table).  While 10% of patients with primary hyperparathyroidism have hyperplasia, 42% of patients with thymic parathyroids had hyperplasia.

Conclusion:
Radioguided parathyroidectomy is useful in detecting ectopic parathyroid glands in the thymus.  Patients with hyperplasia disproportionately have thymic parathyroid glands.
 

70.05 Comparison of the Accuracy of SURPAS vs ACS NSQIP Surgical Risk Calculators

Posted on January 31, 2019

S. Khaneki1,2, M. R. Bronsert1, W. G. Henderson1, M. Yazdanfar1, A. Lambert-Kerzner1, K. E. Hammermeister1, R. A. Meguid1  1University Of Colorado Denver,Surgery,Aurora, CO, USA 2Hurley Medical Center,Internal Medicine,Flint, MI, USA

Introduction:

The Surgical Risk Preoperative Assessment System (SURPAS) is a parsimonious surgical risk assessment tool integrated into our electronic health record (EHR) for the preoperative prediction of postoperative adverse events.  SURPAS applies to >3000 operations in 9 surgical specialties, requires entry of 7 readily available predictor variables, and predicts outcomes of mortality, overall morbidity, unplanned readmission and 8 clusters of common complications.  It was developed from the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP) dataset. The objective of this study was to compare the accuracy of predictions of postoperative mortality and morbidity using SURPAS vs. the ACS NSQIP risk calculator.

 

Methods:

We calculated predicted preoperative risk of postoperative mortality and morbidity using both SURPAS and the ACS NSQIP risk calculator for 1,006 patients randomly selected from the ACS NSQIP database across 9 different surgical subspecialties.  We calculated the relative and absolute mean and median of the risk differences and plotted histograms and Bland-Altman graphs to analyze these differences.  We also compared the goodness of fit statistics for expected and observed adverse postoperative outcomes between SURPAS and the ACS NSQIP risk calculator using the c-index, Hosmer-Lemeshow analysis, and Brier scores.

 

Results:

The SURPAS risk estimates for mortality were slightly higher (Mean=0.64%) than the ACS NSQIP estimates (0.59%) and considerably higher for overall morbidity (10.65% vs 7.73%).  The ACS NSQIP risk estimates for morbidity tended to underestimate risk compared to observed adverse postoperative outcomes, particularly for the highest risk patients.  Goodness of fit statistics were similar for SURPAS and the ACS NSQIP risk calculator, except for the c-index for mortality (SURPAS c=0.853 vs ACS NSQIP c=0.937), although this finding is probably tentative because there were only 6 deaths. Hosmer-Lemeshow graphs and fit statistics for ACS NSQIP and SURPAS risk estimates vs observed adverse postoperative outcomes are shown for mortality and overall morbidity (Figure).

 

Conclusions:

The SURPAS risk predictions for mortality and overall morbidity are as good as those of the ACS NSQIP risk calculator.  SURPAS has the advantages that it requires only one-third of the number of predictor variables as the ACS NSQIP tool, provides patient risk estimates compared to national averages for patients undergoing the same operation, is integrated into the EHR, and automatically provides a preoperative note in the patient’s medical record and a graphical handout of risks for the patients to take home.

70.01 Blue Spectrum Filtering Cataract Lenses Are Associated With Reduced Survival

Posted on January 31, 2019

J. Griepentrog1, X. Zhang1, O. Marroquin3, J. Chang3, N. Loewen2, M. Rosengart1  1University Of Pittsburgh,Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,Ophthalmology,Pittsburgh, PA, USA 3University Of Pittsburgh,Medicine,Pittsburgh, PA, USA

Introduction: During the process of aging, the lens undergoes progressive changes that perturb the transmission of light, particularly the short-wavelength (400-500nm) blue spectrum. It is this shorter wavelength that maximally entrains our circadian rhythms, which orchestrate adaptive alterations in physiology, metabolism, and immunity. Several recent studies highlight that cataract surgery is associated with a reduced risk of all-cause mortality. Intraocular lenses (IOL) differ in transmission properties: conventional (Natural-IOL) and blue-light filtering (Blue-IOL). We hypothesized that in patients undergoing bilateral cataract surgery, the restoration of exposure to blue light with the implantation of Natural-IOL compared to continued blockage with Blue-IOL is associated with a reduced risk of death.

Methods: We conducted a retrospective cohort analysis of all subjects undergoing bilateral cataract surgery within a single healthcare system. We abstracted data for each subject regarding age, sex, race, zip code and state of residence, health insurance status, smoking status, alcohol use, and body mass index. Systemic comorbidities were classified using the Charlson Comorbidity Index. The primary outcome was all-cause mortality. We conducted a multivariate Cox Proportional Hazards model, stratified by and clustered on surgeon, to compare the adjusted risk of death in subjects undergoing bilateral implantation of Blue-IOL with those receiving Natural-IOL. A p<0.05 was considered significant. Sensitivity analyses for mortality were performed 1) using a more restrictive definition of ‘concomitant’ bilateral cataract surgery (<90-day interval), 2) excluding any surgeon implanting predominantly (>90%) Blue-IOL, and 3) restricting the analysis to Pennsylvania (PA) residents.

Results: A total of 1482 subjects underwent bilateral cataract surgery during the period of analysis, of which 512 (34.6%) received a Blue-IOL. Natural-IOL were associated with a reduced risk of all-cause mortality: aHR, 0.60 [95% CI, 0.38 to 0.94]; p=0.03. There was a significant difference by age category (p=0.02 for interaction with age >65): for the subgroup >65, Natural-IOL were associated with reduced mortality: aHR 0.52 [95% CI, 0.35 to 0.78]; p=0.001. Restricting bilateral surgery to a 90-day interval (n=1163), eliminating the surgeon implanting predominantly Blue-IOL (n=1133), and restricting the analysis to PA residents (n=1463), each showed that Natural-IOL are associated with prolonged survival.

Conclusion: Among patients undergoing cataract surgery, restoring the transmission of the entire visible spectrum compared to blocking the shorter wavelength blue spectrum, is associated with a reduced risk of death. These data suggest that a progressive blockage of blue light by cataracts may perturb circadian biology, and that cataract surgery that restores the shorter wavelength of visible blue light may restore these homeostatic mechanisms.

69.05 Survival Outcome of RNF43 Mutant-type Differs between Right-sided and Left-sided Colorectal Cancer

Posted on January 31, 2019

Y. Shimada1, Y. Tajima1, M. Nagahashi1, H. Ichikawa1, K. Yuza1, Y. Hirose1, T. Katada1, M. Nakano1, J. Sakata1, H. Kameyama1, Y. Takii2, S. Okuda3, K. Takabe4, T. Wakai1  1Niigata University,Digestive And General Surgery,Niigata, NIIGATA, Japan 2Niigata Cancer Center Hospital,Surgery,Niigata, NIIGATA, Japan 3Niigata University,Bioinformatics,Niigata, NIIGATA, Japan 4Roswell Park Cancer Institute,Breast Surgery,Buffalo, NY, USA

Introduction: Right-sided colorectal cancer (CRC) demonstrates worse survival outcome compared with left-sided CRC, and clinicopathological characteristics of right-sided CRC differ from left-sided CRC. Recently, the importance of RNF43 mutation has been reported along with BRAF mutation in serrated neoplasia pathway. We hypothesized that clinical significance of RNF43 mutation differs between right-sided and left-sided CRCs, and RNF43 mutation associates with tumor biology of right-sided CRC. To test this hypothesis, we investigated the clinicopahotlogical characteristics and survival outcome of patients with RNF43 mutation in right-sided and left-sided CRCs.

Methods: One-hundred-nine microsatellite stable Stage IV CRC patients were analyzed. Thirty-three and 76 patients were right-sided CRC and left-sided CRC, respectively. We investigated genetic alterations using a 415-gene panel, which includes RNF43 and the other genes associated with tumor biology. We analyzed clinicopathological characteristics between RNF43 wild-type and RNF43 mutant-type using Fisher’s exact test. Moreover, we classified RNF43 mutant-type according to primary tumor sidedness, i.e., right-sided RNF43 mutant-type or left-sided RNF43 mutant-type, and compared clinicopathological characteristics between the two groups. Overall survival rates of RNF43 wild-type, right-sided RNF43 mutant-type, and left-sided RNF43 mutant-type were analyzed using log-rank test.

Results:CGS revealed that 8 of 109 patients (7%) had RNF43 mutation. RNF43 mutation was significantly associated with high age (65 or more) (P = 0.020), presence of BRAF mutation (P = 0.005), absence of KRAS and PTEN mutations (P = 0.049 and P = 0.026, respectively). RNF43 mutation was observed in 3 of 33 right-sided CRC (9%) and 5 of 76 left-sided CRC (7%), respectively. Interestingly, RNF43 mutations in right-sided CRC were nonsense mutation (R145X) or frameshift mutation (P192fs, S262fs), while those in left-sided CRC were missense mutations (T58S, W200C, R221W, R519Q, R519Q). All the three right-sided RNF43 mutant-type were high age (65 or more), female, BRAF V600E mutant-type. Right-sided RNF43 mutant-type showed significantly worse OS than RNF43 wild-type and left-sided RNF43 mutant-type (P = 0.007 and P = 0.046, respectively).

Conclusion:Clinicopathological characteristics and survival outcome of patients with RNF43 mutation might differ between right-sided and left-sided CRC. In right-sided CRC, RNF43 mutation is a small, but distinct molecular subtype which is associated with aggressive tumor biology along with BRAF V600E mutation. Future preclinical and clinical studies might have to focus on RNF43 mutation for improving survival outcome in right-sided CRC.

 

68.09 Accuracy of Multidetector Computed Tomography in Preoperative Aortic Valve Annulus Sizing

Posted on January 31, 2019

S. Banerjee1, A. Das1, H. Zimmerman1, R. Jennings1, R. Boova1  1Temple University Hospital,Department Of Cardiothoracic Surgery,Philadelpha, PA, USA

Introduction:

Surgical aortic valve replacement (SAVR) may be associated with unanticipated intraoperative aortic pathology that is not identified by routine pre-operative evaluation. Such findings may alter the conduct of SAVR. Pre-operative multidetector computed tomography (MDCT) was adopted to mitigate unexpected intraoperative aortic findings.

MDCT is integral in preoperative sizing for transcatheter aortic valve replacement (TAVR) sizing. As TAVR emerged as an alternative to SAVR, our institutional TAVR MDCT protocol was implemented in pre-operative SAVR assessment to avoid duplicate MDCT, if findings resulted in pathology more amenable to TAVR than SAVR.

The purpose of this study is to determine if our institutional TAVR MDCT accurately predicts aortic valve prosthesis size. The secondary objective is to determine if there is a trend towards over- or under-sizing, if MDCT is not consistent with implant size.

Methods:

Between July 2012 and July 2017, 102 patients who underwent surgical aortic valve replacement had preoperative aortic valve sizing by MDCT. The aortic annulus diameter calculated using MDCT was compared to intraoperative valve sizing during SAVR. Implanted valve size within 1 mm of the MDCT calculated size was regarded as accurate in predicting valve size. If the implanted valve was outside the 1 mm range, it was classified as either smaller or larger. This was done because valves used in SAVR are manufactured in 2 mm increments. To evaluate if MDCT accuracy was affected by aortic valve annulus size, we stratified the valve diameters based on MDCT measurements into categories: 17.8-19.9, 20- 21.9, 22-23.9, 24-25.9, and >26mm. Statistical analysis was performed using SPS software and paired t-test was used to evaluate whether the results were statistically significant.

Results:

Forty-one (40.2%) of the 102 patients studied had MDCT aortic valve measurements that were within 1mm of implant size. Implanted valves were smaller than MDCT calculation in 40 patients (39.2%) and were larger in 21 patients (20.6%). MDCT measurements remained inconsistent with intraoperative sizing regardless of aortic annulus diameter. The variance between MDCT annulus measurements and intraoperative sizing was statistically significant, p value less than 0.0005, as determined by paired t-test.

Conclusion:

Preoperative aortic annulus measurements by MDCT differed substantially from intraoperative sizing. Furthermore, there was no trend towards over- or under-sizing. These results may impact preoperative planning for patients undergoing SAVR if MDCT is utilized for preoperative planning. The implication of this information on preoperative TAVR planning is indeterminate and may warrant further investigation.
 

61.05 Safety, Efficacy and Cost Analysis of Robotic Sleeve Gastrectomy Compared to Standard Laparoscopy

Posted on January 31, 2019

J. P. Kuckelman1, T. Holtestaul1, D. Lammers1, J. Bingham1  1Madigan Army Medical Center,General Surgery,Tacoma, WA, USA

Introduction: The increasing comfort with robotic methods in concert with technological advances has led to a surge in robotic approaches for bariatric operations, the most common of which being sleeve gastrectomy (SG).  The progression of robotic use for bariatric procedures has forged forward despite a lack of evidence-based support. Current database studies have demonstrated conflicting data regarding the safety of the robotic approach for sleeve gastrectomy. We evaluate the safety and effectiveness of robotic methods when compared to a standard laparoscopic approach.

Methods: Retrospective review of all SG performed between 2010 and 2017 at a single bariatric center of excellence. Patients were followed for a minimum of 3 months with ongoing follow up to one year. Cases were grouped as laparoscopic (LSG) or robotic (RSG) and propensity matched for age, sex, BMI, and co-morbidities. Patient characteristics, intra-operative indices as well as follow up data including weight loss was collected. Patients were categorized based on operative approach and propensity matched for comparison.

Results: 479 patients were included with the majority being categorized as laparoscopic sleeve gastrectomy (LSG, N=403) with 76 patients included in the robotic group (RSG).  There was 99% follow up for 30 day outcomes. LSG had significantly more patients with pre-operative diabetes at 15.8% compared to 1.3% in the RSG group (p=0.003). There were no differences in terms of pre-operative age, weight, BMI, smoking status, ASA, or rates of any other comorbidity. Operative time was significantly longer with RSG at 138 minutes compared to 104 minutes with LSG (p=<0.001). There were no differences in rates of intra and post-operative blood transfusions, hospital length of stay, unplanned return to the operating room or readmission (Figure). Propensity matching resulted in reduction to 75 patients in each group and did not alter the primary results. Estimated percent weight loss (EWL%) was similar at 3 and 6 months between the two groups. Only 41 patients met had 12-month follow-up in the RSG group but EWL% was significantly lower with RSG at 101% compared to 60% in the LSG group (p=<0.001, see figure).

Conclusion:Robotic sleeve gastrectomy was found to be safe and effective with similar results in terms of weight loss when compared to laparoscopic sleeve gastrectomy. Operative times were longer with a robotic approach which did not result in any adverse postoperative events.
 

53.17 Indocyanine Green for Ureter Identification During Robotic Colectomy: A Single Center Study

Posted on January 31, 2019

S. B. Bryczkowski1, J. E. Glanville2, A. H. Khosravi3, A. S. Rosenstock1, G. Mazpule1, S. G. Pereira1  1Hackensack University Medical Center,Surgery,Hackensack, NJ, USA 2Hospital Corporation of America,Surgery,Richmond, VA, USA 3St. Joseph Hospital,Surgery,Tustin, CA, USA

Introduction: Robotic surgery has gained favor across specialties. There is an ongoing effort to make colorectal surgery safer. Urologists have used indocyanine green (ICG) dye to identify ureters during robotic ureterolysis, but no studies existed on ICG use during robotic colectomy. We hypothesized that intraureteral ICG would decrease the time to identify the ureters during robotic sigmoid colectomy.

 

Methods: A retrospective review of prospective data at a single academic center. The use of ICG for ureteral identification reflected a change in practice. Patients either had ureteral stents with intraureteral ICG or stents alone (no ICG). Colectomies were performed by one of three attending surgeons and assisted by one of three robotic fellows. The primary outcomes were time to identify ureters and operative (OR) time. Secondary outcomes were complications of ureteral injury, leak, and infection. All adults (>18) who presented for elective robotic sigmoid colectomy between Oct ’15 – Aug ‘17 were included. Exclusion criteria were pregnancy, age ≤18, and emergency surgery. Data collection included demographics (age, gender), surgical indication (complicated or recurrent diverticulitis or neoplasm), and clinical data (number (n) diverticulitis episodes, n previous surgeries). Data were analyzed using student t test, chi square analysis, or one-way ANOVA.

 

Results: Of 151 patients admitted for colectomy, 30 met criteria. Of those, 16 received ICG and 14 did not (no ICG). There were no differences in age between ICG and no ICG, [presented as mean (m), ± standard deviation (sd)] (59 ± 15 vs. 63 ± 10, p=0.21) or gender, [% female] (50% vs. 71%, p=0.23). There was a statistically significant decrease in the time to identify the ureters in the ICG group [m ± sd] (10min ± 12 vs. 38 ± 81, p=0.04). There were no differences in OR time (264min ± 63 vs. 281 ± 52, p=0.11), n diverticulitis episodes (4 ± 3 vs. 5 ± 9, p=0.39), n previous abdominal surgeries (0.9 ± 0.8 vs. 0.5 ± 0.8, p=0.06), cases of complicated diverticulitis, [n, %] (6, 38% vs. 6, 43%, p=0.76), or in rate of ureteral identification (16, 100% vs. 13, 93%, p=0.14).

 

Conclusion: This single center study demonstrated that intraureteral ICG allowed faster ureteral identification during robotic sigmoid colectomy. Although overall OR time did not differ between the groups, all ureters were identified when ICG was used. Early ureteral identification with ICG could lead to safer colorectal surgery by preventing injury to the ureters. Future studies should focus on whether early ureteral identification using ICG leads to decreased incidence of ureteral injury during robotic colectomy.

53.15 The optimal surgical management for colorectal liver metastases in the era of multidisciplinary treatment.

Posted on January 31, 2019

T. Ochiai1, T. Shigeno1, M. Sakano1, T. Igaki1, R. Matsumoto1, N. Chiyonobu1, I. Saito1, K. Saito1, S. Yamazaki1  1Ohta Nishinouchi General Hospital,Suregry,Koriyama, FUKUSHIMA, Japan

Introduction:  Recent advances in chemotherapy have expanded the resectability of colorectal cancer with liver metastases (CRLM), optimal surgical management for the patients with CRLM is controversial. We studied treatment results in the patients with CRLM since molecular target-based agent was approved in Japan since 2008. 

Methods: Based on data collected retrospectively, we analyzed the demographics, clinical data, operative findings, chemotherapy, and outcomes of 285 consecutive CRLM patients treated between 2008 and 2017. To investigate the optimal surgical management, we devided the observation periods into 2 periods, 2008-2011 and 2012-2017, and analyzed resectability and response rate of chemotherapy. 

Results:The 1-, 3-, and 5-year overall survival rates for the entire CRLM patient and 109 patients who underwent liver resection were 80.4%, 48.4%, and 30.0%, and 94.3%, 72.5%, and 52.8%, respectively. Out of synchronous/metachronous, neo-adjuvant and adjuvant chemotherapy, repeat liver resection, only perioperative chemotherapy revealed significant difference in resected 109 patients. The resectability of whole CRLM was 38.2% in 2008-2017, 46.2% in 2008-2011, and 33.5% in 2012-2017. The response rate of patients with unresectable or neoadjuvant chemotherapy were 43.8% in 2008-2017, 43.1% in 2008-2011, and 45.0% in 2012-2017. The 1-, 3-, and 5-year overall survival rates for the entire CRLM patient and 101 patients who underwent liver resection were 74.8%, 48.4%, 32.6%, and 93.7%, 80.7%, 55.5% in 2008-2011, and 84.0%, 47.1%, 25.2%, and 94.9%, 71.1%, 49.5% in 2012-2017. Three cases of initially unresectable CRLM converted to complete resection with neoadjuvant chemotherapy. 

Conclusion:Although development of various molecular target-based agents has improved short-term survival of CRLM patients, liver resection is the key of long-survival. Neither neoadjuvant nor adjuvant chemotherapy is not significantly different in survival, but perioperative chemotherapy is effective in this study. To improve survival of the patients with CRLM, aggressive surgery and perioperative chemotherapy without missing the timing of hepatectomy are required. 

 

53.13 Two Port plus Teleflex Minigrasper Transabdominal preperitoneal (TAPP) Inguinal Hernia Repair

Posted on January 31, 2019

H. J. Bonatti1, H. Bonatti1  1Meritus,Surgical Specialists,Hagerstwon, MD, USA

Introduction: Transabdominal preperitoneal (TAPP) inguinal hernia repair requires a 10mm and two 5mm trocars. When using a transverse peritoneal flap, a rather long incision is required. Tacks for MESH fixation and re-approximation of the flap may be associated with pain and are costly.

Methods: A two port technique was used replacing one 5mm instrument with a Teleflex minigrasper. The peritoneal flap was created from a 5-10cm vertical incision in the infraumbilical peritoneum and re-approximated with a running suture or tacks. Dissection of the inguinal region was done in a reduced size pocket.

Results: Median age of the 17 men and five women was 64.4 (range 29.5-84.8) years; there were 16 unilateral and six bilateral inguinal hernias (including three recurrent hernias and two incarcerated hernias). Two patient had large inguinoscrotal hernias. Tacks for the flap were used in four of the first seven cases; in the last 15 suture closure was used in all patients. Various techniques to suture the flap were tried out, the V-lock turned out to be the easiest option and was made standard. In eight patient only two 5mm trocars were used, in two patients a 5mm and an 8mm trocar was inserted and in 12 patients a 5mm and a 10mm trocar was used. Progrip MESH without tacks was placed in 20 patients. TAPP was done as outpatient procedure in 50% of cases, six patients required 23 hours extended recovery; only five patients with severe co-morbid conditions required admission. Complication included seroma (n=2), bladder injury (n=1) and urinary retention (n=2); two patients with preexisting groin pain had ongoing symptoms post TAPP. No recurrence was observed during a median follow up of 722 (range 14-1299) days.

Conclusion: Creation of the peritoneal flap from a midline incision and re-approximation using a running suture is technically feasible. The created preperitoneal pocket is smaller than in conventional TAPP but still allows good exposure. TAPP can be done with two 5mm ports and the Teleflex minigrasper. The minigrasper can be used for laparoscopic suturing.

 

53.06 Intrahepatic Cholangiocarcinoma Tumor Burden to Predict Prognosis Following Resection

Posted on January 31, 2019

J. Cloyd2, F. Bagante2,6, G. Spolverato2, M. Weiss1, S. Alexandrescu3, H. P. Marques4, L. Aldrighetti5, S. K. Maithel7, C. Pulitano8, C. Pulitano8, T. W. Bauer9, F. Shen10, G. A. Poultsides11, O. Soubrane12, G. Martel13, B. G. Koerkamp14, A. Guglielmi6, E. Itaru15, T. M. Pawlik2  1Johns Hopkins Hospital,Surgery,Baltimore, MD, USA 2The Ohio State University Wexner Medical Center,Surgery,Columbus, OH, USA 3Fundeni Clinical Institute, Bucharest,Surgery,Bucarest, -, Romania 4Curry Cabral Hospital,Surgery,Lisbon, -, Portugal 5Ospedale San Raffaele,Surgery,Milan, -, Italy 6University of Verona,Surgery,Verona, -, Italy 7Emory University School Of Medicine,Surgery,Atlanta, GA, USA 8Royal Prince Alfred Hospital,Surgery,Sydney, -, Australia 9University Of Virginia,Surgery,Charlottesville, VA, USA 10Eastern Hepatobiliary Surgery Hospital,Surgery,Shanghai, -, China 11Stanford University,Surgery,Palo Alto, CA, USA 12Beaujon Hospital,Surgery,Clichy, -, France 13University Of Ottawa,Surgery,Ottawa, Ontario, Canada 14Erasmus University Medical Centre,Surgery,Rotterdam, -, Netherlands 15Yokohama City University School of Medicine,Surgery,Yokohama, -, Japan

Introduction: We sought to investigate the impact of total tumor-burden (i.e. size and number) on patient prognosis following resection of ICC.

Methods: Patients who underwent curative-intent resection for ICC at one of the 15 participating institutions between 2005-2016 were identified.

Results:Among 1,278 patients who underwent surgery for ICC, 423 (33.1%) patients had no lymph-node metastasis (N0), while 224 (17.5%) had nodal disease (N1); 631 (49.4%) did not have a lymphadenectomy (Nx). Median tumor size was 6 cm (inter-quartile range [IQR], 4-8). While 1,016 (81.8%) patients had a single ICC, 226 (18.2%) patients had multifocal disease. On multivariable analysis, after adjusting for lymph-node status, tumor size (logarithmic transformation: HR 1.35) and number of ICC (logarithmic transformation: HR 1.51) demonstrated a strong non-linear association with overall survival (OS)(Log-model; Figure 1). Log-model (AUC 0.588) out-performed both tumor size (c-index 0.572) and number of tumors (c-index 0.539) in predicting OS. Among N0 patients, 5-year OS of patients with a single ICC ranged from 80-70% among patients with ICC <3 cm to 50% for patients with ICC >6 cm. Conversely, among N1 patients, 5-year OS of patients with a single ICC ranged from 60-50% for patients with ICC <3 cm to 40-30% for patients with ICC 3-6 cm and 20% for patients with ICC >6 cm.

Conclusion:Tumor size and number of ICC demonstrated a strong non-linear association with survival following resection of ICC. A log-model tumor burden score may be a better tool to estimate prognosis of patients undergoing curative-intent resection of ICC.

 

53.05 Usefulness of Fluorescence Imaging for Laparoscopic Liver Resection and Complex Biliary Surgery

Posted on January 31, 2019

Y. Kawaguchi1,2, Y. Nomura1, M. Nagai1, N. Tanaka1  1Asahi General Hospital,Department Of Surgery,,Asahi, CHIBA, Japan 2the University of Tokyo,Hepato-Biliary-Pancreatic Surgery Division,Bunkyo, TOKYO, Japan

Introduction: A fluorescence imaging technique using indocyanine green (ICG) as a fluorophore has been increasingly used for hepatobiliary surgery, and visualizes liver cancer and the bile duct as fluorescence. However, the usefulness of the technique for laparoscopic liver resection and complex biliary surgery remains unclear. We aimed to evaluate the identification of liver cancer in laparoscopic approach and the visualization of the bile duct during complex biliary surgery in open approach using ICG-fluorescence imaging.

Methods: (1) Visualization of liver cancer was evaluated in 6 patients (13 lesions) who underwent laparoscopic liver resection. As a fluorophore of the technique, ICG was injected intravenously at a dose of 0.5 mg/kg as a routine liver function test within 2 weeks before surgery. (2) Visualization of the bile duct was evaluated in 7 patients who underwent complex biliary surgery. ICG was administered by intrabiliary (IB) injection (0.025 mg/mL) or by intravenous (IV) injection (2.5 mg). The values of fluorescence intensity (FI) of the bile duct and the liver were calculated using a luminance analyzing software.

Results:(1) Of the 13 lesions, there were hepatocellular carcinoma (n=3) and colorectal liver metastasis (n=10). Fluorescence imaging visualized 8 (61.5%) lesions, which were invisible on the surface but were located less than 10 mm from the liver surface (Figure 1A). In contrast, the other 5 were located more than 10 mm from the liver surface and were not visualized as fluorescence. (2) Fluorescence imaging technique with the IB injection method was used for 6 patients with severe inflammation (n=3), abnormal biliary anatomy (n=2), and perforation of the bile duct (n=1). In contrast, the IV injection method was used for 1 patient with abnormal biliary anatomy. When using the IB injection method, the liver did not provide fluorescence as it showed fluorescence using the IV injection method. The fluorescence of the bile duct was clearly visualized on the low FI of the surrounding structures using the IB injection method (Figure1B) compared to fluorescence imaging using the IV injection method (Figure 1C). The median (range) FI ratio of the bile duct to the liver was 19.1 (5.0-67.7) using the IB injection method while it was 1.4 using the IV injection method.

Conclusion:ICG-fluorescence imaging is useful to visualize liver cancers which were not visible from the liver surface during laparoscopic liver resection. The IB injection method provided clear contrast between the bile duct and the surrounding structures compared with the IV injection method. The IB injection method is useful for recognizing the biliary anatomy, especially when biliary drainage tubes were inserted as an intervention of severe biliary tract infection.

 

53.03 Perineural Invasion as a Prognostic Factor in Pancreatic Ductal Adenocarcinoma

Posted on January 31, 2019

H. Takahashi1, E. Katsuta1, K. Takabe1  1Roswell Park Cancer Institute,Surgical Oncology,Buffalo, NY, USA

Introduction:

Perineural invasion (PNI) is the process of neoplastic invasion of nerves, and is a morphologic feature observed in various malignancies. It serves as one of the pathologically determined poor prognostic factors along with lymphovascular invasion, and also can be a source of distant metastasis for some tumors. PNI is widely prevalent in patients with pancreatic ductal adenocarcinoma (PDAC). Although the exact mechanism of invasion to nerve still remains unclear, several signaling pathways in tumor microenvironment (TME) have been reported to date. Since PNI is relatively subjective pathological evaluation, there have been some conflicting reports of utility of PNI in the management of PDAC. Therefore, in the present study, we aimed to identify biological factors that are associated with PNI in PDAC using publicly available large data set The Cancer Genome Atlas (TCGA).  

Methods:

Genomic and clinical data of patients with PDAC were obtained from TCGA through cBioportal. Pathological information associated with TCGA was obtained through TIES. Using Kaplan-Meier survival curve and Cox proportional hazards model, clinical and oncologic parameters were analyzed. Gene Set Enrichment Analysis (GSEA) was also conducted between the groups based on PNI status.

Results:

There were 154 patients with PDAC in TCGA. The mean age of the cohort was 65.1 years old, with 83 (54%) patients being male. PNI was positive in 109 patients (71%), negative in 13 (8%), and unknown in 32 (21%). There was no significant difference in overall survival (OS) based on PNI status in TCGA cohort. Median OS was 17.8 months in PNI positive, and 19.9 months in negative (p=0.30). Subsequently, in order to identify the risk factors for OS, univariate analysis was performed with multiple clinical parameters. There was significantly longer OS in the patients who underwent adjuvant radiation therapy or targeted molecular therapy (p=0.002 and p<0.001, respectively). With multivariate analysis, absence of targeted molecular therapy (Hazard Ratio (HR): 4.76, p<0.001), absence of adjuvant radiation (HR: 2.58, p=0.02), and positive PNI (HR: 8.28, p=0.02) were found as independent risk factors of poor prognosis in patients with PDAC.

Furthermore, the PNI positive group was identified to enrich angiogenesis gene set by GSEA (NES: 1.67, p=0.002).

Conclusion:

Positive PNI was one of independent risk factors of poor prognosis in patients with PDAC in this study. It might be due to the associated angiogenesis and possible distant metastasis. 

53.02 Hospital Factors Strongly Influence Robotic Use in General Surgery

Posted on January 31, 2019

C. L. Stewart1, S. Dumitra1, C. Nota1, P. H. Ituarte1, L. Melstrom1, Y. Woo1, G. Singh1, Y. Fong1, H. Nathan2, S. G. Warner1  1City Of Hope National Medical Center,Surgical Oncology/Surgery,Duarte, CA, USA 2University Of Michigan,Hepatobiliary Surgery/Surgery,Ann Arbor, MI, USA

Introduction:   Although the use of robotics in general surgery is increasing in the United States, hospital and patient-level factors driving adoption are sparsely studied.  We hypothesized that general surgeons are more likely to use a robotic surgical platform at hospitals where more urologic and gynecologic robotic surgeries are performed, suggesting that hospital related factors are important for platform choice.

Methods: We queried the Nationwide Inpatient Sample from 2010-2013 for patients who underwent surgery on the gallbladder, pancreas, stomach, spleen, colon, or rectum (general surgery), the prostate or kidney (urologic surgery), and ovaries or uterus (gynecologic surgery).  Operations were classified as robotic if any ICD-9-CM robotic procedure code was used.  Hospitals were grouped into quartiles according to percentage of total volume of urologic or gynecologic surgeries that were performed robotically (0-20%, 21-40%, 41-60%, >60%). Multivariable logistic regression modeling was used to determine independent variables associated with robotic surgery. 

Results:  Survey-weighted results represented 461,368 (47.6%) open, 479,783 (49.5%) laparoscopic, and 27,620 (2.6%) robotic general surgical operations.  For general surgery patients, robotics use increased with each subsequent year studied (5.4% by 2013), and was most commonly performed for rectal surgery (7.0%), on patients with private insurance (3.2%) and higher household income (3.3%, all p<0.001).  Robotic operations were also more frequently performed at urban teaching hospitals (3.4%), compared to rural and non-teaching hospitals (p<0.001).  The odds of a general surgery patient receiving a robotic operation increased directly with increased use in urologic and gynecologic surgery at the hospital (Figure 1, *p<0.001).  General surgery patients treated at a top quartile hospital for robotic urologic surgery had 4 times greater odds of receiving a robotic operation compared to an open or laparoscopic operation (confidence interval 3.0-5.4, p<0.001). This finding was independent of study year, surgical site, insurance type, household income, and hospital type, and also persisted when only comparing laparoscopic to robotic procedures.   

Conclusions:  The use of robotics in general surgery is directly and independently related to its use in urologic and gynecologic surgery at a hospital.  Our study suggests that hospital factors strongly influence robotic use in general surgery. 

53.01 Clinical impact of anatomical resection for HCC treatable with partial resection

Posted on January 31, 2019

T. Gocho1, K. Nakashima1, Y. Shirai1, R. Marukuchi1, J. Yasuda1, H. Shiozaki1, K. Furukawa1, S. Onda1, H. Shiba1, Y. Ishida1, K. Yanaga1  1Jikei University School of Medicine,Department Of Surgery,Tokyo, Japan

Introduction:

Anatomical resection (AR) for hepatocellular carcinoma (HCC) has been reported to have better outcome compared to non-anatomical resection (NR). However, the specific benefit of AR for HCC judged treatable with partial resection remains unclear. The aim of this study is to evaluate the clinical impact of anatomical resection for HCC treatable with partial resection.

Patients and

Methods:
Two-hundred and sixty three patients were treated with primary hepatectomy for HCC between May 1997 and December 2016 at Jikei University Hospital. Of those, 80 patients with solitary tumor which were judged treatable by partial hepatectomy based on preoperative imaging were retrospectively reviewed. We divided such patients into two groups according to the types of resection (anatomical resection (AR) group (n = 28) treated by subsegmentectomy and non-anatomical resection (NR) group (n = 52) treated by partial hepatectomy) and patient factors (age, sex, viral status, ICG R15, Child-Pugh (C-P) grade), tumor factors (size, preoperative AFP and PIVKA-II values and portal vein (PV) invasion), operative factors (operative time, blood loss and blood transfusion) and outcomes (overall (OS) and disease-free (DFS) survival and complications) were assessed.

Results:

The following variables were comparable: sex, HBV infection, HCV infection, ICG 15, C-P grade, Preop. AFP, tumor size, pathological PV invasion, blood loss, blood transfusion and complications. However, AR group had older patients (≥ 65 years) (60% vs. 28.8%, p <0.05), higher preop. PIVKA-II (≥ 100 mAU/ml) (71% vs. 46.2%, p < 0.05) and longer operative time (≥ 360 min) (61% vs. 45%, p < 0.05), which were not independent risk factors related to DFS and OS after primary hepatectomy. There were no statistical difference in 5-year DFS and 5-year OS between AR group and NR group (53% vs. 36%, p = 0.096 and 70% vs. 67%, p = 0.714, respectively). However, for HCC 2 cm or larger, statistically higher 5-year DFS was achieved in AR group as compared with NR group (53% vs. 31%, p = 0.041), while no significant difference was observed in 5-year OS (73% vs. 64%, p = 0.488). Twenty seven of 52 patients in NR group developed intrahepatic recurrence, whose recurrence was in the same subsegment in 9 (33%) and in the other segment in 18 (67%) patients. There was no statistical difference in 5-year OS after recurrence between those with recurrence in the same subsegment and the other subsegment (p = 0.764).

Conclusion:

Anatomical resection (subsegmentectomy) seems to improve DFS of patients with HCC 2 cm or larger in diameter.

51.20 Acute Gastroduodenal Ulcer Perforation under Laparoscopy Highly Selective Vagotomy and Repair

Posted on January 31, 2019

G. Chen1, Y. HE2, G. LI3, L. ZOU4  1GUOBIN CHEN,ZHUHAI, GUANDDONG, China 2YAOBIN HE,ZHUHAI, GUANDDONG, China 3GUOWEI LI,ZHUHAI, GUANDDONG, China 4LIAONAN ZOU,ZHUHAI, GUANDDONG, China

Introduction:  

To investigate the application value of laparoscopic perforation high selectivity of vagotomy plus repair surgery in the treatment of gastroduodenal ulcer perforation.

Methods:

Retrospective analysis data from January 2017 to July 2017, 53 patients with gastroduodenal ulcer perforation include gastric perforation of 31 cases and 22 cases of duodenal perforation. 25 patient were given laparoscopic perforated high selectivity of vagotomy plus repair surgery (study group) while 28 patients had received single laparoscopic perforation repair surgery (control group).

Results:

More bleeding and longer surgical time happened in study group but the exhaust time and hospitalization time is similar. The study group had higher complete cure rate after three-month regular internal treatment.

Conclusion:

Comparing with laparoscopy repair surgery, the treatment of laparoscopic perforation high selectivity of vagotomy plus repair surgery in gastroduodenal ulcer perforation is safer, more reliable with lower recurrence rate.

51.19 Utility of 3D Laparoscopy in Spleen Conserved Surgery in Traumatic Spleen Rupture

Posted on January 31, 2019

Y. He1, G. Chen1, G. Li1, L. Zou1  1Guangdong hospital of TCM,Zhuhai Campus,GUANGZHOU, GUANGDONG, China

Introduction: To analyze the feasibility and safety of utilizing 3D laparoscopy in spleen repair surgery in acute grade ? /?? traumatic spleen rupture. 

Methods: Retrospective analyze 6 patients with acute impatent abdominal trauma which confirmed grade ?/? traumatic spleen rupture by 3D laparoscopy exploration, and treated with laparoscopic spleen repairment by suture in our center from January 2017 to June2018. We analyzed the parameters of perioperative period and summarized the operative experience.

Results: One patient composed with liver rupture while another with jejunum rupture. All repairments of spleen and other organ by suture under 3D laparoscopy were successfully completed without conversion to splenectomy or open surgery. No patient suffered from postoperative intrabdominal bleeding or need secondary abdominal exploration. The average time for spleen repairment is 24±13min, average amount of abdominal drainage in the first 24hours after surgery is 55±33ml, and average postoperative hospitalization days are 6±2.5 day.

Conclusion: 3D laparoscopy providing more magnified view and guarantee more accurative manipulation which make spleen repairment by suture feasible and safe in a less invasive way for grade ?/? traumatic spleen rupture. Also, any other composing intrabdominal organ impairment is feasible to detect and manipulate with 3D laparoscopy.

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