Wissenschaftliches Programm

Background

Spinal anaesthesia as an adjunct to general anaesthesia has been shown to improve perioperative pain management after colorectal surgery. A subsequent reduction of opioid analgesics might further shorten postoperative ileus and costs in colorectal surgery.

Aims

We aim to assess the impact of spinal anaesthesia on pain control, postoperative ileus and costs after colorectal surgery.

Methods

Data of consecutive patients with colorectal resections not receiving an ostomy between October 1st 2021 and July 31st 2022 were entered into a prospective database and included in the preliminary analysis. Peri- and postoperative pain scores (numeric rating scale, NRS) and – medication, parameters of bowel function (flatus, stool, diet) and costs were compared. Prolonged postoperative ileus was previously defined by inability to tolerate a regular diet, radiological ileus and/or absence of flatus for 24 hours after the 4th postoperative day.

Results

Spinal anaesthesia was added to general anaesthesia in 53 of 88 patients included in our preliminary analysis. Patient age and body mass index were similarly distributed between groups. Comorbidity (American Society of Anaesthesiologists classification class 3 and 4) was more frequent in patients not receiving spinal anaesthesia (51% vs. 21%. p=0.003). Spinal anaesthesia was associated with decreased NRS scores at 3h (0 vs 4, p= 0.019), 12h (2 vs. 4, p=0.007) and 24h (2 vs. 5, p=0.002) following surgery. Our preliminary analysis of 88 patients (50% of sample size calculation) did not show any difference in time-to-flatus, time-to-stool, time-to-normal diet and prolonged postoperative ileus between the two groups. Cost analysis of 34 patients operated in 2021 did not show a difference between patients with and without spinal anaesthesia (20'227 CHF vs. 20'876 CHF).

Conclusion

Spinal anesthesia improves postoperative pain control. Our preliminary analysis did not show a decrease of postoperative ileus and costs after colorectal resection.

Background: Postoperative pain management after laparoscopic colorectal surgery is of utmost importance to grant a better outcome, shorter length of hospital stay, and costs. The Transversus abdominis plane (TAP) block is a relatively new technique with great potential and is achieved through a direct blockade of pain fibers in the plane between the transversus abdominis and internal oblique muscles. Delivery can be achieved under ultrasound guidance performed by the anesthetist or under laparoscopic control performed by the surgeon, however, few studies investigated the best administration method.

Aims: The aim of this study was to assess if laparoscopic-assisted TAP block (L-TAPB) is as efficient as ultrasound-guided TAP block (U-TAPB) in postoperative pain control.

Material&Methods: One-hundred-sixteen patients scheduled for elective laparoscopic colon resections from February 2018 to December 2021 at two Swiss hospitals, were included and randomized with a 1:1 ratio to receive either L-TAPB or U-TAPB (Figure 1). The primary outcome was the percentage of patients requesting reserve opioids. Secondary outcomes were total opioid consumption within the first 24 hours after surgery, postoperative pain on the visual analog scale (VAS) at 3, 6, 12, and 24 hours after surgery, and TAP block-related complications.

Results: There were almost twice as many patients in the L-TAPB group requesting opioid reserves compared to the U-TAPB group (54.5% vs. 29.8%, p=0.008) although no statistical significance was found in the overall dose in 24 hours (Figure 2). For all other variables (pain on the VAS at 3, 6, 12, and 24 hours after surgery, the need for epidural analgesia, complications related to the TAP block, and hospital stay no statistically significant difference between the L-TAPB and the U-TAPB groups was noted.

Conclusions: Our results, although marginal differences between groups were noted, showed the non-inferiority of the laparoscopic delivery compared to ultrasound-guided administration.

Background: Enhanced recovery after surgery (ERAS) protocols have shown beneficial outcomes in various surgical fields in the last 20 years. Nevertheless, some benefits such as lower complication rates, shorter length of stay and cost reduction might be related to other, simultaneously implemented technical improvements such as a minimally-invasive access or modified anesthesiology care.

Aim: To analyze the effects after the implementation of an ERAS protocol in 2021 in a high-volume colorectal center.                          

Material and Methods: This is a propensity score matched single-center study comparing the short-term outcomes and cost analysis of patients undergoing elective colorectal surgery in an ERAS program from 2021 to August 2022 compared to regular perioperative care from 2019 to 2020.

Results: A total of 738 patients underwent elective colorectal surgery between 2019 and August 2022. 456 patients were included in the propensity score matched analysis with 228 patients per group (ERAS vs. non-ERAS). The predominant access in both groups was minimally-invasive with 78%; 17% were rectal procedures. There was no significant difference in age, sex, insurance status, body mass index, Charlson’s Comorbidity Index, tumor entity and type of surgery between groups. Major complications (grade 3a or higher according to Clavien-Dindo) occurred in 6.6% vs. 7% (p=0.85) and anastomotic leakage demanding operative revision in 2.2% vs. 2.6% (p=0.68) in the ERAS and non-ERAS group, respectively. Mean length of stay (LOS) and mean costs per case were significantly lower in the ERAS group compared to the non-ERAS group (LOS 9.2 days vs. 12.7 days, p=0.001; costs 30’114 francs vs. 35’991 francs, p=0.004). At 30-day telephone follow-up, 97% of patients in the ERAS group were in a good general state and mean overall satisfaction level was at 9.2/10.

Conclusion: Late adoption to an ERAS protocol leads to a significant reduction of LOS and costs without increasing perioperative morbidity.

Objective

Enhanced recovery after surgery (ERAS) is an established program to improve short-term outcome in colorectal surgery. Similar efficacy, feasibility and safety has been observed in the elderly population. However, little is known about the adherence to the ERAS protocol in this potentially frail population in daily practice.    

Methods

Patients following colorectal resection were prospectively included in the ERAS protocol. The cohort was retrospectively stratified according to age (≥75 years) and ERAS compliance (≥70% adherence). Criteria of exclusion was ≥ 5% missing data. Patients were compared regarding clinical short-term follow-up (30 days).

Results

During the study period between August 2018 and October 2022, 414 patients were recruited, including 131 patients ≥75 years. The two patient groups differed significantly in ASA score grading and in the occurrence of malignant disease (82.4% vs. 57.6%; p<0.001 and 64.1% vs. 45.9%; p<0.001, respectively). Further, we observed a significant difference in post-operative ERAS compliance (73.5% vs. 79.7%; p=0.023). Elderly patients had a significantly longer hospital stay (9.7 vs. 7.8 days; p<0.001). In a further step, the elderly cohort was stratified according to ERAS compliance (≥70% [n=85]; <70% [n=46]). Within these two groups, patients’ characteristics were similar, except for age (82.1 vs. 80.0 years; p=0.012). The patient group with a compliance of <70% showed significantly more complications, re-operations and a longer hospitalization (11.8% vs. 50.0%; p<0.001, 2.4% vs. 15.2%; p=0.005, 7.8 vs. 13.2 days; p<0.001).

Conclusion

The compiled data confirms an inferior adherence to the ERAS compliance in elderly patients following colonic surgery. In opposition, adherence to the ERAS standard was correlated with less short-term complications and shorter hospital length of stay.  

Background

The DV-QOL is a 17-item questionnaire measuring health-related quality of life in patients affected by symptomatic diverticular disease, covering four domains: physical symptoms, concerns, emotions and behavioral changes. It was developed in 2015 in English and helps optimize patient-centered decision-making.

Aims

Validation of the German version of the DV-QOL questionnaire.

Material & Methods

German-speaking patients aged >18 years with history of recurrent diverticular disease admitted to a Swiss surgical department completed the German version of the DV-QOL, along with the SF-36 and the Gastrointestinal Quality of Life Index (GIQLI) questionnaires. Reliability was examined using exploratory and confirmatory factor analysis, a Martin-Loef-Test and Cronbach’s alpha. For convergent validity testing, correlations were calculated with the GIQLI and SF-36. Discriminant validity tests included age and gender.

Results

We included 121 patients, of whom 77 were planned admissions for elective surgery and 44 presented with acute diverticulitis treated conservatively. The DV-QOL total score showed good correlations with the GIQLI (r=-.77) and its subscales (r= -.76 – -.45), as with the SF-36 subscales (r= -.30 – -.57). No relationships were found with age or gender (p<.05). A nonsignificant Martin-Loef-Test indicated unidimensionality (p=1), further supported by the exploratory factor analysis, which showed an item information sharing of 65% (except for the frequency of watery diarrhea). Cronbach’s alpha was .89 overall. Confirmatory factor analysis showed mixed results, in that the four domains mentioned above covered by the instrument did not emerge as distinctly separate dimensions.

Conclusion

Analysis of the German DV-QOL questionnaire showed convergency with other patient-reported outcome measures and discrimination with expectedly unrelated concepts. The four aspects covered by the instrument were more overlapping than expected. Reliability was good, with only one item behaving inconsistently. The German DV-QOL questionnaire can be used as a valid and reliable disease-specific measure for quality of life in patients with diverticular disease.

Background

vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a minimally invasive technique that combines the benefits of laparoscopy and a scar less vaginal approach. This technique is common in gynecologic surgery but is rarely used in visceral surgery, due to lack of familiarity with the technique. In the literature, vNOTES sigmoidectomy is described as safe and feasible for benign disease. For oncological diseases however, some series exist but no clear evidence exists.

Aims

We report a case of pure vNOTES sigmoidectomy for benign sigmoid disease.

Material and Methods

A 77 year- old female with chronic constipation and abdominal pain was diagnosed with transitory sigmoid volvulus in the context of dolichocolon. From a gynecologic point of view, hysterectomy and bilateral adnexectomy was considered due to benign disease. After a posterior endovaginal access, the gynecologist performed the adnexectomy and the hysterectomy. Following hemostasis, we performed a laparoscopic vNOTES sigmoidectomy. The rectosigmoid junction was sectioned following dissection of the mesorectum. The mesocolon was then dissected followed by vascular control. After partial mobilization of the left colon, a near infrared ICG perfusion test was performed. A hand assisted transrectal end-to-end circular stapler anastomosis was then carried out. Due to concern about the integrity of the anastomosis, even if rectoscopy and an air-leak test did not show any defect, an intracorporal suture was performed with the final air-leak test without any leak.

Results

Post-op recovery was uneventful, with bowel passage occurring 2 days post-operatively. The patient was discharged at Day 4.

Conclusions

vNOTES sigmoidectomy for benign disease is safe and feasible in selected patient. The literature is unclear regarding the benefits and risks of vNOTES versus a conventional sigmoidectomy. Ongoing research will clarify long term outcome for oncological disease.

Standardization and technological development of vNOTES will allow to perform more complex procedures and will become an interesting alternative for patient.

Background
In view of the continuous increase of health care costs in Switzerland over the last decades, it is essential to save money by reducing the length of hospitalization. Hence, same day admission (SDA) was implemented recently. The present analysis aimed to analyze financial implications associated with this new strategy.

Method
Patients undergoing left and right colonic resections between January 1, 2019 and December 31, 2020 were included. Costs, revenue and margin generated for the hospital were compared between the hypothetical SDA group and the actual inpatient group, using resampling via bootstrap t test.

Results
The institutional LOS of the 260 patients was 7.8 (5.8) days (median, range: 5.9, 1-39.7), 1.8 days less than the national CH average. The exercise on the inpatient population (N=134) is a loss of CHF 56’038, partly due to low outliers. The virtual exercise in SDA limited the losses to CHF 13’981. The costs related to the day before the intervention and thus saved within the hypothetical DAS strategy was valued at CHF 541. Although there were 3 more low outliers in the virtual DAS group compared to the actual inpatient group, the overall savings of CHF 72 548 (134*541.4) limited the losses.

Conclusion
In a prospective payment system implemented to avoid bad incentives, the latter can unintentionally disadvantage best performing hospitals, especially those operating at maximum capacity. From a healthcare system point of view, a DAS strategy helps to limit expenses in cost intensive hospitals like tertiary academic centers.

Background

Intussusception in adults is rare, but has a leading cause in 90% of cases. Underlying etiologies are of vast origin (benign, malignant, postoperative, systemic). Due to the rarity of this condition and multiple causes, literature consists mostly of case reports and small case series, lacking high-quality sources and treatment plans. The aim of this study was to perform a systematic literature review and to propose a treatment algorithm.

Methods

We conducted a systematic literature review of PubMed/MEDLINE using MeSH terms “intussusception” AND “adults” AND “management”. Study period extended from MEDLINE implementation to 31.12.2022. Inclusion criteria were case series including >10 patients, systematic reviews, and meta-analyses of adult intussusception. Pediatric cases, anorectal intussusceptions, and case reports were excluded. A treatment algorithm for this rare disease was suggested after review of the collected data.

Results

We found 214 articles, and excluded 179 case reports or case series with <10 patients, 20 articles unrelated to intussusception, and 4 articles on anorectal intussusception. A total of 11 articles including 1416 patients were retained for review,. The most commonly occurring type of intussusception was enteric, followed by ileo-colic and colic. A malignant origin was more common in colic and ileocolic intussusceptions, whereas enteric intussusceptions were more commonly of benign origin. Based on these results, we recommend for colic and ileocolic intussusception en bloc resection without reduction to avoid tumor seeding. For enteric origins, we recommend intraoperative reduction followed by resection to reduce the risk of short-bowel syndrome. In case of small (length <3.5 cm) enteric intussusception with a favorable clinical and laboratory presentation, conservative treatment and watchful waiting should be performed.

Conclusion

Adult intussusception is a rare entity in adults with a vast differential diagnosis. For these reasons, management algorithms are lacking. Based on a systematic review, this study suggests a treatment algorithm.

Background: Postoperative infection remain a significant burden, with increased morbidity and mortality. Better perioperative prediction of patients at risk for postoperative infection is needed. Currently, preoperative phenotyping and postoperative markers of inflammation have been assessed as individual but fixed parameters. Machine learning techniques now allow to identify and integrate multiple parameters as well as temporal changes within one model.

Aims: This study tests the hypothesis that a composite score integrating all perioperative laboratory values will be a better predictor of postoperative infection compared to one single value, such as CRP.

Material&Methods: Retrospective analysis of prospectively collected data from all patients who underwent surgery at our institution between January 2014 and September 2022 for whom perioperative laboratory values were available. The primary endpoint was postoperative infection. Dimensionality reduction techniques (tSNE, UMAP, and PCA) were used to visualize the high dimensional data. A random forest model was trained using the laboratory values up to postoperative day 5 on the training dataset (80% of the data) to define a risk of infection score, which was tested on the testing dataset (20% of the data).

Results: 59’758 patients, who underwent 75’245 surgeries in all surgical departments within one University hospital were included. Our machine learning approach identified the changes that allow the earliest prediction for infection, e.g. changes in CRP between postoperative day 1 and day 2 in visceral surgery. A multidimensional model was built for visualization of the risk of infection.

Conclusions: By integrating multidimensional datasets, machine learning allows to identify predictors that are more accurate compared to standard multiple regression analysis. This information is clinically relevant by allowing for earlier identification of postoperative complications.

Background

The vacuum-assisted closure (VAC) system is a useful tool to promote wound healing. However, due to its occlusive system, the wound is often prone to Pseudomonas aeruginosa (PA) infections. Early detection and initiation of treatment is essential to limit the damage (e.g. saving a skin graft), but the black sponge occludes the wound and prevents its visual assessment leading to delayed diagnosis. Fortunately, each bacterium emits a spectrum of specific volatile organic compounds that can be used for detection. For PA, the signature compound is hydrogen cyanide. (Fig.A)

Aims

We aimed to develop a colorimetric biosensor for “naked-eye” detection of PA that takes advantage of the negative pressure created by the VAC to collect hydrogen cyanide.

Materials&Methods

We used aquocyanocobinamide, a derivative of vitamin B12, as a colorimetric chemosensor of biological cyanide. By binding cyanide, the color of the sensor changes from orange to violet (Fig.B), which can be quantified with UV-VIS spectroscopy. The sensor was delivered onto the carrier material polyvinyl acetate. Its sensitivity was assessed using laboratory strains and clinical isolates of PA in-vitro and on an ex vivo skin model.

Results

UV-VIS spectroscopy readings of the sensor were calibrated for the cyanide concentration 0-250ppm. (Fig.C) Cyanide produced by 30 laboratory and 20 clinical PA isolates were quantified based on the colorimetric changes of the sensor. While the sensor detected all PA strains, it did not falsely react to other wound pathogens such as Staphylococcus aureus, Streptococcus pyogenes, Escherichia coli and Enterococci, suggesting a high specificity. In a proof-of-principle experiment, the colorimetric change of the sensor was detected by eye after 3 hours incubation with a PA culture. (Fig.D)

Conclusions

The presence of Pseudomonas aeruginosa can be quickly and reliably detected by our vitamin B12-based colorimetric biosensor. Its incorporation inside the VAC-system can allow physicians to detect PA wound infections early on.

Background: Surgical site infections (SSI) are an important health burden and a major cause of postoperative morbidity and mortality. In more than 65% of the patients after general surgery, bacteria found in the infected wounds include intestinal commensals even without exposure to intestinal contents. Therefore, commensal microbiota from other compartments than the skin may play an unappreciated role in SSI. It remains to be explored if bacteria from the intestine reach wounds internally e.g., hematogenously. The primary objective of this study is to identify if the type of bacteria found in SSI is dependent on patient factors.

Methods: Data from 538'893 patients who underwent surgery between 2009 and 2020 was extracted from the Swissnoso database. In patients presenting SSI after intestinal (cholecystectomy, colon surgery, N = 5’506) and non-intestinal surgeries (hip and knee prosthesis, heart, spinal, and hernia surgery, N = 3’497), wound isolates were analyzed using Principal Component Analysis to find specific microbial pools according to the type of procedure. In a supervised machine learning analysis, we identified patient-related predictors for specific microbial compositions. The presence of single microbial strains was analyzed using a multivariate logistic regression model.

Results: We found distinct bacterial signatures in SSI depending on the type of surgery. Age, ASA score, wound contamination and the type of procedure were significant predictors for the microbial composition of wound isolates in SSI. After non-intestinal surgeries, higher age and ASA score were significantly associated with the presence of bacteria known to originate from the intestinal compartment, like Enterococcus spp. and Enterobacterales.

Conclusion: The increased fraction of SSI with intestinal commensal microbes in patients with worse health status supports the hypothesis that the pathogenesis of SSI not only depends on local spillage of microbes from the site of surgery, but also that host factors critically influence the development SSI.

Background

Abdominal surgeries are often inevitable and live-saving procedures, however, they can be associated with post-surgical complications, such as the formation of irreversible scar bands called peritoneal adhesions. Adhesions in the peritoneal cavity can lead to serious health burden by causing small bowel obstruction, infertility, and chronic pelvic pain. Unfortunately, no effective treatment for adhesion patients exists today.  Mesothelial cells and mesothelial cell-derived mesenchymal myofibroblasts have been identified as key players in the pathogenesis of adhesions, and thus represent a novel target for pharmacological interventions.

Aims

Our aim is to study the molecular mechanisms of mesothelial cell recruitment towards peritoneal adhesion sites, which could serve as potential drug targets to effectively prevent the formation of adhesions.

Material & Methods

By exploiting genetic lineage tracing and experimental animal surgery, we have established a surgical-transgenic mouse model system that allows us to study mesothelial cell recruitment during processes of scar-free wound healing and wound healing associated with adhesion formation. To identify candidate molecules predominantly required for the recruitment of mesothelial cells towards adhesion sites, we apply an untargeted transcriptomics-based research strategy (spatial transcriptomics, single cell RNA sequencing).

Results

Histological characterization of our mouse model showed that over seven days post-surgery increasing numbers of mesothelial or mesothelial cell-derived cells accumulate at adhesion sites whereas their numbers stay constant in wounds healing without scar formation. Along with these findings, we have determined candidate molecules potentially triggering mesothelial cell migration towards sites of adhesion formation and will next test their proposed function in vivo and in vitro.

Conclusions

Mesothelial cells and mesothelial cell-derived mesenchymal myofibroblasts particularly accumulate at sites of adhesion formation. Therapeutic targeting of the recruitment mechanism of these cells might represent a novel strategy to prevent post-surgical adhesion formation in the peritoneal cavity.

Background
Failure in medicine may cause severe harm to patients, especially in surgery where failure has immediate consequences. Despite often being an emotionally stressful experience for surgical residents, failure is a powerful teacher as well. Before entering residency where failure is inevitable, medical students should ideally learn how to talk about and cope with failure.

Aims
Educational interventions to support learners to regulate failure and its consequences are rare. Therefore, a four-day workshop entitled "How Physicians deal with Failure in Medicine" was offered to medical students at an academic institution to open the conversation about failure in medicine.

Material & Methods
The curriculum provided insights into the ubiquity of failure in surgery and beyond. 30 participants wrote reflective essays as a pre- and post-intervention task. Tutors, namely two surgeons and a life coach, facilitated presentations, group discussions, and journal clubs about failure, and discussed potential coping strategies.

Results
The content analysis of 60 reflective essays revealed various self-experienced and observed failures in the clinical context. Experiencing and witnessing failure was emotionally draining and often in conflict with expectations of being a physician. Fear of failure was omnipresent, while students realized that failure in medicine is human and inevitable. Perceived clinical supervision often protected medical students from failure and its potential consequences. However, open communication about failure rarely occurred. Overall, medical students emphasized the importance of open conversations about failure to learn from it.

Conclusions
Medical students wish to discuss failure before entering residency. Without open discourse about failure, medical students, and later residents feel left alone with their experiences, triggering fear. Clinical supervisors should support learners entering clinical training by being more transparent about their own failures and sharing their coping strategies which will ultimately help them to make sense about failure experiences in order to learn from and cope with it.

Background: Noise pollution in the operating room (OR) has been shown to have adverse effects on the surgical team and has been linked to the occurrence of surgical site infections. The aim of this study was to evaluate whether intraoperative sound levels were associated with postoperative complications.

Methods: Sound levels were measured during 407 procedures of patients undergoing elective or emergency surgery in four Swiss hospitals. Sound levels were registered every second in decibels dB(A). The percentage of time above 70dBA and the time-averaged sound levels were calculated. A standard questionnaire at the end of the surgery was used to evaluate subjectively perceived difficulty of the surgery and distraction during the procedure by the OR members. The POSSUM classification (“Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity”) was used to assess complexity of each procedure. Noise levels were then related to the occurrence of postoperative complications in multivariate regression models.

Results: Of the 294 patients included, 38% had any kind of postoperative complication. Intraoperative sound levels (percentage of time above >70dB(A) and time-averaged sound levels) were significantly higher for patients who developed a postoperative complication (0.7% versus 0.5%, respectively 60dB(A) versus 58dB(A), p-value < 0.01). Further, higher sound levels were significantly correlated with the duration and complexity of the procedure as well as subjectively perceived difficulty by the members of the surgical team. In a multivariate analysis including procedure- and patient-related factors, only the duration of the surgery was an independent predictor for postoperative complications.

Conclusion: Higher intraoperative sound levels were associated with an increased rate of postoperative complications. Here, we showed that this is likely the result of louder procedures being technically more challenging for the surgical team. Thus, increased sound levels may represent a surrogate marker for long and complex surgical procedures.

Background

The Cox proportional hazards model is a widely used time-to-event analysis. When Cox models are used, the proportional hazard assumption (PHA) must be reassured.

Aim

The aim of this study is to assess the quality of statistical reporting and testing of the PHA in primary and secondary reports of surgical randomized controlled trials (RCTs).

Material & Methods

Twenty-five primary and 32 secondary reports were identified in the top quartile of surgical journals. Thirty-three RCTs using Cox models out of 130 published in the first half-year of 2019 in the New England Journal of Medicine and The Lancet compiled a benchmark group. Statistical reporting was compared with a 12-item PHA Reporting Score. The PHA was formally tested on reconstructed time-to-event data from Kaplan-Meier estimators if original data were not available.

Results

In statistical reporting in surgical trials compared to benchmark publications, the median PHA Reporting Score for primary reports was 42% (interquartile range [IQR] 33 to 58), for secondary reports 50% (IQR 42 to 58) versus 67% (IQR 58 to 75), p<0.001. Reporting of PHA testing was found in only 2/25 and 6/32 surgical studies, whereas leastwise 28/54 were reported in the benchmark group. There was evidence for a violation of the PHA in seven primary reports; in one trial there was a change in the direction of the outcome when using an appropriate non-parametric test.

Conclusions

Testing of the PHA is highly relevant as a violation can result in misleading findings. Statistical reporting needs to be improved in surgical RCTs. A comprehensive statistical review process and statistical reporting guidelines might help improve the reporting quality and avoid the misapplication of statistical models.

Background

Non-randomized studies suggest that prophylactic negative pressure wound therapy (pNPWT) allows preventing surgical site infection (SSI) after laparotomy.

Aim

Our objective was to determine if pNPWT allows preventing SSI after laparotomy pooling only high-quality evidence.

Material and methods

MEDLINE, Embase, CENTRAL and Web of Science were searched from inception to the 25.08.2021 for RCTs reporting the incidences of SSI in patients who underwent laparotomy with and without pNPWT. The systematic review was compliant with the AMSTAR2 recommendation and registered into PROSPERO. Risk difference (RD) between control and pNPWT patients, risk ratios (RR) and log risk ratio (log(RR)) for SSI for patients with pNPWT were obtained using random effects models. Heterogeneity was quantified using the I²value. Heterogeneity was investigated using subgroup analyses (per RCT sample size, per type of pNPWT device, per quality of RCT), funnel plots and bubble plots. Risk of bias of included RCTs was assessed using the RoB2 tool.

Results

Eleven RCTs were included, representing 973 patients who received pNPWT and 970 patients who received standard wound dressing. Pooled log(RR), RR and RD between patients with and without pNPWT were of, respectively, -0.41 (95%CI: -0.71 to -0.10, I²: 38.7%, p=0.0098), 0.665 (95%CI: 0.49 to 0.91, I²: 38.7%, p=0.0098) and -0.07 (95%CI: -0.12 to -0.03, I²: 53.6%, p=0.0018), therefore demonstrating that pNPWT decreases the incidence of SSI after laparotomy. Investigation of source of heterogeneity identified a potential small-study effect.

Conclusion

The protective effect of pNPWT against SSI after laparotomy is confirmed by high-quality pooled evidence.

Background

The robotic platform offers 3D vision, tremor filter, and articulated instruments, however, superiority of robotic bariatric surgery (rBS) over laparoscopy remains uncertain. The aim of this study was to establish global benchmarks for primary robotic Roux-en-Y gastric bypass (rRYGB) and sleeve gastrectomy (rSG), operated in high-volume centers and compare those to the established laparoscopic benchmarks. Additionally, we aimed to investigate the robotic learning curve.

Methods

This multicenter study included rBS cases of 17 centers from 4 continents: 13 expert centers and 4 centers in the learning phase (Figure 1). Benchmark cutoffs defined as the 75^th percentile of the median outcome values of expert centers were established for low- and high-risk rRYGB and rSG cases until 90-days. Low-risk cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI>50kg/m² or age>65 years.

Results

9097 patients, mainly females (75.5%), aged 40±10.5 years with a baseline BMI of 42.46±3.9 kg/m², were included. 86.5% of cases were primary rBS. Patients’ risk profile and operation type significantly influenced the odds of postoperative complications (Figure 2). 14.8% of rRYGB and 5.9% of rSG patients presented ≥1 complication until 90-days and no patient died. Adverse events related to the robotic platform occurred in 1.13% of cases. Compared to laparoscopic benchmarks, inpatient stay was 1-2 days shorter; rRYGB had lower cutoffs for postoperative bleeding and marginal ulceration, while operation duration was 42 minutes longer (Table1). rSG showed superiority over laparoscopic SG for every surgical outcome, with similar operation duration. Robotic learning phase centers' outcomes were within the benchmarks for rRYGB except for docking times, while overall complication rate for rSG was 10% above benchmarks.

Discussion

With the exception of longer operation times for RYGB, the novel benchmark cutoffs for rBS suggest that the robotic approach improves surgical safety over laparoscopic bariatric surgery.

Background:

A significant proportion of bariatric patients are women of childbearing age. Bariatric patients may be at risk of nutritional and surgical complications that can be impacted by and can impact pregnancy.

Aim:

We aimed to investigate perioperative reproductive health practices, knowledge and recommendations of bariatric  professionals regarding reproductive health counseling, contraception and pregnancy in female bariatric patients of reproductive age.

Methods:

We conducted a national, online survey among bariatric professionals. Survey topics included demographic factors, perioperative reproductive health practices, attitudes and knowledge about contraception and recommendations regarding pregnancy.

Results:

A total of 72 healthcare professionals participated. The majority of participants responded that female patients of reproductive age are more than the half of the referred bariatric patients. Only 23 respondents (31.9%) referred always female patients of reproductive age to a gynecologist prior to a bariatric procedure, but 75% always discuss family planning. 51.4% of the participants do not recommend a certain type of bariatric operation in women of reproductive age, but 19 (26.4%) and 9 (12.5%) participants recommend Roux-en-Y gastric bypass and sleeve gastrectomy, respectively. There was a strong variance regarding the recommendations about contraception after surgery. Only 51.4% inform the patients about possible surgical, bariatric surgery-related complications during future pregnancies. More than half of the participants reported inadequate knowledge regarding absorption and safety of contraception pills after bariatric surgery. Although most professionals routinely follow- up and provide counselling on maternal and fetal risks in pregnant women with previous bariatric surgery, 65% have no standardized protocol for such patients who present with acute abdominal pain in their practice.

Conclusions:

Despite acknowledging the importance of reproductive health counseling, bariatric professionals address perioperative and contraception issues inconsistently and mostly reported lack of adequate knowledge in the latter. Therefore, a stronger collaboration between bariatric professionals and women`s healthcare providers is needed to improve care of female bariatric patients in reproductive age.

Backgrounds:

Some patients who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB) may present with insufficient weight loss or weight regain. Anatomical factors that may lead to failure of LRYGB include the size of the gastric pouch and the diameter of the gastro-jejunostomy.

Aims:

This study explores the gastric pouch size and the size of the gastro-jejunostomy after LRYGB and investigates their impact on weight loss, appetite and quality of life (QoL).

Methods:

Patients undergoing LRYGB in a single centre underwent computed tomography (CT) with oral contrast one day and one year after LRYGB. Volumetry of the gastric pouch and calculation of the size of the gastro-jejunostomy was performed. Appetite was assessed pre-operatively and one year after LRYGB using the Edmonton Appetite Assessment questionnaire. QoL was assessed pre-operatively one year after surgery using the GIQLI and BAROS questionnaires.

 Results

61 patients were included. Of those, 55 patients (90.2%) underwent CT one year after LRYGB. The mean preoperative Body Mass Index was 40.7+ 3.9 7kg/m2. The mean Excess weight loss (%EWL) one year after surgery was 82.1% +21.5. There was no significant change in mean gastric pouch size one day and one year after LYRGB (15.73±11.8 cm3 and 14.4±11.5cm3, respectively, p=0.55). The mean size of the gastrojejunostomy increased significantly from 2.63cm2 to 3.60cm2(p<0.0001). Mean GIQLI and BAROS values improved significantly one year after LRYGB, but no significant changes in the mean Edmonton Appetite Assessment values were found. %EWL and improvement in GIQLI and BAROS values one year after surgery did not correlate with the initial size of the gastric pouch and the increase of the size of the gastro-jejunostomy.

Conclusions:

One year after LRYGB, the size of the gastro-jejunostomy increased significantly, but no difference in the gastric pouch volume was found. Both gastric pouch volume and dilatation of the gastro-jejunostomy did not correlate with weight loss and QoL outcomes.

Background:

Marginal ulcers are serious complications after gastric bypass bariatric procedures. If marginal ulcers fail to respond to medical treatment or result in complications, such as perforation or bleeding, surgical management may be needed. Laparoscopic gastric pouch resection and esophago-jejunostomy (LGPREJ) may be the preferred surgical option for such condition.

Aims

This study analyzes the mid-term outcomes of LGPREJ.

 Methods:

We retrospectively reviewed the data of all patients who underwent LGPREJ after primary laparoscopic Roux-en-Y gastric bypass (RYGB) or one-anastomosis gastric bypass (OAGB) between 2018 and 2022 in a single centre. Mean follow-up time was 20.8 months.

 Results:

 10 patients (7 females, 30%) underwent LGPREJ. Of those, 9 patients had undergone previous RYGB and one patient had undergone OAGB. The indications for LGPREJ after RYGB were: marginal ulcer non-responding to medical treatment (n=7), bleeding marginal ulcer (n=1), perforated marginal ulcer (n=1). The patient with previous OAGB underwent LGPREJ with subsequent Roux-en-Y reconstruction due to desmoid-type fibromatosis at the gastric pouch. The median age at the time of LGPREJ was 44.5 (Interquartile range, IQR 33-62) years. The median time between the gastric bypass procedure and LGPREJ. Patients had a median BMI of 26.3 (IQR 23.4-28.8)kg/m2 at the time of LGPREJ. No intraoperative adverse events occurred. Postoperatively, one patient developed an anastomotic leak, which was managed conservatively. 6 patients presented a stricture of the esophago-jejunostomy during the follow-up, all of which were treated successfully with endoscopic dilatation. One patient underwent a re-operation due to internal hernia 5 months after LGPREJ. One patient developed anemia during the follow-up. No protein malnutrition was detected.

Conclusion:

LGPREJ is safe but associated with a high morbidity, especially anastomotic strictures. These can be successfully managed with endoscopic interventions. No associated nutritional risk was found.

Objective

To compare diabetes remission, metabolic outcomes and surgical adverse events in young (18-35 years) and older (>35 years) adults in the first five years following Roux-en-Y gastric bypass (RYGB).

Background 

Timely metabolic surgery improves glycemic control and reduces cardiovascular risk for patients with type 2 diabetes. Young age is a known predictor of metabolic success but RYGB is often delayed due to the reported vulnerability of young adults.

Methods

We analysed prospective registry data from a single center on young (29.4 years, [standard deviation (SD)=5]) and older (47.7 years, [SD=6.7]) non-insulin-dependent diabetic adults undergoing RYGB. Younger adults were matched one to two to their older counterparts for sex, body mass index, duration of preoperative diabetes and American Society of Anaesthesiologist score (Table 1). The rate of diabetes remission and adverse events in both groups were compared.

Results 

A total of 78.2% (43/55) of the young and 75.4% (86/114) of the older adults attended the five-year follow-up. Diabetes remission occurred significantly earlier in the young adults group with a hazard ratio of 0.57 [95% confidence interval (CI) 0.23-0.87] and a median time to remission of 12 months [95% CI 3.2-20.8]compared to 24 months [95%CI 10.5-37.4, p=0.031] for older adults (Figure1). There were no significant differences in loss to follow-up, percent weight change, and all-cause adverse events (Table 2 and 3). 

Conclusion

Diabetes remission occurred earlier and more frequently in young adults within the first 5 years after RYGB. The risk of surgical complications, nutritional deficiency or failure to achieve successful weight loss did not increase in the investigated young adult group.

Background: The most effective treatment for obesity and associated comorbidities is metabolic-bariatric surgery (MBS). Nevertheless, weight regain is reported in 10-30% of patients after Roux-en-Y gastric bypass (RYGB), eventually with a recurrence of obesity-associated comorbidities. Pouch resizing (PR), the resizing of an enlarged gastric pouch, is commonly performed as a low-risk secondary surgery to stabilize or even reduce the regained weight. However, the effectiveness of PR lacks scientific evidence.

Aims: To analyze the effect of PR after RYGB on long-term weight loss, course of comorbidities, complication rates and patient satisfaction.

Material & Methods: Forty-eight patients undergoing PR between January 2016 and December 2020 were included. Data were collected retrospectively from a prospective database. PR was performed laparoscopically and included a resection of the enlarged gastric pouch and a redo of the gastrojejunostomy. Additionally, thirty-seven patients participated in a survey evaluating postoperative patient satisfaction.

Results: Nadir-weight after RYGB was reached after 26.3 ±19.4 months; PR was performed after a mean time of 106.2 ± 45.5 months. Mean follow-up after PR was 55.9 ± 18.5 months. Mean BMI before PR was 39 ± 5.4 kg/m^2. Mean BMI at 1, 3 and 5 years after PR was 37 ± 5.5 kg/m^2, 35 ± 7.6 kg/m^2 and 35 ± 7.5 kg/m^2 respectively (Figure1). Obesity-associated comorbidities were resolved in 53% of patients five years after PR. Postoperative complications analog grade <= 2 of the Clavien-Dindo classification occurred in 12.5% while complications grade >= 3 occurred in 10.4% of patients. There was no mortality. The postoperative survey showed high levels of satisfaction after PR.

Conclusions: PR for weight regain after primary RYGB is a safe procedure resulting in weight stabilization and resolution of obesity-associated comorbidities. PR is thus a valuable option to at least stop weight regain after primary RYGB in well-selected patients leading to high levels of patient satisfaction.

Background

Misuse of opioid medication has become a major health crisis in several countries. A significant number of patients with obesity use opioid medications, mostly to alleviate symptoms due to obesity-related comorbidities.

Aims

The objective of the present study was to compare patterns of opioid drugs usage before and after bariatric surgery in a population of patients with obesity, hypothesizing that weight loss and improvement of obesity-related comorbidities could reduce opioid use in this population.

Material & Methods

In this retrospective cohort study, the XXXX (anonymized) Bariatric Registry was used to compare opioid consumption in patients undergoing bariatric surgery between 2010 and 2021. The primary outcome was the number of patients using opioid medication at 1-year after surgery. Multiple logistic regression analyses were performed to identify potential predictors of opioid consumption.

Results

Data of 11’179 patients were analyzed. At baseline, opioids were used by 7.7% (N=864) and non-opioid pain medications by 42.3% (N=4731). At 1 year after surgery, the number of patients using opioid and non-opioid medications significantly decreased compared to baseline (Δ-1.9% and Δ-18.0% respectively). Presence of musculoskeletal pain and use of non-opioid pain medication at baseline were identified as independent predictors of opioid consumption at 1 year after surgery.

Conclusions

At 1 year after bariatric surgery, a significant decrease in opioid and non-opioid pain medication consumption was seen among patients with obesity. Aggressive management of excess weight and its related comorbidities, especially with bariatric surgery, can potentially reduce the impact of the opioid crisis in this population. Further prospective studies with longer follow-up are required to confirm these findings.

Background:

One anastomosis gastric bypass (OAGB) results in long-term weight loss and resolution of obesity-associated comorbidities. However, the metabolic effect of the biliopancreatic (BPL) and alimentary limb (AL) length in OAGB still remains unclear. 

Aims:

The aim of this study was to establish an OAGB mouse model with defined proportions of the AL and BPL and to assess the effects of a short versus long BPL on weight loss, glucose metabolism, and immune cell phenotype of colon and adipose tissue.

Methods:

Four weeks old male C57B6/J mice were rendered obese by high fat diet (HFD). After 8 weeks, mice underwent OAGB using a long or short BPL or sham surgery. After surgery, sham mice were food restricted (0.5-1g HFD/day) to achieve similar body weight as OAGB-operated mice, while OAGB-operated mice received ad libitum HFD. Metabolic parameters were assessed 2 and 5 weeks after surgery. Immune cells were assessed by flow cytometry.

Results:

Short and long BPL did not result in significantly different weight loss. However, 2 weeks after the surgery, mice with a long BPL had reduced insulin secretion compared to mice with a short BPL. Five weeks after surgery, OAGB-operated mice with a long BPL showed improved glucose tolerance than mice with a short BPL. OAGB-operated mice with a long BPL had significantly lower cholesterol compared to sham-operated mice. OAGB-operated mice showed reduced adipose tissue eosinophils together with increased colonic eosinophils, innate lymphoid cells and CD4 T cells as well as reduced B cells and inflammatory macrophages compared to sham mice.

Conclusion:

OAGB with a long BPL led to an improved glucose tolerance compared to a short BPL despite similar weight loss. Moreover, OAGB-operated mice with a long BPL had reduced insulin levels, indicating improved insulin sensitivity. OAGB led to profound differences in the immune landscape of colon and adipose tissue, which are independent of the BPL length.

Introduction

Dorsal screw tip protrusion (DSTP) with extensor tendon injury is a well-known complication of volar plating for distal radius fractures. The dorsal tangential view (DTV) and the radial groove view (RGV) have been recommended to detect DSTP. The value of these views depends on their quality and reproducibility. It was the aim of this study to investigate the quality of these views before and after teaching of the involved surgeons.

Methods

All adult patients treated with volar plating for distal radius fractures between 10/2019 and 10/2020 were included. Prior to their first case in the study period, all involved surgeons were instructed in a standardized manner how to perform technically correct DTV and RGV. Patients from an earlier period served as controls. Image quality was rated independently by two investigators. Detection of DSTP based on fluoroscopy was documented and protruding screws were exchanged. The impact of teaching was assessed. Furthermore, reliability of DTV and RGV to detect DSTP was compared to postoperative ultrasound.

Results

A total of 124 patients were included in the study group, 125 patients served as controls. Interobserver agreement for the image quality was 97% for DTV and 98% for RGV. Image quality significantly improved with teaching (p<0.001). Correct images were observed in 81% vs. 58% for DTV and 81% vs. 53% for RGV. From a total of 571 evaluated screws intraoperative fluoroscopy identified 24 DSTP (4.2%) in 23 patients (18.5%). Postoperative ultrasound revealed 4 DSTP (0.8-1.2mm; 0.7%) in 4 patients (3.2%).

Conclusion

Teaching surgeons how to perform technically good DTV and RGV leads to a significant improvement of image quality. DTV and RGV are reliable tools to detect DSTP. However, despite correct views, some minor dorsal cortex penetrations may be missed. Thus, early further investigations are recommended in patients with extensor tendon irritation.

Objective: Presentation of the minimally invasive surgical approach for the treatment of scapular fractures and the clinical outcome of this technique.

Surgical technique. Make a straight or slightly curved incision along the lateral margin of the scapula leaving the deltoid fascia intact. Identify the interval between the musculus teres minor and infraspinatus to visualize the lateral column, whilst retracting the deltoid to visualize the glenoid neck. Reduce and align the fracture using direct and indirect reduction tools. A second window on the medial border of the scapula can be made to aid reduction and/or to augment stability. Small (2.0 -2.7 mm) plates in a 90 degree configuration on the lateral border and, if required, on the medial border are used. Intra-operative imaging confirms adequate reduction and extra-articular screw placement.

Results. We collected data from 35 patients treated with MIPO between 2011 and 2021. Seventeen had a type B and 18 a type F fracture according the AO classification. Double plating of the lateral border (n=30) was most commonly performed as described in the operative technique section. Average time to union was 21.5±8.5 (range 11-36) weeks. One patient underwent an additional osteosynthesis 3 months after initial surgery due to pain and lack of radiological signs of healing of a fracture extension into the spina scapulae. In the same patient the plate on the spina scapula was later removed due to plate irritation. In two patients postoperative images showed a screw protruding into the glenohumeral joint requiring revision surgery. 

Conclusion: The surgical technique, it’s advantages and pitfalls are presented here in detail, furthermore we provide an overview of the patients treated at our institute, which had overall excellent functional results.

Background

Patellar fractures are rare. Displaced fractures are usually treated surgically with anatomical reduction and fixation using tension band or screw and plate fixation. Comminuted fractures can be challenging and equatorial cerclage is often added. Because of the proximity to the skin hardware removal is often necessary after fracture healing. Recently, the usage of non-resorbable sutures in tension band fixation has gained popularity.

Aim

We describe a new technique for fixation of comminuted patellar fracture (Img. 1) using a combination of an equatorial and a tension band technique with a non-resorbable suture.

Patients and Methods

In the “Star-wrap technique” the main fracture fragments are reduced and fixed with at least two screws or K-wires to regain axial stability and alignment of the joint (Img. 2). Smaller fragments are kept in their soft tissue envelope to avoid disruption to the blood supply. A non-resorbable suture is positioned circumferentially around the patella leaving open loops in a garland fashion (Img. 3a). With an additional non-resorbable suture, the loose loops are braided in a star shaped manner (Img. 3b). After tightening and knotting of the equatorial cerclage the star suture is sequentially tightened and knotted (Img. 3c). A tension band stability with equatorial compression is achieved.

Results

Seven patients (age 33 - 90 y) were operated with this technique. Three patients had AO 34-C2 and four AO 34-C3 fractures. At six weeks follow-up all patients showed a good clinical result with only one patient with a slight radiological secondary displacement. In this same patient removal of K-wires was necessary. For all other patients hardware removal was so far not necessary.

Conclusion

This new technique combines the tension band and the cerclage principles in treatment of comminuted patellar fractures. Clinical results show feasibility of this technique and hardware removal seems less frequent compared with other techniques.

Background:

Guidelines suggest that every patient over 65 years, after suffering an index fragility fracture, should be immediately provided with an osteoporosis treatment. But fragility fracture patients aged 80+ are known for an over proportional mortality rate. This is when the latency until onset of therapy can have an effect.  In combination, elderly fracture patients may not experience the effect of a newly started osteoporosis therapy: patients could die before any fracture-reduction effect can take place.

Aim:

Is this scenario only in theory or does it have clinical importance? To answer this question in the real world, we took advantage of a quality assurance initiative within our Fracture Liaison Service.

Patients & Methods:

From January 2021 to January 2023, data was collected from patients aged 65+ (n=1381, female:male=73%:27%, mean age = 83 years) who were treated as “in-patients” with an acute fracture. Patients with fractures due to high energy trauma, isolated skull, toes, or finger fractures, as well as those resulting from metastatic bone disease (n= 368) were excluded. The one-year follow-up determined the occurrence of subsequent fragility fractures as well as mortality.

Results:

Initial fragility fractures included; Hip Fractures (30%), Pelvic Fractures (15%), Humerus Fractures (15%), Distal Radius Fractures (12%), Vertebral Fractures (15%) and other Fractures (13%). Follow-up was achieved in 82.4% of patients: Death occurred in 32% of the patients and 12.5% suffered from another fragility fracture. 0.9% of the cohort suffered from both events.

Conclusion:

Based on these results, the indication for osteoporosis therapy in the elderly high-risk fragility fracture patients is challenged. Shared decision making and individualized therapy may allow physicians an opportunity to choose a treatment path more wisely and enlarge the scope of geriatric fracture care management beyond fracture reduction alone.

Background: Freehand distal interlocking of intramedullary nails remains a challenging task. This surgical step is the most difficult part performed at the end of the operation and may have a catastrophic influence on patients' outcome of not performed precisely. Recently, the AO Research Institute developed a new training device for Digitally Enhanced Hands-on Surgical Training (DEHST), potentially improving surgical skills needed for this surgical step. The device already yielded high scores in terms of face and construct validity in the first step of the validation cascade. Objectives: To evaluate weather training with DEHST enhances the performance of novices without surgical experience in free-hand distal nail interlocking compared to a non-trained group of novices. Methods: 20 novices were assigned in two groups and performed distal interlocking of a tibia nail in an artificial bone model under a real C-arm. Group 1: DEHST trained novices (virtual locking of five nail holes during one hour of training). Group 2: untrained novices without DEHST training. Time, number of x-rays, nail hole roundness, critical events and success rates were compared between the groups. Results: Time to complete the task (sec) and x-ray exposure (µGcm2) were significantly lower in Group1 414.7 (290–615) and 17.8 (9.8–26.4) compared to Group2 623.4 (339–1215) and 32.6 (16.1–55.3); p=0.041 and 0.003. Perfect circle roundness (%) was 95.0 (91.1–98.0) in Group 1 and 80.8 (70.1–88.9) in Group 2; p<0.001. In Group 1 90% of the participants achieved successful completion of the task (hit the nail with the drill), whereas only 60% of the participants in group 2 achieved this; p=0.121 Conclusions: Training with DEHST significantly enhances the performance of novices without surgical experience in distal interlocking of intramedullary nails. Besides radiation exposure and operation time the complication rate during the operation can be significantly reduced.

Background

Trimalleolar fractures are difficult to treat and malreduction can lead to functional impairment. Involvement of the posterior malleolus has a poor predictive value. Current computer-tomography (CT)-based fracture classifications led to an increase in fixation of the posterior malleolus.

Aims

The aim of this study was to describe the functional outcome after a two-stage stabilisation with direct fixation of the posterior fragment in trimalleolar dislocation fractures.

Material&Methods

In a retrospective study, all patients presenting with a trimalleolar dislocation fracture, an available CT scan and a two-stage operative stabilisation including the posterior malleolus by a posterior approach were included. All fractures were treated with initial external fixator and delayed definitive stabilisation including fixation of the posterior malleolus. Next to clinical and radiological follow-up, outcome measures (Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS), Activity of Daily Living (ADL), Hulsmans implant removal score) and complications were analysed.

Results

Between 2008 - 2019, of 320 trimalleolar dislocation fractures, 39 patients were included. Mean follow-up was 49 months (standard deviation (SD) 29.7, range 16 - 148). Mean age was 60 years (SD 15.3, 17 - 84) with 69% female patients. The mean FAOS was 93/100 (SD 9.7, 57 - 100), NRS 2 (interquartile range (IQR) 0 - 3) and ADL 2 (IQR 1 - 2). 4 patients showed a postoperative infection, 6 re-operations had to be performed and implants were removed in 24 individuals.

Conclusion

A two-stage procedure of trimalleolar dislocation fractures with in direct reduction and fixation of the posterior tibial fragment through a posterior approach leads to good functional outcome scores with a low rate of complications.

Introduction: Low-profile-double-plating seems a viable alternative to conventional single-plating for fixation of midshaft clavicle fractures. This study aims to compare the two techniques.

Methods: This comparative retrospective cohort study included all patients that underwent plate fixation for midshaft clavicle fractures between 2020 and 2022. Patients were categorised into two treatment groups: single plate versus low-profile double-plating. Single plates included either Synthes LCP 3.5mm (superior and anterior) or VA-LCP 2.7mm superior plates. Low profile double plating included either a 2.0 or 2.4mm mini plate positioned on the superior surface and a 2.7mm mini plate on the anterior surface of the clavicle. Treatment groups were compared with regard to healing, complications and removal rate.

Results: A total of 102 patients were included: 76 in the single plating and 26 in the double-plating group. Mean age was 44 years (SD 17), 80% was male and 39% were polytrauma cases. Thirty seven (36%) fractures were classified as AO type A, 9 (10%) type B and 56 (54%) type C. All baseline characteristics were equally distributed among treatment groups. Low-profile-double-plating had a significantly lower operation duration (95 versus 111 minutes). All fractures healed in both groups.

Long-term follow-up data was available in 47 patients of the single plating and 10 in the double-plating group. Reintervention was needed in 1 (2%) patient for infection, 22 (47%) for implant irritation (removal) and 1 (2%) implant failure in the single plating group; This was 0%, 3 (30%) and 1 (10%) in the double-plating group. These differences were not statistically significant.

Conclusion: Low-profile-double-plating seems to attain the same healing rates as conventional single plating in midshaft clavicula fractures without the additional risk of complications. The operation duration appears to be shorter for double-plating. Conclusions with regard to risk of implant failure and removal rate, cannot be drawn based on the limited available data.

Introduction: Arthroscopically assisted coracoclavicular (CC) ligament fixation techniques have been promoted as providing superior outcomes for the treatment of acute high-grade acromioclavicular joint (ACJ) dislocations. Nevertheless, there is a lack of high-level evidence for clinically relevant benefits. At our institute, orthopaedic surgeons use an arthroscopically assisted coracoclavicular ligament fixation technique (DB), while general trauma surgeons use a clavicular hook plate (cHP) technique. The aim of the study was to compare clinical outcomes, complication rates and costs between the two groups.

Materials and Methods: The hospital database was searched for patients treated for acute traumatic high-grade (Rockwood Typ ≥III) ACJ dislocation using either a cHP or arthroscopically assisted DB technique between 2010 and 2019. Seventy-nine patients could be included (56 patients in the cHP group and 23 in the DB group). QuickDASH scores, subjective shoulder value (SSV) scores, pain scores (numerical pain rating scale 10) and complication rates were retrospectively collected through phone interviews and by screening patient charts as well as surgical reports. Costs per patient were obtained from the hospital’s accounting system.

Results: Mean follow-up was 54±33.7 and 45±21.7 months in the cHP and DB group, respectively. QuickDASH and SSV scores did not differ but patients in the cHP group reported significantly lower pain scores (p = 0.033). More patients reported hypertrophic or disturbing scars (p=0.49) and sensibility disturbances (p=0.007) in the cHP group. Three patients suffered from a frozen shoulder in the DB group (p = 0.023).

Conclusion: Patient-reported outcomes are excellent after long-term follow up for both techniques. There are no clinically relevant differences in clinical outcome scores based on our results and a review of the literature. Both techniques certainly have their benefits regarding secondary outcome measures.

Necrotizing fasciitis is a rare, frightening condition with an incidence of 0.4-2.79/100’000/year. It occurs in only 13% of cases in the upper limb. The diagnosis is difficult due to its rarity and paucity of symptoms.

We hereby describe the case of a patient who presented to our emergency care unit with an abnormally swollen and painful hand just 36h after removing a thorn on the palm of his hand. The hand was completely swollen, he presented three puncture wounds on the palm of the hand and one on the dorsum. There was a lymphangitic path up to the axilla. He could not stay still in the waiting room and could hardly be examined. There was no blister and no skin necrosis at that time. He was immediately sent to the emergency room. Upon incision, there was expression of dish-water like fluid. Palmar fat was necrotic. At that time, the diagnosis was that of an abscess of the palm of the hand.

On the first postoperative day, the patient felt much less pain, but small blisters appeared on the palm of his wrist and the arm was red up to its middle third (fig. 1). The suspicion was then made of necrotizing fasciitis of the upper arm and the cultures revealed Streptococcus pyogenes. Biopsy of the fascia confirmed it. Opening of the forearm and arm were added to the debridement of necrotic tissue in the palm. The patient underwent four successive debridements until a clean wound was reached. His nerves, vessels and tendons were all uncovered from the palm to the forearm. He was left with a wound of 7x17 cm on the palm and forearm (fig. 2).

On day 7, the wound was covered with an antero-lateral thigh flap on the palm and split-thickness skin grafts on the dorsum.

Four months later, the patient could resume all his activities and feels very little discomfort from his hand (fig. 3).

Giant cell tumor of the tendon sheath is the second most common soft tissue tumor of the hand after ganglion cysts. However it is most commonly located in digits as a painless, slow-growing mass on the volar surface of fingers.

Masses on the dorsum of the carpus are usually caused by arthrosynovial cists. We hereby present an unusual case of giant cell tumour of the tendon sheaths appearing on the dorsum of the carpus. A 28-year old woman presented to our hand center with a history of a mass on the dorsum of her wrist present for several years but growing since 9 months. The mass was located between the 4^th and 5^th compartments. It was painless, with a hard consistence and mobile towards deep and superficial layers. MRI showed a mass of 31 x 7 x 22mm forcing back the extensor tendons leaving a footprint on the carpal bones without cortical lysis invading the dorsal capsule of the wrist (fig. 1). It extended from the dorsum of the trapezoid, capitatum, hamatum and lunatum with extrinsic compression of the dorsal cortex of the capitate.

The patient underwent surgical excision of the mass with the whole dorsal capsule of the wrist including the dorsal intercarpal ligament (DIC) and dorsal radiotriquetral ligament (DRC) (fig. 2, fig. 3). Histopathology confirmed the diagnosis. The DIC and DRC were not reconstructed for fear of bony invasion of the tumor. The patient was immobilized in a forearm cast for 1 month after surgery.

Despite some stiffness in her wrist with a flexion-extension of 35°-0-55°, she resumed all her activities 6 months after surgery including high intensity sport (crossfit). She just now needs to use bars (handles) to do her push-ups. The control MRI did not show any recurrence up to date (1 year, 9 months).

Background

Most soft tissue sarcomas metastasize hematologically, only rarely via the lymphatics, and most prevalently into the lungs, rarely into the bones. The process of metastasis is still being investigated, latest research indicates that metastatic cells may be even present before the primary tumor. In sarcoma, metastasis may be present at initial presentation (synchronous) or subsequently (after 6 months, metachronous). Oligometastatic disease is an emerging concept defining a potential better prognosis for patients with less than 5 lesions.

Aims

To present an unusual case of metachronous multilocular metastatic disease of a soft tissue sarcoma of the hand.

Material & Methods

A 43yo female was presenting with a 5cm soft tissue lump in her right dominant hand involving metacarpals III/IV. Work-up revealed a G2 leiomyosarcoma, which prompted a preoperative radiation followed by resection of the tumor and reconstruction of the metacarpals using a vascularized fibula with skin flap. The initial postoperative was uneventful except for a revision of the anastomosis.

Results

At one year postoperatively, the CT chest showed an indeterminate lesion over the scapula. A whole-body MRI then evidenced also a soft tissue lesion in the left ischiocrural musculature. Both lesions were compatible with the initial tumor at the hand and were removed. After all, because the two latter lesions were indolent, it can not be reconstructed for how long they had been there.

Conclusion

A great level of suspicion has to be maintained in a patient being diagnosed with a soft tissue sarcoma while considering further lumps as reported by the patient. Performing a US-guided biopsy in case of doubt is never wrong.

Background

Unplanned so called “whoops-“resections continue to represent a great problem for sarcoma surgeons, but specifically for the patients. Even today, 20% of all sarcomas are still diagnosed after such unplanned resections. Because incomplete resection leads to contamination of adjacent soft tissues, all surrounding structures with a safe margin has to be re-resected, because there is no adjuvant treatment option which may compensate for an inadequate surgical margin.

Aims

To increase the awareness of the deleterious effects of unplanned whoops resections.

Material & Methods

A 44yo female had a growing lump at the left distal palmar forearm/wrist region, and a ganglion was suspected. Through an extensile palmar approach, this lesion was resected. Intraoperatively, it was realized that the tumor was unlike a ganglion. Most portions of the tumor were removed and then closed-up. A postoperative work-up revealed an epithelioid sarcoma, which is a locally highly aggressive biology, and an MRI showed remaining tumor masses.

Results

At the multidisciplinary sarcomaboard, it was decided that only an amputation of the forearm is able to provide local control. Difficult discussions with the patient followed, and ultimately, it was commonly decided to proceed with amputation. 6 months postoperatively, there was no tumor recurrence, with uneventful healing locally, but remaining some discomfort and phantom pain.

Conclusion

Unplanned whoops resections remain a desperate problem. Increasing awareness of this problem is indispensable. All soft tissue lumps underneath the fascia as well as epifascial lesions larger than 3-5cm and/or those which cannot be resected safely with R0 margin, have to be core-biopsied first.

Introduction: We discuss the treatment of a young female patient, suffering from socially debilitating contracture of the fingers after resection and irradiation of a Gardner fibroma in the anterior muscular compartment of the forearm. The currently propagated techniques for tendon lengthening of the fingers include a Gosset-Scaglietti operation, fractional lengthening or Z-lengthening. For more than 5 cm a superficialis to profundus tendon (STP) transfer is an option that excludes an operation near the potential tumor site in the forearm muscles.

Case: Our 16 years old female patient’s fibroma was resected and had a course of adjuvant radiotherapy. Due to muscle fibrosis her fingers contracted to the palm. After failure of conservative treatment, herself and the parents accepted a tendon lengthening outside of the original tumor location, to allow effortless postoperative checks for recurrence via MRI.

Results: One year postoperatively the patient showed flexion contracture of the PIP-III-joint DIG III and extension deficiency DIG IV/V. Therefore, the patient underwent an arthro-tenolysis of these fingers to enhance the result. Postoperatively weakness to FDS III was persistent wich again was socially not acceptable in a young girl. The lack of motor strength was corrected with a PL to FDS III augmentation with a satisfying result.

Conclusion: In contradiction to technical descriptions for STP-Transfers in textbooks, we performed an individualised tendon transfer and not weaved, where the tendons II-V are sutured together before transfer. This allowed enhancing the result and widening the indication to this case where the fingers are used and controlled to play the piano again.

Background: The surgical revisions after primary neurolysis of median nerve are necessary in case of recurrent symptoms. Soltani et al. (2013) demonstrated that surgical revisions with vascularized flap interposition have a higher success rate (86 %) than surgical revisions without flap (75 %).

Aim: The aim of this study is to present the clinical results of a retrospective study including 36 secondary median nerve neurolysis and synovial flap (fig.1) in case of real recurrent carpal tunnel syndrome.

Materials & Methods: We included thirty-three patients (36 hands) who underwent a secondary neurolysis of the median nerve with synovial flap between 2012 and 2019. Only the cases with recurrent carpal tunnel syndrome presenting a cicatrisation of flexor retinaculum or presenting a median nerve with perineural fibrosis were included and with a free symptom’s interval of at least three months. The results were divided in 4 sections in function of the evolution at the last follow-up. An excellent result is defined as the complete extinction of complaints, a good result as a notable decreased of symptoms, an equivocal result defines a weak or absence of improvement and a bad result being a worsening of symptoms.

Results: Descriptive analyses show that 80% of patients show a favourable evolution, including 33% an excellent result and 47% a good result, while 6% show no amelioration and 14% a bad result.

Conclusions: This poor invasive surgical procedure is interesting and should be part of therapeutic option of recurrent carpal tunnel syndrome in case of median nerve adherence to the transverse carpal ligament.

Background

Perilunate dislocations (PLD) and perilunate fracture dislocations (PLFD) are rare but severe injuries to the wrist, usually resulting from a high-energy trauma occurring in sports injuries, motor vehicle accidents, falls or machine related accidents. Treatment of choice is early reduction with carpal transfixation, fracture fixation and refixation of the injured ligaments.

Aim

As reports on mid- to long-term outcome are scarce, we aimed to investigate clinical and radiological outcome of open treatment after a minimal follow-up of 2 years.

Material & Methods

Patients treated for PLD and PLFD in our institution were identified back to 2008. Inclusion criteria were PLD and PLFD who underwent open surgery, had a minimal follow-up of 2 years and were available for a follow-up. Clinical examination included ROM and grip strength. PRWE, quick DASH, SF-12 and the single assessment numeric evaluation (SANE) score were used as PROMs. Dorso-palmar and lateral X-rays were done and assessed for carpal height, inter- and radio-carpal angles and degenerative changes.

Results

Of 54 identified patients, 29 patients could be located and contacted. By the date of abstract submission 15 patients after PLFD and 9 after PLD had been followed-up in our clinic. Mean follow-up was 93 months (24-170). Mean F/E was 43/0/51° for the affected and 68/0/66° for the healthy wrist, P/S 77/0/73° and 79/0/79°, R/U 24/0/34° and 27/0/44°. Mean grip strength was 41kp and 61kp. Mean score for PRWE was 13.2, qDASH 14.2%, SF-12 physical score 50.9, mental score 55.1 and SANE 86%. 11 patients showed slight to moderate degenerative changes. Carpal height (Nattrass Index) showed a mean of 1.45.

Conclusion

Although the affected wrists showed reduced ROM and SANE scores, patients were mostly satisfied with the outcome and only exhibited little pain. Open reduction and fixation of PLD and PLFD reliably lead to satisfactory results even in the long-term.

Background

Irreparable proximal pole fractures of the scaphoid remain a real challenge for the treating handsurgeon. Standard salvage options include 4-corner fusion or proximal row carpectomy. These procedures limit the range of motion and have a high rate of conversion to total wrist fusion.  The two current biological reconstructive options are the rib graft or the vascularized femoral trochlea osteocartilaginous free flap. In addition, there is the prosthetic semi-replacement arthroplasty using the pyrocarbon adaptive proximal scaphoid implant (APSI).

Aim 

To present our series of patients with non-reconstructable proximal scaphoid nonunion/fracture (not suitable for conventional bone graft reconstruction) who were treated by the rib graft technique

Material/Methods

Our case series of 21 patients treated between March 2013 and January 2019 will been presented (median follow-up 29 months).

The surgical technique will be described and crucial technical steps explained. 

The mean age at surgery was 26 years (SD 5.8) and the median time between injury and rib graft surgery was 2 years (IQR 1.7–3.6). The median postoperative follow-up was 29 months (IQR 19.5–42.4).

Results

All patients returned to their pre-surgical occupation. Significant differences were found in active wrist movements, grip strength, QuickDASH and PRWE pain scores. Union was seen in all 21 patients. The postoperative capitolunate angles were within normal limits. 17/21 patients showed no progessive postoperative osteoarthritic changes, while 4/21 showed slight progression. Progressive ossification of the graft was noted in 14 /21 patients. No donor site complication occurred. One patient failed and underwent excision of the scaphoid and fourcorner fusion 9 months after the rib graft. At the time of revision, the graft was clinically united.

We found statistically significant improvements in QuickDASH and PRWE.

Conclusion

Our results suggest that reconstruction of the irreparable proximal pole scaphoid nonunion with costo-osteochondral graft reconstruction (rib graft) is a reliable and straightforward procedure in this challenging problem.

Introduction: We discuss the treatment of two young male patients, suffering from scaphoid non-union after traumatic scaphoid fracture. The currently propagated techniques for treating a scaphoid non-union in children is either the operative reconstruction of the scaphoid or the conservative treatment with splinting in a scaphoid cast.

Cases: First case operative: 13 years old male patient with a posttraumatic scaphoid non-union in the middle third with a humpback deformity. We resected the middle third of the scaphoid and grafted the defect with an iliac crest bone, the DISI-Deformity was reduced. Fixation was performed with K-Wires and immobilisation in a scaphoid cast. Second Case conservative: 13 years old male patient also with a posttraumatic scaphoid non-union in the middle third and humpback deformity, DISI-deformity. Immobilisation in a scaphoid cast for four months was performed.

Results: Operative: One year postoperatively the patient achieved painless free arc of motion. Flexion/Extension 70/0/60°, Radial-/Ulnarduction 30/0/30° and Pro-/Supination 90/0/90°. The computer tomogram showed complete consolidation and bony fusion of the iliac crest bone. Conservative: Six to eight months after conservative treatment the patient demonstrated painless motion and AROM Flexion/Extension 80/0/80°, Radial-/Ulnarduction and Pro-/Supination in maximum range. Complete consolidation in the computer tomogram with persistent humpback- and DISI deformity.

Conclusion: In the literature both techniques are described, either the operative scaphoid reconstruction or the conservative treatment with splinting. In our cases both the operative and conservative treatment showed comparable good results. However, the humpback- und DISI deformity can only be adressed with a surgical approach.

Introduction: Finger amputations through a joint are usually deleterious. Either an emergency arthroplasty or a shortening arthrodesis is the management choice during replantation. We discuss the treatment of a male patient, suffering from an amputation through the proximal interphalangeal joint (PIPJ) of the non-dominant index finger.

Case: Despite diabetes and an honest explanation regarding outcomes our 55 year old patient wished a replantation of his index finger. The FDS was resected and the crushed joint resected for a primary shortening PIPJ arthrodesis. One year postoperatively the patient wished a mobilisation of his index finger to increase his working capabilities as a fine mechanic.

The arthrodesis was removed and joint-silicon-arthroplasty, type Swanson, implanted.

Rehabilitation was uneventful and the patient gained 60° flexion with an extension deficit of 20°. He will return to normal workload 2 years post trauma.

Conclusion: Destruction of a finger joint poses difficult problems. Arthrodesis provides a strong buttress for pinch grip and relief of pain. The benefits of joint movement are unfortunately lost. There are several reconstructive procedures to restore mobility; interposition arthroplasty (Swanson spacer), vascularised joint transfer and total prosthetic joint replacement arthroplasty.

Total interphalangeal joint arthroplasty is a useful secondary procedure, after initial replantation, for finger amputation and rewards consideration

Introduction

Despite stable numbers of upper limb amputations there is a decline in replantation in Europe. This results in lacking experience, decreasing success rates, and fewer attempts. Training in high-volume centers is crucial for hand surgeons performing upper extremity replantation. This abstract highlights the experience in a US microsurgery fellowship.

Methods

Upper extremity revascularization and replantation cases during a 10 month - period were retrospectively reviewed. Overall, the fellow was exposed to 29 cases: 2 hand, 5 thumb and 9 digitial replantations as well as 13 thumb and digital revascularizations. Primary outcome was the survival of the injured body part. Secondary outcomes were total case time, number of repaired arteries/veins, the use of vein grafts, and early free flap coverage. Whenever possible, all microsurgical steps including vessel debridement and anastomosis were performed under tourniquet.

Results

Success rate was 21/29 (72 %). Failure was limited to avulsion or crush injuries. Mean surgery time for revascularization was 92 min (range, 45-134 min) per digit. Mean surgery time for thumb and single digit replantation was 133 min (range, 62-270 min) and for the two hand replantations 180 min and 300 min, respectively. Routinely, only 1 dominant artery was repaired. Forearm or saphenous vein grafts were used in 14/29 cases. Only in 3/23 cases > 1 vein was repaired and in 3 cases interpositional vein grafts were used for dorsal vein reconstruction. One venous flow-through flap was used and a dorsal hand soft tissue defect was covered with a fascio-cutaneous free flap 5 days after replantation.

Conclusion

Replantation remains a challenge for hand surgeons. The thoughtful use of a tourniquet with vessel debridement in a bloodless field is key to maximize the efficiency of replantation. Furthermore, the liberate use of vein grafts and venous flow-through flaps helps moving outside the trauma zone, thus increasing the likelihood of upper limb salvage.

Background

Although open surgery remains the gold standard for the treatment of post-dissection thoraco-abdominal aneurysms (TAAAs), the endovascular approach using fenestrated or branched endografts has emerged as a valid alternative for patients considered at high risk for surgery. The use of inner branch devices (iBEVAR) combining benefits of fenestrations and outer branches could offer an ideal configuration in this context.

Aims

Our aim was to report our preliminary monocentric experience with iBEVAR in the treatment of post-dissection TAAAs.

Materials&Methods

A retrospective analysis of prospective data retrieved from 1 center between Mars 2020 and January 2023 was done. Endpoints were immediate technical success, postoperative morbidity, rate of endoleaks, re-intervention and mortality.

Results

During this period, 18 patients (mean age 66,5 years, range 41-80) were identified. All were asymptomatic and operated in a 2-steps procedure with a TEVAR first. There were 5 off-the-shelf E-nside (28%) and 13 custom-made Extra-Design grafts (72%). Despite successful endograft deployment in all patients and branch catheterization in 68/70 cases (97%), the technical success was 94% due to an open conversion for ilio-mesenteric bypass. The 30-days mortality was 0%.

During the post-operative period, 17% of patients (3/18) presented complications with 1 case of mesenteric ischaemia requiring a visceral resection and 2 cases of paralytic ileus, treated conservatively. No spinal cord ischemia was observed. During the median follow-up of 16 months (range 1-36), 4 patients (22%) had a re-intervention: one case of type-Ic endoleak treated with an additional renal stent and 3 cases of type-III endoleaks in the celiac trunk requiring a relining. The overall target vessel patency was 100%. In all cases, the sac diameter remained stable.

Conclusion

The use of iBEVAR appears to be safe and effective for the treatment of post-dissection TAAAs with an acceptable rate of complications. Further patients and longer follow-up are needed.

Background

For safe endovascular sealing in thoracic endovascular aortic repair (TEVAR), a sufficient landing zone is essential. Due to the close relationship to the supra-aortic vessels, debranching methods are necessary to expand the proximal landing zone in some cases. New total endovascular methods promise less invasiveness. In Switzerland, a single-branched thoracic endoprosthesis with an integrated branch for the left subclavian artery (LSA) is available since 2022.

Aims

The aim is to evaluate our first experience with a new single-branched aortic stent graft.

Methods

Retrospective analysis of all patients treated with the custom-made single-branched thoracic endoprosthesis (Endovastec™ Castor™, MicroPort, Shanghai, China) between 1/2022 and 1/2023 using descriptive statistics.

Results

Nine patients (67% male, median age 74 years, range 67-80) were treated with the Castor endoprosthesis. Treatment indications involved five penetrating aortic ulcer, two secondary expanding chronic type B aortic dissection, one chronic residual type A aortic dissection and one type 2 thoraco-abdominal aortic aneurysm.

With the Castor prosthesis a median healthy proximal landing zone of 23 mm (range 10-43) was created.

The median time of surgery was 81 minutes (range 47-392) and the length of hospital stay was six days (range 4-16). Technical success was achieved in 8 of the 9 cases. In one patient, the prosthesis dislocated in zone 4 witch was solved by direct surgical debranching and TEVAR. Two patients suffered from transient spinal cord ischemia. No branch failure, stroke, or type 1 endoleak was observed. Hospital mortality was 0%. The median follow-up was 99 days (range 2-335). One patient died of cancer during follow-up.

Conclusions

Implantation of the Castor single-branched endoprothesis is feasible in most cases with high technical success. A direct comparison with surgical debranching and alternative endovascular solutions may further elucidate the safest and most effective solution for the treatment of distal aortic arch pathologies.

Background:

In patients with asymptomatic abdominal aortic aneurysms (AAA), the impending risk of aneurysm rupture, the risk of elective repair, and the life expectancy must be balanced when considering elective AAA repair. Previously internal validation of a predictive model demonstrated good discrimination between low-risk patients with a favourable 5-year life expectancy of 89% (95%-CI 84-95%) and high-risk patients with a 5-year survival of only 40% (32-50%).

Aims:

External validation of a predictive model for survival after endovascular aortic repair (EVAR) for asymptomatic AAA.

Material & Methods:

All patients electively treated with EVAR for asymptomatic AAA at the University of Turku, Finland, between April 2010 and December 2021 were included. Overall survival was assessed in a cross-sectional survey in October 2022. Discrimination ability and model calibration of a predictive Cox proportional hazard model was tested. Non-informative right censoring for patients with follow-up periods <5 years was assumed; pseudo-observations were generated using the jackknife method.

Results:

Of 290 patients treated with EVAR, 253 patients were eligible and had a complete data set to be included in this study. The 5-year survival rate was 63.4% (95%-CI 56.9-70.6%), observing 77 deaths and 96 censorings (follow-up <5 years).

High-risk patients had an observed 5-year survival rate of 53.6% (44.1-65.0%), in low-risk patients the 5-year survival rate was 83% (68.6-100%).

The discrimination ability was good with Harrel's C: 0.68 (0.62-0.74). The calibration at 5-year was good with a predicted median 5-year survival of 70.9% and a pseudo-observed median 5-year survival of 73.5%, see figure.

Conclusions:

This external validation confirms good discrimination ability and calibration of this predictive model on a relatively small sample. Older age, impaired renal function and COPD are independent predictors of poorer survival after EVAR. Low-risk patients are likely to benefit from EVAR, while high-risk patients may not benefit from EVAR at the current diameter threshold.

Background: Thoraco-abdominal aortic aneurysm (TAAA) repair remains a challenging disease pattern. The evolution of fenestrated and branched endografts (f/bEVAR) has provided a less invasive method of treating these aneurysms compared to open TAAA repair (OR).

Aim of the study: To analyse hospital incidence and in-hospital mortality of patients treated for TAAA in Switzerland.

Material and Methods: Secondary data analysis of case-related hospital discharge data of the Swiss Federal Statistical Office for the years 2009-2018. Standardised annual incidences rates were calculated using the European standard population 2013. In-hospital all-cause mortality rates were calculated as raw values and standardised for age, sex, and the van Walraven comorbidity score.

Results: A total of 885 cases were included in this study (16.8% ruptured (rTAAA), 83.2% non-ruptured (nrTAAA)), of which 69.3% were male. Overall hospital incidence rates for nrTAAA were 0.42 in 100,000 women and 0.9 in 100,000 men in 2009 and doubled for both sexes in 2018. For rTAAA, the hospital incidence rate ranged from 0.00 to 0.12 in 100 000 women and 0.02 to 0.18 in 100,000 men, with no trend over the years. 39.5% of patients with TAAA were treated with OR, 44.2% were treated with f/bEVAR, and 9.8% with hybrid repair with no difference in outcome for nrTAAA. All-cause mortality was 55% in rTAAA and 7.1% in nrTAAA. Mortality was lower in rTAAA, when f/bEVAR or hybrid procedures were used. An increased age, a ruptured aneurysm and higher comorbidity strongly correlated with increased in hospital mortality.

Conclusions: Hospital incidence for nrTAAA doubled over the 10-year time period in Switzerland. 44.2% of all TAAA were treated with f/bEVAR with an increasing frequency over the years. However, mortality remained largely unchanged for both, rTAAA and nrTAAA. Increased age, a ruptured aneurysm and higher comorbidity are associated with worse outcome.

Aim: To report our experience with the Relay stent-graft custom-made thoracic endovascular aortic repair (TEVAR) platform in treatment of different aortic arch pathology.

Method: A retrospective analysis of all patients treated with custom-made Relay stent-graft for different aortic arch pathology between July 2016 and December 2022. End points were technical success, perioperative stroke and death.

Results: Twelve patients (nine male) with median age of 76 (range 59-84) were identified. Five patients were treated for penetrating aortic ulcer (max. DM 59 ± 19mm) in the aortic arch . Seven patients had aneurysms (max, DM 64 ± 18mm) of the aortic arch: three degenerative, three combined with type Ia endoleak after previous TEVAR and one chronic post-dissection. Proximal scallop was used in four patients. Five patients received fenestrated stent-graft for the brachiocephalic trunk (BCT) and left common carotid artery (LCCA). Two patients had a double inner-branched stent-graft for the BCT and the LCCA. One patient had a single inner-branched stent-graft for the BCT. All devices were successfully deployed and all supra-aortic branches were patent. We achieved proximal sealing in zone 0 in nine patients and in zone 1 in three patients. Nine patients required additional revascularization of the left subclavian artery (LSA). Median hospital stay was five days (range 3-10). We observed no aortic re-intervention and no death during hospital stay. There was one postoperative stroke (right-sided ischemic infarction of the cerebellum), which resolved entirely prior discharge. Median follow-up was 18 months (range 1-70). One patient died of intracranial bleeding at 42 months after index treatment. One patient had a type II endoleak coming from the LSA, treated with retrograde plug.

Conclusion: The Relay stent-graft custom-made platform allows for treatment of different aortic arch pathology with diverse custom-made solutions. High rate of technical success with low complication rate and favourable long-term results could be expected.

Background: Thoracic endovascular aneurysm repair (TEVAR) is the gold standard for the treatment of thoracic aortic diseases. When coverage of the left sub-clavian artery (LSA) is necessary, patency could be restored by carotid-subclavian transposition or bypass, use of chimney or thoracic branch device. Recently, the use of physician-modified home-made endografts (PMEG) has been reported to be safe.

Aims: The aim of this study is to report our preliminary experience with PMEGs for TEVAR.

Material&Methods: This is a single-center retrospective analysis of all patients treated with PMEGs for TEVAR in our center. The main outcome was the technical success. Secondary outcomes were post-operative complications, the mortality rate and fenestration patency rate.

Results: Between March and December 2022, 6 patients with PMEGs using the Medtronic Valiant Captivia were identified, with 4 (67%) patients treated with TEVAR in zone 2 and 2 (33%) in zone 1. Two (33%) patients were treated for acute complicated type B aortic dissection with one rupture.  There were 1 patient with a type-Ia endoleak after previous TEVAR (17%) and 3 patients with penetrating aortic ulcer (50%). Technical success rate was 100%. One (17%) patient experienced a reversible-postoperative minor stroke. Three (50%) access site complications were documented. One of the two urgent patients (17%) died due to hypoxic-ischemic encephalopathy with cardiovascular decompensation following the initial hemorrhagic shock. Four (67%) type II endoleaks were identified during the mean follow-up of 70 days (range 9-223). There were no case of conversion to open repair, stent rupture or migration. All fenestrations remained patent. No reintervention was required. 

Conclusions: PMEGs seems to be useful and safe for the treatment of complex thoracic aortic disease, especially in emergency. Neurologic morbidity remains the main perioperative concern, especially in elderly and/or high-risk patients. More patients and longer follow-up are required to further assess this technique.

Background:

The association of case volume on hospital mortality in patients with ruptured abdominal aortic aneurysm (rAAA) is well known. Nevertheless, any delay in treatment due to patient transfers must be weighed against the benefits of treatment in a specialised high-volume centre.

Aims:

The aim of this study was to analyse patient flow and hospital mortality in patients with rAAA in Switzerland.

Material & Methods:

First, prospectively collected mission data of Switzerland’s largest helicopter emergency medical service provider were analysed: The mission duration and survival of all inter-hospital transfers for patients with cardiovascular emergencies (i.e. strokes, myocardial infarction, rAAA, and other vascular emergencies) between July 2019, and March 2021 were analysed.

Second, case-related hospital discharge data from the Swiss Federal Statistical Office (SFSO) for the years 2009 - 2018 were analysed: All cases with rAAA as primary or secondary diagnosis were included. A multivariable logistic regression models for hospital mortality was built.

Results:

Between July 2019, and March 2021, a total of 645 patients were transferred for cardiovascular emergencies. The total mission duration from emergency call to landing at the destination was 59.9 (IQR 51.5 to 70.5) minutes. All patients survived the transfer.

The SFSO data included 1'798 cases with rAAA of which 62.5% were treated surgically. 27.1% of all cases were transferred between hospitals. The overall crude hospital mortality was 50.3%. In the surgically treated cohort it was 23.1%, in the palliative treated cohort it was 95.7%. Inter-hospital transfer was associated with lower survival compared to patients directly admitted (OR 0.52, 95%-CI: 0.36-0.75, p<.001).

Conclusions:

It is probably safe to transfer of haemodynamically stable patients with rAAA in Switzerland. A centralised medical care seems to outweigh the potential disadvantages of a limited delay due to patient transfer.

Background

Complex endovascular aneurysm repair (fEVAR / bEVAR) has become standard care for the treatment of thoracoabdominal, suprarenal and pararenal aneurysms, including post dissection aneurysms. At our institution, complex EVAR was only adopted in 2016 and almost all of these procedures were performed by one vascular surgeon. 

Aims

To present our experience and outcomes with complex endovascular aneurysm repair. 

Methods

This is a retrospective analysis of all complex endovascular aortic aneurysms repairs at a single institution between July 2016 and December 2022. Outcomes of interest include 30 day and long term mortality, reinterventions and branch vessel occlusions. Follow up was done until December 2022.

Results

From 2016 to 2022, 55 patients were treated at our institution. Patients' and procedural characteristics are shown in table 1. In short, 30 patients (54.5%) had thoracoabdominal aneurysms and 39 patients (70.9%) had 4 or 5 viscero-renal branch vessels incorporated. Perioperative complications included 1 (1.8%) spinal cord ischemia and 3 patients (5.4%) with perioperative leg ischemia. 

Mean follow up was 26.3 (19.8) months. 24 patients (43.6%) had a total of 41 reinterventions, 32 of which were performed electively while 9 were performed urgently. Indications included 26 endoleaks (1 type Ia, 3 type Ib, 6 type Ic, 2 type II, 11 type III and 3 of unknown origin), 2 bridging stent graft fractures, 3 bridging stent graft balloonings, 7 bridging stentgraft occlusions, 3 bridging stentgraft stenoses and 3 main graft limb occlusions.

During follow up, there were 9 branch occlusions out of 201 branches incorporated (4.5%).

Figure 1 shows Kaplan Meier curves for 30 day overall survival, long term overall survival, freedom from any reintervention and freedom from branch vessel occlusions.

Conclusions

Compex endovascular aneurysm repair can be performed safely and with decent long term outcomes at a medium volume center with a dedicated program. Reintervention rates remain high. 

Einführung

Auch die endovaskuläre Behandlung des Aortenbogens ist mit einem beträchtlichen neurologischen Risiko verbunden. Dabei stehen Eingriffsdauer und die zahlreichen Kathetermanipulationen in der Kritik. Wir berichten über den ersten Patienten, der mit einer endovaskulären Bogen-Prothese versorgt worden ist, die durch vor-kanulierten Seitenäste nur ganz wenige Kathetermanipulationen erfordert.

Ziel und Material

Die Bogen-Nexusprothese ist eine CE zugelassene Endoprothese mit einem integrierten Seitenast für den Trunkus barchiocephalikus. Dieser Endograft kann über einen einzigen Führungsdraht mit einem Minimum an Manipulationen implantiert werden. Nun konnte einen zweiten, vor-kanulierten inneren Seitenast implementiert werden (Nexus DUO). Dabei wird Lage und Design des zweiten Asts jeweils an der Morphologie des Patienten angepasst. Unsere 75-jährigen Patientin erkrankte an einer, im Verlauf komplizierte Aortendissektion. Bei Multimorbidität war eine endovaskuläre Behandlung am sinnvollsten.

Ergebnisse

Zuerst wurde einen Karotis-zu-Karotis Crossover Bypass angelegt. Als die massgeschneiderte Nexus Duo Prothese hergestellt wurde, erfolgte dann die Implantation. Von links und rechts wurden perkutan je einen axillo-rechts-femoralen Durchzugsdraht eingelegt. Letztere wurden durch die entsprechenden vor-kanulierten Prothesenkanäle der Nexus DUO eingefädelt. Die Bogenprothese konnte dann in gewohnter Art und Weise problemlos eingeführt und Abgesetzt werden. Der vorgelegte linksseitigen axillo-femoralen Draht diente als Schienung für die Implantation des zweiten Seitenastes (Stengraft) in die linke Subklavia, was ebenfalls problemlos verlief. Die Patientin erholte sich ohne Zwischenfall und ging am 3. Postoperativen Tag direkt nach Hause.

Schlussfolgerung

Prothesen mit vor-kanulierten Seitenäste sind Routine für die abdominale Aorta. Leider ist die Lage der Seitenäste bei den meisten Aortenbogenprothesen für vor-kanulierten Systeme ungünstig, so dass nur ein Ast im vor-kanulierten Design möglich ist. Offensichtlich ist es mit dem einmaligen Design der Nexusprothese, mit einem bereits integrierten Ast, gelungen eine Mehr-Astprothese mit vor-kanulierten Äste herzustellen. Unsere Première im Aortenbogen war punkto «proof of concept» vielversprechend in Bezug auf Reduktion unnötiger Manipulationen, in einem Aortensegment wo jeder Gefässwandkontakt zu bedrohlichen Komplikationen führen kann.

Introduction:

There is limited data in the literature on the use of thoracic aortic stent graft implantation (TEVAR) to facilitate en-bloc resection of tumors that have invaded the aortic wall. After TEVAR, extended resections can be performed, avoiding aortic wall replacement or catastrophic situations such as life-threatening bleeding from aortic injury. 

Aim

The aim of this interim analysis was to demonstrate the feasibility of TEVAR without increased risk of perioperative morbidity and mortality.

Method:

A retro- and prospective data analysis was performed including all consecutive patients with suspicious aortic wall infiltration on preoperative imaging, who received a TEVAR implantation prior to resection of thoracic malignancy between 1/2008 and 12/2022. In addition, a literature review was conducted (able).

Results:

Thirteen patients (median age 67 years, range 23-75, 62% female) have been treated at our institution so far. Nine patients received neoadjuvant therapy. In all patients it was possible to implant the stent graft with sufficient overlap at the level of the tumor mass. In 69% the proximal landing zone was located in aortic zone 3 to 4. No postoperative endograft related morbidity, especially no spinal cord ischemia, no stroke, no postoperative bleeding or access site complications, as well as no dissection or aortic rupture was observed.

In nine patients, aortic wall infiltration was confirmed intraoperatively, and a partial non-circumferential resection of the aortic wall was necessary (figure).

The 30-day mortality rate was 15% (one case) due to respiratory failure and ARDS as well as postoperative empyema. Eight patients died during a median follow up of 11 month (0.7-94).

Conclusion:

In this, to the best of our knowledge, largest analysis to date, the results of previous smaller series were confirmed. Aortic stent grafting prior to thoracic tumor resection allows extensive resections while maintaining low morbidity and a low 30-day mortality risk.

Background & Aims: The obesity pandemic leads to rising obesity rate in women of reproductive age with emerging evidence that maternal obesity has a negative impact on the long-term health of offspring. Additionally, obesity is an independent risk factor for malignancies and particularly hepatocellular carcinoma (HCC). The aim of our study is to investigate the impact of maternal obesity on the risk for HCC in the offspring and identify potential mechanisms of transmission.

Methods: Female mice were fed either a high fat (HFD) or a normal diet (ND) before mating. Offspring received ND throughout life. We studied the liver histology and tumor load in a short-term transgenic (12 weeks) or a toxin induced long-term (36 weeks) HCC mouse model. To normalize the gut microbiome, we co-housed offspring of HFD and ND mothers after weaning. The composition of the gut microbiota was assessed through 16S rRNA sequencing.

Results: Maternal obesity induced a distinguishable shift in the microbial composition towards decreased microbial diversity (2.56 vs. 2.92, p=0.0089), increased proportions of Firmicutes and decreased abundance of Bacteroidota. At 40 weeks female HFD offspring developed steatosis (9.43 vs 3.09%, p=0.0023) and a higher number of inflammatory infiltrates (4.8 vs 1.0, p=0.018) compared to ND offspring. A higher proportion of female HFD offspring developed liver tumors after DEN induction (79.8 vs 37.5%, p=0.0084) with a higher total tumor volume at 36 weeks (234 vs 3 µm³, p=0.0041). An effect that we did not observe in the short-term transgenic model. Gut microbiome composition was corrected through co-housing offspring and co-housing normalized the tumor number and volume to the level of ND offspring.

Conclusions: Maternal obesity increases the susceptibility to develop HCC in offspring. The transmission of an altered gut microbiome appears to play an important role in this increased long-term risk profile.

Background: The maintenance of genome stability is a key process to slow aging. One of the mechanisms ensuring this stability is the correct coordination of origins of replication (ORI), resulting in the successful transmission of DNA. Previously, we mapped and compared ORI firing between young and aged mice in vivo, using a regenerating liver mouse model. We confirmed a decreased hepatocyte ORI efficiency in aged mice, known to have impaired liver regeneration. ORI firing proved to be fully rescued when blocking the aged mice’s ATR serine/threonine-protein kinase, suggesting that the DNA replication checkpoint actively mediates ORI firing impairment upon DNA damage detection.

Aim: To explore DNA damage differences between young and aged mice regenerating livers.

Methods: To induce proliferation, mice were subjected to partial hepatectomy (PH) and liver sections were harvested at different timepoints. Immunohistochemistry staining (IHC) were used to address proliferation and DNA damage, using Ki67 and serine 139 phosphorylated histone H2AX (g-H2AX) as markers, respectively.

Results: We confirmed a lack of Ki67 signal in young and aged mice prior to PH. The signal takes off at 24-28h post-PH and reaches its peak at 36-48h, which is significantly lower in aged mice. After 48h post-PH, young hepatocytes’ Ki67 reaches its basal level 120h post-PH. However, aged hepatocytes’ Ki67 is maintained at low levels overtime. Next, we compared DNA damage kinetics between young and aged mice livers. Both mouse groups present an increase of g-H2AX upon PH, higher in young mice. The g-H2AX signal decreases in young hepatocytes after 48h post-PH until disappearing 120h post PH. Aged mice hepatocytes maintain the g-H2AX rates overtime after 48h post-PH.

Conclusions: Our data suggests that hepatocytes develop DNA damage upon proliferation, which is able to be resolved in young mice hepatocytes but remains present in aged livers, ultimately leading to impaired liver regeneration.

Background:

Hepatocellular carcinoma (HCC) is a primary liver tumour often linked to portal hypertension. Data over the effect of transjugular intrahepatic portosystemic shunting (TIPS) on HCC affected patients is unclear. Portal venous pressure reduction is hypothesized to prevent HCC carcinogenesis and growth. To support this hypothesis analysis of HCC characteristics in portosystemic shunted mice and retrospective observation in humans treated by TIPS are realised.

Methods:

DEN-injected HFD-fed C57BL/6 mice besides choline-deficient-diet fed LAP-MYC mice were studied as HCC mouse models. Porto-systemic shunts (or sham) were created at 8 weeks, monitoring was conducted up to 40 weeks. The impact on the liver was assessed by looking at portal pressure, hepatic oxygenation, tumour burden and tumour growth.

Sourcing the scientific registry of transplant recipients, we compared the effect of TIPS on HCC growth and carcinogenesis in a human cohort.

Results:

Shunted mice presented reduced number of nodules compared to sham (DEN injected 8 vs 14, p=0.0471 and LAP-MYC 4 vs 1, p=0.0044) but greater growth rate in [mm³/week] (DEN injected 0.189 vs 0.512, p<0.0001 and 39 vs 84 LAP-MYC p=0.1639).

In humans, patients treated with a TIPS presented less growth rate compared to non-TIPS treated patients (n=18494, tumoral growth rate [cm³/month] is -0.21 vs -0.12; p=0.011). This difference is not observed in obese patients, suggesting an adverse effect in this subpopulation.

Conclusions:

These findings demonstrate that a portosystemic shunt in NAFLD mice leads to higher HCC growth compared to sham. Retrospective observation in our human cohort suggests same results thus confirming our hypothesis. Based on these observation, portosystemic shunt in NAFLD patients should be debated.

Background:

Uterine transplantation (UTx) is an emerging therapy for absolute uterine infertility and the need for organ donors is increasing. Organs from donors after circulatory death (DCD) could meet this need. However, DCD transplants have not yet been used for UTx. The aim of this model is to investigate the effects of warm ischaemia followed by static cold storage on the uterine graft .

Methods:

Adult virgin female rats of the inbred Lewis strain served as donors and recipients of uterine grafts. Uteri were subjected to warm ischaemia in situ for 60 min followed by 4 h of cold storage mimicking DCD organ removal and conventional organ transport (n=5). Outcome was assessed 12 hours after uterine transplantation, focusing on reperfusion injury.

Results:

Our results on early graft viability suggest that the rat uterus can survive 60 min of warm ischaemia in situ and 4 h of cold storage without significant damage.

Conclusions:

Our study demonstrates that a DCD model for uterine transplantation is feasible in rats. The rat uterus is remarkably resistant to warm ischaemia, but prolonged ischaemia is detrimental. Therefore, pre-treatment with ex vivo hypothermic oxygenated perfusion may increase the graft viability and will be explored as a novel approach to promote DCD grafts for clinical UTx.

Background: The liver is an exemplar organ to study tissue regeneration due to its inherent ability of repair and regrowth. It replaces its lost or injured tissue by the proliferation, interaction and temporal coordination of multiple residential cell types. Until now we lack a detailed description of the cell-type specific contributions to regeneration.

Aims: we aim to identiy the contribution of each cell-type to the regeneration by using single cell RNA-sequencing (scRNA-seq).

Material&Methods: We analyzed mouse livers 0, 3, 6, 24, 36, 48 and 96 hours following two-thirds partial hepatectomy (PHx) by scRNA-seq.

Results: Our resulting genome wide temporal atlas contains the time dependent transcriptional changes in hepatocytes, endothelial cells, bone marrow-derived macrophages (BMDM) and Kupffer cells. In addition, it describes the cell specific contribution of mitogenic growth factors from biliary epithelial, endothelial and stellate cells as well as chemokines and cytokines from BMDM and granulocytes. In addition, we describe macrophage-derived progranulin as a highly abundant and important growth factor contributing to regeneration.

Conclusions: Here, we provide a robust data set at a cellular resolution to uncover new elements and to revisit current dogmas on the mechanisms underlying liver regeneration.

Background

Recurrence is a significant problem following treatment for Hepatocellular Carcinoma (HCC). It affects more than 70% of patients receiving a surgical resection. Recurrence can arise from undetected micrometastasis (multicentric tumor) or “de novo” cancer. Clinical and experimental studies suggest that liver regeneration ensuing surgical resection may activate occult micro-metastasis leading to tumor recurrence. Here, we aim to establish an in vivo model to understand the impact of liver regeneration on HCC tumor growth.

Materials and Methods

Patient Derived Organoids (PDOs) were generated from HCC tissue obtained from patients that underwent liver resection at the University Center for Gastrointestinal and Liver Diseases (Clarunis). HCC-PDO organoids have been proved to retain the histopathological characteristic of the original tumor. After a laparotomy, HCC-PDO were implanted in the liver of NOD Scid gamma mice. Experimental group undergo a re-laparotomy and 30% or 70% hepatectomy while control group only receives a re-laparotomy. Tumor growth was monitored by ultrasound until the end-point of the experiment. Healthy and tumor tissue were characterized using immunohistochemistry.

Results

We have successfully performed the implantation of 2 HCC-PDO lines. Preliminary results from animals that received resections after implantation, showed an increase in tumor growth compared to control. The resection groups showed a mean increase of 256.4 percent (SD ± 416.9) compared to 45.14 percent (SD ± 9.987) in the control group in line 1 (p = 0.536), respectively 41.50 percent (SD ± 75.13) compared to 22.24 percent (SD ± 12.73) in line 2 (p = 0.632).

Conclusions

Preliminary data shows an increased tumor growth rate in our resection groups compared to control groups. Our established orthotopic xenograft model can help understand the molecular basis of HCC recurrence after surgery. Therefore, this model may provide the basis for future projects for specific drug therapy before or after liver resection to inhibit tumor growth and favour regeneration.

Background: Hepatocellular carcinoma (HCC) accounts for 75-85% of all primary liver malignancies. HCC represents an attractive target for immune checkpoint inhibitors (ICI) and tumor microenvironment (TME) agents. The development and success of ICI therapies require a comprehensive model to study interactions of immune networks in the TME. The lack of mesenchymal and immune components limit the use of patient-derived organoids for testing drug classes such as ICI or studying the interaction between a tumor and its TME.

Aim: After the accomplished preservation of HCC architecture and TME, this study shows the successful ICI-treatment of HCC in a perfused-bioreactor.

Materials and methods: Fresh tumor tissue was obtained from seven patients following HCC resection. Tissue fragments were installed in a perfusion-based bioreactor (U-shaped Culture Under Perfusion; U-CUP) for 5 days. Cell viability and morphology were monitored using hematoxylin and eosin staining. The changes in tumor microenvironment composition were monitored by immunohistochemistry using cell-type specific antibodies like CD3 (T-cells), Ki67 (proliferation), and arginase-L (hepatocytes). For each sample, four different treatments were performed: IL-2 (T-cell growth factor) alone, anti-PD-L1 antibody, the combination of both, and a non-treated U-CUP as control.

Results: While cell viability decreased significantly, 60% of the samples still had a viability above 50% at day 5. CD3+ T-cells decreased as well, but not significantly. There was no difference in Ki67 and Arginase expression. In samples treated with IL-2 and anti-PD-L1, the rate of necrosis was higher than in the untreated or after treatment with a single agent, in contrast to the number of CD3-positive cells, which was not affected by the different treatments.

Conclusion: In addition to the preservation of the TME in a U-CUP, the testing of ICI is feasible and showed a verifiable benefit. These preliminary results are a further step towards a personalized medicine approach in HCC treatment.

Background: Best monitoring practices for patients after resection of hepatic alveolar echinococcosis remain unclear.

Aim: The current study tested if assessment of anti-recEm18 allows for postsurgical patient surveillance.

Methods: A retrospective study with patients undergoing liver resection for alveolar echinococcosis at the University Hospital Bern from December 2002 to December 2020 and at the University Hospital and Medical Center Ulm from January 2011 to December 2017 was performed. Analysis was directed to determine a potential association of pre- and postoperative values of anti-recEm18 with clinical outcomes.

Results: Among 147 patients who underwent liver resection for alveolar echinococcosis in curative intent, perioperative results of recEm18-serology were available in 88 patients. In patients without residual disease, the postoperative anti-recEm18 value after 12 months dropped to a mean of 2 AU/ml (standard deviation: 4 AU/ml). Three trajectories of anti-recEm18 were identified based on a threshold of 10 AU/ml: “Em18-low” (n = 31, 35%) with anti-recEm18 values below 10 AU/ml pre- and postoperatively, “responders” (n = 53, 60%) with preoperative values above 10 AU/ml and a postoperative decrease of more than 80% of the initial anti-recEm18 and “residual disease” (n = 4, 5%) with the postoperative presence of residual disease. The decline of anti-recEm18 in “responders” reached a plateau after 11.4 months at which levels decreased by 80%. The only recurrence in the entire population was identified by a secondary increase of anti-recEm18. Anti-recEm18 levels had a linear correlation to the maximum lesion diameter (R² = 0.558).

Conclusion: Anti-recEm18 antibody levels correlate with the lesion size preoperatively and response to surgery postoperatively. Anti-recEm18 allows to be applied as serological surveillance marker during postoperative follow-up in patients with elevated preoperative anti-recEm18 levels.

Fig. 1. Temporal changes of recEm18-ELISA and different trajectories. 

Background

Low Anterior Resection Syndrome (LARS) after rectal resection is common and debilitating. Current management strategies include behavioural and dietary modifications, physiotherapy, antidiarrheal drugs, enemas and neuromodulation, but results are not always satisfactory. This study examines the efficacity and safety of Ondansetron, a serotonin receptor antagonist, to treat patients with LARS.

Methods

This is a randomized, multi-centric, double-blinded, placebo-controlled, cross-over study. Patients with LARS (LARS score >20) no longer than 2 years after rectal resection were randomised to receive either 4 weeks of Ondansetron followed by 4 weeks of placebo (O-P group) or 4 weeks of placebo followed by 4 weeks of Ondansetron (P-O group). The primary endpoint was LARS severity measured using the LARS score; secondary endpoints were incontinence (Vaizey score) and quality of life (IBS-QoL questionnaire). Patients’ scores and questionnaires were completed at baseline and after each 4-week treatment period.

Results

Out of 46 randomized patients, 38 were included in the analysis. From baseline to the end of the first period, in the O-P group, the mean (SD) LARS score decreased by 25% (from 36.6 (5.6) to 27.3 (11.5)) and the proportion of patients with major LARS (score >30) went from 15/17 (88%) to 7/17 (41%), (p=0.001). In the P-O group, the mean (SD) LARS score decreased by 12% (from 37 (4.8) to 32.6 (9.1)), and the proportion of major LARS went from 19/21 (90%) to 16/21 (76%). After cross over, LARS scores deteriorated again in the O-P group receiving placebo, but further improved in the P-O group receiving Ondansetron. Mean Vaizey scores and IBS QoL scores followed a similar pattern.

Conclusion

Ondansetron should be included in the treatment algorithms of LARS after low anterior resection for rectal cancer because it is a safe and simple treatment that appears to improve both symptoms and quality of life.

Background/Aims: Transanal total mesorectal excision (taTME) is an alternative to laparoscopic and robotic TME owing to its reported superior ability to achieve clear margins in distal rectal cancers. Worrisome reports of high recurrence and complication rates triggered a moratorium in few countries. This study assessed outcomes and resource utilization of taTME in a teaching hospital.

Material & Methods: Patients with distal rectal cancer treated by taTME were prospectively included following ethical clearance and informed consent. Outcomes were reported as median & interquartile range (IQR).

Results: Audited yearly volume for TME was 43 (IQR 37-52). Consecutive 165 patients (67% male, 33% female) with a tumor 7cm (IQR 5-10) from the anal verge and a BMI of 26 (23-29) were followed for 50 months (IQR 32-79). Resection margins were threatened in 25% of the patients in preoperative MRI and 75% received neoadjuvant radiochemotherapy. Surgery lasted 348 min (293-425) and one conversion occurred (0.6%). Length of stay was 9 days (7-13). Good mesorectal dissection and clear margins were achieved in 96% of the specimen and 27 lymphnodes (IQR 20-38) were harvested. Ninety-day major morbidity affected 36 patients (21.8%), including 12 anastomotic leakages (7.2%). All leaks could be salvaged and ileostomy reversed within 6 months but for 2 patients who died (1.2%). Recurrence occurred locally in 9 patients (5.4%) and 44 had distant metastasis (26.7%). Five-year disease-free survival and overall survival were 67% and 90%. In multivariate analysis, long operation and frailty predicted anastomotic leak, while positive distal margin and lymphnodes predicted local recurrence and distant metastasis. A 2-team taTME saved 102 minutes operative time (422 (353-492) vs 320 (276-373) min. p<0.001) and EUR 1’385 when compared to a one-team approach, while allowing improved teaching opportunities.

Conclusions: Transanal total mesorectal excision allowed sound surgical quality and excellent oncologic outcomes in a Swiss teaching hospital.

Background: Multimodal therapy for localized rectal cancer (RC), including
(neo-)adjuvant systemic therapy and surgery, has improved survival outcomes significantly. However, these results cannot be extrapolated to elderly patients.

Aims: The aim of this study was to evaluate whether patients aged >/=75 years receive substandard oncological treatment compared to their younger counterparts and if this affects survival.

Methods: This is a retrospective study from the National Cancer Data Base (NCDB) for histologically confirmed localized RC from 2002–2014. Non-comorbid patients (i.e., Charlson-Deyo comorbidity index 0) between >/=50 - </=85 years were included and assigned to a younger (<75 years) and an older (>/=75 years) group.Treatment modalities and their impact on relative survival (RS) were analyzed using loess regression models. Mediation analysis was performed to measure the independent relative effect of age on RS.

Results: 59,769 patients were identified of which 48,389 (81.0%) were assigned to the younger group (<75 years). Oncologic resection was performed in 79.6% of the younger compared to 67.2% of the older patients (p<0.001). Chemo- (74.3% vs. 56.1%) and radiotherapy (72.0% vs. 58.1%) were provided more often to younger patients (p<0.001). Increasing age was associated with higher 90-day (2.0% vs. 1.1%) mortality in the elderly group (p<0.001) and worse RS rates (multivariable adjusted HR: 1.93 (95%CI:1.87-2.00), p<0.001). Guideline adherent oncological therapy resulted in a significant increase of 5-year RS in both groups(multivariable adjusted HR: 0.80 (95%CI:0.74-0.86), p<0.001). Mediation analysis revealed that RS was mainly affected by age itself (84%) rather than the choice of therapy.

Conclusions: The likelihood to receive substandard oncological therapy increases in the older population and negatively affects RS. Since age itself has a major impact on RS, it is important to identify patients potentially eligible for standard oncological care regardless of their age to improve survival outcomes for this age group.

Background "Tailgut cysts" (cystic hamartomas) are rare, mostly benign congenital malformations. They arise from persistent structures of the hindgut and are mostly found retrorectally in middle-aged women. Malignant transformation of the tailgut cyst has been described in 2-13%. Furthermore, leaving the cyst in place carries a risk of infection, formation of a fistula or abscess, bleeding, pain or defecation problems.

Aims We report the case of a 42-year-old female patient with an asymptomatic retrorectal cyst. The cyst was first detected sonographically during a pregnancy check-up 3 years earlier as an incidental finding. MR tomography described no direct contact with the rectal wall and it seems to be size-stable (43 x 22 x 14mm). Due to the risk of malignant transformation (adenocarcinoma, neuroendocrine tumors) or possible complications, the cyst was radically removed.

Method Our video shows the preoperative diagnostic with following Da Vinci assisted resection of the tailgut cyst after rectal mobilization.

Results The patient could be discharged after 3 days without complications. Histologic examination showed a tailgut cyst, no evidence for malignant transformation.

Conclusions Tailgut cysts are rare findings in the retrorectal space and are manly discovered incidentally. Various posterior approaches (pararectal, transanal, transrectal) as well as abdominal approaches have been described in the literature. Due to the localization deep in the pelvis on the pelvic floor, the minimal-invasive resection can be challenging. Robotic surgery has an excellent visualization and the advantage of additional degrees of freedom, which is very helpful in the tight space of the pelvis.

Introduction

Splenic flexure mobilization (SFM) may be indicated during anterior resection to provide a tension-free anastomosis. Herein, we report our experience of selective SFM during robotic anterior resection and identify predictors of SFM.

Methods

Patients who underwent robotic anterior resection for rectal cancer were identified from a prospective register. Demographic and cancer-related variables were extracted, and predictors of SFM were identified using regression models. Thereafter, 20 patients with SFM and 20 patients without SFM were randomly selected and their pre-operative CTscan were reviewed. The radiological index was defined as 1/(sigmoid length/pelvis depth). The optimal cut-off value for predicting SFM was identified using ROC curve analysis.

Results

Five hundred and twenty-four patients were included. SFM was performed in 121 patients (27.8%) and increased operative time by 21.8 minutes (95% CI: 11.3 to 32.4, p<0.001). The incidence of postoperative complications did not differ between patient with or without SFM. Realization of an anastomosis was the main predictor for SFM (OR: 42.4, 95% CI: 5.8 to 308.5, p<0.001). Based on CTscan, both sigmoid length (15+/-5.1cm versus 24.2+/-80.9cm, p<0.001) and radiological index (1+/-0.3 versus 0.6+/-0.2, p<0.001) differed between patients who had SFM and patients who did not. ROC curve analysis of the radiological index indicated an optimal cut-off value of 0.8 (sensitivity: 75%, specificity: 90%).

Conclusion

SFM was performed in 27.8% of patients who underwent robotic anterior resection, and increased operative time by 21.8min. For optimal surgical planification, patients requiring SFM can be identified based on pre-operative CT using the index 1/(sigmoid length/pelvis depth) with a cut-off value set at 0.8.

Background

Anal incontinence is now recognized as a major health issue due to its economic burden and impact on quality of life. However, the true prevalence of this condition remains a matter of debate.

Aims

Our aim was to evaluate the prevalence of anal incontinence among the collaborators of a tertiary hospital.

Material & Methods

An anonymous questionnaire was sent to the collaborators of a tertiary hospital. Jorge-Wexner and LARS scores and questions related to different definitions of anal and stool incontinence were evaluated. Demographic characteristics of the participants along with specific medical history were also collected.

Results

Among the 14279 collaborators, 2532 participants filled the questionnaire (17.7%). This sample was representative of the total hospital staff regarding age, gender and occupation. Twenty-nine percent of the participants reported occasional episodes of anal incontinence (more than once a month but less than once a week). The Jorge-Wexner score was ≥ 3 in 20.9% of the participants and 15% reported rare episodes of stool incontinence. However, only 2.3% fulfilled the strict Rome IV criteria for stool incontinence. A difference between women and men regarding the presence of anal incontinence was found (32.2 % versus 21% p <0.001) but was not statistically significant for Rome IV criteria. In women, vaginal delivery was not associated with anal incontinence in univariate and multivariate analysis or with Rome IV criteria after adjustment. On the other hand, diabetes was strongly associated with Rome IV criteria (OR: 3.3, 95% CI: 1.09-10.08, p= 0.035). History of proctological procedure was also significantly and strongly associated with anal incontinence and Rome IV criteria (OR: 4, 95% CI: 1.86-8.6, p<0.001).

Conclusion

Prevalence of anal incontinence was higher than expected in an active population. We also demonstrated that the association between childbirth and anal incontinence was less important than expected. 

Background

The high recurrence rate of surgically treated anal fistula remains a concern in proctology.

Aim

This study investigated the healing rate of complex anal fistula procedures supplemented by regenerative therapy with autologous stromal vascular fraction derived mesenchymal stem cells and platelet-rich plasma (SVF-PRP).

Material&Methods

Consecutive patients with complex anal fistula were prospectively assessed by a validated incontinence questionnaire and MRI 4 and 12 months after surgery. Fistula were drained with setons prior to definitive surgery. SVF was harvested from subcutaneous abdominal fat and PRP from peripheral blood. Distal fistulectomy to the sphincter was performed and the wound left open, while the internal orifice was closed. SVF-PRP was injected around the fistula. Patients showered their excision wound until dry. Outcomes were reported as median & interquartile range (IQR).

Results

40 patients (23 males : 17 females) were included from December 2019 to December 2022.  Age was 40 years (IQR 30-53). Five patients (12.5%) suffered from perineal Crohn’s disease and 3 had a rectovaginal fistula (7.5%). Patients had 2 prior fistula surgeries (IQR 1-3) and SVF-PRP fistula repair was performed 8 months (IQR 5-22.5) after initial diagnosis. Operation time was 82 minutes (IQR 73-95). Five patients were discharged on the day of surgery, 32 on postoperative day 1, and 3 on postoperative day 2. Follow up was 12 months (IQR 6-16). There was no deterioration in fecal continence. Two out of 40 patients (5%) experienced an early failure within 2 months of SVF PRP. All others patients were back to work and leisure. At 4 months of follow-up, 34/40 (85%) patients were clinically well with no active fistula. Of 30 patients who reached 12 months follow-up, 5 had an active fistula in MRI (16%) or on clinical ground.

Conclusions

SVF-PRP is a safe and promising addition to the broad armentarium of treatments for complex perianal fistula. 

Aim: The aim of the present study is to present a new surgical technique for thrombosed third degree haemorrhoids. It is well known that laser haemorrhoidoplasty (LHP) is a minimal-invasive, low pain surgical procedure for second and third degree haemorrhoids with promising short- and medium-term results. We have done more than 1900 LHP since 2014.

Methods: 73 patients with thrombosed 3rd degree haemorrhoids underwent surgical therapy using laser surgery with a 1470nm, 8 watt diode laser. All patients had previously received conservative therapy. Perioperative clinical and technical data up to 6 weeks and follow-up data up to at least 19 and 58-62 months were prospectively evaluated.

Results: The average duration of surgery was 6.63 minutes. An average of 3.84 haemorrhoidal nodes were treated. Mean postoperative pain was 2.3/10 (VAS) on the first day and 1.58/10 (VAS) on the second day. Long-term symptom relevance was 100% and patient satisfaction was 93.4%. No complications occurred in any patient. No recurrence could be detected within the first 6 months. 58 (79,5%) patients underwent an examination between 58-62 months after the operation. 4 (6,9%) of this patients had a recurrens after 5 years.

Conclusion:The treatment of haemorrhoidal disease with the diode laser represents a circular surgical procedure even for complicated haemorrhoids. Laser haemorrhoidoplasty is a safe, low-pain and minimally invasive surgical procedure with long-term good patient acceptance and satisfaction in grade II-III haemorrhoids. It is shown here to be a low-pain surgical procedure for thrombosed grade 3 haemorrhoids with a low complication rate and high patient satisfaction after 60 months

Background: To evaluate analgesic effectiveness during proctological surgery, postoperative pain, complications & patient's satisfaction after Pudendal Nerves Block (PNB) performed by surgeons. (Figure 1) Material - Methods: From January 2022 to January 2023, In our out-patient activity  fifty elective proctological surgeries under general anesthesia had been performed, excluding all cases operated under spinal anesthesia. 25 patients randomly allocated to receive PNB (Figure 2) managed by Stimuplex HNS-12 Braun’s neurostimulator, 0.9 mA/ms (Group A), while 25 did not  received any complimentary anesthesic blockage (Group B). Per-operative anesthetic drugs needs has been monitorized by the anesthesist. The Visual Analogic Pain Scale (VAPS) helped for evaluation of pain at 12h, 24h, 48h & 72 h. after surgery. We also recorded the postoperative analgesic medication, patient's satisfaction degree & complications. Results : 14% of patientes in Group A developed hypotension during surgery, patients in Group B did not developped hypotension. There was no reported case of hypotension after surgery in Group A neither in Group B. There was a vey significant difference of median post-operative degree's pain < 12 hours (G=A VAPS p<0.0011), < 24 hours (G=A VAPS; p<0.0013), < 48 hours (G=A VAPS p<0.0024) and finally 72 hours (G=A VAPS p<0.018). Patients were very satisfied on Group A and less satisfied on Group B. (p= 1.001). Patients in Group A required less parenteral analgesics (p<0.003) and had a lower incidence of urinary retention (8.8%, p = 0.03). Group A demonstrated more efficacy controling pain than Group B (p< 0.001). Conclusions: PNB under  neurostimulation management used for proctological surgery, is very safe  & superior in pain releaf than those cases having no other type of anesthetic blockage. We explain this, due to a lower incidence of post-op urinary retention and less requirement of parenteral analgesics post-operatively. Neurostimulation PNB brings more reliability to the procedure.