ABSTRACT. Abstract Objective: Laparoscopic sleeve gastrectomy (LSG) has become a popular one-stage bariatric procedure with a proven efficacy on weight loss. However, the relationship between LSG and gastro-oesophageal reflux disease (GORD) is still unclear and remains a subject of debate. The objective of the study is to determine the long-term effect of LSG on weight loss and symptomatic reflux disease and the need for proton-pump inhibitor (PPI) postoperatively. Methods: A single center, retrospective analysis on 100 consecutive patients who underwent a LSG between January 2005 and March 2009 was performed. The effect of LSG on weight evolution and the relationship between preoperative and postoperative GORD symptoms and PPI dependency was analyzed. Results: At the end of the study period (March 2015), we achieved a mean follow up of 8.48 +- (range 6.1-10.3) years. With a % Excess Weight Loss (%EWL) of more than 60%, very good effect on long-term weight loss was observed. Furthermore, a significant increase in subjective reflux symptoms and PPI use was observed. Seventeen percent of patients suffered from reflux disease preoperatively and 50% at the end of the study period (RR = 2.5882, 95%CI [1.6161-4.1452], p-value = 0.0001). The chance of developing de novo reflux after LSG is 47.8% (32/67). In 7 of the 26 patients who underwent a secondary Roux-en-Y gastric bypass (RYGB), reflux disease was present. In 4 of the 7 patients, reflux disease disappeared completely after the secondary RYGB (57.1%). Conclusions: We observe a satisfactory long-term effect on weight loss but a significant increase in GORD and PPI dependency after LSG and new onset of GORD in more than 40% of the study population.

ABSTRACT. OBJECTIVE To report our initial experience with a new bariatric operation derived from the Magenstrasse and Mill gastroplasty for patients suffering from gastro-esophageal reflux. METHOD Sleeve gastrectomy has rapidly become one of the mostly used bariatric interventions. It entails the risk of initiation or worsening of gastro-esophageal reflux. Other problems are the risk of fistula and the irreversibility of the procedure. Roux-en-Y gastric bypass resolves these drawbacks, but can be contraindicated or not accepted by some patients. Magenstrasse and Mill gastroplasty was described in 1987 by Johnston et al. and recently reevaluated by De Roover et al., with good results in weight loss and safety profile. It consists of the creation of a tubular pouch along the small curvature of the stomach from the cardia to the antrum, preserving a channel to the greater part of the stomach, which is not resected. We proposed to combine this procedure with a Nissen-Rossetti fundoplication using the excluded stomach in bariatric patients suffering from large hiatal hernia and/or severe peptic esophagitis for whom Roux-en-Y gastric bypass was contraindicated or who refused it. RESULTS Our initial experience contains five patients operated since October 2015. All the operations were carried out by laparoscopy through 5 trocars. The Interventions began with the complete dissection of the esogastric junction that was reduced into the abdomen. Magenstrasse and Mill gastroplasty was then created and a Nissen-Rossetti fundoplication was performed. A retro-esophageal cruroplasty completed the procedure. No perioperative complication occurred and the mid-term postoperative evolution was promising. Food tolerance was good without significant complaints of gastroesophageal reflux. Weight loss was satisfactory. CONCLUSIONS Laparoscopic Magenstrasse and Mill gastroplasty with Nissen-Rossetti fundoplication is feasible and safe. It offers advantages over sleeve gastrectomy for bariatric patients with gastro-esophageal reflux. Good initial results await confirmation on the long term.

ABSTRACT. OBJECTIVE: To report 10+ year outcome of laparoscopic biliopancreatic diversion with duodenal switch (LDS), with special focus on quality of life

METHODS: Records of all patients who underwent LDS 10+ years ago were analysed. Patients were contacted to answer a questionnaire based on Bariatric Analysis and Reporting Outcome System (BAROS). Blood work was reported when performed within the last year.

RESULTS: Of the 153 patients who underwent LDS, follow-up was available in 113 (78.5%). Mean follow-up was 130.2 + 4.6 months. Percentage total weight loss was 40.7+10.8%. Weight loss was greatest in the super obese (BMI>50kg/m 2). Remission rate for type 2 diabetes was 87.5% (21/24) and for arterial hypertension 80.9% (38/47). Dyslipidemia remission rates were 93.3% (28/30) for total cholesterol, 89.7% (26/29) for triglycerides and 95.0% (19/20) for LDL cholesterol. However, 42.5% of the patients needed reoperation, including 10.6% for correction of protein malnutrition, the latter exclusively in non-super obese individuals. Most common deficiencies concerned Vitamin A and D, iron and zinc. De novo gastro-esophageal reflux disease (GERD) was reported in 43.8%. BAROS score was good at 4.9+2.2 and 82.3% of participants would choose the procedure again.

CONCLUSIONS: LDS is a very effective metabolic procedure, at the cost of occasional protein and other nutritional deficiencies. Outcome in long-term is best in super obese patients. Overall quality of life is good. The high reoperation rate and incidence of GERD are concerning.

### NOTE: ALREADY PUBLISHED ARTICLE IN ANN OF SURGERY 2016 ###

ABSTRACT. Objective

Parastomal herniation (PSH) is a common and debilitating problem following stoma formation, with up to 30% of patients requiring further surgical intervention. The optimal surgical technique for stoma formation is yet to be defined though recent randomised trials have focussed on whether prophylactic mesh placement at the time of stoma creation can reduce the rate of PSH. The aim of this study was to systematically review use of prophylactic mesh versus no mesh with regard to a) occurrence of PSH and b) peristomal complications

Methods

A systematic search was performed using PubMed, Medline, Embase and the Cochrane Library to identify randomised controlled trials that analysed placement of prophylactic mesh versus no mesh at time of initial surgery to prevent parastomal herniation. Meta-analysis was performed using the random effects methods. The primary outcomes of interest were PSH occurrence and peristomal complications.

Results

A total of 506 studies were identified by our search strategy. Eight studies were included, involving 430 patients (217 mesh vs 213 no mesh). Prophylactic mesh placement resulted in a significantly lower rate of parastomal hernia formation 19.4% (42/217) versus 43.2% (92/213). The combined risk ratio was 0.40 (95% CI, 0.21-0.75, p=0.004). Placement of prophylactic mesh did not result in increased peristomal complications 6.9% (15/218) versus 7% (16/227). The combined risk ratio was 1.0 (95% CI, 0.49-2.01, p=0.99).

Conclusions

Prophylactic placement of mesh at primary stoma formation appears to reduce the incidence of PSH, without an increase in peristomal complications. However, the overall quality of RCTs included in the meta-analysis is poor and should prompt caution regarding the applicability of the findings of the individual studies and the meta-analysis to everyday practice. The optimal type of mesh, location for mesh placement and cost effectiveness still needs to be defined.

ABSTRACT. Reconstruction of complex abdominal wall defects is a challenge. Their complexity offers multiple ways to resolve the problem but needs often the cooperation of plastic and general surgeon.

Our case report is about a 59 year old woman, admitted in our emergency department in shock with respiratory distress and abdominal pain. A thoraco-abdominal CT scan showed multicompartimental ascites and a pneumoperitoneum with suspicion of gastric perforation with fat infiltration in the region of the great curvature. She underwent surgery for perforated duodenal ulcer. Because of multiple complications our patient had recurrent surgeries and finally her abdominal wall was left open due to extended wall necrosis and infection of the wound site. She was treated with negative wound pressure therapy and extensive intravenous antibiotics during weeks. After 60 days she underwent a final surgery for abdominal wall reconstruction by putting a porcine acellular dermal matrix in a retromuscular position, combined with a deep inferior epigastric perforator (DIEP) flap. 1.5 months later the patient finally recovered and went home.

Various techniques have been described for tension-free abdominal wall reconstruction but if complications persist, options for deep abdominal layers reconstructions become fewer. In our case we choose a biologic mesh with a DIEP flap because of the important site infection and enormous skin defect.

ABSTRACT. Background: Although large pore mesh use is now very much accepted to be used in routine abdominal wall repair, criticism has been raised using a large pore partially absorbable mesh for this indication, being too light and not strong enough to resist physiological repetitive forces in the human body. Having implanted this type of mesh for many years now in both ventral and inguinal hernia repair, we aimed to investigate the longterm outcome.

Methods: We performed a cross-sectional study in a tertiary hospital. A prospectively recorded database was used to retrospectively analyze the data of patients treated with this type of mesh. Follow-up data were obtained using the EuraHS self-report questionnaire. Quality of life regarding pain, restriction of activity and cosmetic hindrance was investigated at the time of last follow-up.

Results: Between January 2009 and December 2010, 90 patients underwent retromuscular ventral or incisional hernia repair using Ultrapro mesh. Herniation defect is 11,0 centimeters on average. Mean duration of the operation time is 170 minutes. Hospital stay varies from 1 to 30 days, with a median duration of 7 days. 1 patient (1.1%) developed an infected mesh treated with negative pressure therapy. A clinical seroma was diagnosed in 7 patients (7.8%) of whom 3 needed surgical or radiological drainage. Hematoma that needed surgical management occurred in 5 patients (5.5%). Recurrence after one month occurred in 1 patient (1.1%). Recurrence in the first year after mesh repair occurred in 8 patients (8.9%). These 8 patients had an average herniation defect of 10,4 centimeters.

Conclusions: Compared to the current literature our data show suboptimal results recurrences after retromuscular repair using a large pore partially absorbable mesh. However, mesh rupture was not to be the main reason for recurrence. Postoperative wound morbidity was acceptable as well as the perceptance of the patients regarding quality of life.

ABSTRACT. Objective :

To evaluates the impact of the closure or not of the aponevrotic defect on the results of laparoscopic ventral hernia repair.

Methods :

Multicentric prospective study with consecutive inclusion of patients operated between 01/03/2013 and 01/03/2014 for ventral hernia with a defect of 2cm at least. Only one mandatory technical factor : an overlap of the mesh of at least 3cm over the defect. Prospective recording of patient, hernia, post-operative and follow-up parameters, with clinical recurrence as the first endpoint. Two groups are compared : open (O) versus closed (C) following the closure of the defect.

Results :

384 patients operated by 22 different surgeons : 193 group O, 190 group C. Only one difference : % of defect of >=4cm (46 group O vs 127 group C; p<0.001). Morbidity :8.4% (16/16) ; 22 surgical complications (10/12). Hospital stay : 2.6 and 2.7 days. 154 vs 140 patients with at least 6-12 months follow-up. The global sepsis rate :1.7% (3/2 ). There were 49 (25/24) seroma, 11 hematoma (5/6) and finally 8 hernia recurrences (4 /4). All these were observed for defect of >=4cm. This represents , in the 173 patients with defects of >=4cm, a 8.7% of recurrence in group O and 3.1% in group C (p <0.2).

Conclusions :

This large prospective multicentric study of consecutive laparoscopic ventral hernia repair demonstrated no impact of the closure or not of the defect. Analysis of the recurrences showed a trend, but not significant, in favor of closure for defects of at least 4cm. A randomized study should be focused on this larger defects.

ABSTRACT. OBJECTIVES The goal of this study was to develop a formulation that evenly distributes in the abdominal cavity and prevents postsurgical peritoneal adhesions. This study describes the characterization and efficacy of genipin-crosslinked gelatin microspheres (GP-MS).

METHODS Gelatin microspheres were prepared by emulsification and solvent extraction and crosslinked using genipin. Peritoneal adhesions were induced in Balb/c mice by abrasion of peritoneal wall and cecum. Control (n=11) and GP-MS-mice (n=11) were intraperitoneally injected with 2 ml physiological saline or 50 mg GP-MS dispersed in 2 ml physiological saline, respectively. Hyalobarrier® gel (Anika Therapeutics) (n=11) was applied to cecum and peritoneal defect. Adhesions were scored in a blinded manner day 14 postoperative. The nonparametric Wilcoxon-Mann Whitney test was used to compare total score and grade of adhesion. The incidence of adhesions was compared using Fisher’s Exact test. A P-value < 0.05 was considered statistically significant. Interleukin 1ß, IL-6 and TNF-alpha were quantified in plasma and peritoneal fluid. Histopathological examination of peritoneum, cecum and adhesion tissue was performed.

RESULTS Increasing genipin concentration and crosslinking time resulted in a higher crosslinking degree. GP-MS showed excellent biocompatibility and degradation characteristics. GP-MS were distributed evenly throughout the abdominal cavity. GP-MS-treated mice developed less postsurgical adhesions compared to control and Hyalobarrier®-group (P=0.0039). The difference in total score (type, tenacity and extent) of adhesions between control and GP-MS-group was significant (P<0.0001). GP-MS and Hyalobarrier®-group differed in total adhesion score (P < 0.0001), whereas no difference was reported between control and Hyalobarrier®-group (P=0.42). A lower grade of adhesion was seen in GP-MS compared to control and Hyalobarrier®-group (P<0.0001). A decrease of peritoneal inflammation over time in GP-MS-treated mice with recovery of peritoneal wounds was observed upon histopathological examination. Cytokine evaluation did not show difference between groups, probably due to localized appearance of adhesions.

CONCLUSIONS GP-MS are a promising strategy to prevent postoperative peritoneal adhesions.

ABSTRACT. Objective: Cytoreductive surgery (CRS) followed by intraperitoneal chemoperfusion (IPEC) with platinum (Pt) – based drugs benefits selected patients with peritoneal carcinomatosis (PC). However, little is known about the tumor tissue penetration of these drugs after IPEC, and on the effect of combined hyperthermia on Pt distribution. Highly sensitive bioimaging with laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS) may allow detailed insight in the tissue distribution of Pt. Methods: Tumor tissue samples were obtained from two patients with PC from gastric and ovarian cancer, who underwent CRS followed by 90min. of IPEC (38°C) or HIPEC (40°C) with cisplatin (120mg/m²), respectively. A single tumor nodule from each patient was removed after (H)IPEC and freeze-dried in liquid nitrogen. To analyze penetration depth, distribution and concentrations of Pt within these tumors, LA-ICP-MS was used. Ablation was performed with an Analyte G2 193nm ArF* excimer laser, coupled to an XSeries 2 ICP-quadrupole-MS. Calibration of the system was achieved using four gelatin standards, spiked gravimetrically by 1001 ± 5µg/ml Pt and 1000 ± 5µg/ml Indium standards. Results: Figure 1 depicts LA-ICP-MS and showed that the distribution of Pt can be observed with high sensitivity (5.1x103 counts per seconds /µg g-1). In general, distribution, penetration and concentrations of Pt are limited to the outer layer of the tumor and influenced by tumor type, temperature and tissue density. While the dense tumor derived from ovarian cancer treated with HIPEC demonstrate a Pt-gradient, a more uniformly Pt-distribution can be observed in the less dense tumor derived from gastric cancer treated with IPEC. Conclusion: LA-ICP-MS is a highly sensitive technique for the analysis of Pt distribution in human tumor sections. Additionally, these images can be correlated to histological images and may be of particular interest in the future for investigating the influence of tumor microenvironment on drug delivery.

ABSTRACT. OBJECTIVE: The pre-injury use of antiplatelet and anticoagulant therapy (APAC) in polytrauma patients has been described as a predisposing factor for coagulopathy, an element of the lethal triad influencing mortality after polytrauma. With an ageing population, the number of polytrauma patients using APAC pre-injury increases. We hypothesised that APAC negatively influences outcome after polytrauma and preformed an explorative analysis comparing mortality and bleeding-related morbidity in polytrauma patients on APAC pre-injury versus a control group.

METHODS: A retrospective cohort study was carried out for a three-year-study period (2008-2011) at a Level I trauma center. Inclusion criteria included all patients ≥ 50 years with an Injury Severity Score(ISS) ≥ 16 and known pre-injury medication who were admitted after a trauma. Patients on APAC pre-injury were compared to a control group of non-users for mortality, bleeding-related morbidity, gender, age, ISS and Glasgow Coma scale (GCS). Mann-Withney U tests and Chi-squared tests were used for statistical analysis.

RESULTS: Eighty-six patients were included with 22 (28%) patients taking aspirin, clopidogrel, warfarin or a combination of the three prior to trauma. Except for age (p < 0.001, mean age 76 years APAC vs. 59 years control), no significant differences in ISS or GCS were found between APAC and control group. Mortality was higher in the APAC group (p= 0.066, 25% APAC vs. 10% control). No difference in bleeding-related morbidity was observed between both groups. Irrespective of APAC use, no significant difference in age was reported between deceased patients and survivors.

CONCLUSION: An age-independent trend towards higher mortality was seen in patients with pre-injury APAC, but no difference in bleeding-related morbidity. Further research regarding pre-injury APAC in polytrauma patients is required as this might be a modifiable factor in the outcome of polytrauma.

ABSTRACT. OBJECTIVE: To access the long-term incidence and predictive factors of recurrence after laparoscopic ventral hernia repair with bridging technique.

METHODS: The study group consisted of 213 consecutive patients operated by laparoscopy for primary ventral (n=158) or incisional hernia (n=55) between 2001 and 2014. Patients had a repair without fascia closure by intraperitoneal onlay placement of a Parietex® composite mesh centred on the defect with an overlapping of at least 3 cm. Clinical outcome was assessed by a combination of case notes review, office consultation and telephone interview. Assessment of predictive factors of recurrence was the major outcome of the study.

RESULTS: There were 144 men and 69 women with a mean age of 55±12 years and a BMI of 32±6. All the operations were completed successfully by laparoscopy. With a mean follow-up of 63±47 months, recurrent hernia was noted in 16 patients (7,5%). Univariate analysis showed a statistically significant higher recurrence rate in the following conditions: incisional hernia (15%), BMI ≥35 (21%), defect width >4 cm (27%), defect surface >20 cm2 (28%), mesh overlapping < 5cm (32%) and ratio between mesh and defect surfaces (M/D ratio) ≤13 (45%). Multivariate logistic analysis revealed that M/D ratio was the only independent predictive factor of recurrence (OR: 0,46, 95% CI: 0,27-0,76, p<0.003). With a M/D ratio ≤8, between 9-13, between 14-19 and ≥20, the recurrence rate was respectively 80%, 29%, 6% and 0% (p<0,001).

CONCLUSIONS: In laparoscopic repair of ventral hernia with bridging technique, the M/D ratio is the most important predictive factor of recurrence. If a mesh big enough to get a M/D ratio > 13 cannot be positioned, other surgical option than laparoscopic bridging technique should be proposed to the patient.

ABSTRACT. INTRODUCTION: Intestinal (ITx), Combined Liver-Intestine (CLITx) and Multivisceral transplantation (MVTx) are associated with specific surgical difficulties: 1) Abdominal closure in patients with reduced abdominal domain; 2) Increased surgical complexity in CLITx if the pancreas is to be removed from the liver-bowel bloc; 3) Drainage of the native portal vein in CLITx recipients; 4) Bleeding during abdominal exenteration in MVTx recipients. OBJECTIVE: To propose innovative solutions to these surgical difficulties. METHODS: Analysis of ITx database, demographics and type of surgery. RESULTS: From 1999 to 2015, 16 patients received an intestinal graft. The follow-up period was 12-161 months. Primary closure was possible in all but one recipient by using smaller donors (13/16) or self-inflatable tissue expanders preoperatively (2/16). A pediatric recipient, who could not be closed primarily, experienced major morbidity, requiring repeated surgeries, VAC therapy and skin grafting. In 3/6 CLITx, the pancreatic head was left with the liver-bowel bloc to avoid lengthy donor pancreatectomy and the risk of vascular torsion. However, this led to pancreatitis in 1. To avoid this problem, full pancreas was included in the next 3 CLITx recipients without complications. In CLITx recipients, the native portal vein was anastomosed to the donor portal vein in 2/6 and to the donor inferior vena cava in 4/6. Two of the latter patients developed stenosis of this anastomosis. They were treated successfully by stenting. Major bleeding reported in MVTx was prevented in all 3 cases by preoperative complete embolization of the visceral arteries. CONCLUSION: Specific surgical issues/complications in ITx can be prevented or solved by appropriate strategies: 1) Use of smaller donors and self-inflatable prosthesis; 2) In CLITx, the inclusion of the full pancreas; and 3) Stenting of the portocaval anastomosis in case of stenosis; 4) In MVTx, embolization of visceral arteries prior to surgery. These strategies eliminated technically related mortality in this series.

ABSTRACT. OBJECTIVE: The majority of patients with resectable esophageal cancer (rEC) nowadays undergo neoadjuvant therapy (NT) followed by surgery. However not all patients who start NT will undergo surgery, but little is known about these patients since they are excluded from most studies. The aim of this study was to evaluate this specific patient group. METHODS: Between 2002 and 2014, 623 consecutive patients with locally advanced rEC were scheduled for NT in our hospital or a referring centre, due to be followed by esophageal resection in our department. In 110 (17.7%) patients, esophagectomy was not performed after start of NT. In this patient group, besides tumour characteristics, reason for cancelled surgery, location of tumor board discussion, pre-treatment functional evaluation, NT regimen and clinical complete response (cCR) on NT were retrospectively gathered. Overall survival was calculated by means of Kaplan-Meier curves. Multivariate analysis was performed by Cox regression analysis. RESULTS: Most important reasons for cancelled surgery were disease progression (38.2%), poor general condition (20.0%), irresectability (17.3%), patients own decision (17.3%) and death during treatment (4.5%). Only patients who refused surgery had a significant survival benefit (p<0.0001) in this group. Location of tumor board discussion (p=0.258), pretreatment functional assessment (p=0.805) and NT regimen (p=0.624) did not significantly influence survival. Multivariate analysis showed that adenocarcinoma (p=0.005, HR=0.43, CI=0.24-0.78), cT2 (p=0.008, HR=0.24, CI=0.08-0.68), completion of NT (p<0.0001, HR=0.32, CI=0.18-0.58) and cCR (p<0.0001, HR=0.14, CI=0.06-0.33) were positive predictors of survival. CONCLUSIONS: 17,4% of patients scheduled for NT followed by esophageal resection for rEC did not undergo the planned esophagectomy. Fifty-six percent of them because of oncological reasons. Adenocarcinoma, cT2, completed NT and cCR were positive predictors for survival without planned surgical treatment.

ABSTRACT. Objectives: To compare structural changes, host inflammatory responses, and local tissue reactions to decellularized porcine small intestinal submucosal extracellular matrix (CorMatrix; CorMatrix Cardiovascular, Roswell, GA) and three other commercially available tissue substitutes (porcine pericardium (Vascutek; Scotland, UK); bovine pericardium (SJM; St Paul, MN); and GoreTex (W.L. Gore & Associates, Inc., Flagstaff, AZ)) in pigs over one year. Material and methods: Four miniature pigs were studied, each representing a time point (1, 3, 6, and 12 months). Materials were implanted subcutaneously, and tissue explants processed for histology and immunohistochemistry. Histopathological parameters were graded semi-quantitatively (1+ = mild; 2+ = moderate; 3+ = severe). Results: At 1 and 3 months, CorMatrix was minimally and moderately degraded, respectively, and surrounded by dense fibrous tissue (2+) and severe inflammation (3+). By six months, CorMatrix was almost completely degraded and severely fibrosed (3+) with moderate perivascular inflammation (2+). By one year, CorMatrix was fully degraded and replaced with fibrosis (1+) and subcutaneous tissues. At 1 month, Vascutek graft were intact and surrounded by moderate fibrosis (2+) and a severe inflammatory reaction (3+). By three months, there was less, mainly perivascular inflammation (2+) and fibrosis had increased (3+) to encapsulate the patch. The patch remained intact at 6 and 12 months but with reduced fibrosis (1+) and mild chronic inflammation (1+). SJM explants were similar to Vascutek but with significantly less encapsulating fibrosis (1+) and inflammation at three months, which remained stable at 6 and 12 months. GoreTex grafts were visible as exogenous material in a fibrotic capsule (2+), which reduced after one month, and moderate, foreign body-type inflammation (2+).

Conclusions: The patches were biotolerated by both animal models. CorMatrix was completely resorbed and showed signs of early and consistent degradation. Local tissue reaction to CorMatrix doesn’t show encapsulation, which can promote regeneration and matrix remodeling.

ABSTRACT. OBJECTIVE Combined liver/lung transplantation(cLiLuTx) is a complex procedure for end-stage/advanced liver/lung disease. In accordance to the tolerable cold ischemic period -shorter for lungs than for liver- all cLiLuTx reported were performed in the same sequence: lung prior to liver. We introduce the liver-first principle, a concept not earlier described.

METHODS cLiLuTx in our center (01/2000-02/2016) were reviewed for demographics, indications, ischemic/ex-vivo time, rejection, patient survival. We discuss the surgical sequence and its (dis-)advantages. Results are reported as median(range).

RESULTS Ten patients underwent cLiLuTx. Recipient age was 31years(17y-63y). Indications were cirrhosis/cystic fibrosis(n=5), cirrhosis/pulmonary fibrosis(n=2), epithelioid hemangio-endothelioma/lung metastasis(n=2), and acute liver failure/end-stage COPD(n=1). One liver graft developed acute rejection and hepatic artery thrombosis, followed by re-transplant. Three lung grafts developed late/mild acute rejection, 1 chronic rejection followed by re-transplant. Follow-up was 2years(3mo-15y), all are alive.

DISCUSSION Lungs were transplanted first in seven. In the case of acute liver failure, the liver was transplanted first to correct the coagulation(INR>10) and render LuTx safer. Due to longer preservation time, lungs were normothermically perfused (OCS™/Transmedics/Andover/USA). Following this success, we performed two other liver-first cases. Hypothetical incentives are: (i) liver reperfusion-injury hits the native lungs instead of the new lungs, reducing lung oedema; (ii) coagulation restoration might reduce the need for transfusion during LuTx, thereby preventing oedema of the new lungs; and (iii) shorter liver ischemia time, decreases biliary strictures rate. However, in retrospect, it might have been preferable to transplant the lung first in our third liver-first case (cystic fibrosis) due to limited oxygen delivery during LiTx (pO2:23mmHg/pCO2:59mmHg/Lactate:6.1mmol/L). The benefit of liver-first should always be outweighed against the medical need to transplant the sickest-organ (eg.lung) first in order to maintain cellular oxygen delivery.

CONCLUSION cLiLuTx is feasible with excellent outcome. Although hypothetical benefits are linked to the liver-first principle, the sickest-organ-first principle should be followed for pre-transplant/anticipated lung failure.

ABSTRACT. OBJECTIVE Since the last quarter of 2012, major efforts were made to reduce central line associated bloodstream infections inserted for thoracic surgery. Care-bundles were introduced, including evaluation of the need of the catheter and hand hygiene practices, and the introduction of new wound dressing. Despite this multifactorial approach, an increased number of catheter infections was shown during the third quarter of 2015. Therefore, Arrow Guard Blue Plus deep venous central catheters coated in chlorhexidine (n=78) were introduced between October 2015 and March 2016 in a subpopulation of thoracic surgical patients. Colonization of the catheters at removal and signs of infections were compared to the non-coated central catheters (n=61). METHODS Chlorhexidine-coated catheters were used in 46% of the preconceived indication of esophagectomy, 54% in other surgical interventions. Type of catheter, anatomic place of insertion, parenteral feeding (Y/N), number of days in situ, cultures of the catheter tip, and reason for removal were registered. RESULTS Central catheters were placed in the jugular vein (n=113), subclavian vein (n=23) or a peripheral vein (n=2). Parenteral feeding was given via coated catheters in 62% and via non-coated catheters in 31%. Mean days in situ were comparable (p=0.27) between coated (8.09 days) and non-coated (7.72 days) groups. Only one catheter tip (1.28%) was positive in the coated group, while 10 (16.39%) were in the non-coated group. A coated catheter was removed in 1 patient (1.28%) because of fever. In the non-coated group, 8 (13.1%) were removed because of the clinical suspicion of a catheter-associated infection. CONCLUSIONS Chlorhexidine-coated catheters produced less positive catheter tips compared to non-coated catheters although parenteral feeding was administered more via coated catheters. Days in situ were comparable in both groups. Non-coated catheters were more often removed for clinical signs of catheter infection.

ABSTRACT. Objective: Mediastinitis is a devastating surgical site infection (SSI) after CABG. The incidence ranges from 1.3 to 4.7% in patients with bilateral internal mammary arteries (BIMA) and the risk increases > 10% in diabetic patients. Daily practice in our center presumes harvesting BIMA for every patient. The aim is to present our results to prevent superficial and deep SSIs.

Methods: 90 consecutive patients that underwent off pump coronary artery bypass grafting (OPCAB) using BIMA between June 2015 and February 2016 were included in the study. The Fowler model was used to identify the high risk patients for SSI. Three steps were designed for sternal wound closure. First step includes sternal closure. Second step refers to presternal subcutaneous tissue closure. Third step refers to skin closure with either 2-octylcyanoacrylate or negative wound pressure therapy.

Results: Mean age was 71.33+/-10.12 years. Mean risk for major infection was 3.25 % +/- 2.72. There were no cases of deep SSIs and 2 cases of superficial SSIs. 33.34% (n=30) patients had diabetes, 33.34%(n=30) patients had a BMI over 30 and 16.67% (n=15) patients had both diabetes and obesity. Maximum probability for SSI using Fowler score was 17% (a obese and diabetic patient that associated other 3 risk factors). More than half of the patients (n=56) were over 70 years. Other factors for SSI were renal failure in 13.34% (n=12) patients, heart failure in 11.12% (n=10) patients, peripheral arterial disease in 14.45% (n=13) patients, previous myocardial infarction in 26.67% (n=24) patients and COPD in 8.9% (n=8) patients.

Conclusions: We used this strategy in all our patients including those with diabetes, obesity or both. We managed to have no deep SSIs and only 2 superficial SSI by following the steps designed for sternal wound closure. This concept can be easily applied in any cardiac surgery service in order to prevent SSIs.

ABSTRACT. OBJECTIVE Double-lung transplantation (DLTx) using the sequential-single lung technique and double-lumen endotracheal tube allows bilateral-lung implantation without extracorporeal life-support (ECLS), thereby avoiding ECLS-related complications. Since 2005, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has replaced cardiopulmonary bypass (CPB) in our center for DLTx-recipients needing ECLS. The aim of this single-centre retrospective study was to: 1/ analyze recipients needing intra-operative VA-ECMO; 2/ compare outcome with NON-ECMO patients; 3/ describe the timing of intra-operative VA-ECMO placement.

METHODS From 01/2005-01/2015, 498 DLTx were performed. Patients transplanted on veno-venous ECMO or CPB and combined-organ or lobar recipients were excluded. Recipients (n=453) were divided into VA-ECMO and NON-ECMO groups. Indication for DLTx, demographics, complications, ICU/hospital stay and 5-year patient survival were compared between both groups. ECLS indication and technique were analysed in the VA-ECMO-group.

RESULTS There were 94 (21%) VA-ECMO versus 259 (79%) non-ECMO patients. Differences between both groups are shown in Table. VA-ECMO was mostly needed for fibrosis and pulmonary arterial hypertension. VA-ECMO-group had more postoperative complications with a higher tracheostomy and hemothorax re-intervention rate, resulting in longer ICU/hospital stay compared to non-ECMO group. Overall 5-year survival was 78% (VA-ECMO) versus 85% (NON-ECMO); p<0.01 [Figure]. Timing for VA-ECMO-support was categorized into three groups: A/ pre-emptive, at start of DLTx (n=37: 41% fibrosis; 38% pulmonary arterial hypertension); B/ during first-lung implantation (n=28: 40% fibrosis; 29% emphysema); C/ during second-lung implantation (n=29: 41% emphysema; 31% fibrosis). Central cannulation was performed in 80%. Among the three groups, intra-operative VA-ECMO-time was 279min(187-631min)/215min(157-494min)/150min(75-340min) with similar 5-year patient survival.

CONCLUSIONS VA-ECMO support was needed in 21% of DLTx recipients. Pulmonary fibrosis/arterial hypertension patients were more at risk for VA-ECMO-support. Long-term survival in ECMO patients was inferior to NON-ECMO. This may be related to their worse general condition and complicated post-operative period. Timing of VA-ECMO-placement was correlated with DLTx indication and did not influence survival.

ABSTRACT. Objective: The use of wound drains after mastectomy or axillary lymph node dissection is common practice in breast cancer surgery (BCS). However, the optimal time to remove drains is not clearly established. Relatively little research has been conducted to assess the impact of their usage on patient comfort. Thence, the purpose of this study is to investigate the effect of early removal of drains on clinical outcome and quality of life (QoL) in breast cancer patients.

Methods: Prospective randomized study with 106 patients included, preliminary data of 64 patients are available at present. Patients scheduled for BCS with placement of suction drainage were randomized into 2 groups: GROUP 1: drains removed output-based i.e., less than 30 ml/24h and GROUP 2: drains removed at hospital discharge i.e., usually 4 days after surgery. Each group includes 32 patients. A questionnaire on QoL was completed pre- and postoperatively.

Results: Early removal is associated with less impact on mobility (75% versus 34%, p=0.0023) and social life (63% versus 19%, p=0.0008), reflecting better QoL in group 2. Additionally, total duration of home care nursing was significantly lower in group 2 (17 versus 1, p<0.0001). No differences are seen in wound healing or rate of wound infections; the latter being slightly lower in group 2 (13% versus 6%, p=0.67). Total volumes of fluid drained and/or aspirated are lower in group 2 (1749 ml versus 977 ml on average, p=0.0067), but more seroma aspirations were needed in group 2 (1 versus 3, p=0.0004). However, 91% of the group 2 patients prefers to go home again without drains.

Conclusions: Early removal of wound drains is clinically feasible and improves QoL after breast cancer surgery. In addition further analysis of all included patients in the next months will also give a better view on predicting factors of seroma formation.

ABSTRACT. Objective The incidence of vascular synthetic graft infection varies from 1 to 6% and remains a serious complication, with high mortality rates. Radical excision of the infected graft is theoretically mandatory, with revascularisation in a contaminated field. We reviewed our experience at an academic hospital over the past 15 years, especially focusing on the performances of the arterial homograft.

Methods We retrospectively identified all patients treated for a prosthetic graft infection in our department form 2000 to 2015. All the data regarding the prime operation type, the duration between the initial surgery and infection signs, the site of infection, the surgical treatment modalities and long- and short-term results were evaluated.

Results Sixty-four vascular graft infections in 59 patients were identified. It represents 3% of all vascular bypass surgery in our department. Thirty percent had initially an aortic bypass. The mean time between the initial surgery and the infection was 27 months, 33% were early (within the 3 months) and 67% were late infections. Complete excision of the graft was accomplished in 83% of the cases. Thirty-seven homografts were implanted. The overall survival was 70% at 5 year. The freedom of reinfection was 88%. Arterial homografts used as conduct for reconstruction had better results with a survival rate of 84% and a freedom of reinfection of 100% at 5 years.

Conclusions Synthetic graft infection is still a major complication after vascular bypass surgery, with mortality rates of up to 30%. The main factors that influence the mortality are hemodynamic instability, patient BMI, intra abdominal infection site and type of graft substitution. Homograft reconstruction is a safe option with outstanding short-and long-term results for in situs vascular reconstruction in infected regions.

ABSTRACT. OBJECTIVE Pectus carinatum is the second most abundant chest-wall deformity, predominantly affecting males. It often occurs during the vulnerable, pubertal life stage and can cause great physical, emotional and social changes. One efficient treatment for pectus carinatum is the Ravitch procedure. The purpose of our single-center retrospective study was to investigate experience with Ravitch procedure in a tertiary medical center and to determine the cost/benefit for patients undergoing the procedure.

METHODS We searched our database for patients who underwent a Ravitch procedure over the course of 21 years (1993 until 2014). A total of 273 patients underwent the intervention: 144 (52%) procedures were performed for pectus excavatum, 6 (2%) for pectus arcuatum and 123 (45%) patients for pectus carinatum. The latter group was selected as our target population. We examined indications for surgery, most common comorbidities as well as postoperative complications, as defined by the Clavien-Dindo scoring system.

RESULTS Our population was divided in 109 males (88.62%) and 14 females (11.38%) with a median age of 15 years (IQR=2) at the time of surgery. 91% of carinatum patients underwent the Ravitch procedure for a perceived negative impact on self-esteem. Pectus carinatum coincided most frequently with scoliosis (n=5), Poland syndrome (n=1) and previous heart and/or lung surgery (n=6). The mean length of hospital stay was 7.4 days. 46 complications were found in 38 patients. Early complications included pneumothorax, pleural effusion, pneumonia, bleeding, wound infections, cardiac arrhythmia and minor complications due to the patient-controlled epidural analgesia. Keloid formation was the most common long-term complication (n=27), of which one third of the affected patients received surgical correction of the scar. Only one recurrence was detected which however did not warrant a new correction.

CONCLUSION Despite its invasive character, the Ravitch procedure is a safe operation for pectus carinatum with good results in experienced hands.

ABSTRACT. OBJECTIVE: Minimal invasive techniques as alternative to open exploratory cervicotomy have been developed for primary hyperparathyroidism. We aimed to compare feasibility and outcomes of lateral cervical robot assisted parathyroidectomy and endoscopic parathyroidectomy.

METHODS: Prospectively collected data of all performed parathyroidectomies at a single centre (January 2009 to December 2016) were retrospectively analysed. Pre-operative examination included blood analyses (Ca, PTH), vocal cord assessment, ultrasonography and SPECT-CT. Only posterior localized unilateral adenomas, confirmed by concordant results on ultrasonography and SPECT-CT, were considered for robot assisted parathyroidectomy through modified Henry technique with Da Vinci robot. PTH was monitored according to the National Academy of Clinical Biochemistry guidelines and additional sampling was performed post-operatively after 4h and 24h.

RESULTS: In total, robot assisted parathyroidectomy was performed in 23 and endoscopic parathyroidectomy in 30 patients for pathologically confirmed adenoma. Median [IQR] operating time was 68 min [53-94] for robot assisted and 50 min [40-78] for endoscopic parathyroidectomy (p=.17). PTH was normalized median 5 min after resection in both groups. No cases of hypocalcaemia were seen. Permanent recurrent nerve paralysis occurred once after robot assisted and endoscopic parathyroidectomy each (4.4% vs 3.3%; p= .85) and relapse once after robot assisted parathyroidectomy. Conversion to open surgery was performed in 9 robot assisted procedures [bleeding (n=2), difficult dissection (n=5) and intrathyroidal adenoma (n=2)] and 6 endoscopic procedures [intrathyroidal adenoma (n=1), difficult dissection (n=4) and large adenoma (n=1)] with similar rates for both techniques (39% vs. 23%; p= .13). Median [IQR] hospital stay was 1 day [1-1] for robot assisted and 1 day [1-1] for endoscopic parathyroidectomy (p=.99)

CONCLUSION: Robot assisted parathyroidectomy for primary hyperparathyroidism seems feasible with similar outcomes and conversion rates compared to endoscopic parathyroidectomy. Even though the robot assisted parathyroidectomy is a technical more demanding procedure, there is no significant difference in operating time nor in conversion rate.

ABSTRACT. Objectives: Combined modality treatment for MPM patients (pts) remains a matter of debate, especially regarding the choice of surgery between extrapleural pneumonectomy (EPP) or pleural decortication (P/D). Methods: Our combined modality treatment (CMT) protocol consisted of induction chemotherapy (IC), followed by EPP and thoracic radiotherapy (RT). Candidates were discussed at the weekly multidisciplinary round. Survival was calculated from histological confirmation of MPM and analysed by Kaplan-Meier. Results: From March 2003 till December 2014, in total 197 MPM pts were discussed of which 97 pts started CMT. After IC, 18 pts were deemed irresectable and 3 pts refused surgery. Seventy-six pts underwent surgery: 56 pts EPP and 20 pts exploratory thoracotomy. Postoperative mortality was 3.6% (2/56 pts). After EPP, 5 pts were not referred for RT and 2 pts didn’t complete radiotherapy. Finally, 52 pts received CMT, 47 pts trimodality and 5 pts IC+EPP, with a median survival of 33.1 months. Intent-to-treat overall 5-year survival (n=97), overall and disease-free 5-year survival in MPM pts who fully completed CMT (n=52) were: 12,8%, 22.1% and 15.3% respectively. Cox proportional hazards model showed a significantly lower DFS in non-epithelial MPM pts (HR=4.24, 95%CI=1.81-9.98; p=0.001) and in node positive patients (pN1 pts: HR=4.55, 95%CI=1.09-19.00; p=0.038 and pN2 pts: HR=2.57, 95%CI=1.06-6.23; p=0.036). None of the other examined covariates (laterality, pT nor R-status) reached significance. Conclusion: This study demonstrated that CMT with EPP for MPM pts is feasible and safe, with an acceptable surgical mortality rate, in a tertiary referral centre setting. Careful patient selection (staging and physical performance) is of highest importance, given that only half of all ‘eligible’ pts will finish CMT. Recurrence of MPM is mostly observed in pts with non-epithelial MPM subtype and with nodal disease. Median disease-free survival for epithelial MPM pts who complete CMT looks promising, although unfortunately not yet validated in proper randomised-controlled trials.

ABSTRACT. Objective: This case report describes the use of a hepatic transplantation technique in the field of the nephrectomy.

Methods: We report the case of a 56 years old male patient who was diagnosed to have a renal cell cancer with venous thrombus extending into the right atrium. After early vascular control of the renal artery, achieved by creating a posterior plane of dissection of the right kidney, the liver was mobilized in a ‘‘piggy-back’’ fashion. Such approach, which is routinely performed in liver transplantation, allows complete exposure of the retro-and supra-hepatic vena cava. Next all three hepatic veins were isolated followed by freeing the vena cava from the central tendon of the diaphragm as done in a domino liver transplantation. After clamping of the vena cava beneath the level of the renal veins, the left renal vein, the hepatoduodenal ligament (Pringle manoeuver) and the three hepatic veins, the right kidney was removed ‘en bloc’ with the complete thrombus freed under direct vision from the vena cava wall. This manoeuver was done under trans-esophageal endoscopic guidance and gentle traction on the right atrium.

Results: No extracorporeal bypass was used. The vena cava was next closed wit a simple veinoraphy. No blood transfusion was needed and the patient could be discharged at day 8. Pathology showed a clear cell renal carcinoma pT3c and a 16cm intact tumor thrombus.

Conclusions: Renal cell carcinoma with extended tumor thrombus of the inferior vena cava represents a surgical challenge which can be overcome by the use of surgical techniques derived from liver transplantation surgery. Most of these tumors can be removed via a transabdominal approach without the need for veno-venous or cardiopulmonary bypass.