ABSTRACT. Objective: End-stage renal disease (ESRD) and renal replacement therapy (RRT) are known risk factors for post-operative morbidity and mortality. However, there are few series on colorectal surgery in those patients. We decided to evaluate the morbidity and mortality of patient with ESRD receiving RRT requiring colorectal resection surgery. Methods: All patients receiving chronic RRT having colorectal resection between 2006 and 2019 were identified. Standardized retrospective chart review was performed. Data regarding surgical indication, surgical procedure, utilization of stoma, morbidity and mortality were recorded. Results: A total of 42 patients in ESRD under RRT underwent colorectal resection. Twenty-seven procedures were emergent procedure while 15 procedures were elective. Most frequent surgical indication was acute colonic ischemia for emergent procedure and colonic malignancy for the elective ones. Twenty-three anastomosis were performed without diverting stoma. Nineteen patients had a stoma creation without anastomosis. Three anastomotic leaks were reported (13%). Overall 30-days mortality rate was 23,8% (10/42), 8 in emergent (8/27) and 2 in elective procedure (2/15). Overall complication rate was 50% with severe post-operative morbidity occurring in 21% (Dindo-Clavien 3-4). Six reinterventions were needed: 3 for bleeding and 3 for anastomotic leak. Median post-operative length of stay was 14,5 days. Conclusions: Colorectal surgery in ESRD patient carries a high morbidity and mortality risk even in the elective setting. History of cardiac event, diabete metillus and acute colonic ischemia are risk factors of mortality. Primary anastomosis is associated with a 13% rate of leak in our serie. Careful patient and surgical condition selection is advised before offering elective colorectal resection in patient with RRT.

ABSTRACT. OBJECTIVE Mesenteric panniculitis (MP) is a rare, benign and chronic fibrosing inflammatory disease that affects adipose tissue of the mesentery of the small intestine and colon. Specific etiology of the disease is unknown. Diagnosis is suggested by imaging and is confirmed by surgical biopsies. Treatment is empirical and based on few selected drugs. Surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited. We report a rare case of MP recurrence occurring only 2 weeks post bariatric surgery. METHODS A female, 43y, undergoes bariatric surgery. In her history she reports small bowel resection due to (pseudo)tumour and microscopy showed MP. During laparoscopic gastric bypass adhesiolysis was needed around the old enteroenterostomy (located on the alimentary limb). Two weeks after surgery she presents with symptoms of nausea and vomiting. Rx transit showed stopsign on alimentary limb. Exploratory surgery was performed with resection of inflammatory pack of small bowels surrounding old enteroenterostomy of first surgery. Microscopy showed MP. She recovered well and was discharged, only to be readmitted with the same symptoms 1 week later. Rx transit showed a stopsign again. RESULTS Review of literature showed possible connection with malignancy, but chances were slim in this case regarding the fact that the first time was 15years ago and no malignancy found since. Infectious causes (e.g. TBC) were ruled out. Corticoids were given, first intravenously because per oral intake was nihil. After one week of corticoid therapy imaging showed passage throughout distally without obstruction. Per oral intake was restarted. Patient was discharged with corticoid therapy and dosage was slowly reduced with success. CONCLUSION Surgery is not always the answer. MP is a rare condition and it needs further research to establish a golden standard. It is best to patienttailor the treatment and minimize surgical trauma. In this case corticoid therapy was successful.

ABSTRACT. OBJECTIVE Little is known about the prevalence of endocrine and exocrine pancreatic insufficiency after pancreaticoduodenectomy (PD). The aim of this retrospective single-center cohort study is to analyze its prevalence and determine its predictors.

METHODS Between 2000 and 2018, PD was performed for pancreatic or peri-ampullary neoplasms in 1075 consecutive patients (F/M ratio 469/606; median (range) age 66 (58-73) years). Exocrine pancreatic insufficiency (EPI) was defined as the need for pancreatic enzyme replacement. Endocrine pancreatic insufficiency (EndoPI) was defined as de-novo diabetes mellitus or the need for insulin therapy in preexisting non-insulin dependent diabetes mellitus (NIDDM). The impact of 12 potential variables on postoperative pancreatic function was evaluated using univariate and multivariate Cox regression models.

RESULTS EPI was observed in 17 (1.6%) patients before and in 396 (37%) after PD. Independent predictors for postoperative EPI were BMI (OR 0.078 (CI 0.024-0.246); p<0,001), primary pancreatic tumor (versus primary ampullary (OR 1.967 (CI 1.313-2.948); p=0.001), versus biliary primary (OR 2.311 (CI 1.380-3.869); p=0.001)), occurrence of severe postoperative complications (TOSGS>3) (OR 1.816 (CI 1.215-2.715); p=0.004), and pancreaticogastrostomy versus pancreaticojejunostomy reconstruction (OR 1.474 (CI 1.115-1.948); p=0.006). NIDDM was present in 124 (11.5%) patients before and in 148 (13.8%) after PD. IDDM was present in 65 (6%) patients before and in 126 (12%) after PD. Postoperative EndoPI was observed in 123 (11.4%) patients. Age (OR 0.137 (CI 0.028-0.663); p=0.014), occurrence of postoperative complications (OR 2.016 (CI 1.024-3.968); p=0.042), and male gender (OR 1.972 (CI 1.024-3.798); p=0.042) were associated with an increased risk for postoperative EndoPI.

CONCLUSION EPI after PD occurs in more than a third of patients and is far more common than EndoPI. The medico-surgical team should be aware of the significantly impaired pancreatic function after PD, and keep a low threshold for early diagnosis and treatment in order to prevent patient malnutrition and improve quality of life.

ABSTRACT. Objective: Major hepatectomy (resection of 3 or more liver segments) is known to be associated with considerable morbidity. The aim of this retrospective single-center cohort study was to determine risk factors for severe complications (Clavien-Dindo TOSGS grade  3) after major hepatectomy for primary and metastatic neoplasms.

Methods: Between 2010 and 2018, major hepatectomy for primary (n = 190, 32%) and metastatic (n = 395, 68%) tumors was performed in 585 consecutive patients (M/F 324/261; median (range) age 61 (0-84) years). Patients who underwent surgery for perihilar cholangiocarcinoma were excluded from this study. Cirrhosis was present in 3 patients. Laparoscopic resection was performed in 250 (43%) and open in 335 (57%) patients. Intra-operative blood transfusion was given in 162 (28%) patients. Seven potential risk factors for the occurrence of postoperative severe complications were evaluated using univariate and multivariate cox regression models.

Results: Severe complications were observed in 71 (12%) patients (11 laparoscopy; 60 open), including 48 (8%) deaths and 71 (12%) patients admitted at the intensive care unit. Independent risk factors for severe complications were the need for intra-operative blood transfusion (OR 3.63, CI 2.05-6.42; p<0.001), open surgery (OR 3.30, CI 1.61-6.77; p = 0.001), and primary liver tumors (OR 2.15, CI 1.23-3.75; p = 0.007).

Conclusion: Intra-operative blood transfusion, open liver surgery, and primary liver tumor as indication are the most prominent predictors for severe postoperative complications after major hepatectomy, and reflect the complexity of the surgical procedure that is preferably performed via standard open surgery.

ABSTRACT. Objective: Laparoscopic liver surgery is considered a safe and feasible procedure for minor hepatectomies. The aim of this monocentric retrospective cohort study was to analyze the predictors of severe complications after laparoscopic and open minor hepatectomies to treat benign and malignant liver lesions.

Methods: 815 minor hepatectomies (< 2 segments) were performed between 2010-2018 (F/M ratio 377/438; median (range) age 64 (13-91) years) for malignant 98,8% (n=805) (primary and metastatic) or benign (1,2%, n=10) liver tumors. 533 procedures (65%) were performed by laparoscopy. 352 patients (43%) received local ablative therapy with or without concomitant liver resection. Severe complications were defined as complications needing any type of interventional therapy (Clavien-Dindo grade >3). Potential predictors of severe complications after minor hepatectomy were evaluated using univariable and multivariable logistic regression models.

Results: Severe postoperative complications were observed in 37 patients (4.5%), 12 in the LLS group (1.5%) and 25 in the open group (3%). Postoperative mortality rate was 0.4% (n=4). The only independent risk factor that could be identified for the development of severe postoperative complications was the need for intraoperative blood transfusion (OR 3,201, CI 1,512-6,777, p=0,002).

Conclusions: Laparoscopic surgery for minor hepatectomies is associated with less severe postoperative complications. The need for intra-operative blood transfusion reflects a more complex procedure and thus carries a higher risk for severe complications.

ABSTRACT. OBJECTIVES

We present a case of diaphragmatic hernia, occurring after coronary bypass with the right gastroepiploic artery. It contained stomach and part of the liver and was treated by laparoscopy. Review of the literature on this rare affection is proposed.

METHODS

The patient was referred by a gastroenterologist for a prophylactic cholecystectomy after a putative gallstone migration, due to the impossibility of endoscopic access to the duodenum. He had been operated 13 years earlier for coronary bypass and right gastroepiploic graft had been performed. He suffered for years from postprandial abdominal discomfort and pyrosis along with breathlessness and surgical workup had revealed the diaphragmatic hernia two years ago, but surgical repair had not been advised. Recently the patient complained of worsening respiratory symptoms. Physical examination showed subxiphoid incisional hernia. We convinced the patient to undergo a laparoscopic diaphragmatic repair associated with cholecystectomy and incisional hernia repair.

RESULTS

At intervention, gastric antrum, first duodenum and middle part of the liver left lobe were found herniated in the pericardium along the right gastroepiploic vessels. They could be easily reduced while preserving the vascular pedicle which had been mobilized anterior to the stomach during the coronary bypass. Diaphragm was sutured with non-absorbable barbed thread overlock, as was the incisional hernia, maintaining the passage for the right gastroepiploic vessels. Liver left lobe was glued to the diaphragm to reinforce the repair. Postoperative course was uneventful, and the patient went home on day two. One month later, he is free of digestive or respiratory complaint and says he's “10 years younger”.

CONCLUSIONS

Review of the literature allowed us to retrieve only 20 cases of diaphragmatic hernia after coronary bypass with the right gastroepiploic artery, most of them from Belgium or Japan. We report the second case of laparoscopic treatment of this condition and emphasize the need for surgery.

ABSTRACT. BACKGROUND Patients with heterotaxy syndrome (HS) can present with an associated complete dorsal pancreas agenesis (DPA). They are considered to be at increased risk for the development of diabetes due to a reduced functional beta cell mass (FBM) as well as for chronic pancreatitis leading to untreatable pain. CASE DESCRIPTION We report the case of a patient that developed chronic pancreatitis due to HS and associated DPA. She presented to our center with severe abdominal pain refractory to non-surgical treatment. Unlike in previous reported cases, this patient had a high FBM (i.e. 150% of normoglycemic controls) determined by a hyperglycemic clamp. She was treated with total pancreatectomy followed by islet auto transplantation, leading to an adequate postoperative FBM (72% of normoglycemic controls) with preserved glycaemic control without need for exogenous insulin. After surgery, the pain disappeared, eliminating the need for opioid and other analgetics. CONCLUSIONS This case report shows that selected patients with HS and complete DPA can be considered for total pancreatectomy followed by islet autotransplantation in the presence of a sufficient FBM before surgery.

ABSTRACT. Introduction Postoperative pulmonary complications (PPC) after aortic valve replacement (AVR) carry a high mortality and morbidity and should be prevented by avoiding modifiable predictors. Identification of its modifiable predictors could improve referral policy and hence postoperative results. Methods Retrospective analysis of 2,500 consecutive patients who underwent AVR with a biological valve in aortic position in a general hospital, from 01/01/1987 to 06/07/2017. Patients with a mitral valve or mechanical valve in any position were excluded. Other procedures such as CABG, mitral and tricuspid valve repair, if performed, were included. PPC was defined as atelectasis or pneumonia on clinical or radiological grounds. Preoperative parameters under investigation include era (before or after 2008, the year when trans-catheter valve was introduced), gender, age, any cardiovascular condition, chronic pulmonary and kidney disease, diabetes, prior and current malignancy as well as operative data (cross-clamp time, bypass time, other cardiac procedures). Statistical analysis included chi-square analysis for categorical variables and Student-t test for continuous variables (presented as mean +/- SD). To identify independent predictors, significant categorical variables were entered in a logistic regression analysis. Results There were 330 patients with PPC with 76 fatalities. However, in only one fatality, PPC was the sole complication. Operative and preoperative predictors are shown in the table. Pulmonary artery hypertension (p=0.001) and smoking (p=0.027) were only significant in a univariate analysis. PPC was associated with increased use of blood products, increased length of stay in the ICU, delirium, renal and cardiovascular complications (p<0.001 for all items). Conclusion The most important predictor for postoperative pulmonary complication is preoperative heart failure. This predictor seems modifiable through earlier referral for AVR. Preoperative physiotherapy might improve FEV while renal function might be protected by hydration.

ABSTRACT. We present a rare case of myocardial neuroendocrine metastasis in a 45-years old male patient. The tumor was localized on the left side of the inter-ventricular septum. Surgical excision of the tumor was successfully performed using a robotic approach. Complete excision was achieved through a left atriotomy by a trans-mitral approach. Postoperative course was uneventful. Robotic mini-invasive approach is a safe and feasible alternative to conventional surgery and should be considered when the anatomy is suitable for a minimally invasive approach.

ABSTRACT. Objective To report three cases of patients with a parathyroid carcinoma, a very rare cancer. Methods Retrospective patient file analysis and Pubmed search using the key words “parathyroid carcinoma”. Results Since 2014 three patients were diagnosed with parathyroid carcinoma at our institution. Parathyroid carcinoma is a very rare cause of hyperparathyroidism with an approximate incidence of 0.03/100,000/year. All three cases were diagnosed with primary hyperparathyroidism. One patient was diagnosed with progressive kidney injury. Another patient presented with abdominal pain due to urolithiasis. The third patient was hospitalised because of diverticular disease, with hypercalcemia as a coincidental finding on bloodwork. A parathyroidectomy was performed in all three cases. Diagnosis was made after definitive pathological examination. There are no arguments for metastatic disease in any of these cases. Germline HRPT2 mutation screening will be performed to assess the need for stricter follow-up and screening of relatives. Conclusions Three cases of parathyroid carcinoma were diagnosed at our institution over the last six years. Parathyroid carcinoma is a very rare disease with an indolent course and symptoms mostly due to the hypercalcemia. The cornerstone of treatment is surgery. Results of chemotherapy or radiotherapy have been disappointing. Because of the higher risk of sporadic parathyroid carcinoma in patients with HRPT2 germline mutation, screening is advised. In our series there were no arguments for metastatic disease, or disease recurrence after a relatively short mean follow-up of 22 months.

ABSTRACT. Objective: The most widely etiology for fistula-in-ano is cryptoglandular. Once obstruction of an anal crypt gland occurs, infection and suppuration follow. Depending on the path of least resistance, different kind of abscesses and fistula form. With much less frequency fistula occur from trauma, surgery, obstetric complications or Crohn’s disease. Little is mentioned in literature regarding underlying anal fissures as a possible cause.

Methods: Between September 2011 and June 2019, patients treated for anal fistula in our center were studied. All cases in which the first anal exploration was well documented, were studied. Specific attention was payed to reports of the presence of an anal fissure at the internal opening.

Results: A total of 104 patients were treated for an anal fistula. In 25 patients (24,04%) an anal fissure was seen at the internal opening. Of these, 20 (80%) were located at the dorsal midline, 4 (16%) at the ventral midline and one (4%) at the dorsolateral right side of the anal canal. None of the retrofissural fistula were, to our knowledge, associated with Crohn’s disease.

Conclusion: Although this is barely mentioned in literature, in our experience, one anal fistula out of four is a complication of an anal fissure. Complicated anal fissure should be acknowledged as a common cause of anal fistula. This could be an incentive to treat anal fissures before infection and fistula formation can occur. On top of that, the fissure in which the internal opening is located might limit the options of sphincter-sparing surgical treatments.

ABSTRACT. Objective The aim of this case series is to describe 2 cases of aortic valve replacement due to granulomatosis with polyangiitis (GPA). GPA, formerly known as Wegener’s granulomatosis, is a systemic inflammation predominantly affecting upper and lower respiratory tract and kidneys. Valvular heart disease is a rare manifestation of GPA.

Methods We report two cases of acute valvular heart disease mimicking acute endocarditis caused by GPA. Patients were treated in Ghent University Hospital.

Results Both patients were middle-aged females with acute aortic valve regurgitation suspect for infective endocarditis. In their recent medical history atypical otitis and sinusitis were noted. The first patient was admitted because of heart failure due to aortic valve regurgitation, the second patient because of persisting fever. A cardiac ultrasound revealed a severe aortic regurgitation with an additional structure on two cusps, suspect for infective endocarditis in both patients. Urgent surgical replacement was performed, however, peroperative findings did not show infective endocarditis, but severe inflammatory changes of the valve and surrounding tissue. In both patients the valve was replaced by a prosthetic valve. Pathological findings showed inflammation with necrotising granulomas matching with GPA. One patient suffered from postoperative fever, but disease remission was obtained in both patients, in one with Rituximab and in the other with Glucocorticoids and Cyclosporine. Both had an uneventful follow up.

Conclusions GPA can be a rare cause of acute aortic valve regurgitation mimicking infective endocarditis with the need for surgical valve replacement. Atypical ear-, nose- and throat symptoms can be a first sign of GPA. Symptom recognition is important for early diagnosis and appropriate treatment to prevent further progression of the disease.

ABSTRACT. Background: Laparoscopic liver resection (LLR) as a treatment for colorectal liver metastases (CRLM) has proven to be feasible and safe in selected patients. The role of LLR in two stage hepatectomy (TSH)is poorly documented. Patients and methods: A single-center retrospective study was performed in which the role of LLR in the first and second stage of TSH was evaluated. Results: Between April 2014 and September 2019 239 liver resections for CRLM were performed (65% laparoscopic cases).Twenty patients were planned to undergo a TSH. FSH was performed laparoscopically in 19 patients (95%).All FSH were parenchymal sparing minor hepatectomies.Overall there were no transfusions and 85% were R0 resections.There were 3 R1 resections(15%), but all were R1vascular.Median blood loss was 50cc(IQR:40-100 cc);operative time 125minutes(IQR: 97.5 - 162.5 minutes);and hospital stay 4 days(3.75-6). Portal vein embolization (PVE) was performed in 11 patients(55%).Eleven patients (55%) underwent second stage hepatectomy (SSH).These were all major hepatectomies.Reasons why SSH could not be performed include disease progression(7), insufficient future liver remnant volume(1) and refusal for surgery(1).SSH was performed laparoscopically in 5 patients(45%). Operative time and overall blood loss were slightly higher in the LLR group compared to the OLR group(190minutes(IQR: 180-240 minutes) vs 180minutes(IQR: 152.5 - 200 minutes)) and 200cc (IQR: 100 - 300 cc) vs 160cc(IQR:105-312.5 cc)).Mortality was nil in both groups.There were no postoperative complications (Clavien-Dindo ≥ 3) in both groups. Conclusion: The already proven advantages of LLR in the treatment of CRLM favor the role of a laparoscopic approach in TSH for CRLM. In first-stage minor hepatectomy, LLR is progressively becoming the gold standard. Laparoscopic second stage major hepatectomy is feasible in experienced hands, but should be limited to selected cases and should be performed in expert centers.

ABSTRACT. OBJECTIVE Unilateral absence of the pulmonary artery is a rare congenital malformation often associated with other cardiac anomalies. In most cases the right pulmonary artery is involved, and the distal part of the affected lung receives its blood supply from systemic collaterals, such as bronchial, intercostal, internal mammary, subclavian arteries. We describe a complex case of a symptomatic adult patient where a major collateral came from a coronary artery.

METHODS A 52-year-old man was referred for angina. The angiography showed a significant stenosis of the left anterior descending artery (LAD) and right coronary artery (RCA), which were stented. A collateral arising from the left circumflex artery (LCx) to the right lung was diagnosed. Absence of the right pulmonary artery was confirmed by CT. Symptoms persisted and a new angiography showed an RCA restenosis, which was again stented. However, the patient continued to have angina and a third angiography demonstrated significant stenosis of the LCx and the LAD.

RESULTS: Off-pump coronary artery bypass surgery was performed with a free left internal mammary artery to the LAD (the left lung was overdeveloped) and a vein to the LCx. The postoperative follow-up was complicated by recurrence of ischemia. A fourth angiography was performed which showed good patency of the grafts, but a steal effect from the collateral of the proximal LCx. The decision was made to stent the LCx and the patient remained asymptomatic.

CONCLUSION: Unilateral absence of the pulmonary artery with a major collateral coming from a coronary artery combined with coronary artery disease can be a complex problem that necessitates a hybrid PCI and off-pump CABG revascularization strategy to avoid infarction of the affected lung.

ABSTRACT. Disseminated peritoneal leiomyomatosis (DPL), unlike as uterine leiomyomas, is a rare condition (less than 150 reported) with an unclear true prevalence. Malignant transformation of DPL has been rarely reported (11 cases). Various etiologies have been proposed, including mesenchymal stem cell metaplasia and hormonal, genetic, and iatrogenic factors. Multiple recurrences have been reported after myomectomy and particularly after laparoscopic surgery with morcellation. Adenomyomas are benign tumours composed of smooth muscles cells, endometrial glands, and endometrial stroma. Extrauterine adenomyomas are even rarer than extrauterine leiomyomas with 23 cases reported. The finding of both types of tumours simultaneously has only once previously been reported in the literature.

A 46 years old woman admitted for left lower quadrant abdominal pain started 15 days before and abdominal bloating. She had history of embolization and myomectomy of a large uterine fibroma ten years ago. The CT scan showed sigmoid tumour with peritoneal carcinomatosis and a fibromyomatous uterus but colonoscopy only attested extrinsic compression. Laparoscopy showed diffuse lesions with peritoneal carcinomatosis index (PCI) at 9. Pathology concluded in leiomyomas and adenomyomas with no evidence of malignancy. Because of the high risk of recurrence, the extent of the disease and after discussion with a high volume French centre who has similarly treated a few patients before we proposed complete cytoreduction (CC) and hyperthermic intraperitoneal chemotherapy (HIPEC). In laparotomy the final PCI was 13 with CC0 surgery (low anterior resection with partial mesorectal excision en bloc with radical hysterectomy and peritonectomies) followed by HIPEC with cisplatin and doxorubicin. In follow up the patient is free of disease one year later.

We report a rare case of DPL associated with extrauterine adenomyomas treated radically with complete cytoreduction and HIPEC because of its diffuse distribution and high risk of recurrence as only a few patients have already been treated and not yet reported.

ABSTRACT. OBJECTIVE 10 years have passed since the first transanal total mesorectal excision (taTME) has been introduced as a surgical resection technique for rectal cancer. In this paper, we present a patient with well leg compartment syndrome (WLCS) as a complication following taTME at our center. In order to avoid this complication in the future, we present a specific protocol that has been designed at our institution, based on the available literature and our own experience.

METHODS A thorough literature search on the topic of WLCS after taTME has been conducted using the MEDLINE database. Based on the currently available evidence and recommendations, the authors have created a specific protocol to prevent this complication at their institution.

RESULTS The incidence of WLCS in abdominopelvic surgery has been reported in 0,01% of all cases. There’s a consensus that a prolonged Lloyd-Davies position, especially when combined with the Trendelenburg tilt, is the most probable causal factor. In our protocol, we suggest to systematically register the ‘elevated legs’ time in every procedure requiring the lithotomy position. After 4 hours, we recommend to lower the legs to heart level for a time period of at least 15 minutes. After the surgical procedure, there should be raised awareness for signs and symptoms of WLCS, which should be systematically examined.

CONCLUSIONS Well leg compartment syndrome is a rare, although probably underestimated, complication after taTME for rectal cancer. By designing a standardized protocol for the positioning and follow-up of all taTME patients, we hope to raise the awareness of WLCS, and to aid an early diagnosis and treatment.

ABSTRACT. OBJECTIVE Necrotizing soft tissue infection is a life-threatening condition. Mortality rate remains high despite optimal management with antibiotic therapy and surgical debridement. Even in case of successful outcome, surgeon must often deal with complex soft tissue reconstruction. Nowadays, surgical residents are less exposed to old “tips and tricks” of general surgery. This can be problematic when faced with situations where plastic and reconstructive surgery techniques cannot be applied. We report the case of a necrotizing soft tissue infection of the groin with a large defect repaired by omental transposition and skin graft.

METHODS A 66-year old female patient was admitted to the ICU for major crush syndrome after being found lying on the ground at home for more than 24 hours. She developed a large necrotizing soft tissue infection of the groin due to compression. Emergency surgical debridement was performed which resulted in a large defect exposing the pubis bone and vulva. Even though the patient recovered from sepsis after long-term VAC-therapy and large spectrum antibiotics, local infection did not improve enough and myocutaneous flap was considered contraindicated. Two months later, a laparotomy with epiploplasty was performed bringing the omentum, pediculated from the right gastroepiploic artery, through the right internal inguinal ring, placing it onto the infected tissue. After one week, the local infection was definitively controlled and a split-thickness skin graft was finally possible.

RESULTS The postoperative period was uneventful, with significant local improvement due to the antibacterial and regenerative role of the omentum. The patient left our service 45 days postoperatively without signs of graft rejection.

CONCLUSIONS The biological properties of the omentum have been reported in general surgery in the past and wrongly neglected by latest generation of general surgeons because of growing number of subspecialties. The omentoplasty is still a valid option when facing necrotizing soft tissue infection.

ABSTRACT. OBJECTIVE: In the era of minimal invasive surgery even for technical demanding procedures, robotic surgery can be helpful. Therefore, robotic assisted distal pancreatectomy and pancreatoduodenectomy are recently developed.

AIM: What are the perioperative characteristics and outcome in robotic pancreatic surgery?

METHODS: A descriptive analysis of peril-operative characteristics and clinical outcome in a surgical cohort of patients undergoing robotic pancreatic surgery from December 2017 until June 2019.

RESULTS: Eighteen out of twenty-nine cases underwent robotic pancreatoduodenectomy. Conversion to open pancreaticoduodenectomy was necessary in three cases. The median age was 68 years and the median hospital stay was 12 days [6, 38]. Median surgery time was 470 minutes [442, 571]. The median per-operative blood loss was 100 cc [20, 350]. In 94% of cases revealed a R0 resection. Median number of lymph nodes dissected was 14 [8, 30]. Four patients needed a revision, mainly due to postoperative bleeding. There was one post-operative mortality. Nine patients (31%) underwent a distal pancreatectomy. Median surgery time was 190 minutes [101, 158] Mean per-operative blood loss was less than 80cc. There was no morbidity nor mortality.

CONCLUSION: These findings show that robotic pancreatic procedures are feasible and safe. The morbidity and mortality rates are comparable with non-robotic procedures.

ABSTRACT. Objective

Though rare, the Candy-Cane Syndrome is a real cause of digestive uncomfortable conditions in some patients after Gastric Bypass surgery and should be considered as such.

Symptoms range for dyspepsia, nausea, to pain, vomiting, GERD and other painful symptoms. We here describe the path of diagnosis, available treatments and a review of the literature regarding this complication, poorly reported.

Methods

A 62 years old woman underwent a Gastric ByPass in another hospital 3 years ago. Since then she complained of nausea, heartburn, early feeling of painful repletion, vomiting and halitosis.

She consulted several times her surgeon and others and underwent several endoscopies and upper GI series, all considered to be normal. An unsuccessful explorative laparoscopy was even done by one of the consulted surgeons. The patient was dismissed as “ psychologically weak”. She heard about us.

Considering the anamnesis and unable to get the images of those exams we asked for new studies. The diagnosis of candy cane was confirmed by the images and we proposed a resection of the too long limb.

Results

The relief of the symptoms was immediate.

Conclusions

We should be aware of this easy to solve pathognomonic cause of complications. Furthermore, as surgeons we also need to watch the images of the studies we ask for and not only read the conclusions.

ABSTRACT. Objective Previous research has shown unwarranted variation in the performance and duration of important interventions that are well described in evidence based guidelines for patients undergoing colon surgery. Therefore, the objective of the present study is to evaluate the effect of an improvement collaborative with feedback and knowledge-sharing on the adherence to those guidelines.

Methods A pre-test – post-test multicenter study was performed 12 Flemish hospitals. Patient records of consecutive patients, admitted for non-metastatic colon cancer surgery and above 18 years old, were analyzed. Key interventions were selected based on ERAS guidelines. The first retrospective audit took place from June until November 2017, the second from March until October 2019. Participating centers were asked to improve their care process, based in the feedback they received after the first retrospective measurement.

Results In total, 630 patients were included. The average length of stay decreased with 0,5 day, but not significantly. The amount of admissions in the ICU (intensive care unit) decreased significantly. A significant decrease was showed in the administration of sedative medication pre-operative, performance of mechanical bowel preparation and the use of midthoracic epidural analgesia. The use of blather catheters and drains decreased significantly, and if they were used, there was a singificant decrease in time to removal. Moreover, on average, patients were sitting and walking earlier than before the improvement period. On average, overall protocol adherence improved from 49% to 56.3% (p<0.001), but adherence to individual interventions remained highly variable. Moreover, overall protocol between hospitals ranges from 33% to 80%.

Conclusion Feedback on the delivered care for patients undergoing colon cancer surgery significantly improved protocol adherence. However, results show large variation within and between hospitals. This study shows a lot of progress is made but there is still room for improvement.

ABSTRACT. OBJECTIVE : Enhanced recovery after surgery (ERAS) programme reduces length of hospital stay (LOS) and postoperative complications after colorectal surgery. It is now the standard of care for colorectal surgery. Patients with inflammatory bowel disease (IBD) present often with preoperative risk factors for postoperative complications, which explains the reluctance to propose this programme to these patients. This study aims to compare postoperative outcome of patients with and without IBD included in a same ERAS protocol for right colectomy.

METHODS : The first 508 consecutive patients scheduled for colorectal surgery and prospectively introduced in our audit database were retrospectively analyzed. Only patients who had right colectomy were considered (n=160). LOS, postoperative complications and outcome of IBD patients (n=45) were compared with those of non-IBD patients (n=115). The same ERAS protocol was used in all patients and comprised intravenous lidocaine infusion (3). Data were compared using the Student t, Mann-Whitney U and the chi-square tests when appropriate. P < 0.05 = statistically significant.

RESULTS : IBD patients were significantly younger (38.9±13.8 vs. 58.9±18.5 y.o., P <0.001) and had smaller BMI (23.0±5.0 vs. 25.1 ±5.0 kg.m-2, P< 0.01) than non-IBD patients. Incidences of postoperative complications (13.3% vs. 17.3%), ileus (6.7% vs 7.8%), anastomotic leakage (2.2% vs. 4.3%), redo surgery (2.2% vs. 4.3%), and hospital readmission (6.6% vs. 4.3%) were similar in both groups. Tolerance of early feeding (73.3% vs. 85.2%, P < 0.05) was less and postoperative pain (P<0.05) greater in IBD patients. LOS were 3 [3-4.5] vs. 3 [2-5] days respectively in IBD and non-IBD patients (NS).

CONCLUSIONS : Not only ERAS is feasible and secure in IBD patient, but these patients benefit from this perioperative care after right colectomy as much as non-IBD patients.

ABSTRACT. Background and Aims Patients with ulcerative colitis (UC) and prolonged exposure to medical therapy come to surgery debilitated by disease severity, malnutrition, and reduced immunity. In this context, pouch construction should be postponed to a second stage to minimize the risk for postoperative complications and long-term pouch failure. Recently, a transanal approach to pouch surgery has been introduced to overcome the well-known pitfalls of laparoscopic rectal dissection and transection in the narrow pelvis. Aim of the article is to present short-term outcome of transanal pouch surgery for therapy refractory UC according to a modified 2-stage approach.

Methods Data from all patients who underwent a modified 2-stage Ta-IPAA operated between October 2015 and July 2019 were retrospectively retrieved from a prospective IPAA database. Dindo-Clavien classification was used for 90-day postoperative complications. Conversion rate, duration of surgery, hospital stay, and reoperation were also considered. A logistic regression model was used to assess potential risk factors for IPAA septic complications (anastomotic leak or pelvic abscess).

Results Seventy-five patients (68.8%) with a median age of 34 years (16-70) were identified in a cohort of 109 consecutive IPAA for therapy refractory UC. Of those, 58 patients (77.3%) received preoperative medical therapy. Median operation time was 159 min (98-237). Conversion rate was 4%. Ninety-day overall surgical complication rate was 32%. Anastomotic leak rate was 10.6%. Median hospital stay was 6 days (4-24). Reoperation was performed in 17.3% of the patients. No risk factors for the development of postoperative IPAA-related septic complications were identified.

Conclusions This study showed the feasibility and safety of Ta-IPAA in the setting of a modified 2-stage approach. Standardization and reproducibility of the technique is reflected in few conversions and intraoperative events. Finally, morbidity and anastomotic leak do not differ from those reported in previous Ta-IPAA series with a variable proportion of multistage procedures.

ABSTRACT. Objective

Chronic pelvic sepsis remains of great concern especially after distal colorectal anastomotic failure. Immediate salvage procedures have their limitations and many patients will need an elective redo procedure. Other than anastomotic breakdown, rectovaginal fistula, recto-urethral fistula and IBD can be responsible for chronic pelvic sepsis. The goal of surgery is to resolve pelvic inflammation while restoring intestinal continuity. The pull-through procedure achieves this by mobilizing a healthy conduit into the pelvis and creating an anastomosis beyond the source of sepsis. We aimed to review our experience with pull-through procedure for chronic pelvic sepsis in the setting of a tertiary referral center.

Methods

Patients requiring the procedure from 2010 to 2018 have been retrospectively reviewed. Morbidity and mortality have been evaluated and intestinal continuity rate was the main endpoint.

Results

Twenty-one patients underwent 23 pull-through procedures with direct anastomosis. The main indication was chronic pelvic sepsis due to anastomotic failure. Initially, 15 patients were operated for rectal cancer. The median age was 60 (42-86) years and the median BMI was 26 (18-37) kg/m². In the majority of the patients, a straight manual colo-anal anastomosis was constructed (82.6%) after a median number of three elective or emergent procedures. The rate of defunctioning stoma was 95.6%. The average time carrying a stoma before the intervention was 19 months while the average time from primary surgery to intervention was 49 months. There were no death and morbidity reached 47.8%. Overall anastomotic leak rate was 8.7%. An anastomotic leak occurred twice in a single patient (1 redo procedure) and he eventually needed a permanent colostomy. At one year, 69.5% of the patients had their intestinal continuity restored.

Conclusion

Pull-through with direct anastomosis for chronic pelvic sepsis is feasible, has good leak rates and acceptable morbidity. A satisfying rate of intestinal continuity can be achieved

ABSTRACT. Objective: The aim of this study was to evaluate the safety and feasibility of a standard Enhanced Recovery After Surgery (ERAS) program following colorectal resection in a geriatric population, aged 80 years and older. Methods: In this single-center before-after cohort study all patients aged 80 years and older were included after colorectal resection. Patients were divided in a pre-ERAS group and an ERAS group, according to the type of perioperative care. Data were prospectively collected and analysed retrospectively. The primary outcome was short-term complication rate. Secondary outcome parameters were length of stay (LOS), 30-day mortality and readmission rate. Results Over a period of 4 years, 219 patients were included. Of those, 151 underwent colonic resection, with 45 following the ERAS protocol perioperatively. The remaining 68 patients underwent resection of the rectum, following the ERAS protocol in 21 cases. LOS after colon resection was reduced by 2.5 days in the ERAS group (p=0.018). There were no statistical significant differences in complication rate, 30-day mortality or readmission rate in the pre-ERAS versus the ERAS groups. There was no effect of ERAS on LOS after resection of the rectum. Laparoscopy was found to be an independent influencer of LOS (p<0.001) and complication rate (p=0.011) for surgery of the colon and of LOS (p=0.008) and complication rate (p<0.001) for surgery of the rectum. Conclusions A standard ERAS protocol is safe and feasible in older patients (>80 years) undergoing colorectal surgery. Colon resection was related with a shorter hospital stay, complication rate was unchanged. No adverse outcome after rectum resection was found. Laparoscopy appears to be associated with less morbidity and shorter LOS and should be considered for every patient regardless from age.

ABSTRACT. OBJECTIVE Tracheomalacia can be responsible for severe and recurrent airway infections in infants, and cause brief resolved unexplained events (BRUE). Both are an absolute indication for surgical intervention. However, the surgical strategy is center specific and varies from simple aortopexy to a complete tracheopexy. We report our initial experience with a novel surgical technique.

METHODS Via median sternotomy, a posterior tracheopexy is performed followed by an anterior tracheopexy using a commercially available reinforced PTFE prosthesis (tracheal splint). We finish the procedure with a classic aortopexy. Before sternal closure, a flexible bronchoscopy is performed to evaluate the patency of the tracheal lumen.

RESULTS Since August 2018, three infants with severe long segment tracheomalacia were treated at our hospital. Two patients experienced BRUE and all had recurrent chest infections. Two patients had a previous history of tracheoesophageal fistula repair. One child required mechanical ventilation before surgery. All patients were treated with a complete tracheopexy and aortopexy. Postprocedural flexible bronchoscopy showed good patency of the trachea in all patients. Two children were extubated the day of surgery, the previously ventilated patient was extubated 5 days postoperatively. There were no postoperative pulmonary complications and no postoperative deaths. Patients are seen in outpatient clinic and are doing very well. Bronchoscopy at six months and 1 year shows an excellent result.

CONCLUSION Surgical treatment of severe long segment tracheomalacia in infants can safely be performed by a combination of posterior tracheopexy, anterior tracheal splinting, and aortopexy. Immediate postoperative and mid-term results are satisfying with an excellent clinical recovery. Further follow-up is required to evaluate the long-term results.

ABSTRACT. Background: Thymolipomas are rare and benign prevascular mediastinal tumours and comprise approximately 5% of all thymic neoplasms. The majority remain asymptomatic and are found incidentally. The aetiology of thymolipoma remains uncertain and, unlike thymomas, no clear association has been found with myasthenia gravis (MG). Surgical resection remains the gold standard. However, due to the rarity and low incidence rates, there is a lack of data on long-term survival and optimal surgical approach. Methods: Patients surgically treated for thymolipoma between 2010-2019 were included in this case series. Data regarding patient characteristics, clinical symptoms, surgical treatment, postoperative, complications, and overall (OS) and disease-free survival (DFS) were included. Statistical analysis was performed using descriptive statistics. Results: A total of 7 patients (4 male and 3 female) with a mean age of 41±15 years (range 13-57 years) were included. Five patients had clinical symptoms of MG and received surgical treatment due to a suspicion of thymoma. Two patients did not have clinical symptoms related to the thymolipoma and were diagnosed with an anterior mediastinal mass as an incidental finding. Six patients were treated with robotic-assisted thoracoscopic surgery (RATS) and 1 patient had a sternotomy for additional coronary artery bypass grafting. After a mean follow-up period of 12 months (range 7-18 months), OS and DFS were both 100%. Furthermore, pathological examination of all specimens showed R0 resection margins. Postoperative complications included a pneumonia in 1 patient and a temporary unilateral diaphragm paralysis in 2 patients. Mean amount of blood loss was 83 mL and average duration of surgery was 174 minutes. Conclusion: Thymolipomas are rare and benign prevascular mediastinal tumours of unknown aetiology. Although not clearly described in earlier studies, a possible association with MG may be present. Surgical treatment with RATS is a safe and effective approach for obtaining a complete resection with excellent long-term outcomes.

ABSTRACT. Objective Early mortality is the most devastating complication after aortic valve replacement (AVR). If modifiable predictors can be identified, avoiding these predictors can lead to improved outcome.

Methods Retrospective file study of patients undergoing isolated AVR (with exclusion of all other procedures) in a general teaching hospital, from 1987 to 2017. Age, gender, comorbid conditions (diabetes, pulmonary, renal, hypertension, cerebrovascular and peripheral artery disease) as well as cardiac factors (left ventricular dysfunction, conduction defects, arrhythmias, coronary artery disease, valve regurgitation, endocarditis, need for emergent surgery, defined as need to operate within 24h after admission) were included for analysis. In a first step, a chi-square analysis was used. Significant factors were entered in a backward stepwise logistic regression (table). The association of early mortality with postoperative conditions and use of resources was also screened.

Results 825 patients could be identified. The mortality was 26 (3.2%) and its predictors are shown in the table. Although postoperative endocarditis was rare, it was the most lethal complication (3 of 4 patients died), followed by low cardiac output syndrome (14/39 or 36%). Bleeding, arrhythmias, pulmonary and renal complication were also associated with mortality, but in a lesser degree (12-20%). Early mortality was also significantly associated with increased use of resources (prolonged mechanical ventilation, prolonged stay in intensive care unit, increased use of blood products and of continuous veno-venous hemofiltration).

Conclusion The most important predictor for early hospital mortality after AVR is the need for emergency surgery, which is twice as important as age over 80 and as preoperative renal dysfunction. Need for emergent surgery is the result of an exhaustion of all compensatory mechanisms of the left ventricle to maintain an adequate circulation. Avoiding this development by early referral could result in lower mortality.

ABSTRACT. Objectives. The aim of this study is to analyze on a multivariate basis both our preoperative and postoperative pleural lavage cytology (PLC) practice and its impact on recurrence-free survival for all non-small cell lung cancer (NSCLC) surgically treated in our institute, both by open thoracotomy and robotic approach. We created our own PLC protocol and expose its effectiveness through preliminary results.

Methods. From January 2015 through December 2018, PLC was performed both preoperatively and postoperatively in 167 patients without pleural effusion undergoing pulmonary anatomical resection. Cytology was realized with Papanicolaou’s method and, in case doubtful of result, immunohistochemical analysis. Both pre-PLC and post-PLC status were tested using univariate and multivariate Cox regression of recurrence-free survival.

Results. Our positive pre-PLC and post-PLC rate was respectively 10.2% and 12%. Median follow-up time was 1.9 year. Pre-PLC and post-PLC showed no statistical impact on recurrence-free survival in our multivariate analysis.

Conclusion. There is currently no internationally recognized and standardized PLC procedure which may lead to highly variable positive PLC rate in literature. We therefore elaborated our own protocol based on a double cytological analysis. The preliminary results we produced from our prospective study tends to show the feasibility of our technique in both open and robotic approach. Considering our short follow-up period and relatively small number of patients, we did not obtain any statistically significant results from our pre-PLC and post-PLC cohort multivariate analysis.

ABSTRACT. OBJECTIVE

Various simulation-based tools such as cadaveric and animal models, virtual reality and e-learning modalities have currently been implemented in surgical training programs to enhance the efficiency of the learning process and to achieve proficiency in procedural skills prior to patient contact in the operating room. Touch Surgery (TS) is a novel, phone-based, serious game for cognitive training of surgical procedures. The aim of this study was to validate the surgical procedure chest tube insertion (CTI) on the TS application and to assess the utility of this new educational tool for future training curricula.

METHODS

Experts (surgeons) and novices (senior medical students) without previous experience with TS were recruited. Both groups completed the CTI testing module and automated performance scores were compared (construct validity). Questionnaires using a Likert-scale assessed realism (face validity) and usefulness (content validity). Additionally, participants answered questions regarding serious gaming.

RESULTS

Twenty-five experts and 25 novices were enrolled. Experts significantly outperformed novices on the TS CTI testing module (mean score ± standard deviation 81.76 ± 5.04 vs. 55.88 ± 7.50 respectively, p< 0.001). Both experts and novices agreed that TS is realistic and useful. Students indicated more than surgeons that using TS is fun and that more serious games should be used for professional learning (p< 0.001).

CONCLUSIONS

The module CTI on TS has demonstrated construct, face and content validity. Consequently, it could serve as a cognitive training tool for training CTI and might be integrated in future surgical training curricula.

ABSTRACT. Background: Thermal ablation is an accepted treatment for liver malignancies, particularly for central and for small lesions. In extensive colorectal liver metastatic disease, hepatectomy can be combined with ablation and thus spare liver parenchyma. This strategy is considered to increase salvageability rates in case of recurrence.

Methods: All patients with multiple colorectal liver metastases (CRLM) that underwent CARe with microwave ablation (MWA) between April 2012 and January 2020 were retrospectively analyzed from a prospectively maintained database. Primary endpoints include postoperative 30-day morbidity and mortality, in loco recurrence and disease-free survival. Lesions treated with MWA were systematically screened for in loco recurrence on postoperative follow-up imaging.

Results: Of the total of 37 patients that underwent CARe, 20 (54.1%) were approached laparoscopically, 17 (45.9%) were open. Eight (21.6%) procedures were minor resections, 20 (54.1%) were technically major and 9 (24.3%) were anatomically major resections, according to the Southampton Consensus Guidelines. Postoperative complications occurred in 7 patients (19.9%), among which Clavien-Dindo ≥3 in 1 patient (2.7%). Thirty-day mortality rate is 0%. Four patients (10.8%) had confirmed in loco recurrence in MWA ablated lesions. Disease-free and overall survival rates are being analyzed to date.

Conclusion: Microwave ablation is an effective tool to treat multiple CRLMs in combination with resection in a parenchymal sparing strategy. Laparoscopic CARe is feasible and safe. Long-term oncological data is being collected to confirm the non-inferiority of laparoscopic CARe, compared with open CARe.

ABSTRACT. OBJECTIVE There is inconsistent evidence to recommend surgical therapy for hepatic oligometastases from pancreatic ductal adenocarcinoma (PDAC). The aim of this retrospective single-center cohort study is to evaluate the survival after surgical treatment of liver metastases (LM) from PDAC.

METHODS Between 2000 and 2018, twenty consecutive patients (M/F: 10/10; median (range) age 57 (32-78) years) underwent surgical therapy for synchronous (n=4) or metachronous (n=16) LM from PDAC. Surgical resection (2 or less liver segments) was performed in 13 patients and ablation in 7. Median interval between pancreas and liver surgery was 17.5 (0-32) months. All patients received preoperative systemic chemotherapy, and only patients without tumor progression were treated with surgery. Kaplan-Meier method was used for survival analysis.

RESULTS Postoperative complications were observed in 3 patients; i.e. 2 after simultaneous liver and pancreas resection, and 1 after metachronous liver resection. Postoperative mortality (90-day) was zero. Median length of hospital stay was 5 (range 1-44) days. Median overall survival (OS) time after liver surgery was 27.9 (CI 13.2-45.3) months, and after pancreatic surgery 48.1 (CI 25.3-65.6) months. The OS-rates at 1,3, and 5 years after liver surgery were 80%, 33%, and 18%, and after pancreatic surgery 90%, 68%, and 39%, respectively.

CONCLUSION Liver surgery for metastases from pancreatic cancer can offer very promising survival rates in highly selected patients. Larger series are needed to confirm these results and to identify candidates who may experience a survival benefit.

ABSTRACT. OBJECTIVE Infectious complications are frequent after pancreaticoduodenectomy (PD), and antibioprophylaxis could influence their occurrence. While pancreatic head tumors are frequently associated with biliary obstruction, biliary stasis can predispose to biliary infection, especially with preoperative biliary drainage (PBD). This study aims to analyse intraoperative bile cultures and postoperative outcome of patients undergoing PD to modify our antimicrobial protocol during PD.

METHODS All patients undergoing PD in our centre between 2014 and 2019 were retrospectively reviewed, analysing PBD status, perioperative antimicrobial management, bile culture and postoperative outcome.

RESULTS Among 167 patients who underwent PD, intraoperative bile culture was performed in 164 patients who were included in the analysis: 73 (45%) underwent PBD and 91 (55%) did not. Positive/polymorph bile cultures were found in 95% of PBD patients compared to 32% of no-PBD (p<0.001). Both groups were similar regarding age, sex, body mass index, comorbidities and preoperative bilirubin levels. Intraoperative small spectrum antibioprophylaxis was administrated in 85% and 95% of PBD and no-PBD, respectively (p=0.038). The most common pathogens were Escherichia Coli (13%), Enterobacter (10%) and Klebsiella (11%) species, which were frequently resistant to small-spectrum antibiotherapy. The rates of postoperative overall and intraabdominal infectious complications were similar between groups (p>0.050), but the need for antibiotherapy change or reintroduction of large-spectrum antibiotics was more frequent in PBD group (p<0.001). A total antibiotherapy duration >7 days was more frequent in PBD group (p<0.001). At multivariate analysis, infected bile culture was associated with ampulloma (odd ratio, OR 4.801 [1.337-17.236), malignant indication (OR 2.247 [1.004-5.029) and PBD (OR 11.766 [1.490-92.942]).

CONCLUSIONS PBD exposes to nearly 100% of bile infection during PD, with pathogens frequently resistant to small-spectrum antibiotherapy, resulting in a bad use of antimicrobial agents. Ampulloma, malignant indication and PBD present an increased risk of bile infection, constituting a potential high-risk group needing a large-spectrum prophylactic antibiotherapy.

ABSTRACT. Objective: There is a lack of good evidence and major concern regarding early enteral nutrition (EEN) and enhanced recovery (ERAS) programs after minimally invasive pancreaticoduodenectomy (MIPD). The aim of this prospective single-center cohort study was to evaluate the effect of EEN and ERAS program in patients undergoing 3D-laparoscopic pancreaticoduodenectomy (3D-LPD) for pancreatic or periampullary neoplasms.

Methods: Between March 2016 and March 2019, a total of 183 patients (M/F: 104/79; median (range) age 66 (30-85) y.) underwent 3D-LPD with stented pancreaticogastrostomy (sPG) and RY-gastroenterostomy (RYGE). Median duration of surgery was 280 (160-800) minutes and intra-operative blood loss 10 (0-2000) ml. Superior mesenteric or portal vein resection was done in 25 patients. On the day after surgery, the nasogastric tube, epidural anesthesia and urinary catheter were removed, and patients were allowed to start enteral nutrition and fast mobilization according to our ERAS program.

Results: Postoperative complications were observed in 95 (52%) patients, with severe complications (Clavien-Dindo TOSGS >3) in 31 (17%) including 2 deaths (1%). Clinical pancreatic fistula (POPF grade B/C) were observed in 32 (17%), hemorrhage (PPH gr A/B/C) in 14 (7.6%). None of the patients needed the reinsertion of a nasogastric tube nor developed delayed gastric emptying (DGE). In 37 (22%) total parenteral nutrition was given as part of complication management. Time to 1st flatus (TFF) and to 1st stool (TFS) was 32 (8-137) and 80 (6-336) hours, respectively. Length of hospital stay (LOS) was 11 (3-112) days. After discharge from the hospital, 21 patients (11%) were readmitted. Weight loss at first follow-up visit after surgery was 5 (-5-22) kg.

Conclusion: EEN and ERAS in 3D-LPD with sPG + RYGE is associated with good clinical outcomes and no DGE.

ABSTRACT. Objective: Although liver transplantation techniques and perioperative management have improved over the last decades, perioperative death remains a possibility with a reported incidence of 3 %. We aimed to determine the incidence, the causes, and the factors influencing the perioperative mortality (within the 24hours), in the light of the literature. Methods: We performed a retrospective observational analysis on data collected from all perioperative deaths between 1990 and 2019. A descriptive analysis was performed for different outcomes (Incidence, comorbidities, etiology). A review of literature using pubmed, google scholar and Cochrane database was done to determine the incidence, causes, prevention and outcomes for per and 24 hour postoperative mortality death. We then compared the results of literature to our own data. Results: Incidence of death within 24 hour was 1,33% (20/1500). The most common per and 24 hour postoperative mortality found in the litterature is caused by uncontrolled bleeding, intracardiac and pulmonary thrombus (ICPT) and primary graft failure. Post reperfusion syndrome and sepsis have also been described as factors of mortality in the early per/postoperative period. In line with this in our series, 4 patients died from ICPT, 5 from massive bleeding, 1 from primary graft failure, 1 from spontaneous cerebral death, 2 from sepsis, 1 from cardiac arrest, and 6 from unknown causes. No particular risk factor could be identified. Conclusion: Per and 24 hour postoperative mortality has an incidence of 1,33% (which compares favorably with the literature). Most frequent causes are massive bleeding, ICPT and sepsis. No predictive factors could be found.

ABSTRACT. OBJECTIVE: Laparoscopic ventral hernia repair with intraperitoneal mesh placement (IPOM) is a well-accepted and safe technique. However little is known about the influence of the mesh on the occurrence of early postoperative small bowel obstruction (SBO). We embraced the idea of IPOM early in our department and used many different meshes, none of which was deemed ideal, until we started to use the Dynamesh®-IPOM, which we found easier to handle than any other mesh we used before. However we noticed a steep increase in early postoperative SBO after Dynamesh®-IPOM than after IPOM with any other mesh we used before. We wanted to analyse the occurrence of SBO, compared to the other mesh we used for IPOM during the same period. METHODS: 437 patients who underwent ventral hernia repair with IPOM, either with a Dynamesh®-IPOM (FEG Textiltechnik mbH, Aachen, Nordrhein-Westfalen, Germany) or a Parietex™ Composite mesh (Medtronic, Minneapolis, Minnesota, USA) between 2012 and 2017 were retrospectively compared with regard to the occurrence of early postoperative (≤ 6 weeks) SBO. Baseline demographics and clinical data up to 3 months postoperatively of the patients in the two mesh groups is provided. RESULTS: The Dynamesh®-IPOM mesh group was associated with a significantly higher incidence of early postoperative SBO compared with the Parietex™ Composite mesh group (n=25, 8,2% vs. n=2, 1,5%; P=0.008). We identified the use of the Dynamesh®-IPOM mesh (OR=6,22, 95% CI: 1,44 - 26,91; P=0.014) as a significant risk factor for developing an early postoperative SBO after laparoscopic IPOM ventral hernia repair. CONCLUSION: Our results confirm current literature available concerning the Dynamesh®-IPOM mesh. Namely that the Dynamesh®-IPOM might be associated with a higher incidence of early SBO than other meshes. However, further research with well-designed, multicenter randomized controlled studies to evaluate the use and complications of these meshes is needed.

ABSTRACT. Objective: The International Hernia Collaboration (IHC) Group is a closed group social media application on Facebook which enables members to ask for advice on management of hernia patients. Our aim was to assess the threads on abdominal wound dehiscence and to establish the potential conformity to the European Hernia Society (EHS) guidelines published late 2018. Methods: De-identified cases from IHC were identified using search terms ‘dehiscence’ and ‘evisceration’. Duplications were removed. Responses were analyzed and compared to available evidence from EHS guidelines. Results: Twenty-four unique clinical scenarios were identified between May 2013 and December 2019. Eight posts were excluded as these dealt with management of open abdomen (n=1), parastomal hernia (n=1 and incisional hernia (n=6) , leaving 16 patient scenarios for inclusion. The majority of the clinical scenarios posted questions about therapeutic management (n=14). Other posts concerned prophylactic management or clinical definitions (both n=2). A total of 182 individual responses were counted with a mean of 11 threads per scenario. Four out of sixteen scenarios were posted after publication of the EHS guidelines, and only one thread mentioned the guidelines prepublication. Users engaged most with regard to the use of retention sutures, negative pressure wound therapy and closure of the abdomen in presence of purulent peritonitis. Conclusions: Advise on social media is often based on personal experience. Promotion and implementation of EHS guidelines should be extended to online platforms in order to reach surgeons with relevant advise for individual clinical cases.

ABSTRACT. Objective Laparoscopic umbilical hernia repair is mostly done with intra abdominal mesh with or without closing the defect. These years concerns exist about intra peritoneal mesh placement. Transabdominal retromuscular umbilical prosthetic hernia repair (TARUP) mostly done robotic assisted in some belgian centres seems to be a solution. We developed a complete laparoscopic technique in our hospital.

Methods The patient is placed in supine position, arms on arm’s board. The operator is placed at the left of the patient with assistant at his right. The border of the rectus sheath is marked on the patient’s skin 15cm large centered on the midline. The pneumoperitoneum is created with a Veress needle, using an intra-abdominal pressure of 12 mmHg. The first port is placed in the left flank, the second in the left iliac fossa and a third one in the left hypochondrum all on the same horizontal line. The procedure begins with the dissection of the posterior rectus sheath to access the retromuscular space. When arrived at the linea alba, the posterior rectus sheath is incisated 0,5cm from the meeting line, at this point we are in a pre-peritoneal space. The hernia is reduced during dissection. The defect is closed with 0 barbed suture as well as the rectus muscles diastasis, we use FLEXDEX needle holder which permits robot like movements. The mesh is placed, we use 15X15 or 30x30cm Progrip mesh without fixation, the dissected sheath is closed with 3/0 barbed suture as well as the eventual peritoneum disruption done during the dissection.

Results This procedure is technically demanding but we have good early results, none abdominal drainage system compare to the open technique, mesh completely covered to avoid risk of intra-abdominal adherence, no post-operative pain caused by mesh fixation.

Conclusion Laparoscopic TARUP is a feasible technique with good results, shortening the hospital stay.

ABSTRACT. Background A Transverse Rectus Abdominis Muscle (TRAM) flap is commonly used in reconstructive breast surgery. After harvesting the skin, the anterior rectus fascia and muscle, the resulting abdominal wall defect can be closed using a mesh. Nevertheless, this often results in bulging, an asymmetrical abdominal contour and/or ventral hernia.

Objective and Methods To report a minimal invasive abdominal wall reconstruction technique in case of an invalidating bulging or ventral hernia due to rectus abdominis muscle harvesting.

Results We present a video of a 54-year-old female with a history of a mastectomy of the right breast and TRAM flap reconstructive breast surgery in 2011. She complained of progressive pain and bulging of the abdominal wall at the donor site location. On clinical examination, a massive bulging reducible in supine position of the right hemiabdomen is seen. Abdominal CT scan shows a wide eventration of the right hemiabdomen. Robot-assisted laparoscopic retromuscular repair with bilateral posterior component separation (TAR) was performed. Central mesh failure of the lightweight mesh, used for bridging during the first operation, was noticed. The defect was closed using barbed V-loc 0 sutures. A large monofilament polyester macroporous midweight mesh with a length of 40 cm and a width of 26 cm was placed in the retromuscular plane to cover the defect. The postoperative course was uneventful and the patient was discharged at the second postoperative day.

Conclusion Donor site morbidity after TRAM flap surgery is common: bulging and ventral hernias are often seen. Recent hernia guidelines recommend to avoid the use of meshes in a bridging fashion to prevent bulging. In case of bulging or a ventral hernia, posterior component separation with transversus abdominis release is a valid technique.

ABSTRACT. OBJECTIVE Endoscopic Mini/Less Open Sublay (EMILOS) is an operative technique recently developed by Schwarz et Al. which has been used to treat ventral wall hernias with promising results. Currently, two techniques are most frequently used to treat ventral wall hernias, each with their own disadvantages. An open sublay approach is associated with higher chance of wound infections, whereas a laparoscopic intraperitoneal onlay mesh (IPOM) has an increased chance of bowel-related complications and longer operative times. EMILOS combines the advantages of a minimally invasive approach and a retromuscular position of the mesh. We describe our initial experience with the technique and share some technical considerations.

METHODS From September 2019 until November 2019, eight patients were treated for ventral wall hernia using EMILOS. Operative indications were ventral wall incisional hernia or ventral wall hernia with concomitant rectus diastasis. The operative procedure was performed as described by Schwarz et Al. Posterior inverting plication of rectus diastasis was performed at the request of the patient. Patients were seen at 6-week follow-up.

RESULTS Eight consecutive patients successfully underwent EMILOS surgery. All but one of the patients were male (87.5%). Median age was 58 years. Seven out of eight patients were operated for primary ventral wall hernia with concomitant rectus diastasis, one patient for incisional ventral wall hernia. Four patients received plication of rectus diastasis. Mean operative time without plication of rectus diastasis was 80 minutes, mean overall operative time was 104 minutes. No patient stayed longer than two nights postoperatively. No complication-related readmissions or reoperations occurred.

CONCLUSION EMILOS is a novel technique offering a minimally invasive approach to place a mesh in the retromuscular plane. Our initial experience shows a low early postoperative morbidity.

ABSTRACT. Objective: Recurrence after esophagectomy for esophageal cancer is related to poor prognosis. Brain metastasis remain a rare type of recurrences, however its incidence is increasing due to increased overall survival. These metastases are frequently symptomatic and, due to the presence of the blood-brain-barrier, more difficult to treat with systemic therapy. Identifying risk factors for brain metastasis and factors influencing mortality could guide treatment and surveillance strategies in order to improve survival.

Methods: A retrospective cohort study was conducted between January 2000 and December 2019. 1631 patients who underwent esophagectomy for locally advanced esophageal cancer were identified. Patient demographics and tumor characteristics were collected for the cohort, as well as tumor characteristics of the brain metastases. Risk factors for brain metastasis were identified using logistic regression analysis. Overall survival in different subsets was determined by Kaplan-Meier analyses.

Results: Sixty-eight patients (4,17%) developed brain metastases after esophagectomy for locally advanced esophageal cancer. A significant difference in incidence between adenocarcinoma(4.8%) and squamous cell carcinoma(2.7%) was present (p=0.05). Patients with brain metastasis had a median overall survival of 16.4 months after esophagectomy and comparable to patients with solid organ metastasis (p=0.30). Mean survival after treatment of brain metastasis was 21.9 months (CI: 12.4-31.4). In the adenocarcinoma-group, cisplatin- (OR=2.73, CI: 1.35-5.53) and CROSS-based chemotherapy (OR=2.40, CI: 1.04-5.54) were independent risk factors for development of brain metastasis.

Conclusion: Neoadjuvant treatment is identified as an independent risk factor for the development of brain metastasis after esophagectomy for locally advanced adenocarcinoma. Therefore, we believe it should further be investigated whether chemotherapy influences metastatic potential of the tumor or if a certain subset of tumors preferably metastasizes to the brain. In selected patients, increased survival can be achieved after metastatic treatment. Patients who received neoadjuvant treatment may benefit from surveillance imaging during the first 2 years after diagnosis.

ABSTRACT. Objective Current gold standard for treatment of locally advanced esophageal adenocarcinoma is neoadjuvant chemoradiotherapy (nCRT) followed by surgery, driven by the results of the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS). This study aimed to reassess the presumed advantage on long-term survival of nCRT followed by surgery compared to primary surgery.

Methods This retrospective cohort study analyzed all patients treated between 2005 and 2018. Inclusion criteria of the CROSS-trial were used. Overall survival was primary endpoint. In-hospital mortality, 90-day mortality, major postoperative complications, readmission to ICU and length of hospital stay were prospectively recorded.

Results Between January 2005 and December 2018, 455 eligible patients with cT1/2N+ or cT3/4N0/+ staged adenocarcinoma underwent primary surgery (158 patients) or nCRT followed by surgery (297 patients). Overall survival after 5 years did not differ significantly between both groups (p=0.89). In comparison to the CROSS-trial, results showed an apparent trend that patients after primary surgery only, through a transthoracic approach, achieved a survival equivalent to the survival after nCRT. nCRT was associated with significantly more major postoperative complications (p=0.014) and ICU readmissions (p=0.031). Transthoracic resection allowed an extensive lymphadenectomy with median of 25 and 29 resected lymph nodes after nCRT followed by surgery and primary surgery respectively.

Conclusions Based on results of this study, primary surgery offers non-inferior overall survival after 5 years and fewer major postoperative complications and ICU readmissions compared to nCRT followed by surgery for patients with locally advanced esophageal adenocarcinoma.

ABSTRACT. We describe the case of a 71 years old woman who came at the emergency room for abdominal pain since 7 days and symptoms of occlusion since 4 days. On physical examination, there were signs of peritonitis with a left flank defence.

The scanner demonstrated a colonic occlusion resulting from an incarceration what was diagnosed as a hernia of Bochdalek.

But two old rib fractures and a past history of a fall two years earlier directed us to the diagnostic of delayed diaphragmatic rupture.

The patient was operated by anterolateral thoracotomy in the 7th right intercostal space. Reduction of the partially necrotic colon associated with the closure of the diaphragmatic hernia reinforced with a pledged of polypropylene was performed. A laparotomy was also necessary for the segmental colon resection. The post-operative follow-up was simple and the patient was able to return to her home on the 10th post-operative day.

Traumatic diaphragmatic hernias are rarely diagnosed directly after trauma. Complications such as pneumonia, occlusion, enteric ischemia, visceral perforation and twisting of the splenic hilium can occur many years after the trauma. Diaphragmatic rupture occurs in 5% of severe closed thoraco-abdominal injuries.

This is why, patients with intestinal obstruction or association of pulmonary abdominal symptoms and history of thoraco-abdominal injury, the diagnostic of diaphragmatic hernia should be considered.

When patients present complications there is a higher rate of morbidity and mortality (31%) reason why, emergency surgery is mandatory.

ABSTRACT. Objective: To share the single-center experience of a tertiary referral center using the Belsey Mark IV operation (BM-IV) in the treatment of large primary hiatal hernias and recurrent hernias after failed antireflux surgery.

Methods: We conducted a retrospective analysis of all patients with large hiatal hernia or recurrent hernia after antireflux surgery operated between January 1, 2002 and December 31, 2016 and who underwent a Belsey-Mark IV antireflux procedure. Collected data included patient demographics, surgical history, indication, short- and long-term complications graded by the Clavien-Dindo classification, recurrence rate and post-thoracotomy pain syndrome (requiring neuromodulatory pain medication or local analgesic infiltration).

Results: A total of 243 consecutive cases were included for analysis: 149 primary BM-IV and 94 redo BM-IV. Eighteen patients were lost to follow-up (i.e. not reaching a minimal follow-up of 4 months - accounting for 136 primary and 89 redo BM-IV). Table 1 demonstrates the patient demographics, symptoms and the short- and long-term outcome. For the redo BM-IV, 55 patients had one previous intervention (58.5%), 33 patients had two previous interventions (35.1%) and six patients had three previous interventions (6.4%), the majority being a Nissen fundoplication. Postoperative leakage of the fundoplication complex occurred in 3.6% (n=8). Treatment consisted of conservative measures (n=3), thorax drainage (n=3), immediate revision (n=1) or esophagectomy (n=1). Post-thoracotomy pain syndrome was present in 9.8% (n=22).

Conclusion: Primary and redo BM-IV are different entities, with different complication and recurrence rates. Post-thoracotomy pain syndrome remains a challenge and must by timely recognized during follow-up. The Belsey Mark IV repair is a safe and effective procedure in experienced hands, with well-defined risks and an acceptable recurrence rate, given the nature of the condition and patient’s comorbidities.

ABSTRACT. Introduction The route and type of peri-operative feeding after oesophagectomy varies widely across centres, based on local experiences and standing orders. The aim of this survey on PeriOperative Nutrition after OeSophagectomy, was to create a snapshot of how perioperative nutrition preceding or following oesophagectomy is established accross the recently created reference centers on oesophageal surgery in Belgium, and what the reasons are for preferring one method over another.

Methods A survey consisting of four parts was distributed to one or more leading surgeons within each reference centre for oesophageal surgery in Belgium. The first part contained some general questions regarding demographics and type of performed surgeries. In the second section, centres were asked about practices in preoperative nutrition. The third section entailed current practices in postoperative nutrition, where in the last part daily practice is reflected against the current available ESPEN guidelines. Results Nine out of ten centers were willing to share their practices. The majority (7 out of 9) had a structured nutrition team in their institution, most often involving at least a dietician and a physician. An Enhanced Recovery Pathway was implemented in 2/3 of centres. A majority of centres said to use the ESPEN guidelines. Routine preoperative nutritional assessment was performed in 88%, usually only based on BMI and %weight loss. Preoperative nutritional support consisted mainly of enteral and oral support, whereas immediate postoperatively oral, parenteral and enteral and at discharge oral and/or enteral nutritional supplementation were used. Timing, definition and means of postoperative oral intake also seemed to differ widely accross centres.

Conclusion The PONOS survey confirmed our assumption that peri-operative feeding after oesophagectomy exists in a wide variety across the recently appointed reference centres in Belgium. The recent centralisation of centres performing oesophagectomy might enhance the exchange of experiences in order to try to harmonise nutritional care pathways.

ABSTRACT. Background: Total robotic-assisted Aorto bifemoral Bypass for both occlusive disease and infrarenal aneurysm is safe and feasible with a good postoperative recovery in selected patients. We present our early clinical experience with aortobifemoral bypass, aided by the Da Vinci X Surgical System (Intuitive Surgical Inc, Sunnyvale, California).

Methods: Between Augustus 2019 and February 2020, we performed ten robot-assisted laparoscopic aorto-bifemoral bypasses for both aorto-iliac occlusive disease (8 cases) and infrarenal aortic aneurysm (2 cases). Seven of the patients were male; Three of them were female. Median age was 58 years. Both dissection of the aorta using a transperitoneal retrocolic approach (reported by Coggia) and the aortic anastomosis were performed by the robotic system.

Results: The robot-assisted anastomosis was successfully performed in 9 patients. Conversion was necessery in one patient for bleeding. Median operative time was 262 min (range: 181–380), with a median aortic clamp-time of 55 min (range: 28–84). Median blood loss was 658 ml (range: 100–1548). No conversion was necessary. Postoperative complication occurred in one patient who underwent laparoscopic surgery for retained foreign body (O-6 Needle) causing abdominal pain and discomfort, 3 weeks after robotic surgery. Mean Intensive care Unit stay was 1 day. Mean hospital stay was 5.8 days (Range: 3-11).

Conclusion: Aorto-bifemoral bypass using a total laparoscopic approach can be performed safely. Despite the learning curve observed in all new techniques, our extensive experience in total laparoscopic aortobifemoal ByPass allows shorter operative and aortic clamp-time, reducing therefore postoperative complications and hospital stay. Nevertheless, this technique should be evaluated in a larger randomized trial to assess its accurate clinical value

ABSTRACT. Endovascular aneurysm repair (EVAR) is an established method for treating abdominal aortic aneurysms. The second generation of stent grafts addressed problems of anchoring and sealing at the neck of the aneurysm. Graft occlusion is a complication with a reported incidence of 0% to 7,2% and is still poorly understood. We present a case of a 75-year old patient that was referred to our centre with a total occlusion of his aortic stent graft from 3cm under the right kidney artery downward, only one month after implantation. The body and both limbs of this aortobi-iliac graft were occluded as well as both the iliac axes down to the femoral bifurcation. Because of its suprarenal fixation, we performed a partial explantation of the distal part of the graft. Then we constructed an aortobifemoral bypass with a classic Dacron graft after thrombectomy of both iliac axes down to the common femoral artery. We will discuss the causes of stent graft occlusion and possible risk factors as well as the treatment options.

ABSTRACT. Objective: The purpose of this study was to further investigate the safety and feasibility of percutaneous axillary artery access (PAxA) using vascular closure device for different endovascular procedures. Methods: All patients, in which PAxA was used, in our hospital in the period between 1/2019 and 12/2019 were included in this study. PAxA was used not only for endovascular repair of thoracoabdominal aneurysms with fenestrated or branched endoprotheses but also for visceral revascularization and complex iliac branched devices. Different sheath sizes were used, varying from 6-12 french. Ultrasound guided percutaneous puncture was performed with the use of one Proglide closure device. Endpoints were primary technical success, need for secondary closure procedure, cerebrovascular complications, peripheral nerve damage, other regional complications and 30 day complications. Results: Twenty-three patients were included, 20 male patients and 3 female). Axillary artery size varied from 6-10mm. In 12 (52%) patients PAxA was used for upper extremity access in thoracoabdominal aneurysm repair, in 8 (40%) patients PAxA was used for mesenteric revascularization, in 3 (13%) patients for complex iliac branched devices. Successful PAxA was performed in all patients. Primary success was achieved in 95.7% (22/23 patients). Only one patient needed additional covered stenting of the axillary artery to achieve closure of the puncture site. One patient suffered from temporary peripheral nerve damage with some numbness. Other complications were not related to PAxA and included pneumonia, cardiac failure (3/23 patients). Conclusion: Percutaneous axillary artery access with a Proglide closure device is a feasible and safe method for upper extremity access with limited complication rate. PAxA can be used, not only for thoraco-abdominal aneurysm repair, but also for other procedures such as visceral revascularization.

ABSTRACT. OBJECTIVE A compression of the coeliac trunk by the median arcuate ligament (MAL) is often asymptomatic. The diagnosis of MALS is made in patients who suffer from chronic, often nonspecific, epigastric pain and already underwent numerous diagnostic investigations. It is believed that chronic mesenteric ischemia only occurs if the superior mesenteric artery (SMA) is involved due to its anatomical importance. However, patients suffering from MALS often exclusively have compression of the coeliac trunk. One of the hypotheses is that symptoms are related to compression of the coeliac plexus. In this small case series we want to focus on the surgical technique and short-term results which could shed light on the pathophysiology of MALS.

METHODS In four consecutive patients with MALS we conducted a laparoscopic transperitoneal retrorenal release of the MAL (video available). On the second postoperative day a diagnostic angiography with PTA(S) of the coeliac trunk was performed if a high-grade stenosis was persistent. One day post PTA, patients were discharged from the hospital.

RESULTS Of the four patients suffering from coeliac trunk compression, none had a stenosis situated at the SMA. Compression of the coeliac trunk by the MAL was confirmed peroperatively and a clear decompression of the artery was seen with section of the MAL. Intervention time was around one hour. No significant complications occurred. Postoperative results immediately after laparoscopic release show full relief of the subjective patient-specific chronic abdominal pain in spite of the persistent stenosis in all patients. The persistent arterial stenosis was dilated successfully on the second postoperative day.

CONCLUSIONS The laparoscopic transperitoneal retrorenal approach is a straightforward method with promising results to release the coeliac trunk in patients with MALS. Postoperative patient feedback, in combination with anatomical cornerstones, suggests a neurological (coeliac plexus) rather than a vascular underlying cause. However, long term results need to be further assessed.

ABSTRACT. OBJECTIVE – Vascular graft infection is a rare but feared complication after arterial reconstruction. In situ reconstruction combined with thorough debridement is now considered as the treatment of choice. Several materials and techniques have been proposed to perform these secondary reconstructions but for most only small series are available. We studied our results with the use of cryopreserved arterial allografts (CAA) for this indication. METHODS - 142 patients treated between January 2000 and December 2018 with CAA for vascular prosthesis infection were retrospectively reviewed in a single centre study. Short and long term outcomes were reported and uni- and multivariate statistical analysis was performed in search of risk factors. RESULTS - Patients undergoing aorto-iliac (n=98), femoral (n=21) and extra-anatomic (n=23) revascularizations with cryopreserved allografts were included. The 30 day mortality and in-hospital mortality were 10,4% and 8,9%, respectively. Long term outcomes at 1, 3 and 5 years, were 83,6%, 82,1% and 79,7% for graft related survival; 66,6%, 49,9% and 35,6% for overall survival; 76,1%, 64,7% and 55% for primary patency. Reinfection rate was 7,8%. The Chi-square test and Cox regression analysis showed that antibiotic treatment of less than 3 weeks after hospital discharge was a risk factor for overall mortality (p= 0,035 at 1 year, p=0,007 at 2 years), ASA 4 for graft related mortality (p=0,012), aorto-enteric fistula for graft related reintervention (p=0,003 at 1 year, p<0,003 at 2 years) and ABO mismatch for primary patency (p=0,011 at 1 year and p=0,038 at 2 years). CONCLUSION – The treatment of vascular graft infections remains a challenge for patients as well as physicians with high morbidity and mortality rates. Consensus about the right treatment method is still lacking. We obtained excellent results with cryopreserved allografts in different areas. These compare favorably to the use of prosthetic materials or autologous veins for this indication.

ABSTRACT. OBJECTIVE: We report the case of a 34-year-old male who was referred to the emergency department after the recent onset of jaundice, weight loss and pain in the upper abdominal quadrants. Insignificant medical history, apart from 10 pack year. METHOD: CT-scan showed a cystic structure at the hepatic hilum of 14 cm diameter with intra- and extrahepatic bile duct dilation and a thrombus in the inferior vena cava. Total bilirubin was 12 mg/dl. Careful interpretation of the imaging led to the diagnosis of a type IV4a bile duct cystic dilation (multiple intra- and extrahepatic bile duct cysts - according to the modified Todani classification) with a thrombus in the IVC as a result of compression. Due to the risk of malignant transformation, an oncologic resection of the affected bile duct segments was planned, although no malignancy was suspected. RESULTS: Surgery was performed according to the planning with a combination of left hepatectomy, duodenopancreatectomy and thrombectomy of the inferior vena cava. There were no major complications and the patient was discharged after 20 days. Pathology report showed a pT3N2 cholangiocarcinoma with R0 resection. CONCLUSIONS: Cystic dilations of the bile ducts are rare disorder which can pose diagnostic and therapeutic challenges, especially when only recognized at a later age. Without giving away the clues beforehand to our trainer-trainee case: the diagnostic work-up, the interpretation of imaging and treatment will be open for an interactive discussion.

ABSTRACT. EPITHELIOID ANGIOSARCOMA, A RARE COMPLICATION OF ENDOVASCULAR ANEURSYM REPAIR Maxime Foguenne and Denis Dasnoy.

We report the case of an 67-years old man presenting an epithelioid angiosarcoma developing from the left iliac artery and occurring four years after the endovascular repair of a left primitive iliac aneurysm.

42 months after initial surgery, a left iliac artery angioplasty-stenting was performed for parietal thrombosis of the prosthesis, causing claudication.

1 month later, the abdominal CT demonstrated a size augmentation of the aneurysm, which was assumed to be an type-2 endoleaks ; this diagnosis was refuted by surgical arteriography. During the same procedure, a new left iliac artery angioplasty-stenting was performed for recurrence of parietal thrombosis.

3 months later he presented an abdominal and dorsal pain, constipation and weight loss. On biology, he suffered from an inflammatory syndrome without association with fever. The radiological findings showed both parietal thrombosis of the right iliac artery and growing enlargement of the initial aneurysm site without evidence of endoleaks. The MRI showed no arguments for a spondylodiscitis. PET-CT revealed an hyperfixation at the endoprosthesis-site; there was no capture on the marked-white blood cell scintigraphy. Hemocultures were 3-times sterile, a trans-esophageal echocardiography was performed without signs of endocarditis.

With all this information, the diagnosis of endovascular graft infection was retained, the Dacron-endovascular graft was totally removed and a new aorto bi-iliac prosthesis was implanted by laparotomy.

The bacteriological analyses of the initial graft were sterile instead of the anatomo-pathological analysis which revealed an epithelioid angiosarcoma developing from the prosthesis ; a taxol-based treatment was immediately started. Unfortunately, the patient’s general condition worsened very quickly with development of multiple lymphadenopathies in both inguinal regions. The patient was transferred for palliative care a few days later.

ABSTRACT. OBJECTIVE To discuss the treatment of an erosion of the small intestines and formation of an entero-cutaneous fistula after repair of a perineal hernia after rectal amputation in 2007. The perineal hernia was first repaired by Permacol mesh in 2009 and after recurrence a Ventralex mesh was used in 2015. Our patient developed perineal pain, but initial examinations showed no anomalies. After, she also developed high fever, redness and fluctuation. A CT scan showed a perineal collection in the pelvis, alongside irritated edematous small intestines.

METHODS Antibiotic treatment was started. Because of persistent high fever the fluctuating perineal swelling was punctured under echo-guidance, resulting in persistent faecal drainage from the wound. Firstly, parenteral nutrition, somatostatin and Imodium were commenced and peroral intake was stopped. Secondly, the mesh was removed via perineal incision combined with debridement and suturing of the eroded portions of small intestine. Thirdly, a laparotomy was performed one week later because of recurrent fecal drainage from the perineal wound. An ileal resection of 2 eroded portions of small intestine was performed.

RESULTS After the last surgery, enteral feeding could be recommenced and somatostatin and Imodium were ceased. The perineal wound was treated twice daily with topical wound care and later with vacuum-assisted-closure with good results. The postoperative course was complicated by herniation of the stomach in the known parastomal hernia and by Candida septicaemia, both successfully treated, after which our patient had a further favourable recovery and was transferred to the revalidation unit of the hospital.

CONCLUSIONS Our patient developed an entero-cutaneous fistula due to erosion of small intestines after mesh-repair of a recurrent perineal hernia after rectal amputation. This was successfully treated by a two-staged surgery: the mesh was removed via perineal approach and via laparotomy the affected small intestine was resected and anastomosed. The perineal wound was treated by vacuum-assisted-closure.

ABSTRACT. Case: A 52-year-old woman suffered from Budd-Chiari syndrome and extensive splanchnic thrombosis, secondary to polycythemia Vera, with underlying TET2 mutation. There was no hepatic failure, but she suffered from therapy refractory esophageal varices and hemorrhoids. Due to cavernous transformation of the portal vein, TIPS was deemd technically not possible. A meso-caval shunt between the still partially open superior mesenteric vein and the vena cava was constructed. Unfortunately, shortly thereafter, shunt thrombosis occurred due to accidental interruption of anticoagulation rivaroxaban. Restoration of anticoagulation failed to recanalize the shunt. At surgical revision it was impossible to reopen the meso-caval shunt. As an alternative, we decided to perform a shunt between the still open inferior mesenteric vein and the left gonadal vein. A splenectomy was also performed.

Results: In the postoperative period, there was a quick physical recovery, but a lymph leakage needed to be treated by lymphography and lipiodol embolization. Gastroscopy after one month already showed signs of diminished esophageal varices. At three months there was almost no sign of varicose veins in the esophagus, nor did she have any more complaints of her hemorrhoids.

Conclusion: Budd-Chiari and splanchnic thrombosis can cause severe portal hypertension. TIPS is frequently used when the portal vein is still open. When TIPS cannot be performed, surgical shunting may become necessary. In our case our ‘out of the box’ approach was the construction of a shunt between the inferior mesenteric vein and the gonadal vein. This resolved the portal hypertension symptoms.

ABSTRACT. OBJECTIVE: Endovascular aortic aneurysm repair (EVAR) is a popular minimal invasive technique to treat infrarenal abdominal aortic aneurysms (AAA). In those aneurysms with unsuitable anatomy open surgical repair remains the golden standard but fenestrated EVAR (FEVAR) or branched EVAR (BEVAR) may be an alternative to treat juxtarenal or thoraco-abdominal aneurysms (TAAA). The objective of this study is to report our results with this technique and to evaluate its safety and efficacy. METHODS: A retrospective single center cohort study analysing all consecutive patients undergoing a complex endovascular abdominal aortic repair (FEVAR or BEVAR). RESULTS: Hundred patients underwent a FEVAR or BEVAR between June 2012 and December 2019. Mean age was 73,3; 94% of the patients were male, 47% had a history of coronary artery disease and 31% of aortic repair. Sixty percent of the patient were treated because of a juxtarenal and 40% because of a TAAA with a mean diameter of 61,6 mm (SD 8,19). In 64% a device with four fenestrations or branches was used. Thirty-day in hospital mortality was 5%, with three deaths occurring during the initial 25 procedures (12%) and two in the next 75 cases (2,7%). Mean follow-up was 33,6 months with an overall survival of 67,5 %. One year survival was 86,7% and 3-year survival was 78,7%. Major reinterventions were required in seven patients and minor in five patients. During follow-up seven renal artery events were observed in 6 patients resulting in temporary dialysis in two patients and permanent dialysis in another two cases. CONCLUSION: This study demonstrates that fenestrated and branched endovascular repair is a safe and feasible treatment modality for juxtarenal and thoracoabdominal aortic aneurysms with acceptable complication rates but is associated with a learning curve.

ABSTRACT. OBJECTIVE Good radiation safety practice in the angiosuite is essential to protect patients and healthcare workers. Most strategies aim to advance radiation safety through technological upgrades and educational initiatives. However, safety literature suggests that additional ways to improve radiation safety in the angiosuite do exist. The safety climate reflects the way team members perceive various key characteristics of their work environment and is closely related to relevant safety outcomes. A specific ‘radiation safety climate’ has not been described nor studied in the hybrid angiosuite. This study explores the radiation safety climate in the hybrid angiosuite and its relation to team members' radiation safety behavior, knowledge and motivation.

METHODS Vascular surgeons, fellows/trainees and operating room nurses active in the angiosuite at five hospitals were invited to complete an online self-report questionnaire assessing the radiation safety climate (28 items); radiation safety behavior; radiation safety knowledge and radiation safety motivation. Relations between climate scores and behavior were investigated using Pearson correlations. Mediation was analyzed using the Barron-and-Kenny analysis. P-Values < 0.05 were considered statistically significant.

RESULTS No major differences were identified in total radiation safety climate scores between centers or team member functions. Scale reliability for radiation safety climate was good to excellent (α > .663). Total radiation safety climate scores were positively related to the radiation safety behavior score (r=.403; p=.015). This relation was partially mediated by radiation safety knowledge (95% CI: β=0.1730 CI: [.0475 - .3512]), while radiation safety motivation did not act as a mediator: (95% β=0.010; CI: [-0.0561; 0.0998]).

CONCLUSION A well-developed radiation safety climate in the hybrid angiosuite fosters positive radiation safety behaviors, which may partially be explained through improved radiation safety knowledge transfer. Further research on (radiation) safety climate and its impact on radiation safety-related outcome measures for patients is recommended.

ABSTRACT. OBJECTIVE: Heparin induced thrombocytopenia (HIT) is an autoantibody mediated, life threatening complication of exposure to heparin. The clinical presentation of HIT varies widely from only thrombocytopenia to thromboembolic complications involving both the arterial and venous systems. Our purpose is to present a rare case of a 72-year-old woman with a clinical presentation of threatening bilateral lower limb arterial insufficiency. Given the suspicion of aortic thrombosis, an angiography was made, revealing complete aortic occlusion beneath the inferior mesenteric artery. An emergency Fogarty thrombectomy was executed. Postoperatively thrombocytopenia was seen, and Heparin-platelet factor 4 autoantibody testing was positive. Fondaparinux was administered. After this procedure our patient recovered completely with capacious perfusion. Furthermore, our objective is to perform a literature review regarding HIT manifestations and the necessity of vascular surgery. METHODS: An extensive literature search was performed in different databases (PubMed, and Web of science). RESULTS: Literature search resulted in a limited number of useful articles (19). More venous than arterial thromboembolic complications of HIT were described. Non-heparin drug therapy was sufficient in most cases; exceptional surgical intervention was needed. In only two cases a partial amputation was reported after phlegmasia cerulea dolens. Additionally, three vascular surgical interventions, thrombectomies, are described owing to HIT. Only one case of aortic thrombosis after aortic surgery due to HIT has been described, leading to lower limb ischemia (wherefore thrombectomy), but also fatal mesenteric embolism. CONCLUSIONS: Although arterial ischemia is a rare complication of HIT, a high level of suspicion and a prompt diagnosis of this coagulation disorder are necessary to avoid life-threatening thromboembolic complications. In most cases non-heparin drug therapy is sufficient, and no surgical interventions are needed. We describe a rare case of acute aortic thrombosis, complicated with lower limb ischemia and need for surgical intervention. Adequate and fast operative and drug treatment are mandatory.

ABSTRACT. Vascular management of aneurysms in patients with genetic disorders We report a case of a 38-year-old male with Loeys-Dietz syndrome (LDS) suffering from major aortic complications. LDS is an autosomal dominant connective tissue disease. It is a rare multisystemic disorder with serious vascular impact, it includes vascular tortuosity, aneurysm formation and aortic dissections. LDS is caused by mutations in the transforming growth factor (TGF) beta-receptor I (TGFBR1) and II (TGFBR2) genes. In this particular case, the mutation concerned the TGFBR2 gene. The disease initially manifested itself as a type A dissection, successfully treated by open ascending aorta replacement. In the immediate postoperative period, the patient presented an asymptomatic type B dissection from the descending thoracic aorta to the iliac arteries. During follow up, the patient became symptomatic in his left leg (rest pain). Due to major true lumen compression, an endovascular treatment (TEVAR) was retained. Computer tomography angiogram (CTA), realized during follow up, showed a persistence false lumen perfusion and an aortic diameter increase. Multiple additional endovascular procedures and a final open procedure were needed to exclude completely the false lumen. Open surgical repair is still the gold standard therapy for patients with connective tissue disease. With the nowadays progress in endovascular technologies; hybrid procedures (combining endovascular with open surgery) could be a better option. The goal of a hybrid procedure is to reduce the morbidity and mortality associated with extensive aortic repairs, and at the same time, offering a durable treatment to these young patients. With this article we want to show that a hybrid procedure is a safe and feasible option with good short-term results in a patient with LDS.

ABSTRACT. Background Innominate artery aneurysms (IAA) are extremely rare. There etiology is mostly degenerative. In contrast to thoracic/abdominal aortic aneurysms, the main risk of an IAA is a thromboembolic event. Approximately one sixth of patients present with a CVA/TIA. Other symptoms can be caused by the mass effect and/or rupture of the aneurysm: dysphagia, vena cava superior syndrome, hoarseness, Horner’s syndrome and a palpable, sometimes painful supraclavicular mass. Because of improved imaging techniques and intensified screening for thoracic pathology most IAAs are diagnosed during routine screening or follow-up. The gold standard treatment of IAA is the use of an interposition graft. When the aortic arch is involved as well, cardiopulmonary bypass and deep hypothermic circulatory arrest may be necessary. Methods We present a case of a 73-year-old Caucasian man with an asymptomatic IAA. The patient underwent an open bifurcated graft replacement for an infrarenal aortic aneurysm and an open tubular graft replacement for an aneurysm of the thoracoabdominal aorta. During follow-up a progressive growth of the IAA was observed. When it reached 35mm in diameter, surgery was proposed. We describe a hybrid technique: a total debranching of the aortic arc with a simultaneous antegrade thoracic endovascular aortic repair (TEVAR). Results After an uneventful recovery, the patient was discharged from hospital at day 5. A CT angiography one month postoperative showed a successful debranching with excellent alignment of the endovascular stent without sign of endoleak. Conclusions Hybrid approach to innominate aneurysms is feasible and safe. It makes aortic cross-clamping and deep hypothermic circulatory arrest unnecessary. This case is remarkable because an antegrade TEVAR was implanted in the same procedure as the debranching.