ABSTRACT. Objective Although Hartmann’s procedure is commonly performed, subsequent reversal is less frequent. The most common reasons for declining intestinal reconstruction are advanced age, high ASA score and short rectal stump. The main objective of this study was to investigate if length of rectal stump influences the outcome of Hartmann’s reversal procedure.

Methods We retrospectively analyzed data from 105 patients who underwent Hartmann’s reversal procedure between 2007 and 2019 in two centers. We evaluated following variables: patient demographics, length of rectal stump, intraoperative surgical details, short-term and long-term outcomes. Length of rectal stump was measured in centimeters as well as according to the sacral vertebra reached by the Hartmann’s stump.

Results From 2007 to 2019, 105 patients underwent Hartmann’s reversal procedure. There were 65 men (60%). Nine patients were above 80 years old (9%). Short-term morbidity rate was 58% (61 patients), including 16% (17 patients) with severe postoperative complication (Clavien-Dindo≥3). Anastomotic leakage rate was 2.9% (3 patients). Long-term complications were present in 41% (43 patients) of which abdominal wall defect was the most frequent complication. The mean length of the rectal stump was 15 centimeters. In almost 1 out of 5 patients (17%) the rectal stump was shorter than 10 cm. In 1 out of 4 patients (27%) the rectal stump did not reach the third sacral vertebra. The three anastomotic leakages appeared in the long rectal stump group (3.6% vs 0%, p=0.273). The complication rate for patients with a short rectal stump was similar to those with a longer rectal stump (50% vs 63%, p=0.275). Smoking, high ASA score, obesity and advanced age did not influence the outcomes of the intestinal reconstruction intervention either.

Conclusions Length of the rectal stump is not a predictive factor for postoperative complications after Hartmann’s reversal procedure. Intestinal restoration can be performed safely in patients with short rectal stumps.

ABSTRACT. Objective: The efficacy of sacral neuromodulation (SNM) in the treatment of low anterior resection syndrome (LARS) is still poorly documented compared to its efficacy for fecal incontinence (FI). The primary aim of this study was to report on the short and long-term efficacy of SNM therapy for patients with LARS at our center. Furthermore we evaluated the safety of the procedure as well as the relevance of adequate follow-up. Methods: A retrospective analysis was performed upon a prospectively maintained database of all patients who underwent SNM therapy for major LARS between January 2014 and January 2019. The Wexner and LARS score were evaluated at baseline, during test phase, after definitive implantation and annually during follow-up. Treatment success was defined as at least 50 % improvement of the Wexner score compared to baseline and a reduction to minor or no LARS. Results: 25 patients with LARS who underwent a SNM test phase. Mean age was 65 years with a male to female ratio of 16/9. Almost all of the LARS patients (23/25) underwent a LAR for colorectal malignancy. 17 patients were eligible for implantation of the permanent SNM device. Eventually, 16 patients had an implantation. All patients had severe fecal incontinence. The median LARS scores of the patients at baseline, 3 weeks, and 1,2,3,4 and 5 years were 40, 12.5, 12, 14, 12, 14 and 16 respectively (Fig. 1). The median Wexner scores of patients at baseline, 3 weeks, and 1,2,3,4 and 5 years after definitive implantations were 18, 4, 5.5, 5, 4, 3 and 4 respectively (Fig. 1). Revision was required in 18.7% of the patients. Conclusions: SNM therapy is a safe and effective treatment for patients with LARS. Adequate follow-up is essential to ensure long term effectivity.

ABSTRACT. Objective To evaluate functional outcome in patients following rectal cancer resection at long-term and to identify the risk factors associated with worse functional outcome.

Methods From January 2010 to December 2012, all consecutive patients who underwent resection for rectal cancer were included. Data were retrospectively retrieved from a prospectively maintained database. Rectal function was assessed by LARS (Low Anterior Resection Syndrom) score, Urinary disorder was evaluated by USP (Urinary Symptom Profile) score and sexual function by Female Sexual Function Index (FSFI) or Male Sexual Health Questionnaire (MSHQ).

Results A total of 80 patients completed the trial with a mean age of 65 ± 11,8 years (range 35-90). The mean follow-up time since surgery was 104 months (range 86–121). Preoperative radiochemotherapy was given to 26 (32,5%) patients. At preoperative work-up, the median level of tumor from the anal sphincter was 7,6 ± 3,1 cm (range 2-11). Colorectal anastomosis was done within the middle third of the rectum in 35 (44%) patients, within the lower third in 37 (46%) patients. Eight (10%) patients underwent coloanal anastomosis. A straight anastomosis was created in 52 (67%) patients followed by side-to-end anastomosis in 22 (28%) patients and colonic JPouch in 6 (8%) patients. LARS was reported by 50 (63%) patients (27 with major LARS and 23 with minor LARS). Preoperative radiochemotherapy(P=0,006) and lower anastomosis(P=0,04) increased the risk of major LARS. Gender, age, type of anastomosis was not significant. Male and female sexual problems were reported in 33% patients and 18% patients respectively. Urinary disorder was reported by 42 (52%) patients. Subgroup analysis showed that Age > 75 at follow-up time (P=0,03) and preoperative radiochemotherapy (P=0,03) significantly increased the risk of urinary incontinence.

Conclusion Up to 60 percent of patients reported functional symptom more than 7 years following surgery. Preoperative radiochemotherapy and lower anastomosis were the most deleterious factors.

ABSTRACT. OBJECTIVE Iatrogenic ureteral injury (IUI) is a rare but feared complication in pelvic surgery. Some surgeons rely on prophylactic ureteral catheterization (PUC) to prevent accidental lesions. Unfortunately, no strong evidence illustrating such a benefit is found. The objective is to investigate the impact of prophylactic ureteral catheterization in pelvic surgery.

METHODS The database (1995-2018) of our tertiary referral hospital was retrospectively queried for ureteral repairs. The search yielded 845 unique patient files. After application of exclusion criteria and manual review of files, 155 individual cases remained. Statistical analysis was performed on the following parameters: surgery type, timing of injury discovery, duration until final catheter removal and postoperative complications.

RESULTS Prophylactic ureteral catheterization was shown to significantly enhance intraoperative injury discovery (p<0.001, number needed to treat 2.6) and significantly reduce postoperative complications (p=0.03).

CONCLUSIONS Prophylactic ureteral catheters appear to have a beneficial effect on iatrogenic ureteral injuries in pelvic surgery. A significantly reduced diagnostic delay and postoperative morbidity are found. Immediate repair reduces need for further diagnostics and secondary interventions.

ABSTRACT. Background: Rectourethral fistulas often arise as complications of prostate/rectal cancer treatment. Standard management and treatment still needs to be defined. The aim of this study was to report surgical outcomes with regard to number of attempts, type of operation and previous radiotherapy. Methods: This was a retrospective study of a prospectively maintained database. Men with acquired rectourethral fistula, who underwent surgical repair, were included. Surgical strategy was tailored to anatomical complexity of the fistula, presence of sepsis, history of pelvic radiation and residual urinary/fecal functionality. Techniques included transanal layered closure or mucosal advancement flaps, transperineal interposition flaps, transabdominal approach with primary fistula repair or en-bloc fistula removal +/- restoration of bowel/urinary tract continuity. Outcomes measured were successful fistula closure, permanent fecal/urinary diversion and impact of radiotherapy. Results: Between 2002 and 2019, 52 patients were identified. Overall, rectourethral fistula closure rate was 96.1% after a median follow up of 10.5 (0.5-16.8) years. Three patients (5.8%) had spontaneous closure of the fistula after conservative management. Forty-nine patients underwent a total of 76 procedures. Overall cumulative closure rates after the first, second and third attempts were 55.1%, 85.7% and 95.9%. Fistula closure together with preservation of the fecal/urinary function was achieved in 49%, 65.3% and 67.3% after the first, second and third repair. The overall success rate for transanal, transperineal, restorative transabdominal and non-restorative transabdominal procedures was 35.7%, 64.3%, 57.1% and 94.1%. A significant higher rate of urinary/intestinal stomas and transabdominal operations was observed in the irradiated vs non-irradiated patients (84.2 vs 42.4%, 70% vs 36.4%). Conclusion: Surgery is the mainstay of treatment for rectourethral fistula. Radiotherapy has a significant impact on the outcomes of surgical repair. When indicated, a transperineal repair with gracilis flap interposition has to be adopted as first surgical option. Transabdominal procedures in irradiated patients will ultimately lead to definitive urinary/fecal diversion.

ABSTRACT. BACKGROUND: Because of the clear volume-outcome relation for complex cancer surgery, Belgian government imposed centralization of pancreatic and esophageal surgery since July 2019. Several initiatives were taken to meet these volume criteria but a lot of them are clashing with the existing competitive atmosphere of our hospitals and there mindsets. With two of the bigger departments of our province we managed to overcome these drawbacks and turn it into a unique collaboration.

OBJECTIVE: To share our experience and evaluate the effect of centralizing pancreatic and esophageal cancer surgery in West Flanders.

METHODS: Since June 2019, all patients with pancreatic or esophageal cancer are discussed in a multidisciplinary team (teleconference with 10 sites). Patients with pancreatic cancer are exclusively operated in AZ Sint-Jan Brugge and patients with esophageal cancer in AZ Delta Roeselare. All patients are operated by 2 staff members. Demographics, pre-, per- and 90-day postoperative data are stored in a national database.

RESULTS: In 2019, a total of 69 pancreatic and 42 esophageal resections have been performed. Median hospital stay was 11 days in each center. 30-day mortality was 0% (0/69) for pancreatic cancer and 2.4% (1/42) for esophageal cancer. In contrast to some presumed drawbacks (logistics, doctor-patient relationship), an overall improvement was seen: surgical techniques and postoperative care were standardized, co-operators were more familiar with the pathology, and postoperative morbidity/mortality is decreasing. Operating time, although not of primary importance, was reduced.

CONCLUSIONS: Centralization of pancreatic and esophageal cancer surgery in West Flanders was successful. Positive effects were seen on patient-outcome and on the experience of health care providers. The number of surgeries have been multiplied and a tendency of reduced postoperative morbidity and mortality was seen. This is a unique and successful collaboration and probably an example for similar initiatives in the future.

ABSTRACT. Introduction: Intraoperative margin evaluation during breast conserving surgery (BCS) is of critical importance for surgical treatment planning of breast cancer (BC) patients. Currently used techniques are time consuming with additional cost or are insufficient in accuracy. There is an obvious need for novel peri-operative strategies to assess the margins of breast surgical specimens. Indocyanine green fluorescence imaging (ICG-FI) has emerged as a new technique for improving tumor detection and to guide surgical resection in different oncological conditions. The purpose of this study is to evaluate the role of ICG-FI for intraoperative assessment of surgical margins during BCS. Material and methods: Patients with BC who underwent BCS were prospectively included in this study. Free ICG (0.25 mg/kg) was injected intraoperatively. ICG-FI were correlated with the final pathological reports. Signal-to-background ratio (SBR) was calculated for all breast surgical cavity. Results: Thirty-five breast surgical specimens from 35 patients were analysed. Positive margins at final pathology were identified in 5 (14.7%) breast surgical specimens The median SBR in patients with positive margins was 1.8 (SD 0.7) and 1.25 (SD 0.6) in patients with clear margins (p=0.05). At ICG-FI evaluation of breast surgical cavity, 15 of them were classified as hyperfluorescent and 20 as non-fluorescent. The sensitivity, specificity, negative predictive value, false negative rate, and false positive rate of ICG-FI for breast surgical margins evaluation were 100% , 60%, 100 % , 0% and 40% respectively. Conclusions: Intraoperative ICG-FI of surgical margins in BCS had a good sensitivity (100%) but is not specific enough (67%) to discriminate between benign and malignant breast residual tissue. Nevertheless, its high negative predictive value (100%) could make it an appropriate tool for intraoperative evaluation of breast surgical margins during BCS, reducing the risk for unnecessary additional resections.

ABSTRACT. OBJECTIVE: Inflammatory myofibroblastic tumors (IMT) are rare and intermediate malignancy diseases with frequent somatic molecular rearrangement. In the Era of targeted therapy, guidelines on optimal management are lacking. METHODS: We retrospectively reviewed patients with IMT treated in 5 tertiary pediatric centers between 2000 and 2018. RESULTS: Thirty-four cases were identified. Median age at diagnosis was 7 years (range:1m-16y). Tumor location included thorax (n=13, one metastatic), abdomen (n=12), head and neck (n=7) and limbs (n=2). One patient had metastatic disease. Fifteen cases (44%) were ALK-positive, 5 ROS1-positive and 4 ETV6-NTRK3-positive. Primary surgery was performed for 22 patients (65%): 13 R0 resections, 4 R1-margin and 5 voluntary partial resections for organ preservation, with complementary treatment for 3 of them. One patient had mutilating surgery. Seven patients had various medical therapies (anti-inflammatory, targeted therapy and/or chemotherapy), followed by delayed surgery (R0=4, R2=3). Four patients received only a medical therapy and one orbital IMT was not treated. After a median follow-up of 25 months (range:1m-9.3y), 6 recurrences occurred (5/22 primary surgery and 1/7 delayed surgery), all in thoracic group. Three-year event-free and overall survival were respectively 79% (95% CI, 65-96%) and 96% (95% CI, 88-100%). Quality of resection (R0 vs R1/R2) was not associated with higher tumor failure (18% vs 50%; p=0.1941), but location influenced outcome, thoracic tumors having highest risk of recurrence (0% vs 61%; p=0.0002). Three-year event-free-survival was not statistically different comparing cases with or without somatic molecular abnormalities (75% vs 89%;p=0.3955). CONCLUSION: Surgery is effective in most pediatric IMT. If needed, neo adjuvant therapy, including targeted therapy, should be proposed to allow adequate and non-mutilating surgery. The role of other medical therapies should be better evaluated.

ABSTRACT. OBJECTIVE In patients with stage III epithelial ovarian cancer (EOC), the addition of hyperthermic intraperitoneal chemoperfusion (HIPEC) to interval debulking was recently shown to improve survival compared to surgery alone. However, the added benefit of hyperthermia remains unknown. Here, we report secondary outcomes of the OvIP study (NCT02567253), a multicenter randomized trial investigating tumor tissue platinum penetration after normothermic (37°C) versus hyperthermic (41°C) chemoperfusion with cisplatin at 75 or 120 mg/m2. METHODS Following optimal debulking, chemoperfusion with cisplatin was performed during 90 minutes, and sodium thiosulphate was administered IV during chemoperfusion. Morbidity up to 30 days after surgery was calculated using the comprehensive complication index (CCI). Intact cisplatin levels were determined in perfusate and plasma samples using UHPLC-MS/MS, after which area under the curve (AUC) and half-life (T1/2) were computed with noncompartmental analysis. Statistical analysis was performed using the student t, one-way ANOVA and chi squared tests. RESULTS Fifty-four patients were included. The highest dose was amended to 100 mg/m2 due to higher than expected renal toxicity. The mean CCI was similar between the normothermic and hyperthermic chemoperfusion groups (37.1 versus 28.5, P=0.20). Specifically, length of stay, reoperation rate, and readmission rate were similar. The AUC of intact cisplatin in the peritoneal perfusate was similar between groups at both low and high dose (P=0.63 and 0.52, respectively). Mean T1/2 in perfusate was significantly lowered by hyperthermia in the low dose group (39.3 min vs 33 min, P=0.041), and to a lesser extent in the high dose group (42.8 min vs 33.4 min, P=0.068). Hyperthermia had no significant effect on AUC in plasma in both groups (P=0.19 and P=0.44). Mean AUC ratioperfusate/plasma was similar in all groups (9.6 , P=0.26). CONCLUSIONS Compared with normothermic chemoperfusion, hyperthermia does not affect surgical morbidity. Hyperthermia enhances peritoneal cisplatin absorption, without significant effects on plasma drug exposure.

ABSTRACT. OBJECTIVE Ingrown toenail removal is a relatively simple procedure for a very common problem. Patients often report severe pain scores after the procedure due to excision of the very sensitive nail matrix. We propose injection of long-acting local anesthesia immediately after the procedure to reduce patient discomfort and enhance postoperative recovery.

METHODS We conducted a single-blind, randomized controlled trial in which 51 patients (age 10-81 years) were randomly distributed in a control group (25 patients) and a treated group (26 patients) receiving 10 mL 7.5mg/mL local ropivacain injection in the operated toe immediately after the procedure. Surgery was performed under spinal anesthesia. A wedge excision of the toenail was followed by matricectomy and curettage of the wound bed. A questionnaire was given at discharge with a visual analogue scale (VAS) to score pain immediately after surgery, at discharge, on the evening of surgery, and the following morning. A linear mixed-effect model in IBM SPSS Statistics 26 was used to analyze the data.

RESULTS Patients assigned to the treated group reported significantly lower pain scores at every time of measurement. Pain scores were significantly higher in both groups before bed and the following morning compared to immediately after surgery (VAS 4.14±0.62 vs. 1.9±0.37; VAS 4.43±0.76 vs. 2.45±0.477, respectively). Before bedtime, the difference between groups was most significant (p<0.001) (Fig 1). Within both the control and treated group, there was no significant difference in pain scores immediately after surgery and at discharge, and before bedtime and the following morning.

CONCLUSIONS Postoperative local infiltration is a useful and cost-effective strategy to enhance postoperative recovery and significantly reduce patient discomfort after ingrown toenail surgery.

ABSTRACT. Objective

Minor laparoscopic liver resection through day-case surgery becomes an attainable goal. The aim of this article is to evaluate the feasibility of an ambulatory surgery protocol while maintaining patient satisfaction and safety.

Methods

A single-center, prospective study including all patients who underwent minor laparoscopic liver resection between June 2019 and January 2020. Patient and procedure specific data were collected. The protocol was evaluated through an integrated pathway with multiple checkpoints. Pain scores and quality of life were assessed by telephone questionnaires day 1, 2 and 5 postoperatively. Subsequently, consultations were scheduled 1 week and 1 month after surgery. The primary outcomes were compliance of protocol and overnight admission rate. Secondary endpoints were complication data and satisfaction.

Results

Twenty patients underwent minor laparoscopic liver resection through day surgery. Mean patient age was 60 years (SD:13) with an average body mass index of 26.20 (SD:4.75). Indications for the procedure were liver metastasis (n=13), hepatocellular carcinoma (n=3) and benign lesions (n=4). In 19 patients a non-anatomical resection was performed, while one patient underwent a segmentectomy. Mean lesion size was 15.1 mm (SD:9.5). Twelve of the 20 resections involved posterosuperior segments. Mean operative time was 72 minutes (SD:15) and mean estimated blood loss was 77 ml (SD:159). There were two unplanned overnights (10%) due to urinary retention, one hospital readmission (5%) and no major complications/mortality. The overall compliance with the protocol was 80%. Mean pain VAS score of 1.72 (0.83) at discharge. 88.9% would re- opt for day surgery, with an average satisfaction rate of 4.92 (0.24), with 5 being highly satisfied.

Conclusion

The results of our experience in minor laparoscopic liver resections through day surgery add weight to the feasibility and safety of this approach. A detailed integrated pathway, multidisciplinary team and standardized pre- and postoperative assessments are essential for a successful day-case surgery procedure.

ABSTRACT. OBJECTIVE Pancreaticoduodenectomy (PD) is a complex surgical procedure with significant morbidity and mortality. The introduction of the Enhanced Recovery Program (ERAS) protocols has led to a reduction in hospital stay without compromising the surgical outcome regarding postoperative morbidity, readmission rate, reoperation rate and mortality.

METHODS In this single centre retrospective analysis all patients who underwent a pancreaticoduodenectomy at Ghent University Hospital between August 2016 and December 2018 were analysed. A total of 108 procedures were performed of whom 98 were enrolled in the ERAS protocol postoperatively. The primary endpoint of this study is to evaluate the adherence to the different targets of the ERAS protocol. The secondary endpoints were 30-day readmission rate, reoperation rate and mortality.

RESULTS The epidural analgesia was removed on POD2 in 18 patients (19.8%), NGT was removed on POD3 in 44 patients (45.8%) and a regular diet was tolerated by POD5 in 27 patients (28.7%). The lateral drain was removed in 51 patients (52%) on POD2, the medial drain in 25 patients (25%) on POD3 and the penrose drain in 57 patients (58.2%) between POD3 and POD10. Forty-two patients (42.9%) were discharged between POD5 and 10. Four patients (4%) had post-pancreatectomy haemorrhage (PPH), 7 (7%) postoperative pancreatic fistula (POPF) and 3 (3%) bile leakage. Twenty-seven patients (27%) experienced delayed gastric emptying (DGE). Seven patients (7%) were readmitted and 12 patients (12%) re-operated within one month of surgery. The in-hospital mortality was 1.8% within one month of surgery.

CONCLUSIONS The adherence to the targets of the ERAS protocol was found to be rather low. POPF, DGE, PPH and biliary leakage all led to an adapted ERAS protocol with prolonged LOS. In this study most of the complications were detected along the ERAS pathway, indicating that also patients at high risk for complications could be included in the ERAS-group.

ABSTRACT. Introduction: Standard laparoscopic cholecystectomy is the gold standard treatment for gallbladder diseases. In our department, we’ve been performing this procedure for 10 years by a single incision laparoscopic surgery. This surgical technique and its complications in obese patients are subject to many controversies. The aim of this study is to compare the outcomes of this procedure between normal weight patient and obese ones.

Methods: We retrospectively enrolled patients undergone single incision laparoscopic cholecystectomy at our hospital between 2009 and 2019. We divided patients into 2 groups according to their body mass index (BMI) with a threshold at 30kg/m^2. The study focused on the rate and severity of postoperative complications, the rate of conversion ,the rate of incisional hernia and subsequent surgical treatment. Patients have been clustered by age, gender, ASA score, BMI and comorbidities.

Results: From May 2009 to October 2019, we performed in our department 377 cholecystectomies by single incision laparoscopic surgery (SILS). We enrolled 100 men and 277 women aged between 4 and 87 years old. The mean BMI was 28.4kg/m^2. 127 patients have been included in the obese group (BMI higher than 30kg/m^2). We noticed more postoperative complications in the obese group (p= 0.03): 9 bile leakage were observed, of which 6 in the obese group. We also observed higher rate of conversion to standard laparoscopic surgery in the obese group (11% vs 6% p= 0.04) but no statistically significant difference about the rate of conversion to laparotomy between the 2 groups (p=0.18). The incisional hernia rate was equivalent between the 2 groups at 3 months (p=0.39) but higher by two fold in the obese group at 1 year (p=0.02).

Conclusion: SILS is a safe procedure in normal weight patients but results in higher rate of postoperative complications and incisional hernia on the long run in obese ones.

ABSTRACT. Objective. Pancreatoduodenectomy is a high-risk surgical procedure with substantial morbidity and mortality. The aim of this monocentric retrospective cohort study was to identify predictors of severe complications after pancreatoduodenectomy for malignant or premalignant pancreatic head and peri-ampullary tumors.

Methods. Between 2000 and 2018, pancreatoduodenectomy for pancreatic (n=691) or peri-ampullary (n=384) tumors was performed in 1075 consecutive patients (M/F 606/469; median (range) age 65 (14-85) years). Pancreatic texture was judged to be soft in 499 (46%) and pancreatic duct diameter smaller than 3 mm in 562 (52%) patients. Vascular resection was performed in 144 (13%) patients. Pancreatic duct stent was used in 249 (23%) and somatostatin or its analogues in 613 (57%) patients. Eighteen potential predictors of severe complications (Clavien-Dindo grade >3) were evaluated using univariate and multivariate cox regression models.

Results. Severe complications were observed in 207 (19%) patients, including 33 3%) postoperative deaths, 106 (10%) reoperations, and 62 (6%) patients admitted at the intensive care unit. Risk factors for the development of severe complications were the length of the surgical procedure (OR 8.585, CI 2.854–25.906; p<0.001), patient age (OR 5.032, CI 1.582– 16.515; p=0.005), intra-operative blood transfusion (OR 1.613 , CI 1.134–2.295; p=0.008), and ASA score 4 (OR > 7.185, CI 1.156-62.274; p=0.0278).

Conclusions. Older patients with ASA score 4 are at higher risk to develop severe complications after PD. Intra-operative blood transfusion and the length of the PD procedure reflect a more complex procedure and increase the risk of severe complications.

ABSTRACT. Objective. Pancreatic ductal adenocarcinoma (PDAC) is a devastating malignancy with poor survival, even after curative surgery. The aim of this retrospective single-center cohort study is to define predictors of survival after curative surgery for PDAC.

Methods. Between 2000 and 2018 pancreatic resection for PDAC was performed in 738 consecutive patients (M/F 390/348; median (range) age 66 (32–87) years). Pancreaticoduodenectomy was performed in 561 (76%), distal pancreatectomy in 146 (20%), and total pancreatectomy in 31 (4%) patients. Vascular resection was performed in 148 (20%) patients. Sixty-seven patients (9%) had neo-adjuvant systemic chemotherapy and 438 patients (59%) received adjuvant chemotherapy. Forty-two patients had synchronous metastases (pM+) at the time of surgery and were excluded for further survival analysis. Follow-up was closed in November 2019, with a median follow-up time of 17.3 months (range 0 – 188 months). Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. Twenty-one potential prognostic factors were evaluated using univariate and multivariate Cox regression models. Survival data were obtained from the national registry.

Results. Median disease-free survival was 12.6 (IQR 11.8-13.7) months, and median overall survival (OS) 21.1 (IQR 19.4-23.8) months. OS rates at 1, 3 and 5 y. were 73%, 30%, and 18%. In univariate analyses, tumor stage and surgical resection margin status were the most prominent predictors of survival (p<0.001). In multivariate analyses, the absence of extracapsular lymph node involvement (ECLNI) (RR 0.730, CI 0.541-0.984, p=0.039), laparoscopic resection (RR 0.618, CI 0.386-0.971, p=0.037), and younger age (RR 1.881, CI 1.012-3.531, p=0.047) had a beneficial influence on OS.

Conclusions. ECLNI, open surgical approach, and older patient age have a negative influence on survival after curative surgery for pancreatic adenocarcinoma. Efforts to implement minimally invasive surgery to treat PDAC should be stimulated.

ABSTRACT. Objective: Relatively high mortality and morbidity rates are reported after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). However, early predictors of complications after CRS plus HIPEC have not been identified. The aim of this study was to evaluate the predictive role of early postoperative serum C-reactive protein (CRP) level (Day 2-4) for the detection of post-operative complications. Methods: We performed a retrospective study including 94 patients treated with complete CRS (R1) and HIPEC for PC from various primary origins between 2011 and 2016. Post-operative complications were recorded. The values for postoperative inflammatory markers (white blood cells [WBC] and platelet counts, CRP) were compared between the different groups. Results: CRP on post-operative days 2-4 was significantly higher in patients with than without complications (124 mg/L vs 46 mg/L; p<0.0001) and higher in those with more major complications (162 mg/L vs 80 mg/L; p< 0.0012). The patients who were more prone to develop postoperative complications, were those in whom CRP levels tended to rise, and maintain a plateau between postoperative days 2 and 4. WBC and platelet counts showed no difference within 5 days postoperatively. Conclusion: CRP levels, and kinetics mainly, between post-operative day 2 and 4, are decisive predictive markers of early and late post-operative complications after CRS plus HIPEC. The presence of post-operative complications should be suspected in patients with a relatively high CRP mean, and a plateau level, on post-operative days 2-4.

ABSTRACT. Objective: Gastroschisis is a rare anomaly with a prevalence in Belgium of 1/10.000 births. We use the Alexis® wound protector-retractor (Applied Medical, USA) for newborns in whom the viscera could not be reduced at birth. The aim of this study was to evaluate the clinical outcomes of patients where a staged closure of gastroschisis with the Alexis® was performed, compared to the ones where primary closure of the defect could be achieved. Methods: Retrospective, bicentric study of 11 consecutive patients born with gastroschisis from 2012 to 2019. In six infants, primary closure of the abdominal wall could be achieved. Five needed a staged closure. In the latter, one of the rings of an Alexis® (size XS) was placed intra-abdominally after bringing the eviscerated organs inside the bag, under general anesthesia. Traction on the bag was daily applied in order to achieve further reduction of the viscera. The abdominal wall was closed in a second operation 5-8 days afterwards. Results: The median ventilation time was double as long when secondary closure was necessary: 10 days [9,15] versus 5.5 days [3,8]. Median start of enteral feeding commenced later when delayed closure was performed: 21 days [11,25] versus 10.5 days [6,27]. Full enteral feeding was accomplished on a median of 29 days [4,17] almost similar to primary closure: 31 days [19,60]. Median discharge time from NICU was after 34 days [25,48] and 31 days [19,60], respectively. One patient died due to volvulus 33 days postoperatively. Conclusions: Although infants who underwent delayed closure of gastroschisis had a longer need for mechanical ventilation, and enteral feeding was initiated later, the medium-term clinical outcomes are comparable to those of infants in which the defect was closed primarily. Staged closure with Alexis® Wound-Retractor is an easy, safe and reliable technique and does not complicate medium term prognosis.

ABSTRACT. OBJECTIVE: International rotations have shown to benefit training of medical residents due to exposure to an increased scope of pathologies, improved physical examination skills, communication across cultural boundaries, and more efficient resource utilization. Currently there is no formal mechanism for Belgian surgical residents to participate in international training opportunities and little research has addressed the attitudes of the Belgian residents about international rotations, volunteerism & humanitarian rotations. The goal of this study was to examine interest in international training of surgical residents. METHODS: A structured electronic questionnaire (Google Sheets) was exposed on residentsabroad.org and sent anonymously and voluntarily to a cohort of Belgian residents, including surgical residents, by email. RESULTS: 327 of the residents filled in the questionnaire, representing 10% of the total medical specialists in training. 34,5%(113) were surgical residents. Almost all residents want to undertake an international elective (95%), but a minority will actually do so (30%). Low-income countries are seldom visited (12%), as most residents perform a rotation in High Income Countries. Even without financial compensation (86%) or without formal recognition (66%), the majority of residents would like to gain international training experience. CONCLUSIONS: Belgian residents are highly motivated to undertake an international rotation during their training. Low income countries are seldom visited as shown in this questionnaire. To create more international mobility and cooperation Belgian universities and government bodies will have to facilitate administration and financial compensation.

ABSTRACT. Background

Surgical skills are under-taught in medical school, which can affect confidence in real-life situations. We organized surgical courses to improve student confidence and surgical skills. The aim of this study was to assess confidence and verify a near-peer model for quality and tutor accessibility.

Methods

A total of 180 medical students participated in four suturing workshops (two basic, two advanced). A 2-hour custom suturing and hand tie course on synthetic pads and pork feet was taught by final year medical students and young residents whom were supervised by a senior surgeon to ensure accessibility and quality. Advanced courses further included vascular anastomosis and layered suturing. Participants completed pre-and post-course Likert-scale questionnaires on operative confidence and course satisfaction, which were analyzed with a paired T-test.

Results

The mean overall rating (1–poor, 4-excellent) was 3.88 for the basic course and 3.92 for the advanced course. The accessibility and quality of the tutors was rated 3.93 and 3.90 respectively for the basic course and 3.94 and 3.92 for the advanced course. A statistically significant improvement in confidence was observed in basic surgical techniques in the basic (83%; p<0.001) and the advanced course (14%; p=0.01). Similar findings were noted for confidence in suturing in the operating theatre in the basic (74%; p<0.001) and advanced course (15%; p=0.03). Hand tying in theatre showed the most significant amelioration in confidence in both basic (108%; p<0.001) and advanced courses (48%; p<0.001).

Conclusions

Practical workshops provide an interactive and fun way for medical students to improve surgical skills. The use of a near-peer training model allows students to train under close supervision of young doctors who are confident to handle the hurdles faced by medical students. These supervisors provided relevant and appropriate advice and were easily accessible for the students.

ABSTRACT. Objective Preoperative risk stratification for malignancy in thyroid nodules avoids undertreatment and unnecessary surgery. The effectiveness of different preoperative risk stratification classifications based on ultrasonography (TIRADS classification) and cytology (Bethesda classification) have been previously reported. However, there are little data on how both classifications correlate. This study focuses on the correlation between TIRADS and Bethesda classification for preoperative risk stratification of thyroid nodules in a single center. Methods Data of 241 adults, diagnosed during a 1-year period (1st of April 2017 to 31st of March 2018), with a total of 276 thyroid nodules that were classified both according to TIRADS and Bethesda, were retrospectively reviewed. Correlation between radiological and cytological classification was analyzed based on their relative malignancy risk. Results Overall, a significant correlation between both classifications was found (R = 0.362, p<0.001). Categories with the lowest risk of malignancy (being < 5 %; TIRADS 2-3-4a versus Bethesda II; n=134) correlated in 96% of cases. Lesions that were classified by ultrasound in the higher malignancy risk category TIRADS 4b (n=69; 9.2 % malignancy risk) or TIRADS 4c-5 (n=42; 44.4 - 87.5 % malignancy risk) correlated with their respective cytological categories (Bethesda III and IV-V) in 14% and 21% of cases, probably (at least partially) related to an ultrasonographic risk overestimation in these nodules. When looking only at lesions classified by a dedicated radiologist (performing 62% of ultrasounds) this correlation increased to 19% and 27% for TIRADS 4b and TIRADS 4c-5 nodules respectively. Conclusions TIRADS classification is an appropriate risk stratification system for thyroid nodules, especially in benign nodules and when the ultrasound is performed by an experienced radiologist. However, since the good overall correlation is not absolute, both risk stratification systems are complementary in the evaluation of thyroid nodules, mainly for nodules categorized as suspicious for malignancy on radiological evaluation.

ABSTRACT. Background:

Technical and material evolutions in bariatric surgery aim at a reduction in mortality rate, complications and hospital stay. It is now well established that enhanced recovery program (ERP) can also lead to this objective. Our bariatric center was accreditated by “Le Groupe Francophone de Réhabilitation Améliorée après Chirurgie” (GRACE).

Objectives:

We assessed the impact of ERP in our bariatric surgery practice and studied which population could benefit the most from ERP.

Methods:

From January 2017 to December 2018, 345 patients underwent bariatric surgery (BS) in our center. We performed 185 Roux-en-Y gastric bypass (RYGB) and 160 Magenstrasse & Mill (M&M) procedures with a median BMI of 38kg/m2 (35–57,59). Patients were included in ERP following GRACE recommendations. We studied hospital stay duration, re-hospitalization rate at 30 days and factors that impacted these data.

Results:

Median hospital stay was 1,74 days (1–8) with a postoperative complication rate of 2 % (7/345) which mainly consisted in bleeding (4/7). Re-admission at 30 days was 7,2% (25/345), essentially for dysphagia (8/25) and pain (6/25). Fifty-five percent of patients (191/345) were discharged at day 1 with 4,1% (8/191) of re-admission at 30 days. Different factors influenced these results as redo surgery, insulin-dependent diabetes and anticoagulation therapy.

Conclusion:

Compared to reported data, our results demonstrate shortened hospital stay without increased readmission rates and support ERP implementation in high volume bariatric center for well selected patients.

ABSTRACT. Objective Studies describe weight loss, especially bariatric surgery, to be effective in controlling blood pressure in obese patients. Little literature mentions the evolution of natriuresis after weight loss intervention in large cohorts. This study aims to describe natriuresis in overweight and obese subjects, and to describe evolution of natriuresis after weight loss, induced by conservative treatment or Roux-en-Y gastric bypass. Methods A cohort of 5576 overweight and obese patients were retrospectively included. Subjects were weight stable for 3 months, without bariatric history or antihypertensive drug use. Blood pressure and 24h-urine collection were obtained before weight loss intervention and at 12 months. Results Average weight at baseline was 103±22 kg in the entire cohort, 99±20 kg in the conservative group and 120±19 kg in the surgery group (p<0.01). At 12 months, mean weight was 89±16 kg in the entire cohort, 91±16 kg in the conservative group and 89±14 kg in the surgery group (p<0.01). In overweight patients, blood pressure was 127±13 mmHg systolic over 77±8 mmHg diastolic versus 132±16 over 79±11 mmHg in obese subjects (p<0.01). Mean baseline natriuresis in overweight subjects was 144±69 mmol/d versus 166±79 mmol/d in obese subjects (p<0.01). Compared to baseline, mean natriuresis in obese patients dropped to 136±62 mmol/d at 12 months follow-up (p<0.01), while blood pressure dropped to 121±13 over 73±10 mmHg (p<0.01). Mean natriuresis at 12 months in the conservative group was 146±69 mmol/d, compared to 122±56 mmol/d in the surgery group (p>0.05). Decrease of natriuresis was significantly stronger in the surgery group, compared to the conservative group (p<0.01). Mean blood pressure at 12 months follow-up in the surgery group was 119±12 over 71±10 mmHg and significantly lower compared to the conservative group with 124±13 over 75±10 mmHg (p<0.01). Conclusion In our cohort, weight loss induces a significant decrease in natriuresis and blood pressure, especially after bariatric surgery.

ABSTRACT. OBJECTIVE: To assess the need for conversion, weight loss and the occurrence of gastroesophageal reflux disease (GERD) 10 years after sleeve gastrectomy (SG).

METHODS: The study concerned 40 consecutive patients who had a primary SG between 2006 and 2008. In all patients, the stomach was transected at 6 cm of the pylorus and a 40-French tube was used for calibration of the sleeve. A retrospective analysis of our database and telephone interview of patients who defaulted clinic follow-up was conducted. Success of surgery was defined as no need for conversion and percentage of excess weight loss (%EWL) > 50%.

RESULTS: Thirty-four patients (85%) were available for follow-up at 10 years. There were 11 men and 23 women with a mean BMI of 444 kg/m2. Optimal weight loss was reached after a follow-up of 12 months: the mean BMI was 315 kg/m2 and %EWL 7021%. Because of weight regain, 6 patients (18%) were converted to gastric bypass. All had a BMI > 35 kg/m2 at the time of conversion. In non-converted patients, the mean BMI and %EWL were respectively 357 kg/m2 and 5231%. The overall success rate was 41% (14/34). Preoperative BMI was the only parameter that was predictive of the ten-year outcome. We noted a better weight loss in patients with a preoperative BMI < 44 (n=14): the mean BMI and %EWL were respectively 315 (p<0.001) and 5835% (p<0.016) and the success rate was 64% (9/14) (p<0.026). Besides, 22 patients (65%) had GERD requiring medical treatment, 6 had de novo GERD. The occurrence of GERD was not decreased in patients with a preoperative BMI < 44: 9/13(69%).

CONCLUSIONS: The overall 10-year success rate after SG is low. SG should be reserved to patients with low preoperative BMI. The high incidence of GERD is another important concern after SG.

ABSTRACT. BACKGROUND: For patients with advanced heart failure left ventricular assist device (LVAD) can serve as a bridge to orthotopic heart transplantation (OHT) in case of potentially reversible or treatable comorbidities. Patients with class II obesity are eligible for implantation of LVAD, but do not meet criteria for cardiac transplant listing. Laparoscopic sleeve gastrectomy (LSG) is proposed by several small case series as weight losing modality in order to reach the NYHA criteria for listing. OBJECTIVES: We present our results of laparoscopic sleeve gastrectomy in patients with LVAD. We report on safety and efficacy and compare it to the literature. SETTING: Retrospective analysis of patients with LVAD who underwent LSG in a tertiary academic hospital. METHODS: In our center, three patients on LVAD with need for weight reducing therapy in order to reach criteria for transplant listing were treated with bariatric surgery, the first in 2016. In retrospect, information on patient characteristics, weight loss after surgery, surgical complications and patient management was gathered. A literature search on PubMed, Google Scholar and Science Direct, with keywords ‘LVAD, sleeve gastrectomy and bariatric surgery’ was performed. We found eight similar studies and compared them with our case series. RESULTS: Successful weight loss was achieved in all patients. There were no postoperative adverse events. Two out of three were listed on transplant waiting list, the third patient did not meet psychological criteria for listing. Our results are similar to those described in other series.

ABSTRACT. Objective: The aim of this study was to compare the outcomes between Toupet-sleeve (TS) and conventional sleeve gastrectomy (SG) as primary laparoscopic surgical procedure in obese patients presenting with preoperative gastro-esophageal reflux disease (GERD).

Methods: Outcomes of 19 consecutive patients operated between 2016 and 2018 by TS were compared to those of 38 patients operated in 2014 by SG. The two groups were matched by age, sex, ASA classification, BMI, food habits and severity of esophagitis. Stomach transection was performed 5 to 6 cm proximal to the pylorus and a 40-French tube was used for sleeve calibration. The major end-points were assessment of postoperative weight loss and GERD symptoms.

Results: All procedures were achieved by laparoscopy. Preoperative BMI was 435 in the TS and 425 kg/m² in the SG group (NS). Weight loss was lower in the TS group. Respectively 6 months, one year and two years after surgery, mean BMI was: 355, 336 and 332 in the TS vs. 315 (p<0.015), 285 (p<0.06) and 296 kg/m² (p<0.05) in the SG group. Mean %EWL was respectively: 4920, 61+23 and 584 in the TS vs. 6621 (p<0.001), 8625 (p<0.002) and 8328 (p<0.07) in the SG group. GERD symptoms were better controlled in the TS group: the number of patients with complete, partial and no resolution of GERD symptoms were respectively: 17 (89%), 2 (11%) and 0 (0%) in the TS vs. 13 (34%), 6 (16%) and 19 (50%) in the SG group (p<0.001).

Conclusion: TS was an effective procedure for treatment of GERD. However, the observed weight loss was much lower than in the SG control group. Long-term successful weight loss is doubtful after TS.

ABSTRACT. OBJECTIVE Colorectal cancer incidence is decreasing in the overall population. In contrast, several countries have witnessed a sharp increase among young patients over recent decades. Although age is a well-known risk factor of colorectal cancer (CRC), its influence on prognosis remains unclear and discussed. Some studies report poorer survival outcomes for younger patients, while others mention similar or better survival rates compared to the older ones. Our aim was to compare the survival of colorectal cancer in young patients with the elderly ones.

METHODS This retrospective study was based on consolidated data from the Institutional Cancer Registry database. We included patients who underwent curative intent surgical treatment for primary non metastatic or metastatic CRC. Early-onset colorectal cancer was defined as arising before 40 years old and patients were assorted into the young (aged ≤ 40 years) and older (aged > 40 years) groups. Overall survival (OS) and disease-free survival (DFS) were compared between 21 young and 42 old patients matched for risk factors (ratio 1:2), both being selected among 424 patients from the database.

RESULTS Median OS and DFS were respectively of 42.9 and 14.1 months for ≤ 40 years old patients and of 108.4 and 17 months for > 40 years old patients. Despite a trend in favor of patients > 40 years old, the difference did not reach statistical significance (p > 0.05). Another finding reveals that none of the young patients benefited from a colonoscopy (p < 0.05). Yet, screening was associated with better OS and DFS (p < 0.05).

CONCLUSIONS We did not observe any statistically significant difference in the outcomes between young (≤ 40 years) and old patients (> 40 years) when these patients are matched for risk factors.

ABSTRACT. Background. Since the implementation of Total Mesorectal Excision (TME) in rectal cancer surgery, oncological outcomes improved dramatically. With the technique of Complete Mesocolic Excision (CME) with Central Vascular Ligation (CVL), the same surgical principles were introduced to the field of colon cancer surgery. Until now, current literature fails to invariably demonstrate its oncological superiority when compared to conventional surgery, and there are some concerns on increased morbidity. The aim of this study is to compare short-term outcomes after left-sided laparoscopic CME versus conventional surgery. Methods. In this retrospective analysis, data on all laparoscopic sigmoidal resections performed during a three-year period (October 2015 to October 2018) at our institution were collected. A comparative analysis between the CME group - for sigmoid colon cancer - and the non-CME group - for benign disease - was performed. Results. One-hundred sixty-three patients met the inclusion criteria and were included for analysis. Data on 66 CME resections were compared with 97 controls. Median age and operative risk were higher in the CME group. One leak was observed in the CME group (1/66) and 3 in the non-CME group (3/97), representing no significant difference. Regarding hospital stay, postoperative complications, surgical site infections and intra-abdominal collections, no differences were observed. There was a slightly lower reoperation (1,5% versus 6,2% - p=0,243) and readmission rate (4,5% versus 6,2% - p=0,740) in the CME group during the first 30 postoperative days. Operation times were significantly longer in the CME group (210 versus 184 minutes - p<0.001), and a trend towards longer pathological specimens in the CME group was noted (21 vs 19 cm - p=0.059). Conclusions. CME does not increase short-term complications in laparoscopic left-sided colectomies. Significantly longer operation times were observed in the CME group.

ABSTRACT. Objective: Patients with symptomatic internal hemorrhoids (IH) usually present with bleeding and prolapse. Degrees I, II and III are mostly treated by cheap and painless outpatient procedures but symptoms tend to recur. While hemorrhoidectomy is very effective, it is associated with severe postoperative pain and a significant number of complications. Laser hemorrhoidoplasty (LHP) was introduced in 2009 as an alternative to hemorrhoidectomy. Previous studies on LHP only included grade II and III hemorrhoids. We used LHP for all IH requiring surgery and wanted to analyze its efficacy in the treatment of all IH requiring more than rubber band ligation Methods: Between June 2016 and September 2019, patients experiencing early relapse of symptoms after rubber band ligation of IInd or IIIrd degree IH or presenting with IVth degree IH were treated using LHP. All procedures were analyzed retrospectively. Resolution of preoperative complaints, number of postoperative checkups and complication rate were evaluated. Results: 100 patients underwent LHP treatment. Of these, 59% had grade IV, 18% grade III and 20% grade II hemorrhoids. The most frequent pre-operative complaints were blood loss (69%) and prolapse (26%). 76% was discharged from follow up after 6 weeks with complete resolution of symptoms. 2% needed a redo LHP after treatment of grade III hemorrhoids. In 13 symptom free patients, additional rubber band ligation was deemed necessary because of residual prolapse at postoperative proctoscopy. 3 complications occurred: one complex abcess, one minor one and one case with severe edema of external hemorrhoids requiring in-hospital conservative management. Conclusion: Our data seems to confirm LHP to be a safe and effective technique associated with little postoperative pain. No differences in complications where seen between all treated grades, making it a valid treatment option for all grades of HD. Short-term results show a resolution of preoperative symptoms in a majority of cases.

ABSTRACT. Background: Spleen-preserving surgical techniques combined with a minimally invasive approach have become increasingly common for benign or borderline malignant lesions of the pancreas. These more challenging procedures have immunologic advantages due to the maintenance of a functional spleen. The aim of this study is to evaluate the patency of the splenic vessels and splenic perfusion after spleen and splenic vessel-preserving distal pancreatectomy. Methods: This retrospective single-centre study included all patients who had undergone a spleen and splenic vessel-preserving distal pancreatectomy between April 2009 and October 2018. Both patency of the vessels and splenic perfusion were assessed by computed tomography or magnetic resonance. The patency of the vessels was classified into three grades according to the degree of stenosis and the perfusion of the spleen into four degrees according to the level of infarction. Results: Twenty-five patients underwent a spleen-preserving distal pancreatectomy of which 20 patients also had a splenic vessel-preserving surgery. The majority of the patients was operated with a minimal invasive technique (17 via laparoscopy or robot-assisted surgery and 3 via laparotomy). Five patients had no postoperative imaging. Normal patency of the splenic artery and vein was observed in 14 and 9 patients, respectively. Partial occlusion of the splenic vein was observed in 5 patients and total occlusion of the artery and vein was observed in 1 patient. Only 2 of these last 6 patients showed a limited infarction (< 50%) of the total splenic volume although without functional consequences. Conclusion: Spleen and splenic vessel preserving distal pancreatectomy is safe and feasible. The patency of the splenic vessel is preserved in the majority of the patients and the perfusion of the spleen is also maintained, even when the splenic vessels are compromised.

ABSTRACT. Objective: Fistulotomy remains the gold standard for the surgical treatment of simple anal fistula, but may cause fecal incontinence and a characteristic deformity of the anus (known as ‘keyhole deformity’). In the hope to avoid the keyhole deformity created by simple fistulotomy, we instead performed a fistulectomy with primary sphincter repair (FIPS). We analysed the occurrence of postoperative wound dehiscence, which essentially transforms a FIPS into a simple fistulotomy.

Methods: A retrospective study was performed on all consecutive patients who underwent FIPS for a simple anal fistula at our institution between January 2015 and August 2019. A simple anal fistula was defined as either an intersphincteric or a low transsphincteric fistula (crossing < 30% of the external anal sphincter). All patients received follow-up at regular intervals with anal examinations to evaluate fistula healing and the presence of keyhole deformity.

Results: FIPS was performed in 24 patients (mean age: 49.7 years). The anal fistula was intersphincteric in 3 (12.5%) patients and low transsphincteric in 21 (87.5%) patients. After a mean follow-up time of 7.4 (range 1-53) months, the overall healing rate was 95.8% (23/24 patients). One patient experienced fistula recurrence after 20 months, which was treated successfully with repeat FIPS. Six (25%) patients developed keyhole deformity due to postoperative wound dehiscence. Five of them were symptomatic (mainly soiling). Keyhole deformity was diagnosed at a mean time of 6.2 (range 1-13) months postoperatively.

Conclusions: FIPS is a very effective treatment for simple anal fistula and avoids the creation of a keyhole deformity in the majority of patients. Avoiding keyhole deformity is important because of the bothersome symptoms that come with it. Since FIPS is a fast and simple procedure, it should be considered a valid alternative for the treatment of every simple anal fistula.

ABSTRACT. We present a 54 years old man with a distal pancreatic cancer and a chronic lithiasic pancreatitis undergoing a spleno-pancreatectomy with distal Y pancreatico-Jejunostomy by standardized full robotic approach.The decision of the distal anastomosis has been cause of the chronic lithiasic pancreatitis with an high risk of high intra-ductal pressure and leakage.The patient underwent a fast-track protocol and he started drinking the day of the operation, eating and mobilizing the 1 day after the operation. The patient has been dismissed the 7th postoperative day without complications.The histological examination showed an pancreatic ductal adenocarcinoma pT3, N2, R0.

ABSTRACT. Standard pancréatic résections carry a significative risk of endocrine and exocrine dysfunction which is difficult to accept for management of benign/low grade lesions. Parenchyma sparing resections, especially énucléation can be useful in this setting. We present the video of the énucléation of a non-functioning neuro-endocrine tumor of the isthmus of the pancréas with emphasis on a few key technical aspects and briefly review the literature on the subject.

ABSTRACT. Objective: Median arcuate ligament syndrome(MALS) describes a rare clinical entity with symptoms of foregut ischemia caused by celiac artery compression by the median arcuate ligament (MAL). Although doppler ultrasonography can reveal severe stenosis of the celiac artery, catheter angiography performed during inspiration and expiration is still considered the gold standard for diagnosis. Treatment is based on MAL release through open, laparoscopic or robot-assisted surgery; although succes rates are limited by need for additional endovascular treatment in up to 25 procent of cases. In this study we present a new technique for hybrid endovascular and laparoscopic treatment of MALS.

Methods: 2 patients with clinical and radiographic diagnosis of MALS underwent hybrid endovascular and laparoscopic treatment. First, catheter angiography through femoral access and under local anesthesia confirmed the diagnosis. Then, the patient was brought under general anesthesia and laparoscopic release by cutting the mediane arcuate ligament followed. After laparoscopy, immediate angiographic imaging showed if the external compression of the celiac artery was resolved. When needed, remaining celiac artery stenosis could be treated with percutaneous angioplasty and stenting.

Results: Hybrid treatment was uncomplicated and succesful in both patients. DSA immediately after laparosopic release showed no residual stenosis. Both patients were discharged after two days. Follow-up after 6 weeks showed no celiac artery stenosis on doppler ultrasonography.

Conclusions: Preliminary results in the first patients report succesful release of the median arcuate ligament with no peroperative complications. The benefit in this technique lays in the immediate feedback on the postoperative angiography. Further data will be needed to predict the clinical correlation of succesful release with residual symptoms. We conclude that hybrid endovascular and laparoscopic surgery is a valuable technique for the treatment of MALS.

ABSTRACT. BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most popular bariatric procedure to treat morbid obesity. However, long-term complications such as marginal ulcers, nutritional deficiencies, stricture, fistulation and weight gain can occur. The incidence of marginal ulceration is widely variable between 0,6-16%. Nine % of the patients are resistant to medical treatment, needing a revisional surgery.

METHODS: This video reports a 42-year-old male presenting a solid dysphagia since one year. The patient had undergone a LRYGB for morbid obesity without comorbidities 4 years before. At that time, the gastrojejunostomy was fashioned by side-to-side linear mechanical method. Preoperatively, three gastroscopies showed a deep gastro-jejunal ulcer with partial stenosis, probably based on chronic ischemia. A three-trocar laparoscopic re-gastrojejunostomy, fashioned in an end-to-end, single-layer hand-sewn method is here showed.

RESULTS: The total operative time was 150 minutes, and per-operative blood loss was estimated at 50 milliliters. Postoperative pain was well controlled with paracetamol 1g four times a day for 48 hours. The patient was discharged after 72 hours. Six months post-operatively, the patient didn’t have any complaints, and the weight was stable.

CONCLUSION: Marginal ulcer after LRYGB can safely be treated by laparoscopic re-gastrojejunostomy, preferably performed by the handsewn method.

ABSTRACT. In this video we illustrate the laparoscopic salvage of an Endoscopic ultrasound-Directed transGastric ERCP (EDGE) causing a perforation of the alimentary limb in a patient with Roux-en-Y Gastric Bypass (RYGB) anatomy.

Our 46-years-old female patient was referred to our hospital with a hepatic mass in the right hemiliver, extending into segment 4. She underwent RYGB surgery 8 years prior to presentation. After Portal Vein Embolisation (PVE), an extended right hemihepatectomy was performed. The initial postoperative course remained uneventful, and our patient was discharged on postoperative day 6. Unfortunately, she was readmitted two weeks after surgery with a significant biloma at the transection plane. Percutaneous drainage resulted in a persistant leakage of around 200-300 cc of bile daily. Because of the RYGB anatomy, our patient was scheduled for an EDGE-procedure. After ultrasound-guided localization, accessing the excluded stomach was unsuccessful and resulted in a perforation of the alimentary limb. During laparoscopy, the lumen-apposing metal stent (LAMS) was easily located, indeed perforating the alimentary limb approximately 5 cm distally of the gastro-enterostomy. Subsequently, a LA-ERCP was performed after enlarging the opening in the excluded stomach. A plastic endoprothesis was placed in the Common Bile Duct (CBD) after papillotomy. Because primary closure of the perforation in the alimentary limb would result in a significant stenosis, and removal of the endoprosthesis in the CBD to be done in the near future, the enterotomy and gastrotomy were closed using the LAMS. The further postoperative course remained uneventful.

The EDGE-procedure is an emerging minimally invasive procedure in patients with RYGB anatomy, that provides an alternative to LA-ERCP. Current available literature reports similar technical success rates and adverse events of EDGE and LA-ERCP. With this particular case we aim to illustrate how both procedures can be complimentary.

Link for video https://drive.google.com/open?id=1MGZEMgwBy0-HYknH75k89kggn7RFF7qm

ABSTRACT. Abstract

Robotic-assisted surgery is an evolving matter and a wide array of disciplines are using this method of surgery. We would like to present a video of a robotic-assisted superior segmentectomy of the lower lobe of the right lung performed with the Davinci Xi with the use of Indocyanine Green to locate the margins of the segment. The purpose if this video is to show that the determination of the margins of the segment can be precisely seen using this technique. The other advantage of the robotic-assisted technique is the complete lymph node staging that can be easily done because of the magnified view and the freedom of motion of the arms.

ABSTRACT. Objective Rectal prolapse with its affiliated rectocele and enterocele is responsible for symptoms such as obstructed defecation and faecal incontinence. Ventral mesh rectopexy, either laparoscopically or robotic assisted, is considered as the gold standard treatment for rectal prolapse. Good functional outcome and low recurrence rates are reported. Mesh erosion is a rare but important complication occurring in up to 4% and almost always demands surgical management.

Methods We present a case of a 58-year-old woman who underwent a robot-assisted ventral mesh rectopexy and cystopexy for rectocele and cystocele with a polypropylene synthetic mesh. Two years later she presented with red blood loss anally and colonoscopy showed a mesh erosion through the rectum. We performed a partial mesh resection with closure of the rectal wall defect with a mucosal advancement flap by means of TAMIS. A derivative loop ileostomy was constructed.

Results Six weeks after her revision surgery, no mesh was palpable by digital examination and colonoscopy showed an intact rectal wall with minor scar tissue at the operated sites. Stoma closure was performed 2 months after the TAMIS procedure.

Conclusion Mesh erosion is infrequent but implies substantial morbidity. Scarce evidence is found in the management options regarding this issue besides removal of the mesh. We present a successful case of a transanal partial mesh removal and closure of the defect with a mucosal advancement flap.

ABSTRACT. Objective. Resectability of pancreatic adenocarcinoma is defined by tumor involvement of the surrounding major blood vessels. In order to achieve an R0-resection in borderline resectable pancreatic cancer, vascular resection and reconstruction is needed. The aim of this study was to evaluate the safety and feasibility of 3D-laparoscopic superior mesenteric (SMV) / portal vein (PV) resection and reconstruction in pancreaticoduodenectomy (PD) for borderline resectable pancreatic cancer (PC).

Methods. Between March 2016 and March 2019, 3D-LPD with simultaneous resection of SMV/PV was performed in 26 patients . Complete vascular control was achieved using vessel loops and/or laparoscopic vascular clamps. Depending on the VMS/VP resection size, the reconstruction was accomplished in different ways: wedge-resection with primary closure using a running suture (n=22), wedge-resection with reconstruction using a peritoneal patch (n=3), segmental resection with primary end-to-end reconstruction (n=1). The patency of the venous reconstruction was routinely assessed intra-operatively and reassessed on the first postoperative day using transabdominal duplex ultrasound.

Results. Median operating time of LPD was 340 minutes (range 240 – 420) and median intra-operative blood loss was 100 mL (range 0 – 1000). Median mesoportal clamp time was 20 minutes (range 0 – 74). There were 4/26 (15%) conversions to a laparotomy. Mortality rate was zero. Reoperation was performed for thrombosis in 2 and for hemorrhage in 1 patient. An R0-resection was achieved in 21 (81%) patients. Long-term patency was achieved in 23/26 patients (88%). Median follow-up time was 6 months (range 0 – 25).

Conclusions. 3D-laparoscopic SMV/PV resection and reconstruction in PD for borderline resectable pancreatic cancer is safe and feasible with a high patency rate, and results in highly acceptable R0-resection rates.

ABSTRACT. BACKGROUND Rectourethral fistula (RUF) is an uncommon pathology, usually iatrogenic occurring as a complication of surgical or ablative treatments for prostate or rectal cancer. Previous pelvic radiation is associated with worse outcomes, more complex surgeries and higher rate of definitive fecal diversion.

OBJECTIVE To describe a transanal minimally invasive (TAMIS) assisted Turnbull-Cutait technique for radiated rectourethral fistulas.

DESIGN Description of surgical technique of this approach with a complementary video.

SETTINGS A tertiary referral hospital.

PATIENTS Two patients with prior prostatectomy and radiotherapy which developed delayed RUF. One after a pelvic abscess drained transrectally and the second after transanal endoscopic microsurgery (TEM) of a low rectal villous polyp.

INTERVENTIONS Turnbull-Cutait pull-through with delayed coloanal anastomosis technique, with a TAMIS proctectomy.

MAIN OUTCOME Fistula closure.

MEASURES Perioperative events were recorded, including intraoperative surgical details, postoperative outcomes and fistula closure data.

RESULTS Surgical intervention and postoperative period were uneventful. Fistula closed in both cases.

LIMITATIONS This is a report of 2 cases from a tertiary referral center. Larger number of patients would be recommended in order to further assess this technique.

CONCLUSION A TAMIS assisted Turnbull-Cutait technique is safe, feasible and effective for the treatment of RUF, allowing access to the narrow inflamed pelvis, appropriate fistula visualization and restoration of the intestinal continuity.