ABSTRACT. Objective

Failure to close the abdominal wall after intestinal (ITx) and multiviseral transplantation (MvTx) remains a challenge, associated with increased morbidity. An attractive method is the use of non-vascularized rectus fascia (NVRF) in which both layers of the abdominal rectus fascia are used as an inlay patch without vascular anastomosis. The aim of our study is to provide a multi-level analysis (clinical, radiological, histological, contrast-enhanced microCT and immunological) of the neovascularization and integration process based on three cases.

Methods

Three patients underwent a NVRF transplantation in combination with an ITx between 09/19-09/22. A retrospective analysis was performed. Ethical approval was obtained (S67453).

Results

The first patient was a 49-year-old female who received a NVRF during combined liver-ITx. At 1 month, doppler confirmed neovascularization of the graft. At 6 months during reintervention, the fascia was macroscopically integrated. H&E on biopsy confirmed integration of the graft with fibrotic reaction without rejection. CD31 showed neovascularization on the interface with the native fascia. Contrast-enhanced microCT analysis revealed presence of microvasculature enveloping the donor fascia as well as penetrating the graft (figure). The second patient was a 51-year old male who received a NVRF after MvTx. Two weeks later, during a re-operation the fascia showed macroscopic neovascularization. A VAC-system was placed on top of the fascia and secondary closure was obtained. The patient died six months post-transplant from a metastasized mesothelioma. The third patient was a 31-year old male who underwent MvTx. Eleven days later, after re-operation for intra-abdominal collections, primary closure could not be attained and a non-ABO-matched third party fascia was used. Six days later, anti-A natural and immune antibodies were increased suggesting the presence of de-novo specific antibodies against the third party. Twelve days later, the patient died of a mycotic aneurysm.

Conclusions

We showed evidence of the neovascularization and integration of donor NVRF.

ABSTRACT. Objective: To assess the influence of patient’s physical capacity on outcomes after esophagectomy.

Methods: The study concerned 59 consecutive patients operated for esophageal cancer. There were 42 men and 17 women with a mean age of 66±8 years and BMI of 27±6 kg/m2. Patients’ preoperative performances were evaluated by 3 tests: 6 minutes walking test in meters (6MWT), hand grip strength in kg (HG) and time up and go in seconds (TUG). The recorded values were compared to the expected normal values in an equivalent healthy population in term of sex, age and BMI. Patients with one of the following criteria: 6MWT < to 80% of the normal value, HG < to 80% of the normal value or TUP ≥ 10 were classified as frails. Postoperative complications were recorded according to the Dindo-Clavien classification.

Results: For the whole series, the mean 6MWT and HG were lower than the normal values 428±102 vs. 513±72 m. (p<0,001) and 32±9 vs. 37±8 Kg. (p<0,003) and normal TUG was noted in 42 patients (71%). Complications Dindo-Clavien ≥ 2 were observed in 30 (51%) and Dindo-Clavien ≥ 3b in 13 patients (22%). The median hospital stay was 13 days (range:8-90). Comparison between frails (n=31) vs. non-frails (n=28) showed that the patients’ clinical characteristics were similar in both groups. In the sub-group of frails patients, we observed a higher rate of Dindo-Clavien ≥ 2 and ≥ 3b complications: 68% vs.32 % (p<0,009) and 35 vs.7 % (p<0,012) and a longer hospital stay: 15 vs.11 days (p<0,004).

Conclusions: The physical status of patients requiring esophagectomy is impaired compared to healthy patients. Patient’s real frailty can only be determined by objective physical tests. Low physical performances are associated with increased rate of postoperative complications. Those observations highlight the potential benefit of a program of prehabilitation.

ABSTRACT. Objective: The heterogeneity of rectal biopsy techniques encourages us to search for a surgical and pathological standardisation of this diagnostic technique to exclude Hirschsprung’s disease. The varying amount of information on the anatomopathology report prompts us to compile a template concerning the anatomopathology report for diagnostic rectal biopsies for colleagues surgeons and pathologists working on Hirschsprung’s disease. Methods: We gathered the anonymous biopsy information and its pathology information from five hospitals of all patients in which rectal biopsies were taken to diagnose Hirschsprung’s disease over two years (2020-2021). Results: 90 biopsies of which 21 suction (23.3%), 30 punch (33.3%) and 39 open biopsies (43.4%) were taken. 78 are first biopsies of which are 19 suction biopsies (24.4%), 29 punch (37.2%) and 30 open (38.4%). 12 biopsies are inconclusive (15.4%) and needed second biopsies of which 2 biopsies are suction, 3 punch and 9 open. One second biopsy (suction) was inconclusive. In the suction biopsy group 58% are conclusive, 42% not, for punch biopsy 90% and 10% respectively and for open biopsy 97% and 3%. Inconclusive results are due to insufficient submucosa in 6/8 suction biopsies, 3/3 punch and 0/1 open biopsies. We had one case with major postoperative bleeding post suction biopsy; there were no further adverse effects. Conclusions: Diagnostic rectal biopsies in children are safe. In comparison to suction biopsies, punch biopsies are more likely to be conclusive because they result in more submucosa in the specimen. Open biopsies are very useful when previous punch biopsies are inconclusive. An experienced pathologist is a key factor for the result. The anatomopathology report should specify the different layers present in the specimen, the presence of ganglion cells and hypertrophic nerve fibers, their description and a conclusion.

ABSTRACT. Objective: Totally minimally invasive Ivor-Lewis Esophagectomy (TMIE) is increasingly performed around the world with the goal of reducing morbidity. The intrathoracic anastomosis is a key element in the procedure. This retrospective study reports the perioperative outcomes after TMIE with intrathoracic hand-sewn anastomosis in our center.

Methods: All consecutive patients who underwent Ivor-Lewis TMIE for cancer from 2017 to 2022 were retrospectively analyzed from a prospective maintained database. Data included demographic variables, primary tumor characteristics and management, operative data, tumor pathology and outcomes.

Results: Sixty-one patients were included in this study with a mean age of 65 years (38-82). Histology of the tumor was adenocarcinoma in 55 cases (90 %), squamous cell carcinoma in 5 cases (8%) and primary esophageal melanoma in 1 case. Tumor was located in the lower third of the esophagus in 38 patients (62%), the esogastric junction in 22 cases (36%) and in the middle third of the esophagus in 1 case. 45 patients (74%) received neoadjuvant treatment. The median operative time was 301 minutes (205-540). R0 resection was achieved in 59 patients (97%) and proportion of patients with more than 15 lymph nodes removed was 92% (n=56). The overall major morbidity (Clavien Dindo 3b-V) was 21 % (n=13). No complication was observed in 47.5 % of the patients. Anastomotic leaks occurred in 16 % of the cases (n=10) and were classified type I in 6 cases and type II in 4 cases. Pulmonary complication was seen in 19.7 %. No chyle leak was observed. 5 patients required reoperation including abdominal bleeding in 2 cases and acute hiatal hernia in 3 cases. Median length of stay was 13 days (9-105). Thirty-day and 90-day mortality rates were respectively 1.6 % (n=1) and 3.3 % (n=2).

Conclusion: TMIE with intrathoracic hand-sewn anastomosis is feasible and reproducible with acceptable morbidity and mortality rates.

ABSTRACT. OBJECTIVE: Sarcopenia is a predictor of postoperative morbidity in patients with Inflammatory Bowel Disease(IBD). There is no consensual method to evaluate sarcopenia and nutritional status in this population. To evaluate preoperative sarcopenia and body composition of IBD patients undergoing intestinal surgery by bioelectrical impedance analysis(BIA), Skeletal Muscle Index(SMI) and muscle strength and the impact of sarcopenia in postoperative outcomes.

METHODS: Prospectively enrolled adult IBD patients undergoing elective intestinal surgery and preoperative nutritional assessment from January-November 2022. BIA parameters were reviewed including total body lean mass(LM) and total body fat mass(FM). CT images performed up to 90 days before surgery were assessed for SMI(sarcopenia defined by EWGSOP2) and also for visceral fat area(VFA) and subcutaneous fat area(SFA). Hand-grip strength test was performed. All patients were coded for postoperative complications using the Clavien–Dindo classification system (major complication if ≥III).

RESULTS: 26 patients included, 85% had Crohn’s Disease, 66.7% male, median age 43y(IQR 19-77). There were 5 major postoperative complications, all requiring surgical interventions. Prevalence of sarcopenia according to EWGSOP2 criteria was 69.2%. SMI was moderately correlated with LM and BMI (r=0.626 and r=0.630, both p<0.001) but was not correlated to handgrip muscle strength (r=0.408,p=0.066). Handgrip muscle strength showed a moderate positive correlation with LM (r=0.55,p=0.009). Both VFA and SFA were correlated with FM (r=0.707 and r=0.888, both p<0.001). Patients with major postoperative complications had significantly lower LM (38.5kg vs 56.0kg, p=0.005) however both SMI and handgrip muscle strength were not significantly different (p=0.087 and p=0.059).

CONCLUSIONS: The prevalence of sarcopenia based on EWGSOP2 criteria is high in IBD patients undergoing bowel surgery. LM may be a better predictor of major postoperative complications and it is just moderately correlated to SMI or handgrip muscle strength. Further prospective evaluation with an expanded cohort is needed to determine the accuracy of BIA in predicting outcomes after IBD surgery.

ABSTRACT. OBJECTIVE Despite improved medical treatment, about 30% of patients with Crohn’s disease require surgery. Recurrence at the anastomotic site remains an ongoing challenge. In attempt to improve anastomotic safety and reduce the risk of surgical recurrence, the Kono-S anastomosis has been recently introduced. At this stage, Kono-S has shown to be safe and to reduce endoscopic, clinical, and even surgical recurrence after ileocecal resection. METHODS Retrospective analysis of prospectively collected data on patients undergoing primary ileocecal resection for symptomatic ileal or ileocolic Crohn’s disease. Between January 2016 and February 2022, 50 Kono-S anastomoses were performed. RESULTS Median age at surgery was 33 years {18-75 years}, with a median disease duration of 60 months {0-529 months}. Post operative course was uneventful, as there were no leakages and no need for reinterventions. At a median time of 168 days, endoscopic recurrence (modified Rutgeerts scores ≥2b) occurred in 15 of 45 patients (33%) who underwent colonoscopy. 20 patients (44%) showed ulceration on the anastomosis. At last follow-up after a median of one year {8 months-6 years}, no patients underwent surgical reintervention. Thirty-six patients (72%) showed complete clinical remission, 15 patients (30%) without any postoperative medication. CONCLUSION This retrospective series confirmed the safety of Kono-S anastomosis. With the limitations of a short median follow-up, Kono-S anastomosis is associated with no surgical recurrence.

ABSTRACT. Introduction: Anal fistula pose a major burden on patient’s wellbeing with current treatment standards for complex anorectal fistula showing a varying success rate between 20-88.6%. Laser ablation of the fistula tract (LAFT) has been proposed as a novel minimally invasive technique with promising yet varying results. The aim of our study is to assess the efficacy and morbidity of the LAFT procedure ten years after implementation.

Methods: A systematic review (PROSPERO registered) of all published articles from 2011 up until the end of 2021 investigating the efficacy of LAFT will be reported according to the PRISMA guidelines. Our search was conducted using PubMed/Medline, Scopus, Web of Science, Embase and Cochrane Central Registry of Controlled Trials. Studies reporting on recurrence, incontinence and postoperative morbidity were included. A meta-analysis of proportions was conducted. JBI Critical Appraisal Checklist was used for quality assessment.

Results: Seventeen studies (n = 1103 patients) were included out of 48 records retrieved for eligibility. Primary healing rate ranged from 20- 89% among studies with a net pooled healing rate after proportional meta-analysis of 54.80% (95%CI: 43.12 – 65.96%). Complication rate was 0 – 52% (range). The net pooled rate after proportional meta-analysis was 2.41% (95%CI: 0.64 – 8.66%). Healing rate among subgroups was 54.71% when the internal opening was closed (95%CI: 37.71 – 70.67%) and 54.87% when the internal opening was not closed (95%CI: 39.07 – 69.75%). There was no statistical significant difference (p = 0.99). Overall quality of included studies was low.

Conclusion: Primary healing after LAFT is moderate to low, with a low rate of post-operative morbidity. Closure of the internal opening does not effect outcome. Due to the high heterogeneity and relatively low quality of the included studies, randomized control trials are necessary to provide strong evidence on the use of laser devices in the treatment of anal fistula.

ABSTRACT. BACKGROUND The sleeve gastrectomy (SG) has become over the years the most commonly performed bariatric surgery. The Magenstrasse and Mill gastroplasty (M&M) shares with SG the tubular gastric restriction but avoids stomach resection, with a reported low incidence of minerals and vitamins deficiency and of gastroesophageal reflux.

OBJECTIVE Two studies evaluating M&M (one prospective at 1 year and one retrospective at 4 years) on a small population showed comparable results on weight loss with SG. The present study was made on a larger population to confirm these results.

METHODS Data from medical records of patients who underwent M&M procedure in two medical centers between 2014 and 2020 were retrospectively reviewed. Preoperative weight and comorbidities and data up to two years after surgery were analyzed.

RESULTS A total of 734 patients (56,5% females) who had a M&M between 2014 and 2020 were included in the study. Mean age and baseline body mass index (BMI) were 44,3± 13,8 years and 41,8 ± 4,7 Kg/m2. Incidence of diabetes and hypertension in the population at baseline was respectively 31% and 54,5%. Median length of stay (LOS) was 2,1 days with a readmission rate of 3 % at 30 days. Overall complication rate at 30 days was 5 % including staple line leak 0,5%, intradigestive hemorrhage 0,8% and extradigestive hemorrhage 0,7%. The reoperation rate was 1,4% at 30 days. For 348 patients with 2-year follow-up results, percentage of excess weight loss (%EWL) was 66.5 ± 26.2 % (p<0.0001) at 2 years.

CONCLUSIONS These results confirm the validity and safety of M&M as a bariatric procedure. Weight loss and comorbidities outcomes are being studied, at 5 years from surgery, to confirm the indication of this technique.

ABSTRACT. OBJECTIVES: Sarcopenia(loss of skeletal muscle mass and/or strength) is a predictor of postoperative morbidity in various surgical populations. We evaluated the impact of sarcopenia in postoperative outcomes after intestinal surgery in patients with Crohn’s disease(CD) at a tertiary referral centre.

METHODS: Retrospective analysis of all CD patients undergoing intestinal surgery at our centre, between January 2013 and September 2019 with available abdominal CT within 90 days of surgery. The images were assessed for sarcopenia according EWGSOP2 criteria (Skeletal Muscle Index <39cm2/m2 for female and <55cm2/m2 for male) and visceral and subcutaneous fat areas. All patients were coded for postoperative complications using the Clavien–Dindo classification system.

RESULTS: A total of 114 patients with CD were included. The prevalence of sarcopenia was 67.5%. Common intestinal procedures were ileocecal resections(49%), segmental small-bowel resections/stricturoplasty(6.1%), and colon resection(8.8%). Sarcopenic patients have more frequently penetrating phenotype than patients without sarcopenia (p=0.007)(table 1). Body mass index and serum albumin levels were significantly lower (p<0.001 and p=<0.037, respectively) and C-reactive protein levels were significantly higher (p=0.014) in sarcopenic patients compared to non-sarcopenic patients. Furthermore, both visceral and subcutaneous fat were significantly lower (both p<0.001) in patients with sarcopenia. ICU admission, rates of postoperative complications within 30 days, infections, reoperation and re-hospitalization were not significantly different between sarcopenia and non-sarcopenia groups. However, there was a trend of a longer length of hospital stay (p= 0.062) in patients with sarcopenia. Sarcopenic patients received significantly more preoperative and postoperative parenteral nutrition (p=0.006 and p=0.035, respectively) and protective ileostomy (p=0.025) compared with patients without sarcopenia.

CONCLUSION: The prevalence of sarcopenia based on EWGSOP2 criteria is high in patients with CD requiring bowel resection. In this cohort, sarcopenia was not linked to higher rate of postoperative complications, although this might be explained by different surgical procedures and nutrition management before and after surgery for CD.

ABSTRACT. Objective: The role of radiotherapy in the therapeutic sequence of non-metastatic pancreatic cancer (PC) is controversial. Isotoxic high-dose stereotactic body radiotherapy (iHD-SBRT) consists of delivering higher doses per fraction on smaller volumes, limiting the toxicity of surrounding structures. This study aimed to compare postoperative outcome of patients with non-metastatic PC undergoing neoadjuvant treatment (NAT) including iHD-SBRT versus upfront pancreaticoduodenectomy. Methods: All patients undergoing pancreaticoduodenectomy for non-metastatic PC from 2017 to 2021 were retrospectively analysed from a prospective database, identifying patients receiving NAT with iHD-SBRT. Toxicity of treatments and postoperative outcome were assessed and analysed in a propensity score-matched population. Results: Eighty-nine patients underwent upfront surgery (Surgery group) and 22 after NAT and iHD-SBRT (SBRT group). No major side effects SBRT-related were identified preoperatively. During surgery, more concomitant venous resections were performed in SBRT vs. Surgery groups (p=0.006), and the operative time was longer (p<0.001). Postoperative morbidity was similar between groups. There was no postoperative death in the SBRT group, and 6 in the Surgery group (p=0.597). No difference was observed in the rates of complications related to pancreatic surgery. The postoperative hospital stay was shorter in SBRT vs. Surgery groups (p=0.016). After propensity score matching, no significant difference in the postoperative morbidity was observed between the 2 groups. Conclusion: Incorporation of iHD-SBRT in the NAT sequence before pancreaticoduodenectomy for non-metastatic PC did not increase the postoperative morbidity compared with patients undergoing upfront surgery. These results confirm the feasibility and safety of iHD-SBRT for the upcoming STEREOPAC trial.

ABSTRACT. Background Many patients with aortic valve disease also suffer from coronary artery disease (CAD). The management of this double disease is aortic valve replacement (SAVR) combined with CABG. Sometimes, coronary arteries are too small or too diffusely affected to obtain complete revascularisation. The research questions: what are the independent predictors for incomplete revascularisation? What are its postoperative consequences?

Methods This is a retrospective study of 2,234 consecutive patients who underwent SAVR with a biological valve, between 1996 and 2017. Mechanical valves and valves in other positions are excluded. Follow-up is more than 15,000 patient-years. Twenty cardiac and non-cardiac preoperative factors are included in an univariate chi-square analysis. Significant factors are entered in a multivariate logistic regression analysis to identify independent predictors. A chi-square analysis identifies the short-term consequences of incomplete revascularisation and a calculation of Odds Ratio (OR) and 95% Confidence Interval (95%CI). A log-rank test shows its consequences on long-term survival.

Results Significant CAD is found in 1394 patients. In 220 (15.8%), revascularisation is incomplete. The predictors for incomplete revascularisation are 1) NYHA functional class III/IV; OR=2.65 and 95%CI (1.35-5.21), p=0.005, 2) chronic kidney dysfunction; OR=1.97 (1.20-3.25), p=0.007 3) diabetes; OR=1.88 (1.13-3.31), p=0.015. Prior CABG (p=0.001), myocardial infarction (p=0.007), ejection fraction <50% (p=0.041) and age >80y (p=0.053) are only significant in a univariate analysis. The short-term consequences of incomplete revascularisation are seen in the table. Five-year survival is higher in patients with complete revascularisation: 77.0+/-1.3% v. 70.0+/-3.3%. For 10 year survival, this is 45.2+/-1.7% v. 35.3+/-3.9% (p=0.048). LVEF during follow-up is higher in patients with complete revascularisation: 56.7+/-15.5% v. 51.5+/-15.3% (p=0.022).

Conclusions Diabetes, chronic kidney dysfunction and high functional NYHA class are predictive for incomplete revascularisation. Incomplete revascularisation results in higher rate of cardiac injury, 30-day mortality, prolonged ventilation and stay on ICU. At long term, LV function and survival are lower.

ABSTRACT. Objective In rectal cancer (RC) with synchronous liver metastases (SLM), the optimal treatment sequence to achieve complete resection of the primary tumour with metastases and, consequently, the best possible survival is still a matter of debate. The aim of our study is to compare different liver surgical strategies in terms of complete resection rates (CRR).

Methods Patients with locally advanced RC (≤ 11 cm from the anal verge) and resectable SLM from 2 European institutions, operated between 2010 and 2019 were included and retrospectively analysed. Three timing strategies of both sites resection, namely rectum-first strategy (RFS), liver-first strategy (LFS) and synchronous (SRS) approach were compared. Primary endpoint was the comparison of CRR achieved in every group. Intra-operative and post-operative variables, including morbidity and mortality, were also analysed to understand if one particular strategy could make rectal surgery more difficult.

Results Overall, 36 patients were included: 11 in RFS, 12 in LFS and 13 in SRS. RFS achieved a CRR of 36%, LFS of 83%, and SRS of 77% (p-value 0.052). LFS had longer median overall survival (OS), without reaching significance: 51 months compared to 27 months in RFS and 32 months in SRS. We observed an anastomotic leak rate of 30% in RFS, 33% in LFS and 57% in SRS, but the difference was not significant. SRS showed overall shorter operative time (OT) and length of stay (LS). Post-operative morbidity, mortality, quality of lymphadenectomy and surgical margin involvement were similar between groups.

Conclusions In RC with SLM, compared to the classical approach, the liver-first strategy seems to assure better CRR and consequently OS. The synchronous approach can be used in very well selected patients, with overall shorter LS and therefore lower hospital charges. There is no evidence that the liver-first strategy or synchronous approach, compared to rectum-first strategy, could jeopardize rectal surgery.

ABSTRACT. Objective Surgical site infection (SSI) occurs in 2-10% of the patients after abdominal surgery and has an impact on morbidity, mortality and medical costs. The aim of this systematic review and meta-analysis was to evaluate whether the use of triclosan-coated sutures for fascial closure in adominal surgery decrease the rate of SSI compared to uncoated sutures.

Methods A systematic review and meta-analysis was conducted using the PRISMA guidelines. A literature search was performed in Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Embase. The latest search was performed on January, 21th, 2023. Risk of bias was assessed using the Cochrane RoB 2 tool. A pooled meta-analysis was performed using RevMan.

Results Out of 1356 records, ten RCTs, with a total of 9432 patients were included: 4763 in the Triclosan-coated group and 4660 in the uncoated group. The overall rate SSI was significantly reduced in the Triclosan-coated group with an odds ratio (OR) of 0.84 (95% CI = [0.76,0.94], p <0.01). If PDS was evaluated separately (PDS Plus = 3999, PDS = 3900), triclosan-coating reduced SSI with an OR of 0.86 (95% CI = [0.77, 0.96], p < 0.01). When Vicryl was evaluated (Vicryl Plus = 764, Vicryl = 760), the OR was 0.71 (95% CI = [0.48,1.04], p = 0.08) and was not significant.

Conclusion In this current meta-analysis, it was found that the incidence of SSIs decreases when triclosan-coated sutures are used for fascial closure, compared to the uncoated sutures group.

ABSTRACT. OBJECTIVE: To assess the 4-year outcomes after Toupet-Sleeve (TS) gastrectomy in morbid obese patients with concomitant preoperative gastro-esophageal reflux disease (GERD).

METHODS: The study group consisted of 19 consecutive patients operated on between August 2017 and February 2019. There were 5 men and 14 women with a mean body mass index (BMI) of 43±5 kg/m2 and a mean age of 42±15 years. A retrospective analysis of database and telephone interview of patients who defaulted clinic follow-up was conducted. The main study end-points were weight loss and success of surgery, defined as no need for conversion and %EWL > 50%. Resolution of GERD was a secondary end-point.

RESULTS: No patient was lost for follow-up. Optimal weight loss was reached after a follow-up of one year: mean BMI was 32±5 kg/m2 and %EWL 61±21 %. Thereafter, we observed a progressive weight regain over time. With a mean follow-up of 51±6 months, mean BMI was 36±8 kg/m2 and %EWL 43±35 %. Two patients were converted to another bariatric procedure and overall surgical success rate was 32% (6/19). However, a higher weight loss was noted in patients with preoperative BMI ≤ 42 kg/m2: %EWL was 57±33 vs. 18±23 % (p<0.024) in patients with BMI > 42 kg/m2. Resolution of GERD without any PPI treatment was noted in 88% (15/17) of the non-converted patients.

CONCLUSIONS: In our experience, TS is associated a moderate 4-year weight loss and a poor success rate especially in patients with a BMI > 42 kg/m2.

ABSTRACT. We reported the case of a young patient ,who intensively playing football during summer. His core temperature jumped near 42°c when he fell inconsious. Unfortunately, he stayed without appropriate care during what is so called « the gold half hour »,even he were rapidely transferred to an ICU ,and received promptly supportive treatments . He was suffering of intravascualr coagulopathy ,with MOF , but the major lifethreatening failure were the liver . He was transferred to chu for a fulminant hepatic failure ,listed on a HU waiting list and were transplanted within the 24 hours. The outcome of the liver graft were eventless, but he developped a extensive broncho-pulmonary mucormycosis and died after one month due to this intractable pulmonary disease We described the physiopathology of the exertional heat stroke, (ferroptosis) ,so tracking possible innovative treatments for advanced forms and insist to remind the basic lifesaving emergent care. Then we reported this uncommon indication for liver transplantation (only 11 cases reported in the literature)

ABSTRACT. OBJECTIVE: To describe the use of the wired sternal crane technique to lift the sternum during bilateral lung transplantation in a patient with severe pectus excavatum deformity.

METHODS: The presence of significant chest wall or spinal deformity is currently an absolute contra-indication for lung transplantation according to ISHLT guidelines. We present the case of a 28-year-old female patient who underwent a bilateral lung transplantation for underlying terminal bronchopulmonary dysplasia with a deep pectus excavatum (Haller index 11). Bilateral anterior thoracotomy was performed. Per-operatively, the view of the right pulmonary artery was significantly compromised due to the presence of the pectus. We used a wired sternal crane technique to elevate the sternum and gain exposure of the mediastinum.

RESULTS: The use of the crane technique resulted in an additional 4 centimeters gain in anteroposterior distance and significantly increased access to the right pulmonary artery. Both lungs could hereafter be successfully implanted. Release of the crane after implantation went smoothly, as did the postoperative recovery. The patient could be weaned and extubated on postoperative day 5 and could be discharged home on day 27.

CONCLUSIONS: To our knowledge, this is the first case reporting the use of the pectus crane during transplantation. The sternal crane provided us an easy and safe method to gain additional exposure without the need for a more morbid clamshell incision. We suggest considering the use of the pectus crane in recipients with pectus excavatum at the moment of transplantation, thus avoiding having to decline an otherwise good transplant candidate. Similar cases should be discussed with experts in the field, both concerning surgeons dedicated to lung transplantation and to pectus excavatum, before denying the patient access to the waiting list. A staged approach can be an alternative, depending on the urgency to transplantation. Changes in the ISHLT guidelines should be reconsidered.

ABSTRACT. Objective In August 2020, the first robotic pancreaticoduodenectomy was performed after an extensive training program (hands-on course, virtual training on Intuitive Xi robot, training on pig model at ORSI, case observations abroad) and after performing distal pancreatectomies for six months. We want to present the results of our initial experience. Methods All procedures were performed by two surgeons who alternate between console and patient-side, using the DaVinciXI platform (Intuitive Surgical Inc.). All case-related data were prospectively collected. Complications were scored using the 2016 ISGPS definition. The standardized surgical procedure is to place the patient on a Pink Pad® in Y-position with 15° anti-Trendelenburg, and 5° left tilt. Pneumoperitoneum (12mmHg) is created via Verres needle at Palmer’s point. Four 8mm robot trocars are placed just above the umbilicus on a horizontal line, 8cm apart. A 12mm assistant trocar is placed under the umbilicus; a 5mm trocar is placed 8cm to the right. The infra-umbilical incision is widened to 10-15cm to extract the specimen. An Alexis wound protector® is placed for the reconstruction phase. Pancreaticojejunostomy is done with interrupted Vicryl 3/0 or continuous V-loc 4/0 sutures, and a silicon stent is placed in the pancreatic duct. Hepaticojejunostomy is performed with continuous PDS 5/0 or interrupted PDS 5 or 6/0, depending on hepatic duct diameter. The gastroenterostomy is a side-to-side continuous monolayer V-loc 3/0 anastomosis. Results Between the 12th of August 2020 and the 12th of January 2023, 72 robotic pancreaticoduodenectomies were performed. Sixty-two patients had a resection for a malignant tumor. Patient characteristics, operative details, outcome parameters, and oncological results are summarized in Table 1. Clavien ≥3b complications were more frequent in the first twenty cases. Conclusions In a high-volume center, robotic pancreaticoduodenectomy is feasible with good short-term outcomes, even during the initial learning curve. In addition, it has equivalent oncological results compared to open surgery.

ABSTRACT. BACKGROUND Pectus carinatum is a thoracic deformity of the sternum that can be treated in a non-invasive manner by compressive bracing. Therapeutic compliance can be a challenge, especially in adolescents for whom the bracing treatment can cause social discomfort and psychological distress. We report our institutional experience in treating pectus carinatum patients with a Wilmington brace.

METHODS All patients who started bracing therapy between 2019/01/01 and 2021/12/31 in our hospital, and who subsequently received follow-up by the same physician, were collected. Firstly, we retrospectively collected data from clinic reports. Secondly, we used the validated PCEQ (Pectus Carinatum Evaluation Questionnaire) and PeCBI-QOL (Pectus Carinatum Body Image-Quality of Life) questionnaires to investigate treatment compliance, complications, physical limitations and social and psychological well-being during and after brace use.

RESULTS 79 patients were included, with a median age at the start of treatment of 14 years old. 16 patients finished treatment and 52 patients are still under treatment. 14%(n=11) were lost to follow-up. Twelve patients finished treatment successfully and 4 experienced treatment failure. A complete correction was obtained after a mean treatment duration of 7 months. Mean total treatment duration was 16 months. Skin problems occurred in 11%(n=9) of patients. Pain during bracing treatment was present in 11% (n=9) of patients and was mainly manifested by chest pain (n=3) and back pain (n=4). In regards to QoL, patients responded to have been compliant ‘many times’ regarding the prescribed wearing time. The degree of chest pain, back pain, dyspnoea and limitation in activities during brace wearing was reported as low.

CONCLUSIONS In this study, the Wilmington brace seems to be an effective and safe non-invasive treatment for pectus carinatum in combination with regular clinic follow-up as a key to treatment success. Complications were minor and were related to skin problems, pain during bracing treatment and minor brace damage.

ABSTRACT. Objectives: Congenital deformities can have a broad impact on the self-awareness of adolescents. Being an intermediate solution between Ravitch and bracing, the Abramson procedure with the placement of a presternal bar is performed as a less invasive but still operative treatment for pectus carinatum. We analysed the institutional experience with the Abramson-procedure in view of complications and patient satisfaction.

Patients and methods: We analysed the patient records from all patients who underwent the Abramson procedure in our institution from 2013 until 2021 (n=59). For the assessment of quality of life (QoL), we conducted prospective research whereby 3 questionnaires (EQ-5D-5L, SF-36v2, SSQ) were sent. All questionnaires probed patients about their QoL and satisfaction about the result of the operation. Thirty-two patients responded to these questionnaires.

Results: A total of 216 complications were registered within these 59 patients; 84,72% classified as Clavien-Dindo grade I, 7,41% as grade II and 7,87% as grade IIIb, respectively. Based on the EQ-5D-5L questionnaire, no significant difference was observed between treated patients and a Belgian reference population. Also no significant difference was observed in QoL and result of the operation between patients with no or mild complications and those with severe complications based on the SSQ questionnaire. In terms of overall satisfaction, patients scored higher than the means on the domains probed by the SF36. A large majority (93.76%) was at least satisfied with the outcome of the operation and 96.88% considered their chest as improved.

Conclusion: Patients should make a thoughtful consideration between the risk of complications and the profit in QoL and self-esteem following this operation. This consideration can differ depending on the extent to which the patient is disturbed by this congenital abnormality. Despite complications, the responders stated to be satisfied with the new appearance. Further research must be done with larger study groups to detect significant differences.

ABSTRACT. Objective The robotic platform has known an exponential growth since its introduction in colorectal surgery. This study aims to evaluate the first results of robotic-assisted anterior resection (R-AR) using a single-stapled anastomosis (SSA) in our centre. A drawback to further implementation of robotic surgery is its substantial cost. We address reimbursement in Belgium and report a cost-effective method of performing R-AR. Methods We retrospectively reviewed the first 34 R-ARs, performed by a single surgeon from October 2021 to January 2023. Data from a prospectively maintained database was analyzed. We compared these patients with our last L-ARs (laparoscopic anterior resections) to assess feasibility and safety. Peri- and postoperative complications, conversion rate, length of stay and operative time were analyzed in-depth. All patients followed the same enhanced recovery after surgery protocol. Finally, a financial assessment was made of the consumables used in both R-AR and L-AR. Results A total of 34 patients underwent R-AR and were compared to 34 patients who underwent L-AR. Median age was not significantly different (64.5 R-AR vs. 70.0 years L-AR, p=0.12). R-AR was primarily performed for diverticular disease (94.1% R-AR vs. 44.1% L-AR, p<0.001), while the L-AR case-mix contained more oncological cases. Median operative time was longer in the robotic group (159 R-AR vs. 116 minutes L-AR, p<0.001). One leak was observed in both groups (2.9%). Median hospital stay did not differ significantly (2 R-AR vs. 3 days L-AR, p=0.07). There was one conversion (2.9%) in the laparoscopic group. With our modified surgical technique, the cost of R-AR is substantially reduced below the flat reimbursement rate. Conclusion This review of the preliminary results of R-AR in our centre demonstrates that our approach is technically feasible and safe. With adjustments in surgical technique and used materials we obtain a SSA, as well as a cost-effective way of performing R-AR in Belgium.

ABSTRACT. OBJECTIVE To report a case of ischaemic appendicitis following selective arterial embolization for gastro-intestinal hemorrhage.

METHODS This report revolves around a thirty year-old male with a history of endovascular treatment of a pseudoaneurysm, for which he was under double antiplatelet therapy. Initially he presented with heavy rectal bleeding in need of transfusion, without any other complaints. Investigations, including gastroscopy and CT scan, could not readily determine the source of the bleeding. Upon second look of the scan, hemorrhage originating from the terminal ileum was believed to be the likely cause. Therefore, the patient was transferred to a tertiary center for conventional angiography. Selective imaging failed to demonstrate active bleeding at the terminal ileum. Nevertheless, a temporary empirical embolization of a small arterial branch using gelfoam was performed. Immediately after the procedure, the patient started complaining of intense pain in the right iliac fossa. Initially, a wait-and-see policy was decided upon. However, three days later the patient developed an acute abdomen with sepsis. CT scan showed pneumatosis of the appendix with suspicion of more generalized caecal/terminal ileal ischemia. An urgent explorative laparotomy was performed. Inspection showed isolated appendiceal ischemia, with surrounding reactive inflammation. A classic appendectomy was subsequently performed.

RESULTS Postoperatively, the patient was admitted to the intensive care unit for monitoring and additional treatment of the accompanying sepsis. After discharge to the ward, further recovery was uneventful. Pathological examination showed a necrotic appendix with presence of foreign material in the blood vessels. Follow up has yet to occur, including workup to determine the cause of the hemorrhage.

CONCLUSION This case demonstrates that empirical embolization is not without risk. The unusual consequence of significant ischemia should be kept in mind, and the patient closely monitored after the procedure. Fortunately, in our case the correct diagnosis was made and the patient experienced a positive outcome.

ABSTRACT. Objective: Fluid management is an established part of current Enhanced Recovery After Surgery (ERAS) programs. Pancreaticoduodenectomy (PD) is a complex procedure with a high risk of postoperative morbidity, which could benefit from ERAS-protocol implementation. Excessive postoperative fluid management is an adjustable risk factor resulting in increased postoperative morbidity. The aim of this study is to assess the impact of excessive fluid administration on postoperative major complications after PD and to define thresholds for postoperative fluid management. Methods: Data from a prospectively maintained database was reviewed. A total of 106 consecutive patients who underwent PD from January 2021 to December 2021 were included. Patients’ clinical characteristics and fluid charts were analyzed. Main outcomes were 30-day major postoperative morbidity (Comprehensive Complication Index (CCI)>40) and pancreatic fistula. Univariate analysis was performed for age, weight, ASA score, BMI, volume of fluid administered the first five postoperative days (ml/kg/day), duration of surgery, hospital stay, fistula risk score (FRS). Independent risk factors for the two outcomes were assessed by stepwise regression. Thresholds regarding postoperative fluid management were identified through receiver operating characteristic analysis. Results: Major complications (CCI>40) occurred in 17 patients (16.8%) and clinical pancreatic fistula occurred in 26 patients (25.8%). Median age was 69 (IQR 61-74), BMI 24.4 (IQR 22.6-26.7) and ASA score 2 (IQR 2-3). Median hospital stay was 13 (IQR 10-18.5) days. Univariate analyses showed that FRS, postoperative fluids on day 5, duration of surgery, and hospital stay were significantly associated with major complications (P=0.007, P=0.0019, P=0.0021 and P=0.0001, respectively). In the stepwise regression analysis, postoperative fluid at day 5 (P=0.036, β=0.21) and FRS (P=0.015, β=0.24) retained as independent risk factors for major complications. Optimal fluid administration threshold at postoperative day 5 was 29.41 mL/kg (AUC 0.66, 95%CI 0.53-0.78. Conclusion: Postoperative excessive fluid management and FRS are independently associated with increased rate of major complications after PD.

ABSTRACT. Objective: Single Anastomosis Sleeve Ileal (SASI) bypass has recently emerged as a novel bariatric surgery. The aim of this study was to evaluate the weight loss after SASI bypass and the effect on gastroesophageal reflux disease (GERD) after two years.

Methods A retrospective review of patients undergoing SASI bypass by a single operator that had two years of follow up was performed in a single centre. The technique consisted of a sleeve gastrectomy followed by a latero-lateral gastro-ileal anastomosis, creating transit bipartition. Weight and comorbidities were recorded before and during follow up, and percentage of excess weight loss (%EWL) was calculated.

Results In total, 79 patients were included in this study. The mean age was 43.7 ± 12.6 with a male to female ratio of 0.36. Previous bariatric surgery was reported in 11 patients (13.9%). No intraoperative complications were reported. One deep vein thrombosis was reported at 30 days. The rate of patients followed was 83.5% and 75.9% after one and two years, respectively. The preoperative body mass index was 41.9 ± 5.3 kg/m2 and showed a significant decrease after one (26.2 ± 5.2 kg/m2, p<0.001) and two years (25.3 ± 5 kg/m2, p<0.001), respectively. The mean %EWL was 97.0 ± 28.5 and 101.7 ± 30.4 after one and two years, respectively. Only one (1.7%) weight loss failure was reported (%EWL < 50). No new onset GERD was reported after SASI bypass, and the preoperative GERD rate significantly decreased after 2 years (51.7% to 26.7%, p=0.005). Of the 13 patients with diabetes mellitus, one was still diabetic. Two malnutrition cases were reported with one patient who had to be reverted to sleeve gastrectomy for excessive vomiting and weight loss.

Conclusions SASI bypass is a potent and safe bariatric procedure that improves comorbidities. It could be proposed to obese patients with a preoperative GERD.

ABSTRACT. Objective Minimally invasive inguinal hernia repair results in 6 to 12% of patients experiencing chronic pain. The mesh can constitute the root of the problem. Published literature concerning laparoscopic mesh removal is scarce. A recently published study has demonstrated feasibility and safety of this technique. However, little is known about hernia recurrence after laparoscopic mesh removal. This observational study aims to describe the hernia recurrence after laparoscopic mesh removal in patients with chronic postoperative inguinal pain (CPIP) and reports the effect of the intervention on pain.

Methods A retrospective study of prospectively maintained questionnaires and operative findings was conducted. The patient population constitutes of consecutive patients undergoing a laparoscopic mesh removal for CPIP between November 2011 and July 2022. Hernia recurrence was based on anamnestic and clinical findings. Pain scores were quantified using the NRS.

Results Ninety-eight patients were included in our study (median age 57 years). We noted a hernia recurrence in eighteen patients (20,22%), requiring open surgery. Intraoperative findings concerning the mesh placement were also reported. NRS dropped from 7 to 3.

Conclusion Laparoscopic mesh removal for CPIP results in 1 out of 5 patients presenting with a hernia recurrence. To the best of our knowledge, this is the first study describing hernia recurrence after laparoscopic mesh removal.

ABSTRACT. OBJECTIVE: The Rives-Stoppa (RS) procedure has long been considered the gold standard in the treatment of midline abdominal wall hernias. It remains unclear to what extent pain control and outcomes are comparable to the less invasive enhanced-view totally extraperitoneal prosthetic (eTEP) repair.

METHODS: Single centre surgical cohort including 30 patients who received RS repair (January 2019 – November 2021), and 30 consecutive patients who received an eTEP procedure (September 2021 – August 2022) for midline abdominal wall hernia(s) with rectus abdominis diastasis (RAD). Postoperative pain and outcomes were compared for both procedures.

RESULTS: Conversion to open surgery was needed in 10% of eTEP procedures. Median duration of surgery was 110.5 (open RS) and 164.5 (eTEP) minutes. After RS repair, all patients left the operating theatre with one or more drains compared to 10% of patients after an eTEP procedure. Presence and median duration of postoperative patient controlled analgesia (PCA) were respectively 90% and 3 nights (open RS), versus 30% and 0 nights (eTEP). Median switch to only oral analgesics occurred at postoperative day (POD) 3 in the open RS group and at POD 2 in the eTEP group. Administered analgesics disregarding PCA, and presence of an opioid prescription at discharge were comparable between groups. Median length of hospital stay was 6 nights (open RS) versus 3 nights (eTEP). Amount of postoperative complications was comparable. No early recurrences were observed. Postoperative consultation revealed no minimal residual bulge of the abdominal midline after RS repair, however, this was observed in 11 patients after an eTEP procedure.

CONCLUSIONS: The eTEP procedure is a feasible minimally invasive alternative to an open RS repair for the treatment of midline abdominal wall hernias alongside RAD and is associated with a shorter length of hospital stay, less postoperative pain and a comparable risk of short-term complications. Registration number: NCT05446675 (ClinicalTrials.gov).

ABSTRACT. Objective: In spite of increasing diffusion, Enhanced Recovery Pathways (ERP) have been scarcely assessed in large scale programs of lung cancer surgery. The aim of this study was auditing our practice.Methods: A two-step audit program was established: the first dealing with our initial ERP experience in patients undergoing non-extended anatomical segmentectomies and lobectomies, the second including all consecutive patients undergoing all kind of lung resections for NSCLC. The first step aimed at auditing results of ERP on occurrence of postoperative complications and at assessing which ERP components are associated with improved short-term outcomes. We also audited late results by assessing long-term survival of patients in the first step of our study. The second step aimed at auditing on large-scale short-term results of the ERP in a real-life setting. Results: Over a one-year period, 166 patients were included. The median number of ERP procedures per patient was three (IQR 3-4). No postoperative death occurred. The overall adverse events rate was 30%. In multivariate analyzes, the only element associated with reduced adverse postoperative events was chest tube withdrawal within POD2 (OR = 0.21, 95% CI (0.10-0.46)). The 1-, 3-, and 5-year survival rates were 97%, 86.1%, and 76.3%, respectively. In the second period, 1077 patients were included in our ERP; 11 patients died during the postoperative period or within 30 days of operation (1.02%). The overall postoperative adverse event rate was 30.3%, major complication occurring in 134 (12.4%), and minor ones in 192 (17.8%). Respiratory complications occurred in 64 (5.9%). Thoracoscore independently predicted postoperative death, the occurrence of complications (all-kind, minor, major, or respiratory ones). Conclusions: Compliance to ERP procedures and early chest tube removal are associated with reduced postoperative events in patients with lung resection surgery. In a large setting scale, ERP can be applied with satisfactory results in terms of mortality and morbidity.

ABSTRACT. Background

Although transcatheter aortic valve implantation has been introduced in 2008, patients of 85 years and older are still referred for surgical aortic valve replacement (SAVR). The research questions are: what are the predictors of short and long-term mortality? Can modifiable predictors be identified?

Methods

This is a retrospective file study of 2,500 patients who underwent SAVR with or without CABG, using a biological heart valve in a general hospital, between 1987 and 2017. Mechanical valves and valve replacement in other positions were excluded. Twenty-seven cardiac (valve related, arrhythmias, conduction defect, left ventricular function, heart failure, coronary disease, non-elective surgery) and non-cardiac (era of referral, renal, pulmonary, diabetes, hypertension, CVA, malignancy) categorical preoperative factors, and seven operative (bypass time, cross clamp time, mitral repair) factors were included in an univariate chi-square analysis. Significant factors were entered in a multivariate logistic regression analysis for identification of independent predictors for 30-day mortality. Kaplan-Meier and Cox’ proportional regression analysis were used to identify independent predictors for long-term mortality, for which also early postoperative events were included.

Results There were 154 patients older than 85 years. Of these, 24 (15.6%) died within the first 30 postoperative days. There were three independent predictors for 30-day mortality: 1) prior myocardial infarction with and odds ratio (OR) of 5.10 and a 95% confidence interval (1.83-14.19); p=0.002; 2) need for non-elective SAVR, OR=3.78 (1.40-10.24); p=0.009, 3) atrial fibrillation, OR=3.14 (1.16-8.52); p=0.025. There was a follow up of 775 patient-years, with a mean survival of 5.9 years for hospital survivors. Four independent predictors for long-term mortality were identified and are presented (5-year survival with v. without factor), OR 95%CI).

Conclusions

Postoperative mortality and 5-year survival after SAVR in this age group is acceptable. Results could be improved by avoiding development of congestive heart failure or need for non-elective SAVR by early referral.

ABSTRACT. OBJECTIVE The Bethesda System for Reporting Thyroid Cytopathology is a commonly used classification for fine-needle aspiration (FNA) cytology of suspicious thyroid nodules. The risk of malignancy (ROM) for each category has recently been analyzed in three international databases. This paper compares the diagnostic performance of this classification in a high-volume referral center in Belgium.

METHODS All consecutive thyroid procedures were registered in a prospective database from January 2010 to August 2022. Patient and surgical characteristics, preoperative Bethesda classification, and postoperative pathology results were analyzed. All statistical analyses were conducted in Stata MP14 (Stata Corporation).

RESULTS Out of 2219 consecutive thyroid procedures, 1226 patients underwent preoperative FNA. Bethesda categories 1, 2, 3, 4, 5, and 6 represented 250 (20.4%), 546 (44.5%), 96 (7.8%), 231 (18.8%), 62 (5.1%), and 41 (3.3%) patients, respectively. ROM was 4.4%, 3.8%, 20.8%, 15.2%, 72.6%, and 90,2 %, respectively. Overall ROM of 13.8%. An NPV of 96.2% was found. Sensitivity for “diagnostic” categories 2, 5, and 6 was 79.6%, and 72.4% for “non-diagnostic” categories 3 and 4. Overall specificity was 64.2% and the PPV was 31.9%. Diagnostic accuracy was 67.8%. Compared to international databases (CESQIP, EUROCRINE, BAETS Registry), the risk of malignancy in our series appeared lower for Bethesda classification 4 (15.2 vs 26.7%) but did not reach statistical significance (p=0.612). Papillary thyroid cancer was the most prevalent (N= 119, 70.4%), followed by follicular (N=17, 10.1%) and medullary thyroid cancer (N=15, 8.9%). Micropapillary thyroid cancer was incidentally found in 46 (3.8%) patients.

CONCLUSIONS Despite being validated in numerous studies, the ROM based on preoperative FNA cytology classified according to the Bethesda system, may vary amongst surgical centers and countries. The higher NPV and lower PPV in our series, especially for Bethesda 3 and 4 confirms this geographic variation.

ABSTRACT. Objective Assessments need to have sufficient validity evidence established prior to their use. The ACTION tool evaluates proficiency in Chest Tube Insertion (CTI) and combines a rating scale and an error checklist. The aim was to collect validity evidence for the tool on a porcine rib model following Messick’s framework.

Methods Twenty-nine European experts participated in three Delphi rounds to develop the ACTION tool, consisting of a rating scale with 17 steps and a checklist with 16 errors. A simulator was designed by placing a porcine hemithorax on a wooden frame. Novice and experienced participants were recruited from the departments of surgery, pulmonology and emergency medicine of Ghent University Hospital. After familiarization with the simulation, identical instructions and clinical context were given. They performed two CTIs while being scored with the ACTION tool. Performances were assessed live by one rater and by three blinded raters using video recordings. Inter-item, inter-rater and test-retest reliability of the assessment were calculated, and a Generalizability-analysis was done. Mean scores of both groups on the first performance were compared and a pass/fail score was established using the contrasting groups’ method.

Results Nine novices and nine experienced participants joined this study. Inter-item reliability of the tool was good for the scores (Cronbach’s α=0.81) and moderate for the errors (α=0.55). Inter-rater reliability (Pearson’s r=0.93 and 0.83) and test-retest reliability (α=0.90 and 0.85) were high for both, as well as the G-coefficients (0.92 and 0.86). Novices scored lower (38.11 vs. 47.78/68, p=0.023) and committed more errors (2.44 vs. 1.11, p=0.044) than the experienced in the first CTI. A pass/fail score of minimum 44/68 and a maximum of two errors was established.

Conclusions A solid validity argument is presented for the ACTION tool on a porcine rib model, allowing formative and summative assessment of procedural skills during training.

ABSTRACT. Objective Both anterior component separation technique (aCST) and posterior Transversus Abdominis Release (TAR) are valuable techniques, but the limits for using these techniques are unclear. The aim of this analysis was to compare outcomes regarding postoperative wound morbidity and recurrence for both techniques. Methods A retrospective analysis of prospectively collected data was carried out. Patients with any form of component separation technique, aCST or TAR, between 3/2013 and 8/2022 were included. Data was analyzed for patient demographics, risk factors, surgical site occurrences (SSO), general complications and hernia recurrence. Follow up was performed at 1 month, 1 year and 2 years. Results A total of 258 patients underwent CST: 68 (26.4%) aCST and 190 patients (73.6%) TAR. Patients showed no significant difference for gender, risk factors and comorbidities. The aCST group showed larger defects (EHS-W3 in 64.7% vs. 45.3% , p=0.006). Intrahospital complications were lower in the TAR group (12.1% vs 29.4%, p=0.001). SSO rate at one month was significantly lower in the TAR group (12.7% vs 43.9%, p<0.001) with SSO- procedural interventions 6.3% vs 30.3%, p<0.001). Recurrence was low in both groups (aCST 3.0% vs TAR 1.6%). Follow up was complete in 93.8% of patients. Conclusion Although aCST and TAR are both valid options in large incisional hernia repair, postoperative wound morbidity as well as overall complication rates are significantly increased after aCST. It seems indicated to choose TAR over aCST in laterally located hernia defects and in large midline defects and only consider aCST in case of doubt about complete anterior fascial closure.

ABSTRACT. Objective: Patients undergoing unilateral inguinal hernia repair are at risk of metachronous contralateral inguinal hernia development, requiring reintervention. We evaluated incidence and risk factors of metachronous contralateral inguinal hernia development up to 25 years after unilateral inguinal hernia repair to determine possible indications for simultaneous prophylactic surgery of the contralateral groin at the time of index surgery. Methods: Patients between 18-70 of age undergoing elective unilateral inguinal hernia repair in our centre from 1995 to 1999 were studied retrospectively using the electronic health records, and prospectively via phone calls. Study aims were metachronous contralateral inguinal hernia incidence and risk factor determination. Kaplan-Meier curves were constructed and univariable and multivariable Cox regressions were performed. Results: 758 patients were included (91% male, mean age 51 years). Median FU time was 21.75 years, mean FU time was 18.3 years. The incidence of operated metachronous contralateral inguinal hernia after 5 years was reported at 5.6%, after 15 years at 16.1%, and after 25 years at 24.7%. The incidence of both operated and non-operated metachronous contralateral inguinal hernia after 5 years was reported at 5.9%, after 15 years at 16.7%, and after 25 years at 29.0%. Metachronous contralateral inguinal hernia risk was increased with higher age, and decreased in primary right-sided surgery and higher BMI at index surgery. Conclusion: We believe these data do not provide enough clinical evidence to support the idea of prophylactic contralateral repair in all patients to avoid the development of a metachronous contralateral inguinal hernia. We suggest a patient-specific approach taking into account metachronous contralateral inguinal hernia risk factors, surgical approach and risk factors for chronic postoperative inguinal pain.

ABSTRACT. OBJECTIVE Pectus excavatum is the most common chest wall deformity. Commonly reported symptoms are dyspnea, problems of self-confidence, loss of endurance, palpitations and chest pain. The Nuss-procedure is a minimal invasive surgical technique where metal struts are inserted beneath the sternum to push the deformed sternum forward and removed 3 years later. Studies have shown that patients with pectus excavatum have a significant lower disease-specific and general quality of life. With this project we wanted to investigate the QoL-evolution with a large study population, albeit single center, while also comparing the general health of the participants with those of their peers in a national reference health survey data set.

METHODS All patients who underwent the Nuss-procedure in UZ Leuven between 2013 and 2021 were included in this study. They got sent 3 questionnaires about their quality of life, more specifically the EQ-5D-5L, the SF-36 and the single step questionnaire. We looked at the overall responses, the differences between genders and age-groups and compared our results of the EQ-5D-5L with those of a national reference database.

RESULTS Of the 200 responders 95.5% think the look of their chest has improved and only 3% of all participants were unsatisfied with the overall result. Seventy percent of participants state their health has improved after the Nuss-procedure and sees improvement in their exercise capacity. About 35% state that the procedure had a positive effect on their social life. Our results of the EQ-5D-5L questionnaire were significantly better than or at least comparable with those of the national reference.

CONCLUSIONS It appears safe to state that the Nuss-procedure has a positive effect on the quality of life of patients with pectus excavatum and that their quality of life after surgery is at least as good, if not better than the one of their peers.

ABSTRACT. Objective The Flanders Inguinal and femoral Hernia Repair Prospective Registry (FLIPR) was launched as the first prospective population-based cohort of groin hernia patients in 17 hospitals of the Vlaams Ziekenhuisnetwerk KU Leuven with focus on patient reported outcome measures(PROMs) and chronic pain. We present the operative data of the first 5 years with focus on laparoscopic groin hernia surgery.

Methods The registry is based on standardized and validated questionnaires registered via a secure digital link at specific time intervals (preoperative until 5 year postoperatively). The operating surgeon completes a standardized operation form with compulsory input data including EHS classification, type of surgery and anesthesia, duration of surgery, type of mesh, type and amount of fixation, nerve handling and intraoperative complications. Processed output data is available to all participating surgeons in an online secured dashboard.

Results We present the 5 year inclusion data of 3952 patients operated on between 2018-2022, of which 3354 (85%) had a laparoscopic posterior approach for mostly primary (98%) and unilateral (56%) groin hernias. In total 4848 hernias were operated laparoscopically.

Conversion occurred in only 59(1%) cases. Mostly (99.7%) non-self-gripping mesh was used and 1374 (28%) had fixation [staples(56%)/glue(41%)/sutures(3%)] added. Complications occurred in 51 (1%) cases. Thirty-two (0.7%) neurectomies were performed. 282(6%) of hernias were operated by trainees.

Conclusions The majority of patients was operated laparoscopically by consultants with low conversion, complication and nerve division rate.

ABSTRACT. An atrioesophageal fistula is an uncommon complication of atrial ablation with a mortality rate of 40–100%. Uniform treatment guidelines have yet to be established. Herein, we illustrate the successful surgical management of an atrioesophageal fistula, avoiding the need for an oesophageal surgical intervention by sealing and clipping of the oesophagus. This novel single-step hybrid approach combining cardiac surgical and gastroenterological techniques provides a less aggressive strategy with potentially a more favourable prognosis.

ABSTRACT. OBJECTIVES: Although epicardial bipolar radiofrequency ablation should diminish the risk of esophageal thermal injury in comparison to endocardial ablation, cases of lethal atrio-esophageal fistula have been reported. To better understand this risk and to reduce the possibility of thermal injury, we monitored esophageal temperature with the Circa S-Cath™ temperature probe during and immediately after ablation while implementing three procedural safety measures. METHODS: Twenty patients (15 males; 63±10 years) were prospectively enrolled (November 2019-February 2021). All patients underwent an epicardial ablation procedure including an antral left and right pulmonary vein isolation with bidirectional bipolar clamping, and a roof-and inferior line using unidirectional bi-polar radiofrequency. Three procedural preventive mitigations were implemented: (1) transesophageal echocardiographic visualization of the atrio-esophageal interface, with probe re-traction before energy delivery; (2) lifting the ablated tissue away from the esophagus during energy application; and (3) a 30-s cool-off-and-irrigation period after energy delivery. Esophageal temperature was recorded using an insulated multisensory intraluminal esophageal temperature probe (Circa S-Cath™). RESULTS: Of the 20 patients enrolled, 7 patients had paroxysmal atrial fibrillation (AF), 8 persistent and 5 longstanding persistent atrial fibrillation. The average maximum luminal esophageal temperature observed was 36.2 ± 0.7ºC [34.8-38.2°C]. In our clinical experience, no abrupt in-crease in luminal esophageal temperature above baseline was observed. Since no measurements exceeded the threshold of 39°C, no prompt interruption of energy delivery was required. CONCLUSIONS: Intraluminal esophageal temperature monitoring is feasible and can be helpful in confirming correct catheter position and safe energy application in bipolar epicardial left atrial ablation. Intra-procedural preventive mitigations should be implemented to reduce the risk of esophageal temperature rises.

ABSTRACT. OBJECTIVE The patient was a 62-year-old male who was referred to our center for symptomatic gallstones and perturbation of hepatic blood tests. Preoperative US and computed tomography revealed dilatated intra and extrahepatic bile ducts (depending on segment VI and VII) and two centimetric stones inside a scleroatrophic gallbladder. He had a laparoscopic open-converted cholecystectomy complicated with biliary tract injury (BTI) due to abnormal emergence and path of the right posterior duct along gallbladder wall.

METHODS Primary surgical repair was done using a Kehr 3 French drainage. A week after hepatobilary surgery (HBP), follow up cholangio-MRI was performed and showed post-operative RPD stenosis with dilatation of bile ducts (for segment VI and VII). Secondary conservative management was done by gastroenterologists and consisted in an endoscopic retrograde cholangiopancreaticography (ERCP) with sphincterotomy of the major duodenal papilla and the placement of both pancreatic and 8.5 French covered biliary prothesis. The patient showed a quick biological tests improvement and disappearance of icterus. Seven days after procedure, he was discharged from the hospital and Kehr drainage was removed at four-months-follow-up without any complications such as secondary biliary stenosis, bilioma or even cholangitis.

RESULTS This case report describes per- and postoperative multidisciplinary management of an iatrogenic BTI. This will allow to highlight the conservative treatment of a secondary biliary stenosis after biliary injury and primary surgical repair using Kehr drainage.

CONCLUSIONS The conclusion aims to highlight the prevention of BTI and preconditioning the patient before HBP surgery. We will focus on, in one hand, the role of peroperative cholangiography to identify level of BTI and the limitation of this one to prevent them in case of bile duct variations. It will be focused, on the other hand, over the role of cholangio-MRI and an ERCP to prevent BTI trough the identification of biliary variations.

ABSTRACT. Objective Trauma involving the external iliac arteries is rare. These traumas are usually associated with severe pelvic fracture, have a poor prognosis, and are associated with significant complications such as hypoperfusion of the lower limb that may lead to amputation. This type of trauma must be properly diagnosed and meticulously treated.

Methods We will describe a case of trauma to the left external iliac artery resulting in a pseudoaneurysm on a femoral acetabular fracture with protrusion of the femoral head into the pelvis following a fall in a patient with a hip replacement. The patient was already known in orthopedic department and had been operated multiple times on both hips.

Results The patient presented to the emergency department with left hip pain and nausea following a slip on a carpet at home 2 weeks earlier. The angio-scanner showed an active but small bleeding from the left external iliac artery at the protrusion site. During surgery, mobilization of the acetabulum caused significant hemorrhage. The hemorrhage was stopped by clamping the primary iliac artery during removal of the acetabulum and the cement retroperitoneally, and the new acetabulum was fixed. Subsequently, a split-stitch anastomosis was performed on the external iliac artery.

Conclusion In our case, symptoms were not related to the severity of the pathology. The clinical presentation of external iliac artery trauma is not clear, but it should be suspected in pelvic fractures with hemodynamic instability. A concomitant vascular and orthopedic surgical approach seems to be a good initiative in this type of pathology, as the hip approach has resulted in bleeding from the external iliac artery.

ABSTRACT. Background and Aims: Living donor liver transplantation poses a qualitative, valuable alternative for deceased donation. Therefore, it is important to investigate the risks healthy donors face during and after this procedure. We investigated complications and their impact on long-term health-related quality of life (HRQoL) and physical and mental functioning. Method: Thirty-three out of 51 Belgian liver donors with a donor hepatectomy at the Ghent University Hospital since 1991 were included. A blood sample was collected together with a liver ultrasound, a clinical examination by a liver surgeon, and a socio-psychological interview supervised by a transplant psychologist. Additionally, a questionnaire study was performed: SF-36 questionnaire, Depression, anxiety, and stress questionnaire, EQ-5D-3L, and a personalized donor experience questionnaire. Results: Most common relationship between donor and acceptor was parental (14 donors, 42.2%). Donor complications and long-term physical symptoms were recorded in 6 and 8 patients respectively (18.2%, 24.8%) without relation to the long-term mental quality of life and physical symptoms. Development of complications was not significantly correlated with the preference to donate again (p = 0.49). Type of lobe donation had no significant effect on the mental and physical quality of life, mood, anxiety and stress, and complications. Recipient complications and death (p = 0.04, p < 0.01), negative mood (p = 0.01, p = 0.01), anxiety (p = 0.03, p = 0.03), and stress (p = 0.04, p = 0.02) were found to be related to a lower physical and mental quality of life of the donor. Donors to pediatric recipients scored significantly better for mental and physical HRQoL (p < 0.01, p < 0.01). Conclusion: Donor experience is positive overall. Own complications had no lasting effect on HRQoL and mental health, however, complications in the recipient, are more difficult to cope with and impact the mental HRQoL of the donor.

ABSTRACT. Background There is no consensus regarding the bariatric surgery has to be performed. The most classical interventions are sleeve gastrectomy, gastric bypass and single anastomosis duodeno-ileal bypass with sleeve gastrectomy/SADI. SADI is similar to Duodenal Switch in term of malabsorption by complete exclusion of duodenum. We propose a bipartition achieved by latero-lateral duodeno ileal anastomosis by compression of two magnets. Part of the food passes rapidly from the duodenum into the terminal ileum which immediately secretes satiety hormones (GLP-1, PYY-36) and leads to malabsorption.

Objective The goal of the procedure is to maintain the neuroendocrine effects of the SADI while minimizing deleterious effects of malabsorption. The aim of this study is to demonstrate the feasibility and safety of duodeno-ileal bipartition using latero-lateral anastomosis performed by magnets.

Methods Ten patients underwent the duodeno-ileal anastomosis by magnet in 2021. In 9 patients a sleeve was associated.

Results The postoperative follow-up was 6 months. Median operative time was 119 min (68-187) and hospital stay was 3 days. The elimination of the magnets was spontaneous in all patients after a median time of 43 days (21-104). The placement and expulsion of the magnet system did not lead to digestive perforation, obstruction or any complications. There was no anastomotic leakage. At gastroscopy, all anastomoses were patent, permeable, allowing easily the introduction of gastroscope. Nine patients had an isotopic study with a median of 19% of radioactive activity was found in the ileal branch. Among the immediate complication, one patient had a leak at the Hiss angle at the sleeve. For late complications, there were 4 re-hospitalizations: 3 for dehydration due to nausea and vomiting and one patient for internal hernia.

Conclusion Duodeno-ileal bipartition with a latero-lateral anastomosis performed by magnets is feasible and has satisfactory safety. The median of 19% of ingested radioactive yogurt passes into the ileal loop.

ABSTRACT. Objective

Clearance of common bile duct stones (CBS) in the presence of a gallbladder is most commonly established by ERCP and papillotomy, followed by cholecystectomy in a second stage. After gastric surgery the papilla may not be easily accessible via an endoscopic route. Studies have shown at least equal stone clearance rates, low complication rates and lower cost for single-stage laparoscopic cholecystectomy and common bile duct exploration. More recently, EUS-directed transgastric ERCP has been proposed as an alternative after gastric bypass. The aim of our study was to evaluate therapeutic success of LCBDE after previous gastric surgery.

Methods

We studied a consecutive series of 269 patients who underwent LCBDE between January 2014 and July 2022. Forty-four patients were identified to have previously undergone gastric surgery. Median (range) age of the study population was 68 (25 – 90) years. Gastric surgery consisted of Roux-en-Y gastric bypass, BII subtotal gastrectomy, total gastrectomy and subtotal gastrectomy with Roux-en-Y reconstruction in 31, 6, 5 and 2 patients respectively. Simultaneous cholecystectomy was performed in 38 patients.

Results

At LCBDE presence of CBS was confirmed in 85% of the cases. In five patients there were no further CBS during exploration, one patient had a bile duct polyp and one patient had a local recurrence after total gastrectomy. In case of presence of CBS, clearance rate was 97%. Choledochotomy was performed in fourteen (32%) patients. Median (range) length of stay after LCBDE was 1 (0 – 12) day(s). Ten patients developed a postoperative complication. A major complication (Clavien-Dindo score >3a) was found in four patients. Four patients were readmitted after initial discharge.

Conclusion

LCBDE is a very successful and safe technique to remove CBS after previous gastric surgery, even after previous cholecystectomy. After gastric bypass surgery LCBDE omits the need for complex interventional endoscopy and creation of a gastro-gastric fistula.

ABSTRACT. Background and aims Early reintervention after surgical aortic valve replacement (SAVR) for any reason is a serious event. What are the predictors of need for early reintervention after SAVR? Which other postoperative adverse events are associated with reintervention? What are the long-term consequences of reintervention?

Methods Retrospective file study of 2,500 patients undergoing SAVR with a biological valve prosthesis, between 1987 and 2017. There is a follow-up of 19,744 patient-years. Twenty-seven cardiac and non-cardiac preoperative factors as well as seven operative factors are included in an univariate chi-square analysis. Significant factors are entered in a multivariate logistic regression analysis to identify independent predictors. A chi-square test is also used to find associations with other postoperative adverse events. For continuous variables, a t-test is used. A log-rank test shows the consequences of need for reintervention on long-term events.

Results Eighty-three patients (3.3%) needed early reintervention, mostly because of bleeding. Three factors are identified as independent predictors (table, top half). Prior SAVR (p=0.019) and age >70 (p=0.038) have only an effect in an univariate analysis. The need for resources is significantly associated with reintervention (p<0.001): - more packed cells: 7.2+/-4.9 v. 2.6+/-3.4 - plasma and thrombocyte concentrate 10-fold - stay on the ICU: 10.5+/-15.3 v. 2.9+/-6.9 days - postoperative stay: 19.7+/-19.1 v. 10.0+/-7.8 days - ventilation time: 89.0+/-178.6 v. 14.1+/-39.5 hours Associated postoperative complications: see table, (bottom half). Effect on 5-y event free rates - mortality: 26.4+/-5.3% v. 21.9+/-0.9; p=0.123 - thromboembolism: 42.6/-2.9% v. 23.4+/-10.9; p=0.039 - bleeding: 47.8+/-3.3% v. 21.4+/-17.1%; p=0.011

Conclusion: Independent predictors for need for reintervention are male gender, long bypass time and a procedure on the ascending aorta. There is an association with, renal and pulmonary complications, delirium and increased mortality and an increased need for resources. Long-term survival is not significantly affected, but long-term bleeding and thromboembolic events have increased.

ABSTRACT. Aim: Immunosuppressive medication might increase the likelihood of wound morbidity, with possible higher rate of surgical site infections (SSIs). We aim to identify short-term outcomes and hospital stay after incisional hernia repair with transversus abdominis release (TAR) in patients with versus without immunosuppression.

Material & Methods: All patients undergoing open incisional abdominal wall hernia repair with uni-or bilateral TAR from January 2021 through November 2022 were identified using a prospectively maintained database. Minimum follow-up was 30 days. Outcomes included 30-day SSIs, seroma rate, hospital stay, and early recurrence.

Results: Twenty-seven patients with immunosuppressive medication were identified and 75 without (mean age 59.0 ± 13.9 vs. 65.1 ± 11.4, 74.1% vs. 46.7% male, respectively). Median hernia width was 7.7 ± 5.1 cm vs. 7.9 ± 4.3 cm respectively. At 30 days follow-up, SSI rate was 1/27 (3.7%) in the group under immunosuppression and 5/75 (6.7%) in the group without (p = 0.575). Seroma rate was 3/27 (11.1%) vs. 12/75 (16.0%), respectively (p = 0.539). Mean hospital stay was 6.0 ± 3.6 days in the immunosuppression group vs 8.1 ± 6.7 days in the group without (p = 0.052). No early recurrences were detected in either group.

Conclusion: Immunosuppression does not significantly increase the risk of short-term complications in incisional hernia repair with transversus abdominis release. There is a trend towards a shorter hospital stay in patients under immunosuppression, possibly related to a reduced inflammatory response.

ABSTRACT. Background Undifferentiated embryonal sarcoma of the liver (UESL) is a very rare malignant mesenchymal tumor. UESL is rarely diagnosed in adults. UESL appears to have a poor prognosis: median survival is estimated to be less than a year without treatment. Resection associated with (neo) adjuvant therapies is the cornerstone therapy.

Case presentation/ Material and methods We report the case of a 21-year-old female patient presented back and epigastric pain since 2 months. Computed tomography (CT) and magnetic resonance imaging showed a well-defined central liver mass measuring 16cm. Histopathological and immunohistochemical examinations of the lesion revealed UESL.

Results: Due to its size of the tumor and vascular invasion, the mass was considered as unresectable. Patient underwent an orthotopic liver transplantation with living donor without any major complications. Four months after the surgery, we initiated adjuvant chemotherapy associating vincristine, dactinomycin, ifosfamide, and doxorubicin. Initial postoperative outcomes were good. Reccurence occurred after 41 months and the patient died 43 months after surgery.

Conclusion: The usual treatment approach of this pathology is based on a resection of the mass associated with a adjuvant chemotherapy. This case shows that liver transplantation has to be considered as an alternative treatment for unresectable UESL in specific conditions and selected patients.

ABSTRACT. Secondary hyperparathyroidism (SHPT) is frequent in patients with chronic kidney disease on chronic haemodialysis (HD). Etelcalcetide, an intravenously-administered direct CaSR-agonist, is widely used for SHPT treatment. Yet, little has been described regarding its potential post-kidney transplant (KT) impact ; since there is no marketing authorization for etelcalcetide post-transplantation.

A 68-year-old Caucasian male received a deceased-donor KT for kidney failure of unknown origin. He has been on HD for four years and treated with etelcalcetide for two years. This medication was stopped after KT.

The first week post-KT was uncomplicated. Kidney function rapidly improved and calcemia remained within normal range. On day 8, the patient presented tonic-clonic seizures associated with severe hypertension. Brain MRI was suggestive for posterior reversible encephalopathy syndrome (PRES). Laboratory tests revealed severe hypercalcemia (3.25 mmol/L), hypophosphatemia (0.74 mmol/L), elevated iPTH level at 619 pg/mL and tacrolimus trough level at 30 ng/mL (Figure 1). Other causes for PRES were ruled out.

Levetiracetam, cinacalcet, anti-hypertensive treatment, intravenous hydration and tacrolimus posology reduction were initiated. Cervical MRI showed two parathyroid hyperplasia’s foci.

Two weeks later, the neurological status of the patient improved. Calcemia remained constantly > 2.90 mmol/L despite cinacalcet (poorly tolerated [fatigue, nausea, loss of appetite …]). Therefore, we performed on day 24 a subtotal parathyroidectomy by resecting in toto the two parathyroid hyperplastic foci and the left superior parathyroid gland, together with a partial resection of the right inferior one. Pathological examination confirmed a tertiary hyperparathyroidism.

After surgery, calcium, phosphate and iPTH values returned into normal range (Figure 1) and clinical signs resolved rapidly. A brain MRI was repeated on day 30 and was normal. The patient was discharged on day 36.

Overall, we report a case of severe and acute hypercalcemia with neurological manifestations occurring early after KT, related to SHPT flare-up secondary to etelcalcetide interruption, that prompted early parathyroid surgery.

ABSTRACT. OBJECTIVE Surgical resection remains the cornerstone treatment for liver tumors. Local recurrence risk is determined by surgery radicality which forces significant parenchymal sacrifice or R1 resection in case of vascular involvement. Jump-graft between intra-parenchymal origin and superior stump HVR might be necessary to preserve remnant liver adequate outflow when radical surgery requires a resection at HCo.

METHODS Monocentric retrospective analysis of intraoperative data and outcomes in 16patients who underwent HVR(2018-2021) was performed. After tumor dissection under ultrasound control, proximal and distal HV stumps were clamped and involved hepatocaval segment resected in single block. Reconstruction was performed by interposition of vascular graft between both stumps.

RESULTS Patients presented with different conditions: liver metastasis (n=13), intrahepatic cholangiocarcinoma (n=1), hepatocellular carcinoma (n=2). Non-frozen ABO-compatible venous homograft (n=12), autologous peritoneal patch/tube (n=3), autologous veins (n=1) were used as jump-grafts. Median HV clamping duration was 63min(54-90min). Pedicular clamping was only performed when HVR was associated to IVC replacement(n=2). Double HVR was also performe (n=3). HVR patency at day7 was 94%(15/16), at 3months 81%(13/16). Median blood loss was 1100ml(837-1700ml), R0 resection was achieved in 13/16(81%). Severe morbidity (Clavien III-IV) reached 25%(4/16). Small for size syndrome was null. Day90 mortality was null.

CONCLUSIONS In our series, R0 resection rate was high as well as early and late graft patency. Morbi-mortality was acceptable. HVR technique allows replacement of a single or double HV without significant bleeding nor need for pedicle clamping (if not associated to IVC replacement). Therefore, HVR should be considered as a realistic option in parenchymal-sparing strategy or radical surgery.

ABSTRACT. Background: The last 15 years, robotic assisted minimally invasive esophagectomy (RAMIE) has become an established technique. The preferred technique for intrathoracic anastomosis during RAMIE is not established and may be continuously sutured, circular-stapled end-to-side anastomosis or linear-stapled isoperistaltic side-to-side (LIS). The aim of this study is to present our initial case series of LIS intrathoracic anastomotic technique in patients who underwent RAMIE and evaluate post-operative outcomes.

Methods: A retrospective study of 41 patients who underwent RAMIE with LIS anastomosis from May 2021 until January 2023 was performed. Besides classic postoperative endpoints (pneumonia, anastomotic leak(AL)-rate, chyle leak rate) we were also interested in composite quality measures such as textbook outcome (≥20 resected lymph nodes, R0 resection, no anastomotic leak, no intraoperative complications, no mortality, no complications ≥ Clavien-Dindo IIIa, no ICU/MCU/hospital readmission, no postoperative length-of-stay ≥ 14 days,) and adherence to our ERAS goals (postoperative length-of-stay ≤ 7 days, tolerating oral diet without tube feeding).

Results: Overall post-operative complication rate was 42% with pneumonia in 15%, chyle leakage in 7% and AL in 7% of patients. ALs consisted of 1 type I and 2 type II leaks (ECCG classification) and all healed by nil-per-mouth, temporary tube or parenteral feeding and antibiotics. Mean post-operative hospital stay was 11.5 days and surgery-related readmission rate was 5%. The 30-day mortality rate was 0%, with a textbook outcome achieved in 29 patients (71%). ERAS-goal-adherence was seen in 15(37%) patients that were discharged within one week of which 10 patients (24%) were tolerating sufficient oral diet without tube feeding.

Conclusion: Initial results suggest that LIS intrathoracic anastomotic technique for RAMIE has an acceptable leak rate and importantly all leaks were contained and successfully treated conservatively. The high rate of textbook outcomes with over one-third of patient discharged within one week after surgery is promising and appears oncologically safe.

ABSTRACT. OBJECTIVE: Thyroid nodules are common, but the incidence of cancer is low. Fine-needle aspiration may help to characterize thyroid nodules using the Bethesda international classification. According to Bethesda system and recent literature, the risk of malignancy for Bethesda III (indeterminate) nodules is between 5 and 30%. In such cases, the main options are to repeat the cytology or perform thyroidectomy for diagnostic purposes. Thyroidectomy is not devoid of complications. Nowadays, new diagnostic tools are appearing such as screening for oncological mutations within the sampled nodule by genetic sequencing. The primary objective of this study was to report the nature of lesions (non-malignant or malignant) in aspirated nodules with indeterminate cytology (Bethesda III) in our center. The secondary objective was to evaluate the number of complications after thyroidectomy (hemi or total) in patients with non-malignant lesions on final pathology report.

METHODS: We conducted a retrospective comparative study from January 2015 to December 2021 in our department of surgery. All patients with a Bethesda III cytology who underwent thyroidectomy were included.

RESULTS: We analyzed 82 patients. The final pathology reports after thyroidectomy confirmed that the nodule was malignant in 21 cases and non-malignant in 61 cases. Of the 61 non-malignant patients, 24 had transient hypocalcemia (3 with transient severe hypocalcemia), 2 had permanent hypocalcemia, 7 had transient recurrent laryngeal nerve injury, and 2 had permanent recurrent laryngeal nerve injury.

CONCLUSIONS: In our experience, the rates of malignancy in Bethesda III nodules, and the rate of operative complications following resection of non-malignant nodules, are consistent with those reported in the published literature. New diagnostic tools, including sequencing screening techniques for oncological mutation, and artificial intelligence approaches, could help avoid unnecessary thyroidectomy and its associated complications, and streamline patients for urgent surgery where appropriate.

ABSTRACT. Objective: to assess the operative outcomes after esophagectomy according to the standardized datasheet developed by the Esophageal Complication Consensus Group (ECCG) and to compare them with the benchmark published by the International Esodata Study Group (IESG).

Methods: The study group consisted of 100 consecutive patients operated for esophageal cancer between September 2014 and June 2022. There were 72 men and 28 women with a mean age of 66±8 years and a mean BMI of 26±5 kg/m2. Seventeen patients had a neo-adjuvant chemotherapy and 39 a neo-adjuvant radio-chemotherapy. Two patients were operated in emergency and 3 had a salvage operation. Surgery consisted in 88 Ivor-Lewis, 6 Mac-Keown and 6 trans-hiatal procedures. Open approach was used in 25 patients, hybrid mini-invasive in 74 and totally mini-invasive in 1.

Results: The median post-operative hospital stay was 14 days (range: 7-90). A R0 histologic resection was achieved in 93 patients. Clavien-Dindo complications ≥ IIIb were noted in 21 patients. Pneumonia, atrial fibrillation, chyle leak and anastomotic leak or localized conduit necrosis occurred respectively in 23, 12, 5 and 7 patients. For quality measures, 30- and 90-day mortality were 1% and 3%, readmissions 7% and discharge home 95%. Those results are fully comparable with the contemporary IESG benchmark of morbidity and mortality after esophagectomy. Respectively 1, 3 and 5 years after surgery, the global actuarial survival rates were: 89%, 65% and 51%.

Conclusions: Our study illustrates that a comprehensive multidisciplinary team in a mid-volume hospital can get very good outcomes after esophagectomy.

ABSTRACT. Background Laparoscopic Roux-en-Y gastric bypass has been proven as the most effective bariatric procedure having considerable outcomes on weight loss and improving morbid obesity-related comorbidities. Weight regain or insufficient weight loss always remain worldwide an issue of great concern. Although limited data have been already published regarding revisional bariatric surgery, gastric pouch resizing seems to be a safe option with encouraging short-term outcomes.

Methods All patients who underwent revisional BS for insufficient weight loss or weight regain as a result of an enlarged pouch after LRYGB from January 2014 to December 2021 at the Department of Digestive Surgery of the CHU Saint Pierre, referral center for bariatric surgery were included in this observational cohort study.

Results A total of 31 patients, 25 women and 6 men, with a mean age of 52 years and mean body mass index of 37.1 kg/m2 underwent pouch resizing. The average time between RYGB and LPR was 8 years (2-19). At the time of reoperation, weight regain had occurred such that the mean EWL percent was 26.5 %. All pouch resizing procedures were carried out laparoscopically. Medial intraoperative time was 96.7 minutes with an average hospital stay of 3 days. No patients died; 4 patients (12.5%) developed postoperative complications. Two patients presented staple-line leakage with intraabdominal abscess, requiring surgical procedure for drainage and endoscopic intervention, respectively. Gastroparesis has been presented in 1 patient and surgical site infection in 1 patient. The mean follow-up was 25 months. The mean postoperative BMI was 33.6 kg/m2, and the median %EWL 12 months postoperatively was 45 %.

Conclusions Gastric pouch resizing may be a valuable option in well-selected patients. Relied on low complication rate, weight loss may be sufficient based on a strict medical, psychological and dietary follow-up. Further multicenter studies are needed to further corroborate our findings.

ABSTRACT. OBJECTIVE Chylothorax is the accumulation of lymphatic fluid in the pleural space secondary to damage or obstruction of the thoracic duct or one of its main tributaries. It is a rare condition with potentially life-threatening disorders. In young children, the etiology of chylothorax can be divided into four main etiologies: idiopathic, trauma: iatrogenic or not, and malignancies. Few reports described the occurrence of chylothorax after events that increase intrathoracic pressures, such as severe vomiting and coughing. METHODS AND RESULTS: We herein present the case of a 4-year-old girl with no previous medical history who was admitted to the emergency department from another center with severe dehydration symptoms and massive right pleuritis. After chest tube insertion, the pleural fluid analysis showed a high triglyceride level, confirming the diagnosis of chylothorax. The etiological assessment could not identify specific causes or leaks from the ductus thoracicus. Initial treatment was conservative with fasting, parenteral nutrition, and somatostatin, but after 14 days, the patient showed no significant improvement. It was decided to perform an exploratory thoracoscopy with the injection of indocyanine green. The thoracic duct was visualized during the procedure but showed no active leaks. Pleurodesis was performed. Unfortunately, the patient showed permanent lymph production. Therefore, ligation of the ductus thoracicus was done. Ten days after, the thorax tube was removed. Follow-up radiographs showed the return of minimal pleural effusion with the incomplete collapse of the lower lobe. However, the patient progressed favorably with no signs of respiratory distress or new episodes of vomiting. CONCLUSIONS: The management of chylothorax is numerous. Even though conservative treatments show a high success rate, the efficacy of additional therapies such as somatostatin, and the benefits between thoracic duct ligation, pleurodesis, and pleuroperitoneal shunts need further investigations.

ABSTRACT. Introduction: Ochronosis is a typical bluish-black discoloration of connective tissue, such as joints and heart valves. It's one of the characteristics of alkaptonuria, a rare inherited disorder in the processing of amino acids phenylalanine and tyrosine leading to the accumulation of homogentisic acid. Ochronosis of the aortic valve is considered the most frequent cardiovascular manifestation, however very limited data is available. Prevalence of aortic valve replacement due to Alkaptonuria increases with age and typically occurs in the 5th decade of life.

Case presentation: In this case we present a man of 66 years old without remarkable previous medical history. He suffered from a critical aortic valve stenosis for which surgery was indicated. Perioperatively a black-bluish discoloration of the native thickened and calcified aortic valve was discovered. Later analyses by histopathology confirmed the suspicion of Ochronosis.

Conclusion: The main goal of this case report is to acquaint doctors with this clinical finding. Since knowledge may lead to swift recognition and diagnosis of alkaptonuria. Important since it remains a challenging diagnosis and often leads to significant comorbidity in selected patients.

ABSTRACT. Background: Esophageal replacement surgery in children may be required in those cases of long-gap esophageal atresia for whom native esophageal preservation is deemed unfeasible. The two most common techniques are gastric pull-up and colonic interposition in the posterior mediastinum. Alternatively, the use of ileocolonic esophagoplasty in the retrosternal space might constitute a good technical alternative to avoid a thoracotomy and prevent peptic reflux into the cervical esophageal remnant

Cases presentation and surgical technique: We report 2 cases of infants with long gap esophageal atresia in which ileocolonic transposition in the retrosternal space was performed at 6 months of age. The surgical technique for esophageal replacement was performed through a midline laparotomy incision associated with left a cervical approach. The ileocolonic transplant was pediculized on the right superior colic artery after ligature of the right colonic and ileocolonic vessels. Retrosternal tunnel was opened and the ileocolonic transplant pulled through it to reach the cervical region. Proximally, esophageal-ileal anastomosis and, distally, colonic –gastric anastomosis were performed. Ileocolonic continuity was repaired.

Results: There were no early postoperative complications. In both cases, the patients presented oral feeding difficulties during the first 6 postoperative months. Thereafter, oral feeding was restored in the long-term, and both patients were clinically asymptomatic during the 17 fallowing years with satisfactory oral gastrografin radiological assessments. In particular, these patients have currently no dysphagia or postoperative reflux.

Conclusion: When esophageal replacement has to be considered, ileocolonic transposition in the retrosternal space is a safe procedure for long-gap esophageal atresia. This technique is associated with the advantage of thoracotomy avoidance and, putatively, the beneficial anti-reflux effect of the ileocecal valve to prevent cervical peptic esophagitis.

ABSTRACT. Background Jejunal tube feeding is an important strategy in the nutrition of patients who undergo upper gastrointestinal surgery. Although this therapy has many benefits for the nutritional status of patients, a jejunostomy can lead to serious and deadly complications in an at-risk population. Methods A 73-year-old man benefited from a jejunostomy due to the nutritional risk profile in the treatment of a stenotic adenocarcinoma of the lower oesophagus. He was scheduled for neoadjuvant chemotherapy. In the first postoperative week, a progressive augmentation of the debit of nutritional support was initiated with an excellent tolerance of 80 cc/h of Nutrison multi-fibre. POD 12, he had his first FLOT chemotherapy. POD 17, the patient presented with neutropenic sepsis. A CT scan showed evidence of non-occlusive mesenteric ischemia (NOMI). A laparoscopic exploration showed diffuse ischemia of the small intestines distal of the placement of the jejunostomy. Due to the advanced state of ischemia, the co-morbidities of the patient and the family's wishes, no resection was performed. The patient died 2 days later. Results The literature on NOMI in this patient population is scarce. It’s often seen in patients in deep shock, but several cases describe the contributing factor of enteral tube feeding. A type of demanding ischemia, bacterial overgrowth and the vicious circle of inflammatory products may explain a part of the pathophysiology. The literature on chemotherapy-induced NOMI is even more scarce, but docetaxel, cisplatin and 5-FU have been associated with this pathology. Conclusion The pathogenesis of NOMI is multifactorial. Both the jejunal tube feeding and the chemotherapy are described as risk factors in the development of this lethal pathology. More research is needed to precise the impact of each risk factor. The need to report these complications remains high due to the rare incidence and high morbidity and mortality.

ABSTRACT. Background Esophageal surgery remains the main treatment for esophageal cancer. Despite constant improvements, morbidity of esophagectomy remains high. Enhanced rehabilitation programs have been used to reduce the impact of surgery on the patients to support a faster recovery. This study analyses the first results of newly implemented enhanced program after esophagectomy in our center. Materials and methods Between June 2019 and November 2021, 40 patients with esophageal disease requiring esophageal surgery were included. The enhanced rehabilitation programs includes 23 specific measures validated in multidisciplinary consultation, spread over the pre-, intra- and postoperative period. Compliance to the ERP, severe postoperative complications, mortality, intensive care unit discharge, start of refeeding, hospital stay and readmission were compared. Results Regarding inclusive criteria, 40 patients underwent esophageal surgery. 20 patients were included in the enhanced recovery program and 20 patients, studied retrospectively, underwent conventional care. Demographic data were comparable in the two groups of patients operated mainly for cancer (92.9%). Overall compliance was 94.1%. First mobilisation was significantly earlier in the ERP group (POD 1.1 +/-0.3 vs POD 3.0 +/-3.5 SD). Enteral nutrition and solid food intake occurred earlier for patients in the ERP compared with the control group (POD 1.1+/-0.6 VS POD 1.9 +/-0.9 SD p=0.01; POD 5.0+/-0.7 VS POD 6.8+/-5.6 SD p=0.03, respectively). The median hospital stay was reduced from 13 days in the retrospective cohort to 9.5 days after ERP implementation. No significant difference was found in intensive care stay, morbidity, mortality and readmission rate. Conclusions Enhanced recovery program after esophagectomy benefits patients care resulting in better outcomes. Although with some limitations, the first experience in our centre demonstrates the feasibility of such care program.

ABSTRACT. Objective Congenital peritoneal encapsulation (CPE) is a rare cause of small bowel obstruction, due to the presence of an accessory peritoneal membrane. We aim to describe the challenging diagnostic process and the management of a patient with a known intestinal non-rotation who suffered from recurrent episodes of small bowel obstruction.

Methods A 66-year-old man presented with two-day exacerbation of recurrent right-sided abdominal pain, 38.2°C fever, anorexia and obstipation. His medical history included only an orchidectomy for teratoma. Previous repeat imaging and endoscopy studies offered no explanation for his intermittent pain so far. Current blood test revealed elevated white cell count and CRP 320 mg/L with acute kidney insufficiency. Abdominal computed tomography showed a markedly inflammatory duodenal loop, suggestive of contained diverticular rupture, in the presence of the known intestinal nonrotation. Oral contrast study showed a loop in the descending duodenum (D2) with mucosal oedema and no contrast-leak, suggestive of an internal herniation.

Results Exploratory laparoscopy confirmed intestinal nonrotation without any adhesions. Upon retrogradely running the small intestines from distal to proximal, we encountered a firm duodenal loop in D2, anchored within an accessory peritoneal membrane. The peritoneal sac was resected and the duodenum released. No bowel ischemia or mesenterial defects were present. The postoperative course was uncomplicated with rapid regain of intestinal transit on postoperative day 1 and discharge on day 4 after renal function recovery. Follow-up visit after one month was uneventful and the patient remains pain-free at postoperative month 6.

Conclusion CPE is a rare condition, often manifesting as intermittent abdominal pain due to (sub)obstructive episodes. Furthermore, inconclusive imaging in the presence of malrotation should raise suspicion of concomitant congenital anomaly. Management consists of resection of the accessory peritoneum. This is the first reported case of CPE in the presence of nonrotation.

ABSTRACT. BACKGROUND AND OBJECTIVE Cytoreductive Surgery (CRS) +/- Hyperthermic Intra Peritoneal Chemotherapy (HIPEC), is the only curative treatment available for patients with colorectal peritoneal metastasis. For selected patients it increases the survival rates. The main independent prognostic factors are the extent of the disease, expressed by the Peritoneal Carcinomatosis Index (PCI), and the completeness of the cytoreduction surgery (R1 or CC-0). Despite accurate preoperative assessments, up to 20-25% of the procedures are deemed unachievable during open surgical exploration. Therefore, these patients undergo unnecessary laparotomies. The purpose of this study is to identify potential preoperative factors allowing to predict aborted cytoreduction surgeries.

METHODS A retrospective single center based approach was used to analyze the records of patients admitted for CRS +/- HIPEC from 1st January 2010 to 31st December 2021. The following preoperative factors were considered: patient and tumor characteristics, radiological features, biological tumor markers and previous therapies.

PRELIMINARY RESULTS 123 patients (47.97 % men, 52.03 % women) met the inclusion criteria for the current study, with a total of 161 planned CRS +/- HIPEC. 32 procedures (19.87%) concerning 29 patients were abandoned intra-operatively. The main causes for procedure dismissal were extent of peritoneal disease (PCI>20) (34.4%), extent involvement of small bowel or its mesentery (15.6%), involvement of hepatic pedicle (12.5%), pelvic fixed tumor mass (9.4%), retroperitoneal disease (6.2%), technically unresectable disease (6.2%), involvement of pancreas (3.1%), and others (need for extent resection, incidental multiple hepatic metastases, stoma refusal) (12.5%). Further analyses of predictive factors and scores of non resection are ungoing.

ABSTRACT. Objective: Sleeve gastrectomy (SG) is the most frequently performed bariatric procedure in the world. The aim of the study was to evaluate weight loss after 10 years. Methods: Patients who underwent SG between 2005 and 2010 in a single center were evaluated, analysing the percentage of excess weight loss (%EWL) after 10 years. Weight loss failure was defined as %EWL<50% or need to perform a revisional bariatric surgery during the 10 years follow-up. Results: Overall, 149 patients underwent SG, with a median preoperative body mass index of 42.0 ± 6.5 kg/m². Eighteen patients (12.1%) underwent previous bariatric procedure (gastric banding or transoral gastroplasty) before SG. Eating behaviour of patients were described as volume eaters in 73 (49%), sweet eaters in 11 (7.4%) and both volume and sweet eaters in 65 (43.6%). After excluding 31 patients (20.8%) who died (n=6) or lost (n=25) during follow-up, 35 patients (23.5%) underwent a revisional bariatric surgery, including 28 Roux-en-Y gastric bypass and 7 re-SG. For patients without revisional surgery, the mean %EWL was 35.9% at 10 years, only 23/83 patients (27.7%) had a %EWL≥50%. Overall, 80.5% patients (95/118) presented weight loss failure 10 years after SG. No prognostic factor was identified for predicting weight loss failure after 10 years at univariate analysis, neither preoperative comorbidities, %EWL after 1 year or eating behaviour. Conclusion: Ten years after SG, the rate of weight loss failure was high, reaching 80% of patients. One quarter of patients underwent a revisional bariatric procedure during follow-up time. No prognostic factor of weight loss failure could be identified. Of course new studies must try to identify which patient is still a good candidate for SG.

ABSTRACT. Objective: Patient satisfaction after inguinal hernia surgery is currently underappreciated and not as well studied as other patient reported outcome measures (PROMs) on this topic. Our study aims to review the literature and summarize available data.

Methods: A literature review was conducted using Medline focusing on patient reported satisfaction after elective, inguinal hernia surgery in adults (>18 years old). All inguinal hernia repair techniques were considered, but small sample sizes (<100 patients) and short follow-up periods (<6 months) were excluded. The methodology and results of the remaining articles were reviewed. Due to heterogeneity of reporting between articles, only a descriptive analysis was performed.

Results: The available data from 15 out of 358 articles was withheld for further analysis. Unfortunately it has become apparent patient reported outcome measures regarding satisfaction lack validation and yield considerable heterogeneity, as 53% of all included studies used an asymmetrical response questionnaire. Resulting in an overwhelmingly positive patient satisfaction, be it with wide ranges (78–100% more than averagely satisfied, compared to 0–15% less than averagely satisfied). The number of patients not willing to undergo inguinal hernia repair again ranges from 1–16.

Conclusions: Our study demonstrates patient reported satisfaction is not uniformly surveyed and remains unvalidated. Further research on patient reported satisfaction would benefit from standardization and validation, while using a symmetrical and balanced 5-point Likert or 11-point NRS scale at regular post-operative intervals with addition of open questions to evaluate patient satisfaction after inguinal hernia surgery.

ABSTRACT. Background An anatomical segmentectomy is considered standard of care for ground-glass opacities, adenocarcinoma in situ or adenocarcinoma with minimal invasion (T1a). To identify intersegmental planes in minimal invasive procedures, indocyanine green (ICG) is commonly used. In this systematic review, the efficacy of intravenous ICG in the identification of intersegmental plane will be evaluated.

Methods PubMed, Embase, Cochrane Library, CINAHL Plus and Web of Science were systematically searched for the use of intravenous ICG and visualization of the intersegmental line during minimal invasive segmentectomy. The databases were searched following the current recommendations of Preferred Reporting Items for Systematic Reviews and Meta-analysis Approach (PRISMA). MINORS criteria were used to score the included articles.

Results A total of 640 articles were initially identified, of which a total of 18 articles (1090 patients) met all predefined inclusion criteria. Overall, it is apparent that there is a considerable heterogeneity regarding the injected dose of ICG and the reported outcome measures. However, intravenous ICG does appear to help identify the intersegmental line in up to 100% of the cases. No adverse reactions to ICG were reported. Secondary outcome measures, such as length of hospital stay and prolonged air leak, do not indicate a more complicated post-operative course.

Conclusion The use of intravenous ICG is safe and feasible, with no reported adverse effects in the immediate peri-operative period. While in video assisted thoracoscopic procedures the use of ICG necessitates the use of a near infrared camera, it does offer the benefit of maintaining atelectasis and thus an adequate vision. For robotic procedures, the Da Vinci robot has a build-in infrared camera, facilitating the use of ICG and subsequently segmentectomies. In general, the intersegmental line is clearly visible in up to 100% of the cases. However, the optimal dose of administration is not clear and more prospective data is needed.

ABSTRACT. OBJECTIVE Pericardial cysts are rather rare entities with an incidence of 1/100.000. In most cases, diagnosis is made as an accidental finding in asymptomatic patients. Approximately one fourth of all patients are symptomatic. These symptoms are usually due to the space-occupying feature. The management depends on the presenting symptoms, effects on surrounding structures and cyst size. Management options include conservative follow-up, percutaneous aspiration of the cyst and surgical excision. The aim of this case series is to show the safety and efficacy of uniportal VATS for the excision of pericardial cysts.

METHODS In this retrospective, single-center based case series, we report four cases with a pericardial cyst or mass who underwent a surgical excision by uniportal VATS between March 2022 and October 2022.

RESULTS Four patients with a symptomatic pericardial cyst were referred for excision to the thoraco-vascular department of our institution. A successful excision by uniportal VATS was performed in all of them. In three of four cases, the cysts were giant pericardial cysts (measuring more than 100 mm in maximum diameter). Even in these cases uniportal VATS could be performed, after aspiration by puncture of the cyst. Histopathology revealed that two of the four masses were mesothelial pericardial cysts, one was a thymic cyst and one most likely a bronchogenic cyst. Hospital length of stay was between 2 and 4 days and uneventful. In all four cases, a resection of the cyst resolved the preoperative symptoms.

CONCLUSION Symptomatic pericardial cysts are very rare and can be an indication for surgical resection in symptomatic patients. Uniportal VATS is a safe and effective method for resection of pericardial cysts, even for giant pericardial cysts. It prevents the need for sternotomy or thoracotomy and leads to shorter hospital length of stay and early/rapid recovery.

ABSTRACT. Objective: Surgical resection is the treatment of choice for distal cholangiocarcinoma (dCCA) offering the patient the best chance for long term survival. However, the oncologic benefit of resection in case of positive regional lymph nodes (rLN) is still debated. This study aims to assess survival after resection for dCCA according to LN status and identify prognostic factors of recurrence. Methods: Patients undergoing surgery for dCCA, from 2010 to 2021, in 5 tertiary centers were retrospectively analysed. LN status, pathological margins, recurrence, and survival were reviewed. Results: Seventy-nine patients were included, 64 pancreatoduodenectomies and 15 common bile duct resections with lymphadenectomy. R0 resection was achieved in 51 patients (64.6%), R1[<1mm] in 10 (12.7%), and R1[0mm] in 18 (22.8%). The median number of LN on specimens was 17 ±10. Locoregional and distant metastatic LN were present in 38 (48.1%) and 5 (6.3%) patients respectively. Excluding perioperative mortality and loss of follow-up (n = 8), the median follow-up was 25 months (IQR 14-49) and 35 (44.3%) patients developed disease recurrence. Adjuvant treatment was given in 29 (36.3%) patients, including 19 with positive rLN. The 3-year overall survival was not affected by the rLN status (LN(-) 62.4% vs LN(+) 54.9%, p=0.395), while disease-free survival rate was significantly lower in rLN(+) patients (LN(-) 53.8% vs LN(+) 30.8%, p=0.009). Perineural invasion, positive rLN, R1[0mm] resection and poor differentiation were risk factors of recurrence at univariate analysis. Positive LN status (OR 3.6, 95% IC 1.2-11.2] and poor differentiation [OR 4.4, 1.1-17.8] were prognostic factors of recurrence at multivariate analysis. Conclusion: In patients undergoing resection for dCCA, locoregional LN involvement affects the disease-free, but not the overall, survival. Positive LN status and poor differentiation were independent prognostic factors of disease recurrence. These data suggest that in patients with positive rLN, resection of dCC remains indicated.

ABSTRACT. OBJECTIVE Ventral mesh rectopexy (VMR) has proven successful in the surgical treatment of symptomatic rectal prolapse and rectocele. Most surgeons do not change surgical strategy when perineal descent (PD) is present. The purpose of this study was to analyze the effect of PD on the functional outcome of VMR.

METHODS A retrospective analysis was performed. Fifty-five patients who underwent robotic VMR in a tertiary between 2018 and 2021 were included. Pre and postoperative data as well as radiological studies were gathered from a prospectively maintained database. The Cleveland clinic constipation score (CCCS), the 36-Item Short-Form Health Survey (SF-36), and the Rome IV criteria were used to measure functional results.

RESULTS All 55 patients were female with a mean age of 58. Simultaneous colpopexy was carried out in 48 patients (87%) and cystopexy in 8 patients (15%). Forty-seven patients (86%) suffered from obstructive defecation symptoms (ODS), while 26 patients (47%) had fecal incontinence. Most patients had radiological findings of rectocele (n=45) and severe PD (n=31). Cleveland clinic constipation score and SF-36 subscales bodily pain and vitality showed significant improvement at 3 months post-VMR (mean difference = -4.375, mean difference = 9 and mean difference = 6.1 respectively, p< 0,05). After 1 year, CCCS stayed reduced regardless of PD (mean difference=0.427, p=0.732). However, the significant SF-36 improvement disappeared. The Rome IV criteria only showed an improved outcome at 3 months in presence of severe PD and at 1 year in absence of severe PD (p<0.05).

CONCLUSION This pilot study shows good functional results 3 months and 1-year post VMR in patients with PD. With only a minimal difference between mild/moderate and severe PD. Our study suggests that severe PD does not affect the functional outcome of VMR significantly.

ABSTRACT. Objectives Despite curative-intent surgical resection, most patients with multinodular colorectal liver metastases (CRLM) will recur and postoperative chemotherapeutic treatment is debated for reducing these recurrences. Hepatic arterial infusion pump chemotherapy (HAIPC) allowing higher doses of cytotoxic agents directly in the liver also remains a matter of discussion. This study aims to evaluate the feasibility and safety of postoperative HAIPC in patients who underwent surgery for multiple CRLM and to evaluate its potential survival benefit as compared with a control group without HAIPC.

Methods Consecutive patients undergoing curative-intent resection of CRLM between 2014 and 2020 were retrospectively analyzed. Inclusion criteria were presence of at least four or more CRLM presenting liver only metastatic disease. HAIPC related morbidity and feasibility (at least one cycle administered) were analyzed and survivals among HAIPC and the control group were compared. A propensity score matching (PSM) 1:1 was used to compare groups reducing bias of selection.

Results Seventy-two patients matched the inclusion criteria. Sixteen of them (22%) were treated with HAIPC and 56 (78%) had either systemic chemotherapy 15 (21%) or no postoperative treatment 41 (57%). Four (25%) patients experienced HAIPC related complications of which 3 had to stop HAIPC after the second cycle. The disease-free survival (DFS) was similar in both groups with a median of 9 and 6 months respectively for the HAIPC and control groups (p=0,3). Overall survival (OS) was 63 (CI: 35-91) months for the HAIPC group compared to 39 (CI: 31-47) months for the control group (p=0,07).

Conclusions Our study showed that HAIPC after resection of multiple CRLM is safe and feasible. Despite no benefit in DFS, HAIPC seems to improve OS. The role of HAIPC in this context should be studied and clarified in randomized controlled clinical trials.

ABSTRACT. Objective In non-metastasized pancreatic ductal adenocarcinoma [PDAC], R0-resection is the main determinant of curative intent treatment. Preoperatively diagnosed locally advanced tumors can be converted to potentially resectable disease using upfront neoadjuvant therapy. The best strategy in case of intra-operative diagnosis of unexpected locally advanced disease is not known: proceed with a high risk of an R1/2-resection or abort the procedure and try to convert the patient with a “salvage” neoadjuvant strategy. We aimed to present our experience with this salvage neoadjuvant strategy. Methods In this retrospective single-center study, all consecutive patients who underwent surgical exploration for PDAC between January 2015 and January 2022 were identified. Clinical and tumor characteristics of patients who were found to have unexpected locally advanced disease at exploration were retrieved from medical records. Main outcomes examined were conversion rate to resectable disease and overall survival [OS] from the date of initial surgical exploration. Results Six hundred forty-two patients were surgically explored of which 31 patients (4.8%) had unexpected locally advanced disease. Main reason was venous involvement at the level of mesocolon transversum (n=24; 78%). Salvage neoadjuvant treatment leaded to 11 re-explorations (36%) and 9 (29%) formal resections. Resection resulted in negative margins (R0) in 3 patients (33%). Mean OS was 19.5 months [14.9-28.9] for patients with definitive resection in comparison to 9.8 months [0.5-23.6] for patients not converted to resectable disease (p=0.003). Six patients, of which 5 after formal resection, are still alive at present with a mean follow-up of 20.5 months [12.2-28.9]. Conclusion Salvage neoadjuvant treatment has comparable conversion rates to resectable disease as upfront neoadjuvant therapy for locally advanced disease and offers a survival benefit over palliative chemotherapy. Further research is needed to compare the outcome of this salvage neoadjuvant strategy to upfront neoadjuvant therapy or margin positive resections.

ABSTRACT. OBJECTIVE : Parathyroidectomy is the treatment for primary hyperparathyroidism (pHPT). Different minimally invasive techniques have been proposed in recent decades. Use of intraoperative parathyroid hormone (ioPTH) assay became popular, but remains controversial. In our institution, we perform unilateral neck exploration (UNE) in case of consistent preoperative localization studies, without use of ioPTH. We compared the effectiveness of our strategy with recent literature.

METHODS

77 patients with pHPT and two concordant localization studies with suspected unique adenoma underwent an UNE which involve individualizing one pathologic gland and one normal gland. Macroscopically pathological parathyroid glands were resected and sent to frozen section analysis. The procedure is considered as complete if a normal ipsilateral gland is identified. In case of ipsilateral double gland pathology, ipsilateral grossly normal glands or technical difficulties, surgery was converted to bilateral neck exploration (BNE). Measurement of serum calcium level was realized at day-1 and day-2 to assess resolution of pHPT.

RESULTS

UNE was complete in 65 cases. Twelve procedures (15,6%) were converted to BNE, 8 (10.4%) for peroperative suspected hyperplasia, 2 (2,6%) after the finding of two ipsilateral normal glands and two (2,6%) for technical issues. Definitive histopatholgy showed a single adenoma in 69 (89,6%) cases, double adenoma in 2 (2,6%), hyperplasia in 5 (6,5%) and normal gland in 1 (1,3%). No recurrent nerve palsy was reported. Four (5,2%) symptomatic hypocalcemia were observed, one after UNE, 3 after conversion to BNE. Overall success rate was 96,1%. The success rate in the only UNE group was 98,5%, falling to 86,7% in patients converted to BNE. No recurrent hPTH was observed, with a median follow-up of 70 months.

CONCLUSIONS In case of concordant imaging studies, a minimal invasive parathyroidectomy with individualization of one pathologic gland and one normal gland, performed by an unilateral incision gives an equivalent success rate than techniques using ioPTH.

ABSTRACT. Objective Describing a case of acute gastric outlet syndrome with stomach wall necrosis due to superior mesenteric artery (SMA) syndrome, treated using a surgical technique inspired by a novel bariatric procedure.

Methods A 20 year old male with Prader-Willi syndrome presented to the emergency department in hypovolemic shock with complaints of abdominal pain and vomiting since 1 day. There was a recent history of rapid intentional weight loss. Fluid resuscitation was initiated along with painkillers and antibiotics. A nasogastric tube drained 3.5 liters of bilious fluid. Blood work was significant for leukocytosis of 19.06x10^9/L, creatinine of 1.49mg/dL, lipase of 940U/L. A CT of the abdomen showed a distended stomach due to SMA syndrome, with secondary pneumatosis of the stomach wall and aerobilia. A midline laparotomy confirmed SMA syndrome. An expanded stomach with necrosis of the left lateral part of fundus and corpus was seen, with no defects into the intraluminal space. The necrotic part was resected by means of a sleeve gastrectomy using a linear stapler. A relook after a twenty-four hour interval of stabilization on the Intensive Care Unit revealed a stable situation. An omega loop gastro-enterostomy starting 50cm from Treitz’ ligament was performed, resulting in a non-bariatric single anastomosis sleeve (with limited) ileal bypass (SASI). Postoperatively the patient was started on total parenteral nutrition as well as proton pump inhibitors (PPIs). On day 8 the patient could be discharged from the hospital in generally well condition.

Results After six months there were no abdominal complaints and a weight gain of 7 kg was noted. Control gastroscopy showed mild erosive gastritis, for which PPIs were restarted.

Conclusion After 6 months of follow-up SASI seems to have been a good treatment in this specific case, in which life-saving surgery was performed using some of the principles of a procedure known in bariatric surgery.

ABSTRACT. OBJECTIVE Young onset colorectal cancer refers to cases of colon or rectal cancer that occur in individuals under the age of 50, accounting for about 5% of all cases. Below the age of 40 it drops to less than 1%. However, the incidence of colorectal cancer in younger adults has been increasing in recent years and young people with colorectal cancer often face different challenges compared to older individuals. The aim of this study is to investigate the impact of age, using 40 years as a threshold, on overall and recurrence-free survival in patients with colorectal adenocarcinoma who underwent primary resection surgery.

METHODS Between July 2002 and July 2020, a total of 54 patients with colorectal adenocarcinoma, aged 40 years old or less (median age 35 years), underwent primary surgery for the treatment of colorectal cancer in our center. We compared this group to 54 patients aged over 40 years matched for sex, year of diagnosis, cancer localization and stage using multivariate analyses and Kaplan-Meier survival analyses generated.

RESULTS The overall 5-year survival rates were 75.9% and 74.1% for the young and older group respectively (p=0.394). The 5-year recurrence-free survival rates were 75% and 66,7% respectively with a median recurrence free survival of 14.67 months in the early onset group and 9.14 months in the late onset group (p=0.114).

CONCLUSIONS Our study found no statistically significant difference in overall survival and recurrence-free survival between young and older patients with colorectal adenocarcinoma who underwent primary resection surgery. Our results suggest that age alone may not be a significant prognostic factor in colorectal cancer outcomes, and that careful evaluation of other factors may be more important in predicting patient outcomes.

ABSTRACT. Background Patients with a history of bariatric surgery (BS) are susceptible to developing alcohol use disorder. We and others have previously shown that these patients can develop severe alcohol-related liver disease (ARLD), often at a younger age and despite lower cumulative alcohol intake when compared to ALRD patients without BS. Our aim was to describe the demographics and mortality of a hospitalized population diagnosed with alcohol-related liver disease, in relation to BS. Methods We included patients hospitalized at the University Hospital in Ghent between 1/1/2018 and 31/12/2022 with ARLD. Data were retrieved retrospectively from the most recent hospitalization. Statistical analysis was performed using Mann-Whitney U and Chi2 tests. Results 12.3% (35/284) of patients admitted with ARLD had a history of bariatric surgery, of which 28 (80.0%) underwent Roux-en-Y gastric bypass. Patients with a history of BS were predominantly female (77.1%), in contrast to the non-BS population (30.1%) (p<0.0001) and despite being significantly younger (52.0(45.0,60.0) vs 63.0(53.0,69.0) years old) (p<0.0001), had a similar survival (68.6%vs61.0%) and a higher likelihood of transplant listing (25.7%vs14.2%) (p=0.085). The cause of death was acute-on-chronic liver failure in 77.8% of BS patients, compared to only 15.9% of those without a history of BS (p<0.0001). More than half of the BS cohort suffered from psychiatric illness, compared to a quarter of the non-BS population (51.4%vs28.1%) (p=0.010), paralleled by the number of patients currently treated with psychological counseling (51.4%vs21.0%) (p<0.0001). The weekly amount of alcohol consumed during drinking periods (40.0 (25.0, 50.0) vs 50.0(35.0,79.0) units/week) (p=0.060) and duration of use (8.0(5.0,15.0) vs 20.0(10.0,29.8) years) was significantly lower in the BS population (p<0.0001). Conclusions BS patients hospitalized with ARLD are predominantly young females with a lower cumulative alcohol consumption compared to those without prior BS. There is a need for prospective research to substantiate stricter pre-BS patient selection guidelines.

ABSTRACT. OBJECTIVE Robot-assisted ventral hernia repair has become a feasible alternative for open ventral hernia repair showing fewer postoperative complications and satisfying short-term results. However, long-term results are scarce in current literature. In our center, the program for robotic ventral hernia repair was started five years ago. This study aimed to analyze surgical outcome and long-term results.

METHODS All consecutive patients who underwent robot-assisted surgery for ventral hernias from January 2018 until December 2022 were included. Patient records were retrospectively reviewed for indication, need for conversion, length of stay (LOS), postoperative complications (Clavien-Dindo), and postoperative pain (scale 1-10). In addition, long-term results (recurrence, chronic pain, and esthetic satisfaction) were assessed by phone questionnaire.

RESULTS In total, 167 patients underwent a robot-assisted ventral hernia repair. Indication for surgery was incisional hernia (N=100, 60%) and primary hernia (N=67, 40%), including 59 (35%) cases with abdominal rectus diastasis. A TARUP was performed in 136 (81%) patients. Robotic TAR and eTEP were performed in 18 (11%) and five (3%) cases, respectively. IPOM was performed in eight (5%) patients because TARUP was technically not possible. One case was converted to open surgery. Median LOS was two days for TARUP and four days for TAR. Minor complications (Clavien-Dindo 1 or 2) occurred in 20 patients (14 TARUP, 5 TAR, 1 ReTEP). In four cases (1 TARUP, 3 TAR), a major complication (Clavien-Dindo >2) was reported. The average pain score on the first postoperative day was 1.8. Long-term results (minimum follow-up of 24 months) were assessed in 76 patients. Hernia recurrence developed in four (2%) patients. Chronic pain was reported in two (1%) cases. Seven (4%) patients had esthetic complaints.

CONCLUSION Robot-assisted ventral hernia repair is a safe procedure with low postoperative pain and short LOS. Long-term results including recurrence and chronic pain are satisfying.

ABSTRACT. OBJECTIVE. Over the past decade, studies reported that training opportunities in the operating theatre for surgical residents have declined due to an increased focus on patient safety, working hour restrictions and the COVID-19 pandemic. In 2020, the surgical department launched a training program on Thiel-embalmed human cadavers focusing on technical skills acquisition for surgical trainees, closely supervised by faculty members. During the past three years, the program has expanded and self-reported pre- and post-training performance assessment surveys were carried out to evaluate the impact on surgical skills of the participating trainees. METHODS. The current training program was built on the expertise of the previously presented 2020 program, but involved more sessions (20 vs. 18), more learners (17 vs. 14), use of simulated and animal models, and assistance of scrub nurses. It offered general, gastro-intestinal, hepatobiliary, thoracic, vascular and cardiac technical skills training. Prior to participation, learners completed a questionnaire estimating their own skill level and reporting previous experience with cases treated in the past 6 months focussing on the topic. Likewise, after training they had to estimate how they would perform during the next surgical case in the operating theatre. All questionnaires used a 5-point Likert scale: 1–I am not capable to perform this task; 2-I am capable to perform this task under close, direct supervision; 3-I am capable to perform this task under indirect supervision; 4-I act safely and independently without supervision; 5-I am capable of supervising others independently. RESULTS. Preliminary results evaluating general and gastro-intestinal surgery sessions focussing on junior residents showed an increase of self-reported skill level of respectively 0.74 (p=0.001) and 0.75 points (p<0.001) between pre- and post-training assessments. CONCLUSIONS. First analysis indicates that this curriculum is beneficial in the development of surgical skills. Results will be further analysed once all trainings have been completed.

ABSTRACT. Background

Recently, two distinct histological growth patterns (HGP) were described in patients with limited peritoneal metastases (PCI ≤6) of colorectal cancer and without neoadjuvant chemotherapy (NAC) treated by cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC), the pushing-type (P-HGP) and the infiltrating-type (I-HGP). Patients with dominant P-HGP (>50% of the tumor-peritoneum interface) had a significantly better overall survival (OS).

Objective

To determine if these previous observations are confirmed in patients with higher PCI ± NAC.

Methods

Retrospective study including 76 patients who underwent complete CRS ± HIPEC for colorectal peritoneal metastasis (PMCRC) between July 2012 and March 2019. In each patient, up to 5 of the largest excised peritoneal nodules were analyzed by hematoxylin-eosin staining, showing the tumor-to-peritoneum interface. The association between HGP and outcomes was analyzed, and the effect of the NAC on the type of HGP observed was analyzed.

Results

Two distinct HGP were identified: a pushing-type (P-HGP), and an infiltrating-type (I-HGP). 37 patients (49%) had dominant P-HGP, and 39 patients (51%) had dominant I-HGP. On univariate analysis, patients with dominant P-HGP (>50% of the tumor-peritoneum interface) had a significantly better overall survival (OS) (60 months) than those with P-HGP ≤50% (39 months) (p=0.014), confirmed on multivariate analysis, (HR 2.4, 95% CI 1.3–4.5, p=0.006). There was not significantly association between the NAC and the type of HGP.

Conclusion

This study confirms the distinction of two previously defined HGP in PMCRC. The dominant P-HGP is associated with a favorable prognosis in patients undergoing CRS ± HIPEC, compared to the dominant I-HGP, independently of the extent of the peritoneal disease.

ABSTRACT. OBJECTIVE A patient with an aorta bifemoral bypass graft (2004) due to left iliac tract occlusion received an abdominal ultrasound, where the suspicion arose of an infrarenal aortic aneurysm. Angio CT confirmed the presence of an aneurysm above the proximal anastomosis with a diameter of 54mm and with visualization of two blebs. Endovascular treatment was proposed because of cardiac failure. METHODS An endovascular procedure was performed through percutaneous punctures of the superficial femoral arteries. To start, a plug (Amplatzer) was placed in the right iliaca communis. Thereby excluding retrograde filling of the aneurysm. Subsequently, an aortic endoprosthesis, type Endologix AFX and Velar, was placed via the aorta bifemoral bypass graft into the aneurysm . RESULTS The aneurysmatic formation of the aorta above the proximal anastomosis was excluded completely from the circulation while the blood flow through the present aorta bifemoral bypass graft and the renal arteries was preserved. No wound complications occurred, which is an advantage of the percutaneous technique. The patient had a non-complicated postoperative period and was discharged the second postoperative day. CONCLUSIONS Endovascular approach of an aneurysm situated above the proximal anastomosis of an aorta bifemoral bypass graft is an efficient and elegant method. The patient had a short hospital stay with little postoperative pain and without wound complications.

ABSTRACT. Objective Congenital peritoneal encapsulation (CPE) is a rare cause of small bowel obstruction, due to the presence of an accessory peritoneal membrane. We aim to describe the challenging diagnostic process and the management of a patient with a known intestinal non-rotation who suffered from recurrent episodes of small bowel obstruction.

Methods A 66-year-old man presented with two-day exacerbation of recurrent right-sided abdominal pain, 38.2°C fever, anorexia and obstipation. His medical history included only an orchidectomy for teratoma. Previous repeat imaging and endoscopy studies offered no explanation for his intermittent pain so far. Current blood test revealed elevated white cell count and CRP 320 mg/L with acute kidney insufficiency. Abdominal computed tomography showed a markedly inflammatory duodenal loop, suggestive of contained diverticular rupture, in the presence of the known intestinal nonrotation. Oral contrast study showed a loop in the descending duodenum (D2) with mucosal oedema and no contrast-leak, suggestive of an internal herniation.

Results Exploratory laparoscopy confirmed intestinal nonrotation without any adhesions. Upon retrogradely running the small intestines from distal to proximal, we encountered a firm duodenal loop in D2, anchored within an accessory peritoneal membrane. The peritoneal sac was resected and the duodenum released. No bowel ischemia or mesenterial defects were present. The postoperative course was uncomplicated with rapid regain of intestinal transit on postoperative day 1 and discharge on day 4 after renal function recovery. Follow-up visit after one month was uneventful and the patient remains pain-free at postoperative month 6.

Conclusion CPE is a rare condition, often manifesting as intermittent abdominal pain due to (sub)obstructive episodes. Furthermore, inconclusive imaging in the presence of malrotation should raise suspicion of concomitant congenital anomaly. Management consists of resection of the accessory peritoneum. This is the first reported case of CPE in the presence of nonrotation.

ABSTRACT. Aim: Due to the increased frequency of kidney transplantations and the high incidence of inguinal hernia in men, the coincidence of both features is not uncommon.

Material & Methods: A 58-year-old male patient with a history of a kidney transplantation in the right fossa due to bilateral shrivel kidneys, presented with a bilateral recurrent incisional hernia. Two years before he had an anterior bilateral groin hernia repair; a Liechtenstein repair on the left side and a partial preperitoneal repair with mesh reinforcement on the right side.

Results: The case was approached via a robot assisted TAPP (transabdominal preperitoneal) procedure to perform the preperitoneal dissection of the myopectineal orifices. At the region of the right inguinal hernia, the normal anatomy was distorted, due to the extraperitoneal course of the donor ureter which was freed accordingly. A partial mesh excision of the previous mesh was performed. The preperitoneal dissection area was covered with a self-gripping mesh. The postoperative course was uneventful.

Conclusions: The extraperitoneal course of the ureter in a kidney transplant patient challenges the surgical repair of an inguinal hernia. In primary groin hernias an anterior approach seems best suited, but in case of a recurrence after a previous anterior approach, a laparoscopic approach is a possible though challenging surgical option.

ABSTRACT. OBJECTIVE A 24-year-old female patient presents to the emergency department with abdominal discomfort. She is known with an extensive psychiatric history including pica behaviour, resulting in multiple endoscopic and surgical explorations. At the time of presentation she was under maximum psychiatric supervision and therapy. Once more she states that she swallowed a spoon and two batteries. In the light of this case, we began to question the burden that this type of patient places on healthcare services in general and on the endoscopic and surgical team in particular. The best plan of action to treat these patients was evaluated.

METHODS The gastroenterologist performed an upper endoscopy with retrieval of the two batteries. However, the spoon could not be removed. Subsequently a laparoscopic gastrotomy with extraction of the spoon was performed. The use of an endobag enhanced the removal of the spoon extracorporeally. There was minimal intra-abdominal spillage of gastric content.

RESULTS The postoperative course was uneventful, the patient was discharged to the psychiatric unit the day after surgery. A laparoscopic approach was the correct procedure in this case. Unfortunately, she presented 3 days later with another foreign body ingested. In the following 2 weeks after her first admission she underwent 3 laparoscopic surgeries and 5 upper endoscopies for the extraction of foreign bodies

CONCLUSIONS Underlying diseases should be addressed and treated in pica behaviour. A multidisciplinary approach (gastroenterology - psychiatry - surgery) is extremely important. Evangelos Nastoulis et al (2019) state that the indication for surgery lies in the ingestion of voluminous or sharp objects, rather than endoscopic removal. If the foreign body has caused gastrointestinal perforation, the indication for surgical removal is absolute. Other indications are: absence of an experienced endoscopist, failure of previously conducted endoscopic methods, unaltered localization of the foreign body for 48–72 hours, or the ingestion of cocaine packs.

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