Abstracts DGAV

Endoscopic Vacuum Therapy versus Stenting for postoperative esophago-enteric Anastomotic Leakage: Systematic Review and Meta-Analysis

(Abstract ID: 120)

M. Tachezy¹, P. Sognamiglio¹, M. Reeh¹, K. Karstens¹, E. Bellon¹, M. Kantowski¹, G. Schön¹, A. Zapf¹, S.-H. Chon², J. Izbicki¹

¹Universitätsklinikum Hamburg-Eppendorf

²Universitätsklinikum Köln

Background:

Esophageal anastomotic leakage still represents a challenging complication after esophageal surgery. Endoscopic placed Self-Expanding Metal Stents (SEMS) are the treatment of choice, but since the introduction of the Endoscopic Vacuum Therapy (EVT) of esophageal leakages 10 years ago, increasing evidence evolves that EVT might be a superior alternative. Therefore, weperformed a systematic review and meta-analysis to compare the effectiveness and the related morbidity of SEMS and EVT in the treatment ofesophageal leaks.

Materials and methods:

We systematically searched for studies comparing SEMS and EVT to treat anastomotic leaks after esophageal surgery. Predefined endpoints including outcome, treatment success, endoscopies, treatment duration, hospitalization time, morbidity and mortality were assessed and included in metaanalysis.

Results:

Five retrospective studies including 274 patients matched the inclusion criteria. With respect to stenting, EVT was significantly associated with a higher rate of leakage closure(RR 3.12; 95%CI [1.10, 8.85]), a higher number of endoscopical changes (pooled mean difference of 3.09; 95%CI [1.54, 4.64]), a shorter duration of treatment (pooled mean difference - 11.90; 95%CI [-18.59, -5.21]) and a lower mortality rate (RR 0.38; 95%CI [0.18, 0.82]). Short term and major complications failed to show significant differences.

Conclusion:

Due the retrospective quality of the studies with potential biases, the results of the meta-analysis must be interpreted with caution. However, the data indicate a high potential of EVT and its potential benefit must be further investigated in more robust prospective randomized trials.

Endoscopic Vacuum Therapy With Open-Pore Polyurethan Sponges And Film Drainages For Iatrogenic Perforation Of The Esophagus

(Abstract ID: 198)

D. Wichmann¹, V. Steger¹, A. Königsrainer¹, U. Schempf¹, U. Schweizer¹, R. Archid¹

¹Universitätsklinik Tübingen

Background:

Management of iatrogenic esophageal perforations is challenging. Endoscopic Vacuum Therapy (EVT) with Open Pore Polyurethan Sponges and Film Drainages in the management iatrogenic esophageal leaks is a promising tool. We use EVT for iatrogenic esophageal perforations as first line therapy since 2017. The aim of the study was to figure out the advantages of this interventional therapy mode.

Materials and methods:

Ten patients were treated with EVT for IEP between 08.2017 and 08.2019. Therapy data and outcome measures including duration of therapy, treatment strategies and therapy success were collected and analyzed.

Results:

Time of detection was 2.8 (0-19) days after intervention. After 19.3 (3-39) days of EVT, 3-11 endoscopies and 38.1 (9-147) days of hospitalization, endoscopic treatment using EVT was effective and successful in all patients. Rate of complication was very low. Additional video-assisted thoracoscopic surgery was done in the half of patients.

Conclusion:

EVT is an effective method for the management of iatrogenic esophageal perforations. Combination with minimal invasive surgery for sepsis-control can be recommended.

An intervention-capable training model for flexible endoscopy in postoperatively altered anatomy of the upper GI tract

(Abstract ID: 248)

K. Koch¹, U. Schweizer¹, B. Mothes¹, D. Wichmann¹, K.-E. Grund¹

¹Allgemein-, Viszeral-, und Transplantationschirurgie, Universitätsklinikum Tübingen

Background:

Many surgeries in the upper gastrointestinal tract, especially the steadily growing number of bariatric procedures, result in a fundamentally altered anatomy. Insufficient knowledge of the altered anatomy leads to an increased risk in follow-up endoscopy, for example due to cholelithiasis after bariatric surgery. A realistic, patient-like training model is not yet available, but could improve the quality of diagnostic and, above all, therapeutic endoscopy in patients with postoperatively altered anatomy.

Materials and methods:

First, the altered anatomy was completely reconstructed with digital 3D programs using patient-analog data. Materials from textile research were used as well as rigid and flexible 3D printing materials for tissue replication. Furthermore, already developed and patented artificial tissues, plastics such as latex, acrylic, silicone and various elastomers were used to reproduce animal-free, realistic and interventional organ structures of the upper gastrointestinal tract.

Results:

A modular hands-on training phantom was created, which shows a situation after partial gastric resection with Roux-en-Y reconstruction. Further anatomical variants (gastric bypass, Billroth II, reconstruction after Whipple surgery) are currently being developed. Interventionally, an ERCP can be trained under fluoroscopy with papilla and bile duct intervention with different access techniques (e.g. device assisted enteroscopy) as well as the treatment of a duodenal stump insufficiency with a VAC sponge.

Conclusion:

The training of flexible endoscopy for patients with postoperatively altered anatomy is possible with newly developed phantoms. An evaluation of the phantom is being performed on volunteers with different levels of experience.

Finding the best way to treat a proximal staple line leak after sleeve gastrectomy: Comparison of endoscopic vacuum therapy (EVAC) versus self-expandable metal stent (ESMES)

(Abstract ID: 568)

V. Christogianni¹, R. Dukovka¹, R. Riege¹, J.-C. Halter¹, P. Bemponis¹, M. Reiser², M. Büsing¹

¹Klinikum Vest-Knappschaftskrankenhaus Recklinghausen

²Klinikum Vest- Paracelsus Klinik Marl

Background:

Laparoscopic sleeve gastrectomy is gaining popularity in the treatment of morbid obesity due to its promising results and low complication rate. The occurrence of a proximal staple line leak, although rare, challenges a lot of surgeons, and is associated with a high morbidity and mortality. The aim of the present study is to compare how effective was the EVAC and the ESMES therapy in the management of staple line leak after SG.

Materials and methods:

This was a hospital-based retrospective study, including patients suffering from proximal staple line leak after SG. The patients were classified into 2 groups, a EVAC group (n=22) and a E-SEMS (n=9) group. We evaluated and compared the treatment outcomes in both groups.

Results:

The clinical success in the EVAC group was 82% (18/22) and in the E-SEMS group 56% (5/9). The median time to closure of the leak was 22 and 26,6 days respectively. The complication rate was higher in E-SEMS group reaching up to 78% in comparison to the EVAC group (23%).

Conclusion:

The EVAC therapy appears to have more promising results in the treatment of proximal staple line leak after SG in comparison to the placement of an E-SEMS.

Skills-Lab for tube placement in the upper GI: Experiences with a phantom-based skills-lab course for students

(Abstract ID: 794)

D. Wichmann¹, K.-E. Grund¹, U. Schweizer¹, B. Mothes¹, A. Königsrainer¹

¹Universitätsklinik Tübingen

Background:

There are a lot of indications for gastrointestinal tube placement. This topic is important in clinical practise but underrepressented in the curriculum. We designed a phantom-based student class, for 6 to 8 medical students, to provide theoretical and practical knowledge of gastrointestinal tube placement. Handling with flexible endoscopes and training of basic endoscopic diagnostic are parts of this course.

Materials and methods:

Introducing of the creation and establishment of this students class with results and students rating.

Results:

We performed 4 phantom-based students classes with in total 22 students. Students learned about indications and complications of tube placement into the upper GI. They performed nasogastric tubeplacement, inserted PEGs and knew about the management of therapeutic tubes like senkstakenblakemore tubes.

Conclusion:

The student course "Skills-Lab for tube placement in the upper GI" for medical students at the university of Tübingen is a new, interdisciplinary educational project. This class was offerd as elective subject in the clinical section. Students were enthusiastic but material and personell expenses were rather high.

IGS- Intragastric Single-Port Surgery for Large Benign Gastric Tumors and for Access the ERCP in Remnant Stomach after RYGB- First Clinical Series

(Abstract ID: 847)

C. Grande¹, R. Li¹, M. Specht¹, R. Zorron¹

¹Klinikum Ernst von Bergmann Potsdam

Background:

Benign gastric tumors can be challenging for either endoscopic or surgical treatment. A local gastric resection is usually indicated in tumors with a diameter beyond 3cm if full-thickness resection is needed or endoscopic R0 removal is impossible. The increasing application of laparoscopic techniques with stapled wedge resection is potentially leading to unnecessary loss of unaffected gastric tissue. As an alternative we present a video of a new technique of intragastric single port surgery (IGS) for the resection of solitary large benign tumors of the stomach.

Materials and methods:

14 patients with benign tumors localized at submucosa level with a diameter range between 3-6cm encompassing GISTs, Dieulafoy angiodysplasia and other indications, and 9 patients with RYGB and indication for ERCP were included. A simultaneous intraoperative gastroscopy was performed in each patient in order to define the resection margins. As a next step the stomach wall is percutaneous exteriorized and a single port was introduced in the epigastric space under direct vision. Afterwards part of the ventral gastric wall was eviscerated and fixed at the abdominal wall. The resection was performed with 45mm linear staplers und endoscopic guidance and the tumor was retrieved through the single port access. Hand-sutured oversewing was outinely performed through single port. Finally the gastric incision was closed percutaneously.

Results:

The operative time lasted between 42 and 58 minutes for the intragastric surgery. No intraoperative complications were observed. One patient developed a wound infection, 2 patients had postoperative blleding and treated endoscopically. All resection margins were tumor free. Postoperative control at POD 30 revealed no complications.

Conclusion:

The concept of percutaneous intragastric single port gastric surgery (IGS) facilitates the minimal invasive resection of large benign gastric tumors with reduced loss of unaffected gastric tissue.

Picture:

 

Endoscopic Vacuum Therapy for Treatment of Colorectal Defects: 20 Years of Experience

(Abstract ID: 934)

F. Kühn¹, M. Burian¹, N. Beger¹, J. Zimmermann¹, M. Drefs¹, U. Wirth¹, M. Rentsch¹, J. Werner¹, T. Schiergens¹

¹Klinikum der Universität München

Background:

Endoscopic vacuum therapy (EVT) has become the new treatment of choice for colorectal defects in several institutions and commercially available systems are currently distributed in more than 30 countries worldwide. Success rates of endoscopic vacuum therapy (EVT) for treatment of colorectal defects differ between 56 to 96%, the median duration of therapy ranges from 12 to 40 days. Currently existing data on EVT is based on a few, small patient series from various institutions, employing different methods, treatment algorithms and materials. As EVT was invented and consequently implemented into clinical routine at our tertiary referral center approximately 20 years ago, we are able to report on a broad experience and a large number of consecutive patients.

Materials and methods:

A retrospective analysis of a prospectively maintained database at the Hospital of the University of Munich was conducted. In-house patients as well as those referred from other hospitals that were treated with EVT for colorectal defects at our institution between 2000 and 2019 were included. Statistical analysis was performed using SPSS.

Results:

In total, 281 patients (66 % male, 34% female) with a median age of 65 years (range, 18–96) were treated with EVT for various colorectal defects; of these, 54 patients (19,2%)with colorectal defects were referred from external departments. 234 of the 281 patients (83%) had a previous history of a malignant disease and 228 patients (81%) were labeled ASA III or higher. Most frequent indications for EVT were anastomotic leakage after rectal or rectosigmoid resection (70%) followed by Hartmann stump leakage in 20%. The median number of sponge insertions was 9 (range, 1-65) with a median changing interval of 3 days (range, 0–4). Median time of therapy was 25 days (range, 1-258). Overall, EVT was effective in 258 out of 281 patients (92%). Short- and long-term complications occurred in 15 of 281 patients (5%) with a luminal stenosis in 9 patients (3%) as the most frequent complication. EVT was initiated as inpatient treatment in most of the patients (98%). Of these, 43% could later be transferred into an ambulatory EVT setting.

Conclusion:

This large single center experience confirms data from smaller patient series showing that EVT can achieve a safe and effective control of the local septic focus in the majority of patients.

Transoral Thyroid Surgery vestibular approach. Preliminary results.

(Abstract ID: 380)

E. Karakas¹, G. Klein², P. Busch³, L. Michlmayr², P. Kühn¹, S. Schopf³

¹Krankenhaus Maria Hilf, Alexianer GmbH, Krefeld

²Landesklinikum Wiener Neustadt

³Krankenhaus Agatharied GmbH, Hausham

Background:

Various approaches for endoscopic and minimally invasive thyroid operations have been reported, with some becoming popular to date. The aim is to reduce and prevent visible scars in the neck. This led to the transoral endoscopic thyroidectomy vestibular approach (TOETVA) technique. After implementation of TOETVA in three specialized endocrine centres in 2017 we now report on our preliminary results with this promising technique.

Materials and methods:

We evaluated the transoral technique performed in well selected patients in Germany and Austria since 2017. Transoral operations have been performed by 4 Endocrine Surgeons. In some patients an an additional retroauricular access was used to retrieve bulky thyroid specimens. TOETVA was performed in patients with single thyroid nodules, sporadic primary hyperparathyroidism, isthmic nodule or thyroglossal duct cyst. TOETVA was performed using 3 laparoscopic ports, laparoscopic instruments inserted at the oral vestibule. Patients characteristics, surgical outcome and complications were determined.

Results:

79 transoral procedures were performed in 77 patients. In two patients a transoral completion thyroidectomy was necessary due to papillary thyroid cancer on one side. An additional retroauricular access was performed in 12 patients with bulky thyroid specimen of more than 40ml volume (Median 55ml, range 30-105ml). Overall, median operation time was 207min (range: 90-420min). Permanent recurrent laryngeal nerve palsy occured in one patient (0.9%, 109 nerves at risk). No conversion to conventional open surgery was necessary. Long term mental nerve injury occurred in two patients. No infection and no permanent hypoparathyroidism were identified.

Conclusion:

Transoral thyroid and parathyroid surgery via the vestibular approach is of interest in an increasing number of specialized centres. It is feasible and safe. The rate of thyroid surgery specific complications seems to be equal to conventional thyroid surgery, while procedure related problems must further be evaluated. Combination with an additional extracervical approach, i.e. retroauricular or transaxillary, might be a promising alternative to allow for transoral surgery also in bulky thyroid specimen of more than 40ml.

Postoperative Hyperkaliemia after parathyroidectomy in patients with secondary hyperparathyroidism

(Abstract ID: 411)

D. Uluk¹, C. Bures², E. Dobrindt², N. Sehnke³, A. Akca³, J. Pratschke², P. E. Goretzki², M. Mogl²

¹Charité Universitätsmedizin Berlin

²Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Univers

³Rheinland Klinikum Neuss, Lukaskrankenhaus

Background:

Secondary hyperparathyroidism (SHPT) can lead to severe complications in patients with end-stage renal diseases (ESRD) therefore parathyroidectomy (PTX) is a mainstay of treatment. While preparing patients for PTX, hyperkalemia may lead to serious complications with the need for perioperative dialysis or even ICU treatment. Causes of hyperkalemia in these patients are not clearly understood. Two centers were analyzed in order to define differences in perioperative care.

Materials and methods:

251 patients with SHPT due to ESRD undergoing PTX between 2008 and 2018 at the department of surgery, Charité - Universitaetsmedizin Berlin and Lukaskrankenhaus Neuss have been analyzed retrospectively. Patient demographics, surgery-specific parameters and pre-, intra- and postoperative laboratory chemistries were investigated. Especially the SPL as predictive value was calculated. Associations for both groups were assessed, univariate and multivariate analyses, parametric and non-parametric tests were carried out. The receiver operating characteristic curve (ROC) method was used to assess the cutoff point for probable prediction of preoperative SPL concerning hyperkalemia. Hyperkalemia was defined as a SPL >= 5.5mmol/l.

Results:

Demographic parameters were similar in both hospitals, only BMI was higher in Neuss. Intra- and postoperative potassium were significantly higher in patients in Neuss. 67 of 251 patients (27%) needed dialyses at operation day with significantly more patients in Neuss (Charité vs. Neuss, 25 (19%) vs. 42 (35%), p=0.006). Their mean SPL preoperatively was 4.91±0.9mmol/l (3.5-7.5mmol/l). Hyperkalemia occurred in 19 of 67 patients (28%) prior to surgery, and in 36 patients (55%) postoperatively. In the control group without dialysis, mean SPL preoperatively was 4.99±0.78mmol/l (3.1-6.9mmol/l).

There was no significant correlation of hyperkalemia prior to operation and dialysis at operation day. The development of the SPL from beginning of surgery until postoperative control showed significant differences. While at Charité patients showed a decrease in mean SPL during surgery (∆SPL preopintraop: -0.11mmol/l), in Neuss patients displayed increasing SPL (0.15mmol/l, p=0.008). Overall, patients with dialysis at operation day showed an increase in SPL during surgery. Regarding cutoff values for postoperative hyperkalemia, the preoperative SPL of 4.81mmol/l had a sensitivity of 76% and a specificity of 51% in ROC-analyzes. The area under the curve was estimated 0.639. The duration of surgery was significantly shorter in Neuss (Charité vs. Neuss, 129±40min vs. 113±38min, p=0.01). Parathyroidectomy was equally effective at both centers with a significant decrease of parathyroid hormone (PTH) for all patients (PTH preoperative vs. postoperative: 968±651ng/l vs. 70±148ng/l).

Conclusion:

Postoperative hyperkalemia with the need for dialysis at operation day could not be predicted by pre- or intraoperative values. Previously defined cutoff levels for SPL leading to postoperative hyperkalemia showed low sensitivity and specificity in our cohort. Besides we could not show any significant correlation for dialyses at operation day in multivariate analysis. Despite broad experience with perioperative care for patients with ESRD in both hospitals, specific differences in anaesthesiological management may have contributed to these results.

Indepth investigations and randomized trials will be needed for perioperative risk assessment and stratification of SPL as influencing factor for surgical outcome in PTX.

Clinical Presentation, treatment and outcome of parathyroid carcinoma: First results of the NEKAR study

(Abstract ID: 450)

C. Lenschow on behalf of the NEKAR study group¹

¹Universitätsklinikum Würzburg

Background:

Parathyroid carcinoma (PC) is a rare malignancy for which diagnostic workup and treatment is not established. Aim of the study: To describe the clinical presentation, current workup and treatment of PC and to determine clinical parameters of prognosis.

Materials and methods:

Retrospective cohort study of 83 patients diagnosed with PC from 29 tertiary care centers in Germany, Switzerland and Austria. Disease-specific and recurrence-free survival was estimated with the KaplanMeier method. Risk factors for recurrence were identified by Cox proportional hazards modelling with adjustment for age and sex. 39 tumors underwent central histopathological review.

Results:

Renal failure (39.8%), gastrointestinal symptoms (24.1%), osteopenia/fractures (22.9%) and psychic symptoms (19.3%) were the most common symptoms at diagnosis. Serum concentrations of calcium (median 3.34 mmol/l; range 1.64-6.0) and parathyroid hormone were strongly increased (median 566 pg/ml (range 31.8-8900). Initial surgical treatment was heterogeneous (parathyroidectomy, PTx 22.9%; PTx and hemithyroidectomy, hTT 24.1%; en-bloc resection 15.7%; others 37.3%) and complications of surgery were frequent (recurrent laryngeal nerve palsy 25.3% hypoparathyroidism 6%).

While disease-specific survival was high (81/83), recurrence of PC was observed frequently (32/83) with 75% of these patients showing local recurrence. In univariate analysis the rate of recurrence was significantly reduced when extended initial surgery had been performed (p< 0.04). In multivariate analysis a significantly lower rate of recurrence was observed for low T-status (OR=2.65, 1.02-6.88, p=0.045), lack of initial lymph node metastasis (OR=6.32, 1.33-30.01, p=0.02), Ki-67<10% (OR=14.07, 2.09-94.9, p=0.007) and postoperative biochemical cure (OR=0.023, 0.001-0.52, p=0.018). Importantly, this was not different when the groups of patients with and without histopathologic reevaluation were compared

Conclusion:

Despite a favorable overall prognosis, PC is associated with a high rate of recurrence leading to repeated surgery and complications. A critical awareness for this rare disease is recommended and extended surgery may be warranted when the suspicion of PC is reasonable.

Lenvatinib plus Pembrolizumab - a breakthrough therapy for patients with metastatic poorly differentiated and anaplastic thyroid carcinoma. First results from an ongoing study.

(Abstract ID: 664)

C. Dierks¹, F. Beuschlein¹, M. Manz¹, J. Seufert¹, J. Ruf², S. Kiefer³, R. Rasner⁴, M. Boerries¹, S. Lassmann³, p. la Rosee⁵, P. Mayer⁶, M. Kroiss⁷, C. Weißenberger⁸, O. Tomusch⁹, A. Zielke¹⁰

¹Department of Endcrinology, Freiburg

²German Cancer Consortium (DKTK), Heidelberg

³Department of Pathology, Freiburg

⁴Department of Haematology and Oncology, Freiburg

⁵Klinikum Villingen-Schwenningen

⁶Department of Nuclear Medicine, Freiburg

⁷Universitätsklinikum Würzburg

⁸Zentrum für Strahlentherapie, Freiburg

⁹Department of Surgery, Freiburg

¹⁰Diakonie-Klinikum Stutgart

Background:

Despite extensive multimodal therapy, survival of metastasized poorly differentiated thyroid carcinomas (PDTC) and anaplastic thyroid carcinomas (ATC) rarely exceeds months. These tumors are highly proliferative and frequently display numerous driver mutations and overall increased mutational burden (TMB) as well as elevated PD-L1 levels.

Materials and methods:

The clinicopathological data of eight patients with metastasized ATC (n=6) or PDTC (n=2), who received a combination of lenvatinib (started at 24/20 mg/d) and the immune checkpoint inhibitor pembrolizumab (200 mg/3w) within a compassinoate care program, were retrospectively analyzed. The results are presented herein and founded the rationale for an ongoing prospective phase II trial (ATLEP) that has already included 20 patients with stage IV PDTC/ATC. All tumors were characterized by whole exome sequencing (WES) and PD-L1 expression (TPS 1-90%).

Results:

Up to date more than 20 patients with stage IV ATC/PDTC have been treated with Lenvatinib and pembrolizumab. Maximum duration of treatment with this combination has now reached 30 months and 5 of the 8 initial patients of the compassinate care fgroup are still on therapy. In this retrospectively analyzed cohort, ORR at three months of treatment was 75% (6 PR, 1 SD, 1 PD); with two long term remissions of more than 2 years. 3 of the 8 initial patients had complete remissions at one year of treatment. Current PFS in this cohort is 13.8 months (duration of treatment 1, 4, 9, 10, 13, 14, 25, 30 months). Grade III/IV toxicities evolved in 3/8 patients, but resolved after reduction or discontinuation of the TKI (2/8). OS has not yet been reached, as the majority of patients (5/8) are still on therapy (at 30, 16, 15, 10 and 9 months). All patients with long-term remission (>=24 months) as well as those with CR had increased TMB or PD-L1 TPS > 50%. Results from the first interim analysis of the ongoing prospective phase II ATLEP-trial confirm these results, and demonstrate an ORR of 80% at 3-months of treatment.

Conclusion:

These results suggest the combination of lenvatinib and pembrolizumab to be well tolerated and effective in patients with stage IV ATC/PDTC. For the first time, complete and long-term remissions are seen in these patients, who usually face a very dismal prognosis.

Increased cytoplasmatic expression of cancer immune surveillance receptor CD1d in anaplastic thyroid carcinomas

(Abstract ID: 756)

H. Junger¹, F. Weber¹, J. Werner¹, N. Char¹, C. Rejas¹, H.-J. Schlitt¹, M. Hornung¹

¹Universitätsklinikum Regensburg

Background:

Anaplastic thyroid carcinomas are associated with rapid tumor growth, short survival time and without any promising therapy to improve the poor prognosis. In this study, expression of immunoregulative receptor CD1d and lymphocyte infiltration in different thyroid tumors as well as in healthy tissue were analyzed in order to find new targets for an immunotherapeutic approach.

Materials and methods:

CD1d immunohistochemistry was performed in samples of 18 anaplastic, 17 follicular, 27 papillary, and 4 medullary thyroid carcinomas as well as in 19 specimens from normal thyroid tissue and additionally in 10 samples of sarcoma, seven malignant melanoma and three spindle‐cell lung carcinoma. Furthermore, thyroid samples were stained with antibodies against CD3, CD20, CD56, CD68, and LCA in order to analyze lymphocyte infiltration.

Results:

For the first time CD1d receptor expression on normal thyroid tissue could be demonstrated. Moreover, anaplastic thyroid carcinomas showed significantly higher expression levels compared to other thyroid samples. Most astonishingly, CD1d expression disappeared from the cellular surface and was detected rather in the cytoplasm of anaplastic thyroid carcinoma cells. In addition, histologically similar tumors to anaplastic carcinoma like sarcoma and malignant melanoma revealed distinct CD1d staining patterns. Furthermore, infiltration of T cells, B cells, and macrophages in anaplastic thyroid carcinomas was different when compared to normal thyroid tissue and all other thyroid carcinomas.

Conclusion:

Anaplastic thyroid carcinomas show significantly higher expression of CD1d, a receptor for NKT cells, which are subject of several anticancer therapy studies. These results may offer a novel approach to explore immunotherapeutic treatment options.

Short term outcomes of surgery for Graves’ disease – a plea for total thyroidectomy with continuous intraoperative neuromonitoring

(Abstract ID: 805)

E. Maurer¹, C. Vorländer², A. Zielke³, C. Dotzenrath⁴, M. von Frankenberg⁵, H. Köhler⁶, K. Lorenz⁷, T. Weber⁸, J. Jähne⁹, A. Hammer¹⁰, K. Böttcher¹¹, K. Schwarz¹², C. Klinger¹³, D. Bartsch¹, S. Studiengruppe Schilddrüse¹³

¹Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg

²Bürgerhospital Frankfurt am Main

³Diakonie Klinikum Stuttgart

⁴Helios Unversitätsklinikum Wuppertal

⁵Krankenhaus Salem, Heidelberg

⁶Herzogin Elisabeth Hospital Braunschweig

⁷Universitätsklinikum Halle

⁸Katholisches Klinikum Mainz

⁹Diakovere Henriettenstift Hannover

¹⁰DKD Helios Klinik Wiesbaden

¹¹Diakonissenkrankenhaus Mannheim

¹²Lukaskrankenhaus Neuss

¹³Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, Berlin

Background:

Surgicaltreatment of Graves' disease(GD) has a potentially increased incidence of postoperative bleeding, recurrent laryngeal nerve palsy (RLNP) and postoperative hypoparathyroidism. The aim of this study was to evaluate the current surgical strategy for the treatment of GD and its short-term outcomes.

Materials and methods:

Patients who underwent thyroid resection for GD were identified from the prospective StuDoQ/Thyroid registry. Patients’ data were retrospectively analysed regarding demographics, surgical procedures, and short-term perioperative outcomes. Variables were compared using the Student's t-test or Fisher’s exact test as appropriate, the level of statistical significance was set at p< 0.05.

Results:

1808 patients with GD (81.3% female) with a median age of 44 (range 14-85) years were enrolled in a 25-months period by 78 departments. 34.6% (n=691) of patients had an endocrine orbitopathy and 6 (0.1%) patients a thyrotoxic crisis. Total thyroidectomy was performed in 93.4% (n=1688) of patients. Intraoperative neuromonitoring (IONM) was used in 98.9% (n=1789) of procedures. In 98.3% (n=1777) patients at least one parathyroid gland was visualized and in 21.7% (n=375) of patients’ parathyroid glands were autografted. The rates of unilateral and bilateral transient RLNP were 3.9% (n=134/3429 Nerves at risk) and 0.1% (n=4/3429 NAR). It is of note that the rates of RLNP were higher after the use of intermittent compared to continuous IONM (4.1% vs. 3.4%, p<0.05). The rate of transient postoperative hypoparathyroidism was overall 29% (n= 525). It was significantly higher in patients who underwent parathyroid autotransplantion compared to patients without (43.5% vs. 25.2%, p<0.05). Reoperations for postoperative bleeding (1.3%) or wound infections (0.2%) were rare.

Conclusion:

Total thyroidectomy with IONM is safe and the current operative standard for GD. The use of continuous IONM and a more restrictive attitude to autotransplant parathyroid glands might further minimize complication rates in thyroid surgery for GD.

Influence of parathyroidectomy on kidney graft function in secondary and tertiary hyperparathyroidism

(Abstract ID: 948)

P. Seika¹, C. Bures¹, T. Skachko¹, E. Dobrindt¹, N. Rayes², J. Pratschke¹, P. E. Goretzki¹, M. Mogl¹

¹Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Univers

²Universitätsklinikum Leipzig

Background:

Timing of parathyroidectomy remains controversial in kidney transplant candidates with renal hyperparathyroidism. The aim of this retrospective study was to identify the influence of early versus late post-transplant parathyroidectomy compared to pre-transplant parathyroidectomy on renal graft function and morbidity. This single-center cohort study includes 57 patients with renal hyperparathyroidism and kidney transplantation treated between 2007 and 2017.

Materials and methods:

96 patients were operated for renal hyperparathyroidism between 2007 and 2017 as consecutive sample (Group 1 (n=30/ tHPT), group 2 (n=66/ sHPT). Of group 1, n=4 patients were excluded for PTX before and after kidney transplantation. In group 2, 20 patients were excluded, since they had not undergone kidney transplantation. 12 patients were excluded because of short follow-up (kidney transplantation in 2018) and 3 patients because of transplant failure within 90 days.

26 patients underwent post-transplant parathyroidectomy, 31 patients had undergone parathyroidectomy prior to kidney transplantation. Graft function, serum calcium concentrations, parathyroid hormone levels, postoperative morbidity, 90-day mortality were recorded. The hypothesis was formulated before data collection.

Results:

Median age was 53.1 years in group 1, 49.1 years in group 2. Most patients were male (53.8% group 1, 54.8% group 2). Median preoperative PTH levels were significantly different with 331.6 pg/mL in group 1 and 667.5 pg/mL in group 2 (p=0.003). Creatinine levels changed little from 1.4 mg/dL (0.8 - 2.5) to 1.7 mg/dL (0.7 - 7.3) in group 1, whereas in group 2 creatinine levels were 8.5 mg/dL (4.6 - 11.7) before and 8.7 mg/dL (5.1 - 11.9) after PTX.

We saw no correlation between postoperative PTH and kidney function. 35 patients with postoperative PTH <15pg/mL displayed a mean postoperative creatinine of 5.5 mg/dL (4.3 - 6.8), similar to other patients. Both the 30-day and 90-day mortality rate was zero.

Conclusion:

Parathyroidectomy had no negative effect on graft function, whether performed prior to or early or late after kidney transplantation. Surgical cure of renal hyperparathyroidism should be performed as soon as possible to prevent secondary complications.

A comparison between ABBA and EndoCATS endoscopic thyroid surgery procedures regarding surgical outcome and quality of life

(Abstract ID: 973)

S. Schopf¹, J. Hampel², T. Ahnen von², H. M. Schardey², U. Wirth³

¹RoMed Klinik Bad Aibling

²Krankenhaus Agatharied, Hausham

³LMU München

Background:

Several endoscopic techniques have been developed over the past two decades as life quality and patient satisfaction become more and more important outcome variables. Aim of this work was to compare two endoscopic procedures ABBA and EndoCATS in perioperative as well as postoperative outcome and QoL.

Materials and methods:

We performed a prospective comparison of perioperative and functional outcome between 59 retroauricular (EndoCATS), 52 ABBA at a single specialized institution. Patients completed questionnaires for QoL (SF-12 questionnaire) and patient satisfaction. Perioperative complications were recorded.

Results:

Surgical time was 150.8/ 131.6 Min. by mean (t-test; p=0.154) for ABBA/EndoCATS hemithyroidectomies and 181.8 Min. for ABBA thyroidectomies. Mean hospital stay was 2.7/2.2 days.

Acute hemorrhage was revised endoscopically once each group (1.9%/1.7%, χ2; p=0.928). Temporary hypocalcemia occurred in 9.6% and 1.7% cases (χ2; p=0.066). We had one case of permanent RLN paresis in each group (1.9%/1.7%, χ2; p=0.634/0.928). Temporary numbness along the access occurred in 48.1% and 64.4% respectively in ABBA/EndoCATS procedures (χ2; p=0.083).

Follow-up rates was 92.3%/88.1% respectively. 89.6%/94.2% of patients were at least satisfied (χ2; p=0.191) with surgical procedure. The cosmetic result was rated with best two grades in 93.8% and 92.3% of patients (χ2; p=0.506). 92.7%/92.3% (ABBA/EndoCATS) patients would consider to undergo endoscopic surgery by the same technique again (χ2; p=0.426).

QoL (SF 12) resulted in values of 49.5/50.0 for mental health composite scale (t-test; p=0.843) and 45.3/45.7 for physical composite scale (t-test; p=0.784) for ABBA/EndoCATS patients.

Conclusion:

ABBA and EndoCATS both have higher complication rates for RLN, but not for hypoparathyroidism and postoperative bleeding compared to open thyroid standards. Duration of surgery in both techniques is clearly higher in both techniques compared to open standard. Cosmetic results, patient satisfaction and QoL are excellent.

Carbonic-Anhydrase-IX expression is increased in thyroid cancer tissue and represents a potential target for a TIC-directed therapy

(Abstract ID: 974)

J. Schmidt¹, E. Oppermann¹, W. O. Bechstein¹, K. Holzer², P. Malkomes¹

¹Universitätsklinikum Frankfurt am Main

²Universitätsklinikum Marburg

Background:

Thyroid cancer is the most common endocrine malignancy and its incidence increases worldwide. Growing evidence suggests that thyroid cancer is a hierarchically-organized malignancy and tumor initiation is driven by tumor-initiating cells (TICs). The hypoxia-inducible enzyme, Carbonic-AnhydraseIX (CAIX), was shown to be essential for tumor cell expansion and invasion in different tumor entities. Nevertheless, its expression and role in thyroid cancer is not well known yet. The purpose of this study is to investigate the expression and role of CAIX in thyroid cancer progression and TIC activity.

Materials and methods:

CAIX expression was determined by immunohistochemical stainings of 80 thyroid cancer patients (papillary, follicular and anaplastic cancer) using tissue microarrays (TMA). Further expression of CAIX in monolayer and thyrosphere cultures was analyzed in three different thyroid cancer cell lines (BCPAP, FTC-133, 8505C) using flow cytometry (FACS) and immunofluorescence. To assess the function of CAIX in thyroid cancer, we genetically targeted its expression by shRNAs followed by functional in vitro assays. Pharmacological inactivation of CAIX using the inhibitor Methazolamide was performed to investigate its potential impact on cancer cell proliferation, apoptosis and TIC activity. All experiments were additionally completed by exposing cells to hypoxia.

Results:

We could detect an increased expression of CAIX in primary thyroid cancer tissue in comparison to adjacent normal tissue. Here, patients with papillary carcinoma showed the highest CAIX expression. Furthermore, CAIX protein levels were upregulated in thyrospheres in comparison to monolayers in all thyroid cancer cell lines determined by FACS and immunofluorescence, suggesting its role in the stemness ability to form thyrospheres. Hypoxia led to an additional induction of CAIX expression and cell proliferation. A knockdown of CAIX by shRNA significantly inhibited cell proliferation and thyrosphere formation ability. Most importantly, pharmocological inactivation of CAIX resulted in a strong inhibition of cell proliferation by an induction of cell death under normoxia as well as under hypoxia. Accordingly, an inhibition of CAIX caused a significant reduction of thyrosphere formation capacity in all cell lines.

Conclusion:

We demonstrate here, that CAIX may provide a new target for the diagnosis and treatment of thyroid cancer. Targeting CAIX effectively impacts thyroid cancer cell proliferation and TIC activity.

Usage of the Big Five Inventory-10 for the classification of personality traits in Barrett´s cancer patients, revealing gender- specific differences

(Abstract ID: 446)

C. Gaisendrees¹, N. Kreuser², O. Lyros², J. Becker³, J. Schumacher⁴, I. Gockel², A. Kersting¹, R. Thieme²

¹Uniklinik Köln

²Universitätsklinikum Leipzig

³Universitätsklinikum Bonn

⁴Universitätsklinikum Gießen-Marburg

Background:

During the last decades the number of patients suffering The incidence of Barrett’s esophagus and Barrett’s cancer has been increased in the western hemisphere. There is a controversial discussion about the association of depression, stressors, cancer development and patient’s personality traits. Up to date, there are no data available, correlating personality traits in Barrett’s cancer patients.

Materials and methods:

We conducted a multi-center survey, to characterize the Big Five Inventory-10 (BFI-10) and to evaluate personality traits in patients with Barrett´s cancer between 01/13 and 12/15. In total 1,247 Barrett’s cancer patients received the BFI-10 questionnaire and 839 of them answered (females: 13.8%, males: 86.2%; 66.7±9.7 years) patients (corresponding response: 67.3%). The results were compared with healthy controls from two BFI-10 surveys representing the German resident population with regard to gender and age.

Results:

he personality traits of patients with Barrett’s cancer showed differences compared to the German resident population. Eextraversion and openness were associated with lower values, while neuroticism, conscientiousness and agreeableness showed higher values in the study group. Statistically relevant gender-specific differences were observed in agreeableness (p=0.04) and neuroticism (p=0.000). In Barrett’s cancer patients, age was associated with a decrease in neuroticism, while in the reference group higher age was associated with higher values for neuroticism.

Conclusion:

We were able to show gender- and age-specific characteristics in a large Barrett’s cancer patient cohort. Personality traits, especially neuroticism, might be helpful for patient’s risk stratification in regard to their compliance during surveillance, treatment and follow-up care.

Gender Differences in Outcomes and Long-term Survival of Patients with Colorectal Cancer - A Literature Review

(Abstract ID: 944)

K. Schulte¹, M. Heise¹

¹Sana Klinikum Lichtenberg, Berlin

Background:

Significant gender specific differences in the incidence and outcome for colorectal cancer and colorectal cancer surgery have been previously described and controversially discussed.

However, this could have diagnostic implications and potential benefits for patient groups at risk. We sought to determine which gender specific factors attribute most to the outcome.

Materials and methods:

For the literature review the Medline database (Pubmed) was searched with the search terms "gender differences" AND "colorectal cancer" from 2009 to 2019. From 484 studies a total of 14 studies (one meta-analysis, 13 retrospective cohort studies) were included focusing on gender differences in colorectal cancer surgery patients.

Results:

Eight studies focused on the gender related prognosis after colorectal cancer surgery.

Out of these a total six studies described a survival advantage in females. One especially in older women (aged 50-80 years), one in younger women (aged 18-44 years) a with metastatic colorectal cancer and one in women with synchronous colorectal cancer.

Two studies described no difference in the survival rates, although one found an earlier recurrence rate in men, especially in older men (aged >65 years).

One study found the postoperatively bowel function after colorectal cancer surgery at 3- and 5-years retrospectively to be worse in males. The decline in sexual function was described to be the same for both sexes.

Four studies focused of a gender related location of colorectal cancers. Of those two studies described left sided tumours to be more present in males. One to be more frequent on the left side in females. One study did not find a gender related difference. All the studies found the right sided tumour to be equally present in both sexes. Additionally, two of the studies described the tumours to be more advanced in men at the point of diagnosis.

Conclusion:

Gender seems to impact the outcomes in colorectal cancer surgery although the underlying mechanisms remain undefined. The recognition of important gender related disparities may lead to the implementation of measures to diminish differences and facilitate equitable distribution of health resources.

Population Based Analysis of Gender Disparities in 23,715 Percutaneous Endovascular Revascularisations in the Metropolitan Area of Hamburg

(Abstract ID: 149)

C.-A. Behrendt¹, H. Rieß¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

The worldwide prevalence of peripheral artery disease (PAD) is increasing and endovascular revascularisation (ER) has become the primary invasive treatment option. This study aims to illuminate gender disparities in ER of PAD.

Materials and methods:

This is a retrospective, cross sectional study design. All inpatient invasive, percutaneous endovascular treatments of PAD conducted in the metropolitan area of Hamburg (Germany) were collected consecutively between 01/2004 and 12/2015. Relevant socio-demographic risk factors, technical assessments, procedural details, and in hospital outcomes were collected and subsequently analysed.

Results:

A total of 23,715 ERs were identified (39.7% females). Female patients were older (74 vs. 70 years, p < .001) and more often suffered from rest pain (12.0% vs. 9.7%, p < .001) at the time of presentation. No differences were found for index lesion complexity (Trans-Atlantic Inter-Society Consensus classes) and the ankle brachial index was less often stated not to be valid in females (5.9% vs. 7.1%, p = .005 for intermittent claudication; 28.5% vs. 32.0%, p = .001 for chronic limb threatening ischaemia, CLTI). If the ER was performed for CLTI, crural vessels below the knee were less often revascularised in females (32.2% vs. 42.7%, p < .001). Peri-operative major bleeding complications including pseudoaneurysms occurred twice as often in females, and female gender was an independent predictor of bleeding complications in the adjusted analyses (OR 2.32, 95% CI 1.49-3.64, p < .001 for IC; OR 1.67, 95% CI 1.10-2.53, p = .017 for CLTI). Lastly, females were more often transferred to nursing homes when compared with males (0.3% vs. 0%, p = .001 for IC; 2.5% vs. 1.2%, p < .001 for CLTI).

Conclusion:

In this study considering percutaneous ER for PAD, female patients were older, had different clinical symptoms, suffered more often from complications, and were at risk of social isolation after discharge when compared with their male counterparts. These results emphasise the need for further studies to evaluate a gender based treatment algorithm in PAD.

C reactive protein level after elective shoulder surgery - a gender specific marker

(Abstract ID: 648)

S. F. Hertling¹, K. Freifrau von Wrede¹, G. Matziolis¹, F. M. Loos¹

¹Waldkliniken Eisenberg

Background:

Laboratory examinations are an integral part of perioperative management in all surgical disciplines, including orthopedic surgery. The CRP is used in particular for the detection of inflammatory processes. The possible influence of the patient's gender on the postoperative course of the CRP value after a shoulder prosthesis implantation (SP) is largely unclear. The purpose of the present study is to test the hypothesis that the postoperative complication-free course of the CRP level is gender-specific in the first 10 days after SP.

Materials and methods:

350 patients were included in this monocentric, retrospective study. Patients received a primary shoulder prosthesis between 2009 and 2018. For all patients, the preoperative CRP value was determined and postoperative History recorded from day 1 to 10 and tested for gender specificity.

Results:

On days 2-4 and 6-8 after surgery, men had significantly higher CRP values than women. The maximum difference was at 37 mg / l on the fourth p.o. day.

Conclusion:

The present study showed that the complication-free course of CRP in the first 10 days after primary shoulder arthroplasty is gender specific. The results have clinical relevance for the interpretation of postoperative CRP values to unnecessary investigations and to avoid surgical interventions in women and men with uncomplicated SP.

Sex-stratified outcomes of proximal aortic surgery in a high-volume center

(Abstract ID: 689)

J. Haunschild¹, J. Sternberg¹, K. von Aspern¹, M. Misfeld¹, P. Davierwala¹, M. Borger¹, C. Etz¹

¹Herzzentrum Leipzig

Background:

For female patients with abdominal aortic aneurysms a faster aneurysm growth at an older age, an increased rupture risk and worse outcome after surgery with higher mortality and re-operation rates have been demonstrated. Current guidelines are not yet accounting for possible sex differences in surgical procedures involving the aortic valve and/or the proximal aorta. The aim of this study is to compare outcomes of three common surgical procedures stratified by sex—from isolated aortic valve to complex aortic root replacement—in a high-volume center.

Materials and methods:

Our institutional database was retrospectively reviewed over a 15-year period (01/2004-08/2018). A total of 6030 consecutive patients were included: 4820 with aortic valve replacement (AVR), 631 AVRs with concomitant supracoronary ascending aortic replacement (scAAR) and 579 modified Bentall procedures. Emergencies, concomitant multi valve or bypass surgery and reoperations were excluded. Chi2, unpaired t-test, logrank test, logistic regression for in-house mortality, inverse Kaplan-Meier and Cox regression for time-to-death were utilized.

Results:

In general, the mean age at time of surgery is different between men and women: in average, women are 2 years older when undergoing scAAR, 4 years older when undergoing isolated AVR and 6 years older when undergoing Bentall procedures. However, no difference with regard to relevant comorbidities, i.e. arterial hypertension, diabetes, hyperlipidemia and pulmonary hypertension were present, but men were 2-3 times more often smoker. Among patients requiring AVR and AVR with scAAR, aortic stenosis was the most prevalent valve dysfunction in both sexes (AVR: 87% in women, 81% in men, scAAR: 74% in women, 73% in men). However, among Bentall patients, women had significantly more often aortic stenosis (64 vs. 41%) and men more often regurgitation (57 vs. 34%). Length of surgery was not significantly different between the sexes within all three groups, but women required in median 3 hours longer mechanically ventilation. Postoperative complication rates, e.g. bleeding, pericardial effusion, sternal instability and sternal wound healing disorders, were not significantly different between men and women in all three surgical groups. In-house mortality in the scAAR cohort was not significantly different between the sexes (women:2%, men:1%, p=0.20), however, significantly higher among women in the Bentall group with 6% (vs. <1% in men, p<0.0005) and also among women undergoing isolated AVR (women:3%, men:1%, p<0.0005). In logistic regression analysis significant impact on early mortality was confirmed for age (OR 1.10 [1.06-1.13]; p<0.0005), female sex (OR 2.19 [1.21-2.94];p=0.001) and smoking (OR 1.73 [1.08-2.77];p=0.023). When considering the interaction of female and Bentall, the risk increases significantly (OR 9.92 [1.22-91.5], p=0.037), see table.

Conclusion:

Women in general undergo surgery at an older age in all three surgical cohorts. Except for isolated AVR, where the diagnosis and indication for surgery is symptom driven, the current guidelines constitute the indication for proximal aortic aneurysm repair based on maximum diameter—which women in average may reach at a more advanced age than men. Consequently, in these (older) female patients in-hospital mortality is higher—particularly when receiving the most complex surgery in this comparison, a Bentall procedure. It should be evaluated if delimited (i.e. single sinus replacement) root repair in combination with scAAR is sufficient in women of advanced age with stenotic valve and asymmetric non-coronary sinus dilatation—particularly with borderline diameters.

Recognition of all inguinal nerves during Lichtenstein herniorraphy with glue fixation increases the risk for prolonged acute pain after surgery

(Abstract ID: 43)

K.-H. Moser¹, K. Moser¹

¹Mediapark Klinik Köln

Background:

The purpose of this prospective single-centre trial was to assess the influence of the nerve management during Lichtenstein repair on acute postoperative pain.

Materials and methods:

The Chronic Pain Prevention Screener (CPPS) was used to recruit 163 patients at high risk for developing chronic postoperative inguinal pain (CPIP) from June 2011 to June 2015. Patients were treated consecutively for primary unilateral or femoral hernia using standard Lichtenstein technique with a large porous PVDF mesh (DynaMesh®-LICHTENSTEIN) fixated with synthetic absorbable cyanoacrylate glue (Glubran®). Essential part of the dissection was the attempt to identify all three inguinal nerves, which then were preserved or resected. Primary outcome was the postoperative pain in the groin in relation to the nerve management. Secondary endpoints were recurrence, chronic pain and postoperative complications at 1 day, 6 weeks, 3 months and 6 months after surgery.

Results:

Intraoperatively, the ilioinguinal nerve (IIN) and iliohypogastric nerve (IHN) both have been identified in 85%, and the genital branch of the genitofemoral nerve (GFN) in 68% of the patients. In 3% no nerves could be identified, in 9% only one nerve, in 36% two nerves and all three inguinal nerves in 53% of the cases. Due to iatrogenic injury or interference with mesh placement the IHN had been resected in 69%, the IIN in 24% and the GFN in 19%.

The number of identified nerves had a significant adverse impact on the course of acute pain 6 weeks postoperatively: 14% after identification of three nerves, 7% after two nerves, and 1% after one nerve, respectively. Resection had a significant negative effect on acute pain after 6 weeks only if the IIN (p = 0.031) was involved, and only for the female gender (p = 0.026). CPIP was recorded for 2.8% and 3% at 3 months and 6 months respectively. At the later time point without any impact of the nerve dissection any longer.

There were no recurrences and mesh related complications.

Conclusion:

Pain assessment following tension-free mesh-based Lichtenstein repair showed that the number of identified inguinal nerves had a significantly adverse impact on the course of the pain until 6 weeks after surgery. This was not the case for CPIP at 3 months and 6 months after surgery.

The importance of laparoscopic IPOM in hernia surgery

(Abstract ID: 73)

S. Wais¹, A. Bär¹, N. Bohnert¹, A. Ulrich¹, B. Lammers¹

¹Städtische Kliniken Neuss

Background:

Between 2009 and 2017, after 24 years of application in practice the laparoscopic IPOM repair technique ranked second in Germany with 30 per cent of all executed surgeries of incisional hernia. The aim of our retrospective cohort study was hence to gather the data of all IPOM operations carried out in the Neuss Lukaskrankenhaus between 2011 and 2017 and to analyse them by means of variances set in advance.

Materials and methods:

In the executed retrospective cohort study all cases of the 484 patients operated under the use of the laparoscopic IPOM repair technique in the Neuss Lukaskrankenhaus during the defined 8-year period were considered. The monocentric data was collected prospectively using OPS coding (the German modification of the ICPM coding) and medical records. Thereafter the patient collective's data was analysed by means of the variances set before (postoperative complications, recurrence rate, length of stay).

Results:

Between January 2011 and December 2017 820 IPOM procedures had been carried out - 484 were laparoscopic (55 %) and 336 open (45 %) repairs. The average length of stay being 4 ± 1,3 days after applying the laparoscopic technique was significantly shorterthan after making use of the conventional technique with 8 ± 3,5 days. The patient's average BMI was similar in both groups: the laparoscopic patients had a BIM of 32 ± 4,6 kg/m2 and the conventional patients 30 ± 4,5 kg/m2. The laparoscopic repair patients were significantly younger (56 ± 10,4 years) than the conventional patients (63 ± 10years). The follow-up treatment period was 3,7 ± 1,8 years. 8% of the laparoscopic group had recurrence, 2,1% in the first year. After conventional surgery 13% had recurrence, also 2% in the first year. The postoperative complications were grouped by the Clavien-Dindo Classification. With 8% of postoperative complications, of which 0,5% required subsequent surgery, the risk of complication is much lower under the appliance of the laparoscopic technique compared to the conventional repair after which complications occurred in 26% of the cases and 9% of these patients needed operative revision.

Conclusion:

Our monocentric data, as well as those of the Herniamed register, show that the laparoscopic IPOM technique is an ideal procedure to repair abdominal wall hernia with a hernia gap up to 10 cm because of a low rate of complications, shorter length of stay, shorter operation time and a low recurrence rate. Therefore, the laparoscopic IPOM technique will from an integral part in hernia surgery until further notice

Mankind or Computer: What is the best analysis of CT abdomen with Valsalva’s maneuver prior to grip-based incisional hernia repair?

(Abstract ID: 184)

F. Kallinowski¹, T. Löffler¹, R. Nessel¹, A. Grimm¹, J. Görich¹

¹Universitätsklinikum Heidelberg

Background:

Incisional hernia repair is burdened with frequent recurrences and chronic pain. The grip concept can better this with no recurrences and no chronic pain after one year (Kallinowski et al., Ann Med Surg 42: 1-6, 2019). An adequate grip of the reconstruction requires the determination of the individual tissue elasticity. Computerized tomography of the abdomen with Valsalva’s maneuver can determine the tissue elasticity but requires an estimate by at least three different observers with a total of 10 - 15 observations which takes 30 to 45 min to perform. Can the process by advanced using commercially available Computer-based algorithms?

Materials and methods:

A total of 42 patients with incisional hernias were investigated using computerized tomography of the abdomen with Valsalva’s maneuver. Grip values necessary for a biomechanically stable incisional hernia repair were calculated as previously described (Kallinowski et al. Front Surg 2017; 4: 78| doi.org/10.3389/fsurg.2017.00078). The tissue elasticity was determined from changes of the defect area and of the hernia sac volume using previously published models in comparison to maschinebased algorithms (Ashwin®, Siemens Syn.Go®).

Results:

Since April 2019, 42 consecutive patients were investigated with an average defect area of 137 + 44 cm². On average, the distension of the hernia area was 34 + 11 %, that of the hernia sac being 103 + 65 %. The variation was 13 + 4 % with the human approach and 43 + 13 % using commercial algorithms. Humans used 13 + 4 min for an evaluation by hand. The use of maschine-based algorithms tripled the time to 37 + 11 min (Syn.go® Siemens 30 + 13 min, Ashwin® PACS 44 + 7 min; p < 0.0001).

Conclusion:

Computerized tomography with Valsalva’s maneuver can determine the elasticity of the unstable zone of the abdominal wall prior to grip-based incisional hernia repair. At this moment, the grip calculation is faster and less variable per hand. The development of new routines for evaluation is mandatory to speed up the process in clinical routine.

CiCAT or Progrip: Which DIS class a mesh is advantageous in grip-based incisional hernia repair?

(Abstract ID: 191)

R. Nessel¹, T. Löffler², L. Schneider³, F. Kallinowski⁴

¹SLK Klinikum Am Gesundbrunnen, Heilbronn

²GRN Klinik Eberbach

³Kreiskrankenhaus Bergstrasse, Heppenheim

⁴Universitätsklinikum Heidelberg

Background:

Incisional hernia repair is burdened with frequent recurrences especially in old, frail or obese patients. Low cyclic loading to determine the grip has potential to better incisional hernia repair. The grip is a dimensionless measure of the biomechanical stability of the repair (Kallinowski et al. Front. Surg. 4:78. doi: 10.3389/fsurg.2017.00078, 2018).

Materials and methods:

Nine meshes were subjected to low cyclic loading in a self-built bench test. According to the biomechanical stability three distinct classes were discerned (Kallinowski et al., Biomech J 48: 4026 - 4036, 2015 doi: 10.1016/j.jbiomech.2015.09.045i). Both meshes with the highest stability were used in four hospitals in 73 patients to reach sufficient grip values for the given defect size. Clinical data, pain levels and recurrence rates were monitored for one year in the HERNIAMED/ STRONGHOLD registry.

Results:

A total of 73 patients (39 female, 34 men) with an average age of 63 + 14 years (Range: 27 - 92) were included. Mean BMI was 28 + 5. Primary repairs were done in 59 patients. Recurrences were repaired in 14 patients after 4 + 3 years. Mean OR time was 133 + 61 min. At an average hernia size of 9 x 7 cm, Dynamesh® Cicat was used in 29 patients. Progrip® was utilized in 44 cases. The average overlap was 4.7 + 1.8 cm. The mean mesh: defect area ratio (MDAR) was 16 + 22 (median 11). The average grip value was calculated as 124 + 144 (median 85). Using CiCAT® , lower MDAR but higher GRIP was achieved. Higher grip values at larger hernia sizes are a consequence of more fixation. Recurrences or chronic pain were absent in both meshes after one year.

Conclusion:

Using DIS class A meshes, biomechanically stable incisional hernia repair is possible. Biomechanically stable repairs exhibit no recurrence and no chronic pain after one year.

Short-term outcome after ventral hernia repair using self-gripping mesh in sublay technique

(Abstract ID: 238)

C. Dawoud¹, F. Harpain¹, K. Wimmer¹, P. Ogrodny¹, A. Stift¹

¹Medizinische Universität Wien

Background:

The sublay technique is a generally accepted method for ventral hernia repair. Recently, the application of self-gripping meshes for hernia repair is increasing. However, the regular use of selfgripping meshes in ventral hernia still needs to be evaluated. Accordingly, this investigation assessed the short-term postoperative outcome of conventional meshes versus self-gripping in sublay hernia repair.

Materials and methods:

We evaluated patients undergoing ventral hernia repair in sublay technique in a retrospective data analysis between January 2011 and July 2018 at the Department of Surgery, Medical University of Vienna. Two hundred forty-four consecutive patients were qualified for definitive analysis. We grouped the patients by the used mesh and assessed baseline characteristics as well as postoperative outcome.

Results:

The baseline characteristics of the two groups showed no significant difference. Our median follow-up was 11 months (IQR 3-30). Patients with a self-gripping mesh showed a significantly higher rate of seromas (17.3% versus 6.8%, p=0.013) as well as surgical site infections (12.6% versus 4.3%, p=0.021). Therefore, this group showed an increased overall complication rate as well (28.3% versus 13.7%, p=0.005). Significantly more patients with a self-gripping mesh needed a surgical intervention (21.3% versus 9.4%, p=0.011).

Conclusion:

Self-gripping meshes in sublay ventral hernia repair are associated with a higher overall complication rate. Notably, we observed an increased rate of seromas and surgical site infections. Consequently, complication-associated surgical interventions were significantly higher when compared to non-selfgripping mesh placements.

Botox Supported Abdominal Wall Reconstruction in IPOM Technique (B.U.B.I.) - A technique for everybody? Problems and pitfalls

(Abstract ID: 272)

N. Bohnert¹, E. Elieyioglu¹, A. Bär¹, A. Ulrich¹, B. Lammers¹

¹Rheinlandklinikum, Lukaskrankenhaus Neuss

Background:

One of the biggest problems in hernia surgery is to get sufficient results in cases of hernias with big midline defects (W3 hernias) and/or loss of domain hernias. Even in cases of small defects, loss-of domain can cause serious problems, since reposition of the hernia sac contents will result in an increased intraabdominal pressure with all its problems (compartment syndrome/respiratory failure etc) and too m uch tension on the reconstructed midline.To avoid dissection of healthy parts of the abdominal wall like in the Ramirez operation, which we think is not the best choice for multimorbide patients, we developed our own method of botox supported abdominal wall reconstruction in IPOM technique.But is it a really safe procedure for all day use in general hospitals?Where is the problems and pitfalls?

Materials and methods:

In this method we combine the botox induced relaxation of the abdominal wall with the IPOM technique to achieve a full reconstruction of the midline combined with a mesh.Inclusion criterias were W3 and/or loss-of-domain hernias.Exclusion criterias were pregnancy,Myasthenia,ALS,urostoma and enterostoma.4 weeks prior to surgery patients patients were treated with sonography guided botox injection in both sides of the lateral abdominal wall.To verify the result a low dose ct abd is done.Intraoperative the size of the defect was documented.During the healing process of the midline and the ingrowth of the mesh the botox efect decreases 4-6 months till its gone.During that period the abdominal cavity can get used to the situation slowly without causing any pressure related problems.

Results:

33 patients have been operated so far.In 22 of 33 cases we could do a full reconstruction of the midline.Defect sizes have been between 6x6 to 30x35 cm.In 10 cases we could at least reduce the defect.Mesh sizes have been between 20x30 to 30x50 cm.Introperatively 1 small bowel resection was necessary,postop we had 1 SISSI..Reoperation was not necessary.30 patients went through follow up after 6-12 months and are without a recurrence so far.Overall we had a morbidity of 21% and a wound infection rate of 6%.4 patients (12%) had pulmonary problems.Mean ICU stay was 48 hrs,mortality was 0%.Adverse botox events were problems with defaecation and cuffing.

Conclusion:

As known reconstruction of the abdominal wall is a challenge especially in W3 and/or loss-of-domain hernias.Avoiding the problems of the Ramirez operation and preserving the healthy lateral parts of the abdominal wall BUBI is a chemical component separation with lower risk for the patient.Our results show that its even possible to do a midline reconstruction in huge hernias without creating any pressure related problems.Nevertheless one has to reflect that botox is used off label for the abdominal wall and one has to be aware of pulmonary complications.Its recommended by us to observe those patients on ICU for at least 48 hrs to do extensive lung training.Theres no evidence so far about this procedure so studies are urgently needed.

Abdominal Wall Expanding System (AWEX). A Surgical Technique for thr Repair of Giant Incisional Hernia and Laparostoma. New Results. A three-center-experience.

(Abstract ID: 317)

D. Eucker¹, O. Stern², C. Luedtke³, R. Rosenberg¹

¹Kantonsspital Baselland, Bruderholz

²Asklepios Klink Hamburg

³Westpfalz Klinikum, Kusel

Background:

In large incisional hernias and after laparostoma midline closure may be impossible. A novel abdominal wall expander system (AWEX) was introduced in 2017. In the first pilot Study the feasibility and effectiveness of the novel operation technique was evaluated. After presentation of the technique in Germany for the first time (Cologne 2018 ), two additional centers for hernia surgery applied the technique to giant incisional hernia and laparostoma. We are now able to present additional data.

Materials and methods:

In patients with large incisional hernia and laparostoma where primary midline closure was impossible, AWEX was used. Patients undergoing abdominal wall reconstruction using AWEX between May 2012 and October 2019 were included. Intraoperative the abdominal wall was stretched by attaching the midline fascia borders to a retraction system under tension for 30 minutes. Length and width of the hernia defect were measured in preoperative computed tomography and intraoperatively. Width gain after AWEX procedure, operative time, morbidity, and presence of remaining midline gap was evaluated. Patients operated before 2019 were also followed for hernia recurrence.

In the mean time in 28 Patients AWEX-Procedure was actually used. 15 Patients with incisional hernia and grafted laparostoma underwent abdominal wall reconstruction in the center for hernia surgery Kantonsspital Baselland between 2012 and 2019 using AWEX. In 2018/19 the center for hernia surgery of the Asclepios Klinik Hamburg Wandsbek was able to perform 9 additional reconstructions using AWEX, the Westpfalz Klinikum, Kusel followed with another 4 Patients.

Results:

Median (interquartile range) length and width of the hernia defect was 15.0 (15.0-20.5) and 12.0 (11.813.3) cm. Width gain after AWEX was 12 (11-15.5) cm. Mean operative time was 270 (135–379) minutes. The major morbidity was 20%. In 5 patients a gap of 4 (4-7) cm was bridged by intraperitoneal onlay mesh. There was also an additional TAR performed in 2 patients. After a median follow-up of 21 (7-36) months of patients operated before 2018 no hernia recurrence was observed. In none of the operated patients method-specific complications were reported(!)

Conclusion:

The promising results of the AWEX-procedure as presented in 2018 could be confirmed in additional cases from three different surgical centers. The AWEX-procedure seems to be safe und easy to perform. No method-specific complications were reported.

The use of AWEX during abdominal wall reconstruction allowed successful intraoperative stretching of the muscles and fascia enabling approximation of the midline. The same effect has been demonstrated before by techniques like progressive restressed retention sutures or progressive preoperative pneumoperitoneum (PPP). However the time needed to stretch the abdominal wall is reduced from days and weeks in restressed retention and PPP to only 30 minutes in AWEX. AWEX is also a promising alternative or addition to component separation and Botox in repair of large incisional hernias. After refinement of the system prospective evaluation is required.

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Intraoperative Setting

Postoperative load-bearing capacity and hernia incidence following laparotomy and laparoscopy – results of a national survey

(Abstract ID: 323)

C. Güsgen¹, A. G. Willms¹, C. Weber¹, R. Schwab¹

¹BundeswehrZentralkrankenhaus, Koblenz

Background:

There is lack of evidence regarding the physical activity after abdominal surgery. The personal capacity and duration of incapacity for work depends on the invasivity of surgery and the rates of complications and yet often on medical advice. Recommendations for postoperative restriction of activity are still common due to the fear of developing an incisional hernia (IH). Unnecessary restriction of activity affects quality of life and can cause significant socio-economical costs. The purpose of this study was to survey the recommendation situation of physical activity after surgery in Germany and to examine its possible effect on the development of incisional hernia.

Materials and methods:

In 2016 questinonaires about postoperative activity after Laparotomie (LT) and Laparoscopy (LS) were send to 1078 institutions. Furthermore questinonaires about individual postoperative activity and development of IH and a SF-12 were send to 951 patients who received LT or LS between 2009-2016 at our institution.

Results:

386 surgical departments (35,8%) participated in the survey.Recommendation after surgery (LT 92,7%, LS 77,5%) was given, which was not evidence-based (89,5%). Recommended restriction of activity after LT was 6 weeks and after LS 2,5 weeks. Postoperative binders were seldom advocated (LT 22%, LS 0,5%). Sick leave was recommended for 3 weeks (LT) and 2 weeks (LS). Restrictions for intercourse were rare (LT 5,7%/LS 3%).

402 patients responded to the survey (42%). IH developed in 36 cases (9,2%). The incisional hernia rate was significantly higher in patients after LT compared to patients after LS (18,0% vs. 5,2% (LS) p=,00). Patients with IH were older (65 vs. 57 years; p<,01) and less employed (33,3% vs. 59,6%; p=,00). ASA, BMI, smoking and DM were no risk factors for developing an IH. After surgery Patients with IH complained more often (p=,03) about more intense pain (NAS 4,0 vs. 3,5; p<,01). Postoperative Abdominal binders were seldom used (39%) and more often by Patients who developed an IH (63,2% vs. 38,9; p=,02). Patients with IH complained more often about an numbness of the abdominal scars (25,0% vs. 12,1%; p=,03). Patients without IH had a shorter period of postoperative physical inactivity: 83,4% reached full physical capacity after 4 weeks (69,5% with IH (p=,02)). 33,3% with an IH vs. 11,2% without an IH never achieved their preoperative level of subjective physical capacity (p=,01). The analysis of the SF-12 questinonaires showed that patients with IH had a lower physical (p=,00) and mental (p=,00)score.

Conclusion:

Results of the presented surveys show in the one hand, that there is actually no evidence for postoperative restriction of physical activity in Germany. Recommendation is based on experience.

On the other hand our patient survey show, that earlier mobilisation and moderate, pain orientated physical activity are able to reduce he postoperative incisional hernia rate. Therefor more liberal postoperative algorithms should be deliberated and prospectively discussed.

New device simplifies primary closure in open abdomen treatment (OAT)

(Abstract ID: 343)

A.-S. Peter¹, M. v. Websky¹, J. C. Kalff¹, T. Vilz¹, B. Stoffels¹

¹Universitätsklinikum Bonn

Background:

Fascial retraction remains an unsolved problem treating open abdomen (OAT). All available methods are aiming at a secondary stepwise closure. However, fascial retraction often impedes a direct closure. Fasciotens Abdomen® allows counteracting immediately fascial retraction applying a ventrally directed traction over an external support.

Materials and methods:

5 patients undergoing a median or transverse laparotomy were treated with Fasciotens Abdomen® for abdominal compartment syndrome (ACS) which didn’t allow a primary fascial closure. A vicryl mesh was attached to both fascial margins of the laparotomy. Afterwards, the device was placed on thorax and ventral pelvic ring. Using Vicryl sutures size USP 1, traction was applied to both fascial edges over the interposed mesh. A constant traction of 50-70 N was applied and regularly checked on the scale. Vital and ventilation parameters were recorded.

Results:

Vital and ventilation parameters weren’t affected by Fasciotens Abdomen®. There were no differences during phases of traction and without traction. Even in patients after CPR and with ECMO treatment the device could be used continuously. Weight bearing surfaces didn’t show any important impairment like ulcera or necrosis. Traction force was lowered regularly by enlargement of the fascia during a therapeutical interval. Distance of fascial edges was consecutively diminuished in subsequent revisions. Prevention of fascial retraction enabled later primary fascial closure without alloplastic materials in 100% in these 5 patients.

Conclusion:

The device offers the first treatment option to counteract fascial retraction. It facilitates closing a laparostomy without any alloplastic materials or abdominal wall reconstructions. Fascial closure is possible as soon as the intraabdominal volume has normalized. The new approach reduces ICU stays, repeated surgeries and treatment costs. Early fascial closure also reduces complications (e.g. intestinal fistula). Further prospective trials are needed to confirm these first results.

The biologic mesh is associated with serious abdominal wall complications in patients undergoing emergency surgery – results from a randomized-controlled clinical trial

(Abstract ID: 520)

M. Jakob¹, T. Haltmeier¹, D. Candinas¹, G. Beldi¹

¹Viszerale Chirurgie und Medizin Inselspital Bern

Background:

Open, emergency abdominal surgery is associated with a high incidence of fascial dehiscence and incisional hernia. Biologic meshes potentially reinforce the abdominal wall. The aim of this prospective, randomized study was to compare the outcome after prophylactic, intraperitoneal implantation of biologic mesh with standard abdominal closure in emergency abdominal surgery.

Materials and methods:

A randomized clinical trial was performed in patients undergoing emergency abdominal surgery at Bern University Hospital, Bern, Switzerland from April 2016 to March 2019. Patients were randomly assigned to prophylactic implantation of a biological intraperitoneal mesh (Strattice) or a single, continuous running suture. An emergent interim analysis had to be performed after the enrollment of 48 patients because of safety concerns. Consequently, patient enrollment had to be closed prematurely.

Results:

Eligibility for inclusion was assessed in 61 patients. Of these, 48 patients (21 in the mesh group, 28 in the no-mesh group) were included in the study. No significant differences in baseline characteristics were found comparing the mesh and the no mesh group. Abdominal wall complications requiring reoperations were more frequent in the mesh group compared to the no mesh group (5 of 13 versus 1 of 13 patients, p=0.026). Mesh-associated abdominal wall complications included non-integration of the mesh into the abdominal wall, dissolution of the mesh, and mesh-related infections.

Conclusion:

Intraperitoneal biologic mesh implantation was associated with significantly more frequent high-grade abdominal wall complications in patients undergoing emergency abdominal surgery. Based on this result, the use of biologic meshes cannot be recommended in the contaminated environment of emergency abdominal surgery.

Incisional hernia repair in obese patients – the single most important factor for recurrence

(Abstract ID: 845)

D. Uluk¹, M. Aydin¹, P. Fikatas¹, C. Denecke¹, J. Pratschke¹, J. Raakow¹

¹Charité Universitätsmedizin Berlin

Background:

Incisional hernia is a common surgical long-term complication after abdominal procedures. In present times patient’s overweight becomes a rising challenge in patient care due to high calorie intake. The aim of this investigation was to evaluate obesity as a potential risk factor for postoperative complications after incisional hernia repair and on the long-run for hernia recurrence.

Materials and methods:

A total of 656 patients undergoing primary incisional hernia repair at the surgical department of Charité - Universitätsmedizin Berlin between May 2010 and November 2016 were included in the analyzes. Common risk factors were analyzed for the whole population and especially regarding to patient`s BMI in univariate and multivariate analyses. Obesity was defined as BMI >= 30 kg/m2.

Results:

The study population was divided into 428 (65.2%) non-obese and 228 (34.8%) obese patients. Obese patients undergoing incisional hernia repair were younger (58.0 vs. 55.9 years, p=0.010) and more often female (45.3% vs. 57.5%, p=0.003). Overall non-obese patients had more comorbidities (86.4% vs. 79.8%, p=0.033) but diabetes was more often found in the obese group (14.4% vs. 25.5%, p=0.001). No difference was found regarding the hernia size and location according to the EHS classification. The hernia repair was more often performed by laparoscopy in obese patients (23.1% vs. 35.1%, p=0.001). There was no difference regarding postoperative complications between the two groups. A total of 328 patients completed the long-term follow-up at a mean of 43 ± 22 months after the initial hernia repair. Recurrent incisional hernia could be recorded in 30 (14.4%) cases in nonobese patients in contrast to the obese population with 33 (27.7%) cases (p=0.004). Both univariate and multivariate analyses proved obesity to be a significant risk factor for recurrence of incisional hernia (OR 1.84; 95% CI 1.02 - 3.32; p-value 0.041). No other parameter showed significant association with hernia recurrence.

Conclusion:

Short-term postoperative outcome is comparable between obese and non-obese patients undergoing incisional hernia repair but obesity is significantly associated with long-term hernia recurrence.

Development and Validation of a Machine Learning Algorithm to Predict Disease Free Survival after Resection of Hepatocellular Carcinoma

(Abstract ID: 57)

M. Schoenberg¹, J. Bucher¹, D. Koch¹, S. Hesse¹, E. De Toni¹, M. Angele¹, J. Werner¹, M. Guba¹

¹Klinikum der Universität München

Background:

Due to organ shortage, liver transplantation can only be offered subsidiary to other curative treatments of hepatocellular carcinoma. The objective of this study was to develop and validate a machine learning algorithm (ML) to predict which patients are sufficiently treated by liver resection.

Materials and methods:

26 preoperatively available routine lab values, routine clinical variables and Scores (modified Glascow Prognostic Score (mGPS); Kings Score (KS); Model of Endstage Liver Disease (MELD)) were used in a workflow using random Forest (RF) ML. The workflow included preprocessing, recursive feature elimination (RFE), resampling, and training of the RF model. The final model was validated in a randomly selected test cohort. Based on the RF prediction we divided the test data into high (HR) and low risk (LR) group.

Results:

We identified data from 181 patients resected because of hepatocellular carcinoma (HCC) between January 2007 and through March 2018. RFE resulted in 6 included variables: mGPS, aPTT, CRP, largest tumor size, number of lesions and age at time of operation. After down-sampling prediction based on our model was 0.788 for early DFS. 16.7% of HR and 74.2% of LR patients survived 2 years of follow-up (p<0.001)(Figure)

Conclusion:

Our RF model based on routine laboratory values is a powerful predictor of disease free survival after HCC resection.

Picture:

Survival Analysis of DFS within 2 years of follow-up after defining “Low-Risk” and “High-Risk” patients

Nutritional support in patients with mild and moderately severe acute pancreatitis

(Abstract ID: 137)

S. Chuklin¹, S. Chooklin¹, G. Shershen¹

¹Lviv Regional Clinical Hospital, Lwiw

Background:

Nutritional support is an important factor in the treatment of acute pancreatitis patients. However, the optimal timetable for restoring oral intake is almost not studied. The nutritional support with appropriate nutritional supplements is a key element for limiting local inflammation and preventing or treating pancreatitis-associated complications.

Materials and methods:

We examined 51 patients with mild acute pancreatitis. In 25 patients, an early oral refeeding (EORF) was used when patients experienced hunger, and 26 patients received routine oral refeeding (RORF) after pain disappeared and normalized pancreatic enzymes serum levels. Twenty two patients with a moderately severe acute pancreatitis were recruited: 11 received study feeds (Nutricomp Energy + fish oil 3 g/day for 5 days) via nasogastral tube and 11 received control feeds (Nutricomp Energy).

Results:

Before starting the diet in the EORF group, serum concentrations of pancreatic amylase and lipase were elevated. There was a significant difference in the duration of the hunger strike after hospitalization between the EORF group and the RORF group. In addition, there was a significant decrease in the total number of days of hospitalization in the EORF group compared with the group RORF. There were no differences in the relapse of abdominal pain, abdominal distension, elevated serum levels of pancreatic enzymes, and severity of the condition of patients between two groups in mild and moderately severe acute pancreatitis. All patients who developed relapse of pain and transient abdominal distension did not require a change in nutrition regimen. The activity of inflammation at the concentration of C-reactive protein significantly earlier was leveled in patients from the group of EORF and Nutricomp Energy + fish oil group. All patients were discharged according to standardized criteria.

Conclusion:

In patients with mild AP, early onset of oral refeeding, which is safe, promotes a faster reduction of the inflammatory process, reduces the timing of hospitalization. In patients with moderately severe AP early onset of ω-3 PFA promotes a faster reduction of the inflammatory process, reduces the timing of hospitalization.

Exploring pancreatic ductal adenocarcinoma’s molecular landscape and its prognostic potential from diminutive real-world fine needle aspiration

(Abstract ID: 143)

A. Semaan¹, V. Bernard¹, J. Lee¹, P. Guerrero¹, J. C. Kalff¹, H. Matthaei¹, A. Maitra¹

¹Universitätsklinikum Bonn

Background:

Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis despite progress in clinically relevant molecular subtyping. Most patients are diagnosed with advanced disease at which point tumors are mostly unresectable. This leaves core biopsy or endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) as the sole source of tumor tissue for molecular characterization. Currently, these small tissue fragments are not considered suitable for genomic analysis, which is why this precious snapshot usually remains unexplored.

Materials and methods:

Applying an EpCAM-enrichment strategy in 31 patients, we show the feasibility and reproducibility of in-depth, molecular-barcoded, whole-exome sequencing (WES) analysis in real-world small biopsies.

Results:

EpCAM-enrichment resulted in a significant increase of KRAS mutant allele frequency (MAF) level (26.9% vs. 10.4%, p=0.02) and pushed the MAF above 5% or 10% in a third of cases. Validation experiments show an excellent correlation between digital-droplet PCR and sequencing based MAF for KRAS and GNAS as well as for MYC amplification levels. Despite low DNA level input, genomic landscape resembles previous pattern of high-quality tissue sources. Potentially actionable mutations were present in 40% (12/30) of patients and might be used for trial inclusion. Additionally, a hypermutator phenotype - defined as mutational burden >10 mutations/Mb - correlated with singlenucleotide variants in DNA damage repair genes (p<0.001) and showed prognostic significance. Correspondingly, high aneuploidy increased with tumor stage (5.5 vs. 11, p=0.03) and had prognostic implications (progression free survival: 100 days vs. 391 days, p=0.012). As a proof of concept, sequential biopsies taken before treatment and at the time of progression revealed molecular alterations associated with acquired resistance to immunotherapy.

Conclusion:

Collectively, these results emphasize the value, feasibility and reproducibility of real-world small biopsies for molecular characterization of PDAC.

Possibility of early prognosis of the development of pancreatic cancer

(Abstract ID: 276)

S. Sukhodolia¹, A. Sukhodolia¹, V. Kernychnyi², I. Chubar², O. Savchuk³, V. Mosiichuk²

¹VNMU by name M.I. Pirogov, Vinnica, Vinnytsya

²Khmelnitsky Regional Hospital, Khmelnitsky

³"Institute of Biology of Biology and Medicine" Taras Shevchenko National University of Kyiv

Background:

Pancreatic cancer (PC) is one of the leading causes of cancer-related mortality in the world, with an overall five-year survival rate of less than 6-7%. This is primarily due to the difficulty of diagnosing PC in the early stages. Most patients are asymptomatic until complications and decompensation with develop distant metastases. This is why early detection or prognosis of PC is important for the treatment of patients. Chronic pancreatitis (CP), diabetes (DM), obesity, smoking, alcohol, cancer history are all known risk factors for developing PC.

Materials and methods:

Fifty nonlinear white adult male rats, 135±10 g, were used in this study. CP was induced by intraperitoneal (i.p.) injection of cerulein (Sigma, St. Louis, MO, USA) diluted in physiological saline (5 µg·kg-1 of the body weight), five times per day at one hour intervals. Control rats were received equal volumes of 0.9% NaCl injected i.p. The injections were carried out within five consistent days. After last day of cerulein injection, the rats were at standard conditions for next nine days. Pancreatitis development was confirmed by the high serum amylase levels. On the 14th day since the start of the experiment, half of the animals from CP group was randomly selected and were used for inducing DM. DM was induced in the 16 h-fasted rats by a single i.p. injection of streptozotocin (STZ; Sigma, USA) in a dose of 65 mg·kg-1 of the body weight dissolved in 0.5 mL of freshly prepared 0.01 M citrate buffer, pH 4.5. The other animals from CP group and all control rats were received equal volume of vehicle alone. The diagnosis of DM was verified based on high concentration of blood glucose (higher than 15 mmol·L-1) as well as high glycosylated hemoglobin level. Thus, there were 3 experimental groups: 1) control (n=10); 2) CP (n=20); and 3) CP+DT (n=20). We examined tissue of pancreas and liver, blood serum, liver and pancreas homogenate and determined the relative content of cytokines.

Results:

The development of PanIN is the way to the development of PC, and directly ductal adenocarcinoma. In our study, rats with simulated CP+DM had equal changes in tissue corresponding to high and moderate ductal dysplasia of PanIN2 and PanIN3 (fig. 1,2,3). Also, we observed pronounced acinar metaplasia(fig.4). These changes are a direct precursor of pancreas adenocarcinoma. We found a significant increase in the content of interleukin-6, TNF α, and matrix metalloproteinase-2, -9 in the serum, liver, and pancreas of animals with CP alone and under the conditions of DM. An increase in the level of total protein in the serum of animals with CP was found, and its decrease in liver and pancreas, which was more pronounced under the conditions of CP on the background of DM. In both pathological conditions there were an increase in the level of peptide pools, as well as changes in the quantitative and qualitative composition of peptides, which were manifested in the appearance of a number of molecules missing from the control samples. The above changes were more pronounced in rats with CP+DM compared with the control group and the CP group.

Conclusion:

Taking about our results, we will try to predict the development, and early detection of PC, in patients with a difficult history: surgery for CP, obesity, DM, alcohol and smoking. Thus, we have the opportunity to perform radical surgery at an early stage of the disease and improve the quality of life of the patient.

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Comparative Analysis of the Discriminatory Performance of Different Well-Known Risk Assessment Scores for Extended Hepatectomy

(Abstract ID: 278)

O. Ghamarnejad¹, E. Khajeh¹, N. Rezaei¹, K. Afshari¹, A. Adelian¹, M. Nikdad¹, K. Hoffmann¹, A. Mehrabi¹

¹Chirurgische Klinik, Heidelberg

Background:

A comprehensive preoperative assessment and proper patient selection criteria play an important role to predict and reduce the postoperative morbidity and mortality rates, especially in patients undergoing extended hepatectomy (EH), who have a relatively higher risk than those undergoing minor hepatectomy. The aim of this study was first to evaluate and compare the discriminatory performance of well-known risk assessment scores in prediction of the mortality risk after EH

Materials and methods:

This is a series of 250 patients underwent EH (>= five liver segments resection) between 2001 and 2019. To find the relevant risk scores for predicting mortality after EH, a systematic search in high impact hepatobiliary surgery or hepatogastroenterology journals was performed. Receiver operating characteristic (ROC) curve analysis and diagonal reference lines charting was used to compute the cut-off value, as well as sensitivity and specificity of each risk assessment score for 90-day mortality. The included risk assessment scores were aspartate aminotransferase-to-platelet ratio index (APRI), albumin to bilirubin (ALBI) grade, predictive score developed by Breitenstein et al., liver fibrosis (FIB-4) index, Heidelberg score, and model for end-stage liver disease (MELD) score.

Results:

The proportion major morbidity and 90-day mortality after EH increased with increasing value in all risk scores. Regarding the change in incidence of major morbidity and 90-day mortality from low-risk group to high-risk group, FIB-4 index showed the highest increment of about 40% for both major morbidity and 90-day mortality. APRI (86%), ALBI grade (86%), Heidelberg score (81%), and FIB-4 index (79%) had the highest sensitivity for 90-day mortality. However, only FIB-4 index and Heidelberg score had an acceptable specificity of 70% and 65%, respectively. The overall sensitivity and specificity of proposed two-stage risk assessment strategy (Heidelberg FIB-4 model) will be 70% and 86% for 90 day mortality, respectively.

Conclusion:

There is no specific risk assessment score for patients who undergo EH. In this study, we proposed a two-stage screening strategy using the identified risk scores with high sensitivity and specificity (Heidelberg FIB-4 model) for patients undergoing major liver resection.

Acceptable outcome following ALPPS in Cholangiocarcinoma: A single-center experience

(Abstract ID: 296)

A. Mehrabi¹, M. Golriz¹, A. Hammad¹, O. Ghamarnejad¹, E. Khajeh¹, M. Mieth¹, K. Hoffmann¹, M. Büchler¹

¹Chirurgische Klinik, Heidelberg

Background:

Cholangiocarcinomas (CC) are the second most common primary hepatic malignancy and surgery is the only chance of cure. ALPPS offers this chance through two stage procedure with discussable morbidity and mortality rates. The aim of the present study is to evaluate the postoperative and oncologic outcomes of ALPPS procedure for cholangiocarcinoma.

Materials and methods:

A series of 23 consecutive patients diagnosed with CC (19 Perihilar Cholangiocarcinoma (PHCC) and 4 Intrahepatic Cholangiocarcinoma (IHCC)) underwent ALPPS between 2011 and 2019 at our center. The perioperative data of the patients, liver volumetry, postoperative morbidity and mortality as well as long-term oncologic outcomes were evaluated.

Results:

All of the patients in this study could reach enough hypertrophy and underwent the second step of ALPPS within a mean duration of 9 days. Postoperative PHLF, major complications, and 90-day mortality were 17.4%, 47.8%, and 30%, respectively. After optimizing the perioperative management as well as minimizing the first Step of ALPPS, these rates could be reduced to 14.3%, 33.3%, and 22.2%, respectively. The overall survival (OS) and disease free survival (DFS) rates at 1st postoperative year were 61.9% and 55% respectively.

Conclusion:

Although the results of ALPPS in CC patients are still not as good as the results in other indications, we could reach better outcomes in comparison to the primarily few studies in the literature. Better selection and preparation of the patients and minimizing the first step of the operation are the main keys in this regard. Further prospective randomized trials are needed to evaluate the long term results with larger case series.

Small biopsies of primary and metastatic pancreatic cancers recapitulate tumoral and stromal heterogeneity

(Abstract ID: 304)

A. Semaan¹, V. Bernard², J. Lee¹, P. Guerrero¹, H. Matthaei¹, J. C. Kalff¹, A. Maitra¹

¹Universitätsklinikum Bonn

²MD Anderson Cancer Center, Houston

Background:

Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis and is projected to be the second most common cause of cancer-related deaths within the next decade. With molecular subtypes of PDAC gaining relevance in the context of therapeutic stratification, the ability to characterize heterogeneity of cancer-specific gene expression patterns is of great interest. Single cell RNA (scRNA) sequencing also provides the opportunity to understand multistep progression of cancer and tumor stroma during the metastatic cascade at high resolution. Unfortunately, since the majority of PDAC patients present with advanced disease, only small biopsies (core and endoscopic ultrasound (EUS)-guided find needle aspirations (FNAs)) are feasible to acquire in a real-world setting; however, the molecular heterogeneity within this source material has not been comprehensively profiled.

Materials and methods:

After tissue dissociation, 8 small biopsy samples (4 primary tumors and 4 metastases) from FNAs and core biopsies were processed through single cell RNA sequencing using droplet based technology (10X). After filtering, a total of 31,130 cells were analyzed using Seurat to comprehensively characterize epithelial and stromal cells amongst lesion types.

Results:

Among the biopsies, epithelial cells were most commonly represented (46.17%), followed by T cells (28.52%), and myeloid cells (12.79%), whereas natural killer (NK) cells (5.19%), endothelial cells (1.31%), fibroblasts (1.28%), and dendritic cells (DC, 0.51%) were less frequently found. Subgroup analysis of cells revealed that cell phenotypes were largely equally represented across primary and metastatic lesions. This suggests that the composition of the tumor microenvironment across disease stages is not significantly different. By applying previously identified molecular subtypes of PDAC including Bailey, Collison, and Moffit gene sets, we were able to itemize the contributions of cell type to transcriptomic classifications. This revealed that the Moffit molecular subtypes of classical and basal cells was more specific with identifying cells of cancer origin. Trajectory inference of stromal cells revealed the evolution of an immunosuppressive environment, while epithelial cells demonstrate divergence of basal-like subtype with enrichment of interferon response and metastatic related pathways including epithelial-mesenchymal transition and cell migration.

Conclusion:

Our work demonstrates the feasibility of single cell sequencing from real-world small biopsies. We reveals substantial cellular heterogeneity and uncover molecular subtypes and cell type specific pathways enriched during metastatic progression at single-cell resolution.

Impaired Pre-operative Glycemia is Associated with Reduced Survival in pNENs

(Abstract ID: 310)

M. Sandini¹, O. Strobel¹, T. Hank¹, M. Lewosinska¹, A. Nießen¹, T. Hackert¹, M. Büchler¹, S. Schimmack¹

¹Universitätsklinikum Heidelberg

Background:

Diabetes mellitus (DM) is associated with increased risk of pancreatic cancer and impaired postresection survival. For pancreatic neuroendocrine neoplasms (pNENs) no evidence is available. Aim of this study was to evaluate the glycemic profile in pNENs, and to assess potential impact on pathology and long-term outcomes.

Materials and methods:

Pancreatic resections from 2001-2017 for pNENs were analyzed from prospective databases. Blood glucose (BG) and HbA1c levels were collected from pre-operative tests. Pre-operative dysglycemia was defined as BG>140mg% and/or HbA1c>6.5%. Uni- and multivariate analyses were performed according to the presence of peri-operative dysglycemia. Survival analyses were performed by Kaplan-Meier curves and Cox-proportional hazards method.

Results:

417 patients were analyzed. Medical history was positive for DM in 88 (21.1%) patients. BG evaluation unveiled 30 additional patients, without prior diagnosis of DM, with pre-operative dysglycemia. No differences at pathology were detected between diabetic and non-diabetics. Conversely, patients with poor glycemic control had significant higher rates of metastasis (16.8% vs. 27.4%; p=0.027), vascular, perineural and lympho-vascular involvement than those with normal BG (89.2% vs. 57.4%; p<0.001, 90.0% vs. 65.1%; p=0.046 and 89.3% vs. 61.3; p=0.006, respectively). Pre-operative dysglycemia was associated with impaired overall (HR=1.57 [1.01-2.46]) and recurrence-free survival (HR=1.78 [1.013.12]). By multivariate analysis, pre-operative dysglycemia was independently associated with recurrence-free survival (HR 2.32 [1.29-4.17]), together with lymph-node involvement (HR=2.01 [1.14-3.57]) and metastatic disease (HR=5.10 [2.73-9.55]).

Conclusion:

Pre-operative dysglycemia, but not controlled DM, is associated with advanced disease and impaired long-term outcomes in pNENs. For those patients, closer surveillance and strict glycemic control are warranted.

Better prediction of post-resection survival after neoadjuvant treatment (NAT) in pancreatic cancer: The PANAMA (PAncreatic cancer NeoAdjuvant MAssachusetts)-Score

(Abstract ID: 311)

T. Hank¹, M. Sandini², C. Ferrone¹, M. Mino-Kenudson¹, M. Qadan¹, U. Klaiber², M. Weniger¹, J. Harrison¹, U. Hinz², A. Warshaw¹, T. Hackert², M. W. Büchler², K. Lillemoe¹, O. Strobel², C. Fernandez-del Castillo¹

¹Massachusetts General Hospital and Harvard Medical School, Boston

²University Hospital Heidelberg

Background:

Prognostic stratification following NAT for pancreatic cancer is challenging, since pathological determinants change during therapy. Prediction models such as the recently released 8thedition of the AJCC-staging system are lacking validation in the NAT setting. This study modelled and externally validated a new prognostic score based on pathological parameters and preoperative CA19-9 levels.

Materials and methods:

NAT patients resected at MGH between 2007-2017 were analyzed. Tumor size, lymph-node involvement, R-status and CA19-9 levels were assessed by Kaplan-Meier survival analysis, and weighed with a Cox-proportional model. The PANAMA-score was computed from these variables according to a scale from 0 to 8-points and the predictive ability was compared with the AJCC-staging system. The reproducibility of the score was assessed by receiver operating characteristic (ROC) curves, through external validation in an independent cohort of contemporary NAT patients resected at Heidelberg University Hospital.

Results:

The training cohort consisted of 216 patients. Multivariate analysis identified tumor size (0-3 points), number of positive lymph-nodes (0-2 points), positive R-status (0-2 points) and CA19-9 >=100U/mL (0-1 points) as independently associated with impaired survival. Survival analysis according to a low (0-2 points), intermediate (3-5 points) and high (6-8 points) PANAMA-score indicated a good discriminatory power of the metric system (log-rank p=0.003). The respective median survivals for these groups were 45, 27, and 12 months. The PANAMA-score provided better accuracy than the AJCC-staging system, with AUC=0.656 vs. AUC=0.596, respectively. External validation in 258 NAT patients confirmed the prognostic ability of the score, with an AUC of 0.683.

Conclusion:

Stratification of post-resection survival after NAT using the 8thedition of the AJCC is suboptimal. The proposed PANAMA-score, based on independent predictors of post-resection survival, provides better discrimination and identifies a subgroup of patients who are at very high-risk of early death who therefore could benefit from additional therapies.

ALPPS versus Two-Stage Hepatectomy for colorectal liver metastases

(Abstract ID: 312)

J. Bednarsch¹, Z. Czigany¹, I. Amygdalos¹, G. van der Kroft¹, P. Strnad¹, P. Isfort¹, P. Bruners¹, G. Wiltberger¹, T. F. Ulmer¹, G. Lurje², U. P. Neumann¹

¹UK Aachen, Aachen

²Charité – Universitätsmedizin Berlin

Background:

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and two stage hepatectomy with inter-stage portal vein embolization (TSH/PVE) are surgical maneuvers applied in patients with advanced malignancies considered unresectable by means of conventional liver surgery. The aim of this report is to compare the technical feasibility and oncologic outcome of ALPPS and TSH/PVE in the scenario of colorectal liver metastases (CRLM).

Materials and methods:

All consecutive patients who underwent either ALPPS or TSH/PVE for CRLM between 2011 and 2017 in one hepatobiliary center were analyzed and compared regarding perioperative and long-term oncologic outcome.

Results:

A cohort of 58 patients who underwent ALPPS (n=21) or TSH/PVE (n=37) was analyzed. The median overall survival (OS) was 28 months and 34 months after ALLPS and TSH/PVE (p=0.963), respectively. The median recurrence free survival (RFS) was higher following ALPPS with 19 months than following TSH/PVE with 10 months, but marginally failed to achieve statistical significance (p=0.05). There were no differences in morbidity and mortality after stages 1 and 2. Patients undergoing ALPPS due to insufficient hypertrophy after TSH/PVE (rescue-ALPPS) displayed similar oncologic outcome as patients treated by conventional ALPPS or TSH/PVE (p=0.971).

Conclusion:

ALLPS and TSH/PVE show excellent technical feasibility and comparable long-term oncologic outcome in CRLM. Rescue-ALPPS appears to be viable option for patients displaying insufficient hypertrophy after a TSH/PVE approach.

The role of ALPPS in intrahepatic Cholangiocarcinoma

(Abstract ID: 313)

J. Bednarsch¹, Z. Czigany¹, I. Lurje¹, P. Strnad¹, P. Bruners¹, T. F. Ulmer¹, M. den Dulk¹, G. Lurje², U. P. Neumann¹

¹UK Aachen

²Charité – Universitätsmedizin Berlin

Background:

Surgical resection constitutes the mainstay of curative treatment for intrahepatic cholangiocarcinoma (iCCA). Complete tumor clearance can only be achieved with extended liver resections and as such, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) may facilitate surgical resectability. The present study aims to evaluate the technical feasibility and oncologic outcome of ALPPS in iCCA.

Materials and methods:

A set of 14 patients who underwent ALPPS in a single center between 2011 and 2017 were statistically analyzed for perioperative and oncologic outcome.

Results:

Of all patients undergoing stage 1 of ALPPS, 12 (86%) patients were subsequently completed in stage 2 surgery. Patients who completed the ALPPS procedure showed a median overall survival (OS) of 4.2 years and a 3-year survival of 64%. Individuals without lymphatic metastases (n=7) were all alive 1 year after surgery and if deceased they died more than 4 years after surgery, while no patient with lymphatic metastases (n=5) was alive one year after surgery.

Conclusion:

This is the largest single-center experience of ALPPS in iCCA currently available in the literature showing excellent technical feasibility and encouraging overall survival in these patients.

C-reactive protein and drain amylase accurately predict clinically relevant pancreatic fistula after pancreaticoduodenectomy

(Abstract ID: 316)

I. Mintziras¹, E. Maurer¹, V. Kanngiesser¹, D. Bartsch¹

¹Universitätsklinikum Gießen und Marburg

Background:

C-reactive protein (CRP) and procalcitonin (PCT) have shown to be reliable predictors of inflammatory complications and anastomotic leak after colorectal surgery. Their predictive value after pancreaticoduodenectomy (PD) remains unclear.

Materials and methods:

All consecutive pancreaticoduodenectomies (2009-2018) at our hospital were included. Amylase value in drains was evaluated on postoperative day (POD) 1, 3 and 5. Serum CRP and procalcitonin were evaluated on POD 1-3. Receiver-operating characteristics curves were performed and significant cutoff values for amylase, CRP and PCT were tested using logistic regression.

Results:

Among 188 patients who underwent PD, clinically relevant pancreatic fistulas (POPF) occurred in 30 (16%) patients, including 20 (10.6%) with Grade B and 10 (5.3%) patients with Grade C. Clinically relevant postoperative complications (Clavien-Dindo >= III) were reported in 46 (24.5%) patients, including Grade IIIa in 16 (8.5%), IIIb in 18 (9.6%), IVa in 3 (1.6%), IVb in 2 (1.1%) and V in 7 (3.7%) patients. Drain amylase and serum CRP on POD 3 had the largest area under the curve 0.926 (95% CI 0.880-0.973) and 0.803 (95% CI 0.715-0.891) respectively. Drain amylase > 586 U/l (OR 0.020, 95% CI 0.003-0.136, p< 0.001) and CRP > 203 mg/l (OR 0.088, 95% CI 0.019-0.402, p=0.002) were the only independent predictors of clinically relevant POPF in the multivariable analysis. The combination of CRP and amylase on POD 3 had a sensitivity and specificity of 95.2% and 94.4% to predict clinically relevant POPF.

Conclusion:

Drain amylase and serum CRP on POD 3, but not PCT, can accurately predict clinically relevant POPF after pancreaticoduodenectomy.

Intraoperative transfusion of fresh frozen plasma predicts morbidity following partial liver resection for hepatocellular carcinoma

(Abstract ID: 322)

J. Bednarsch¹, Z. Czigany¹, I. Amygdalos¹, J. Böcker¹, D. A. Morales Santana¹, G. van der Kroft¹, U. P. Neumann¹, G. Lurje²

¹UK Aachen

²Charité – Universitätsmedizin Berlin

Background:

The reduction of perioperative morbidity is a main surgical goal in patients undergoing liver resection for hepatocellular carcinoma (HCC). Here we investigated clinical determinants of perioperative morbidity in a large European cohort of patients undergoing surgical resection for HCC.

Materials and methods:

A total 136 patients who underwent liver resection for HCC between 2011 and 2017 at our institution were included in this analysis. Associations between major morbidity (Clavien-Dindo ³ 3) and general morbidity (Clavien-Dindo ³ 1) with demographics, clinical and operative characteristics were assessed by univariate and multivariable binary logistic regression analysis.

Results:

Multivariable analysis identified Child-Pugh-Score (Hazard Ratio (HR)=3.23; p=0.040), operative time (HR=5.63; p=0.003) and intraoperatively transfused fresh frozen plasma (FFP, HR=5.62; p=0.001) as independent predictors of major morbidity, while FFP (HR=6.52; p=0.001) was the single independent variable associated with general morbidity. No statistical correlation between FFP transfusion and preoperative liver function was observed.

Conclusion:

Intraoperative application of FFP is an important independent predictor of perioperative morbidity in patients undergoing liver resection for HCC. The avoidance of intraoperative transfusion of FFP by optimizing surgical and anesthesiologic conditions should be a key goal in liver resection for HCC.

Robotic-assisted liver surgery – Single center experiences

(Abstract ID: 333)

J. Pratschke¹, L. Feldbrügge¹, A. Kästner¹, W. Schöning¹, M. Schmelzle¹

¹Charité - Universitätsmedizin Berlin - CVK

Background:

Since 2015, patients being scheduled for liver resections at our department have been specifically examined for the possibility of a minimally invasive procedure. As part of a structured program to develop robotic-assisted liver surgery, an increasing number of liver resections have been performed with the Da Vinci Xi Surgical System (Intuitive Surgical Inc.) since January 2019.

Materials and methods:

We retrospectively analyzed all minimally invasive liver resections performed at our center between 1/2015 and 8/2019. Characteristics of patients after robotic-assisted liver resection (group 1) were compared with those after conventional laparoscopic resection (group 2). Excluded from the analysis were patients with multivisceral resection and ALPPS or a follow-up period <30 days.

Results:

Out of 421 minimally invasive resections, 46 were robotic-assisted and 375 conventional-laparoscopic. Demographic characteristics did not differ between the groups. Hepatocellular carcinoma was the most common indication in both groups (30% vs. 30%). The mean diameter of the lesions was significantly larger in group 1 than in group 2 (4.6 vs. 3.0cm, p = 0.014). The mean operation time (260 minutes vs. 240 minutes, p = ns) was comparable between groups despite a higher percentage of major liver resections in group 1 (44% vs. 29%). Postoperative major complication rate (17% vs. 15%), mortality (2.2% vs. 1.3%) and length of hospital stay (9 days vs. 8 days) also did not differ between groups (p = ns).

Conclusion:

Results from conventional laparoscopic liver surgery can be confirmed in robotic-assisted liver surgery. Which subgroups might particularly benefit from a robotic-assisted procedure must be examined upon completion of the learning curve on the basis of a larger group of patients.

Perivascular stranding of the superior mesenteric artery is associated with margin positive resections and reduced overall survival in patients with pancreatic cancer - proposal of a new borderline resectability definition

(Abstract ID: 346)

L. Bolm¹

¹Universitätsklinikum Schleswig-Holstein Campus Lübeck

Background:

The definition of borderline resectability in pancreatic cancer (PDAC) patients is currently debated. Different definition criteria have been proposed to determine borderline resectability. The aim of this study was to compare borderline resectability definitions regarding their accuracy in predicting R status and overall survival. Furthermore, simple additional radiological parameters were evaluated as novel borderline resectability definition criteria.

Materials and methods:

Patients undergoing pancreatic resections with curative intent for PDAC were identified from a prospectively maintained database. Patient baseline characteristics, surgical and histopathological parameters, as well as long-term overall survival (OS) after resection were evaluated. Furthermore, a detailed review of conventional R status by the British Royal College of Pathologists as well as Verbeke circumferential margin status was performed for the PDAC specimens. An evaluation of established radiological borderline criteria was performed. As new borderline criteria, the presence of any alterations of the superior mesenterico-portal vein (SMPV) and perivascular stranding of the superior mesenteric artery (SMA) was assessed in preoperative CT or MRI scans.

Results:

A total of 118 patients undergoing pancreatic resections for PDAC in the time period from 2013 to 2018 were identified from our prospectively maintained database. 43 (36.4%) of the patients had radiological perivascular SMA stranding and 55 (46.6%) had any SMPV alterations. Perivascular SMA stranding was associated with positive N status (p=0.025) and perineural invasion (p=0.032). 50 (42.4%) patients were borderline resectable according to ISGPS 2014 definition and 88 (74.6%) were borderline resectable according to the IAP 2017 definition. The new borderline definition including SMPV alterations and perivascular SMA stranding was the best predictor of conventional R status (p=0.040, sensitivity 53%, negative predictive value 81%) and Verbeke circumferential margin status (p=0.050, sensitivity 73%, negative predictive value 79%) as compared to established borderline resectability definition criteria. Perivascular SMA stranding qualified as independent negative prognostic parameter (HR 3.066, 95%CI 1.078-5.716, p=0.036).

Conclusion:

Radiological evaluation of any SMPV alterations and perivascular SMA stranding showed the highest accurracy in predicting R status and overall survival in PDAC patients. These criteria may serve to identify potential candidates for neoadjuvant therapy.

Lymph Node Involvement in cholangiocellular carcinomas: A Survival Analysis

(Abstract ID: 355)

S.-A. Safi¹, W. T. Knoefel¹, A. Krieg¹

¹Universitätsklinikum Düsseldorf

Background:

Survival after surgery for cholangiocellular carcinoma (CCC) remains poor. CCCs of the biliary confluence (hCCC) account for up to 60% of all cases. In addition, 30% of the tumors originate in the lower bile duct (dCCC), and approximately 10% arise as an intrahepatic mass (iCCC). The 5-year survival rate for all CCCs is about 20-40%. While some studies suggest that positive nodal status (pN1) is one of the most important prognostic factors after margin-negative resection, other data imply that nodal disease is not associated with patient outcome. Thus, aim of this study was to investigate the prognostic value of different lymph node staging (LNS) systems such as lymph node (LN) involvement, LN ratio (LNR) and log odds of positive LNs (LODDS) in CCC.

Materials and methods:

106 consecutive patients with surgically resected and histologically confirmed CCC were included in this study. Clinicopathological data were analyzed in a prospective maintained database. Histopathologic reports were re-assessed and classified according to the 8th edition of the UICC. Both LNR (ratio of positive LN to examined LN) and LODDS (log (positive LN+0.5)/(total LN+0.5)) were calculated from the total LN yield, respectively. Individual cut off levels and subgroups were defind for LODDS by quartiles (qLODDS). In addition, recently published LNR and LODDS classification systems were also appilied in this study. Overall survival (OS) was determined for all patients by the Kaplan-Meier method and Cox regression. The predictive value of the different LNS methods was estimated by calculating the receiver operating characteristic (ROC) curve at 1 and 2 years after surgery, respectively.

Results:

A total of 34 patients underwent partial pancreaticoduodenectomy for dCCCs. Moreover, 44 patients with iCCC and 28 patients with hCCCs underwent liver resection, respectively. Every patient received lymphadenectomy, thus nodal status was available for all patients. Twenty-four of the tumors were classified as UICC I, 21 as UICC II, 51 as UICC III and 10 as UICC IV, respectively. LN metastases (pN1) were apparent in 23 patients with dCCCs, 14 patients with hCCCs and 16 patients with iCCCs. UICC pN staging system (pN1; p=0.000) and qLODDS (p=0.001) were associated with poor OS in univariate analysis. In addition, all recently published LNR and LODDS classifications were statistically significant associated with poor prognosis when performing Kaplan-Meier analysis. Moreover, pNstaging (HR=2.5 95% CI 1.5-4.0, p<0.0001), qLODDS (HR=1.5 95% CI 1.2-1.9, p<0.0001) and all published LNR and LODDS classification methods were independent prognostic factors for OS (range: HR=1.5 95% CI 1.2-1.9 to HR=1.8 95% CI 1.3-2.6). However, LNR was the variable with the highest area under the ROC curve (AUC) for prediction of 1- (AUC=0.67) and 2-year (AUC=0,64) overall survival.

Conclusion:

Our data demonstrate that all investigated LNS correlate significantly with patient outcome in multivariate analyses. However, LNR seems to be the most accurate and predictive LN staging model in our collective of CCCs.

Middle-preserving pancreatectomy: Individual patient data meta-analysis of present literature

(Abstract ID: 381)

T. Pausch¹, X. Liu¹, J. Cui¹, P. Probst¹, T. Hackert¹

¹Universitätsklinikum Heidelberg

Background:

Usual operative treatment of multifocal pancreatic lesions is total pancreatectomy, which causes total exocrine and endocrine pancreatic insufficiency and can cause severe endocrine and metabolic problems. Recently middle-preserving pancreatectomy (MPP) has been introduced as a pancreaticfunction saving alternative. Favorable results have been shown by several centers, yet all of the available reports are case reports or small case series. Therefore we performed this individual patient data meta-analysis of present literature to evaluate indications, perioperative and long-term outcome of MPP.

Materials and methods:

First a systematic search was performed on Web of Science, PubMed, and EMBASE databases to identify relevant articles. Second upon contact authors of included articles accounted for original source data to perform a meta-analysis of individual patient data following Cochrande and PRISMA guidelines. The study was prospectively registered on Prospero (ID CRD42018112324).

Results:

A total of 29 patients who underwent MPP were identified in 19 studies. Indications for MPP could be categorized into four groups: namely multifocal pancreatic neoplasms, multifocal pancreatic metastases, synchronous pancreatic diseases, and chronic pancreatitis. Individual patient data of 13 studies and 24 patients could be included into meta-analysis: median operation time was 430 minutes with an estimated intraoperative blood loss of 755ml. Overall postoperative morbidity rate was 71%, with postoperative pancreatic fistula being the most common complication (50%), but mainly (75% of these cases) non-clinically relevant former type A fistula. Mortality-rate was zero. 66% of patients without preoperative diabetes mellitus preserved intact endocrine pancreatic function, while exocrine functions were not impaired in 63% of patients. Of the 33% of patients with postoperatively new diabetes mellitus one third could be controlled without antidiabetic medication. During a median followup of 92 months median recurrence-free survival time was 88 months. 25% of patients died of tumor recurrence and 71% were reported recurrence or progression free.

Conclusion:

MPP is a safe and feasible procedure for preservation of exocrine and endocrine functions and promises to be a reasonable alternative technique indicated for selected patients with multifocal pancreatic diseases. Prospective controlled studies have to follow.

Inhibition of Vascular Endothelial Growth Factor Protects Against the Development of Oxaliplatin-Induced Sinusoidal Obstruction Syndrome in Wild Type but not in CD39-null Mice

(Abstract ID: 421)

S. Knitter¹, A. S. Beierle¹, S. Pesthy¹, G. Duwe¹, A. Reutzel-Selke¹, A. Arnold¹, E. G. Michaelis¹, P. Lohneis², R. Schmuck¹, I. Sauer¹, I. Sauer¹, J. Pratschke¹, M. Bahra¹, M. Schmelzle¹, A. Andreou¹

¹Charité - Universitätsmedizin Berlin

²Uniklinik Köln

Background:

Sinusoidal obstruction syndrome (SOS) in response to oxaliplatin-based preoperative chemotherapy is associated with unfavorable postoperative and long-term outcomes for patients with colorectal liver metastases (CRLM). Bevacizumab, a monoclonal antibody against VEGF (vascular endothelial growth factor) may prevent SOS development in patients, however, preclinical evidence about its preventive effect is lacking, and its impact on the postoperative outcome after liver resection remains controversial. The aim of this project was to establish a murine model of oxaliplatin-induced SOS with liver resection and to investigate the impact of VEGF-inhibition on the development of SOS as well as on hepatic function and regeneration after liver surgery.

Materials and methods:

Male wild-type (C57Bl6/N,. n=116) and CD39-null mice (n=70) received weekly treatment with oxaliplatin alone (Ox), oxaliplatin and anti-VEGF (OxAV), or controls (anti-VEGF alone, glucose) over five weeks. One week after final treatment, mice were either sacrificed or subjected to 70% partial hepatectomy (PH). Resected specimens were used for histological analysis of SOS. Mice who underwent PH were culled 24, 36, 48 or 72 hours after surgery. Liver damage and function was assessed by plasma levels of liver transaminases, bilirubin and albumin. Immunohistochemistry for Ki-67 and bromodeoxyuridine (BrdU) was used to quantify liver regeneration. The role of the VEGF pathway and other known factors associated with the pathogenesis of SOS was elucidated by quantitative PCR of liver tissue and plasma protein analysis.

Results:

Concomitant inhibition of VEGF facilitated a significantly reduced incidence of sinusoidal dilation and hepatocyte atrophy, two key features of SOS, in comparison to treatment with oxaliplatin alone in wild-type (p = 0.001), but not in CD39-null mice (see Figure 1). Oxaliplatin-induced SOS was associated with increased plasma levels of VEGF-A (p = 0.003) and decreased plasma levels of HGF (p = 0.040) in comparison to OxAV mice without histological changes. After OxAV treatment, VEGFR2 was upregulated in wild-type but downregulated in CD39-null mice (p < 0.0001). Oxaliplatin treatment was associated with higher liver damage after PH than in mice with concomitant VEGFinhibition (at 36 hours, AST: p = 0.004, ALT: p = 0.035). Liver regeneration was diminished after oxaliplatin treatment compared to controls. However, anti-VEGF therapy failed to improve liver regeneration.

Conclusion:

We have established a murine model of SOS induced by monotherapy with oxaliplatin. We provide novel preclinical evidence on the protective effect of concomitant VEGF-inhibition against the development of SOS that may be associated with changes in the pathway of VEGF and its receptor VEGF-R2, as seen in CD39-null mice. Furthermore, concomitant VEGF-inhibition may attenuate liver damage after liver surgery.

Picture:

Figure 1. Wt- and CD39-null mice treated with oxaliplatin alone show histological features of SOS. However, an additional VEGF inhibition facilitated a reduction in SOS development only in wild-type mice.

Is there a role for the Appleby Procedure in 2020?

(Abstract ID: 439)

L. Timmermann¹, T. Malinka¹, F. Klein¹, D. Geisel¹, J. Pratschke¹, M. Bahra¹

¹Charité – Universitätsmedizin Berlin, Campus Charité Mitte | Campus Virchow-Klinikum

Background:

Locally advanced pancreatic cancer (LAPC) of the pancreatic body involving the celiac axis has a sparse prognosis for it often involves vascular structures and has a late point of diagnosis. Although LAPC should be considered as a systemic disease and neoadjuvant chemotherapy (NAC) is an important part of therapy, resection is still the only option for achieving curation. Current definitions of resectability mainly focus on vessel involvement or encasement. Should this anatomically based definition be the limitation in decision-making? One surgical treatment option for patients with LAPC of the pancreatic body involving the celiac axis is the subtotal distal pancreatectomy (SDP) with resection of the celiac axis (Appleby procedure). Perfusion of hepatic and gastric vessels is maintained over collateralization over the gastroduodenal artery, the right gastric artery and gastroepiploic arteries served by the superior mesenteric artery (SMA). A selective angiography and embolization is performed prior to the resection to further enhance this collateralization. Our study aimed to examine the value of the Appleby procedure in the current field of LAPC treatment.

Materials and methods:

Patients who underwent SDP between January 2005 and December 2018 were identified from a prospectively collected database. Twenty consecutive patients undergoing SDP with resection of the celiac axis were matched with 20 patients experiencing SDP without resection of the celiac axis in a one-to-one matched pair analysis. Perioperative parameters were evaluated as well as complications, including ASA scores, BMI, TNM, tumour diameter, R0-resection rates, 30-day mortality, inhospital stay, ICU stay, postoperative pancreatic fistula (POPF), postoperative pancreatic hemorrhage (PPH), delayed gastric emptying (DGE), surgical site infections (SSI), readmission rate, reoperation rate, other complications and the Clavien/ Dindo classification.

Results:

The rate of overall perioperative complications in both groups was comparable (p=0.744). Although the incidence of bleeding complications was comparable (p=0.1), the rate of severe type C PPH was significantly lower in patients with resection of the celiac axis and prior embolization (p=0.035).

Conclusion:

The Appleby procedure is a safe and feasible treatment option with favorable fewer postoperative severe bleeding complications. Such procedures require an experienced interventional radiologist and should only be performed in high-volume centers and by experienced surgeons. Its value in individualized treatment strategies including NAC and minimally invasive operations needs further evaluation.

Magnetic field hyperthermia as treatment option for pancreatic cancer organoids and pancreatic cancer cells

(Abstract ID: 457)

J. Palzer¹, B. Mues², M. Aberle³, S. Rensen³, S. Olde Damink³, T. Cramer¹, T. Schmitz-Rode², U. P. Neumann¹, I. Slabu², A. A. Roeth¹

¹Uniklinik RWTH Aachen

²Helmholtz Institut Aachen

³Maastricht University

Background:

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancer entities with a particularly meager prognosis due to its resistance to chemotherapy. The urge to find new treatment methods has given rise to few alternative therapy strategies. Among these, especially magnetic field hyperthermia (MFH) offers great potential in terms of a neoadjuvant treatment approach in case of locally advanced pancreatic cancer. To optimize this therapy, we assessed the effects of MFH on pancreatic cancer cells in vitro. Models used were conventional 2D cell line cultures and 3D organoids. Here, we report on the successful treatment of PDAC organoids and cell lines with MFH.

Materials and methods:

PDAC organoid lines were generated from resected tissue according to the protocol of the Tuveson lab in Cold Spring Harbor, New York. Prior to tissue use, ethical approval by the IRC and informed consent by the patients was obtained. MFH was achieved by applying an alternating magnetic field (AMF) with an amplitude of ca. 42 kA/m and frequency of 270 kHz in combination with magnetoliposomes (ML). ML are superparamagnetic iron oxide nanoparticles (SPION) stabilized with a phospholipid bilayer. The ML were tested for their cytotoxicity on Mia PaCa-2 and Panc-1 cells in different concentrations and, thereafter, on PDAC organoids. The effects of MFH on cell viability of human pancreatic cancer cells were assessed with cell viability assays, clonogenic assays and western blot protein analysis.

Results:

Cytotoxicity testing of ML on Mia PaCa-2 and Panc-1 cells revealed no cytotoxic effects at concentrations up to 300 µg (Fe) / ml and 225 µg (Fe) / ml, respectively. Affirmingly, no cytotoxic effect was observed when cytotoxicity testing was performed on PDAC organoids at a concentration of 225 µg (Fe) / ml. Cell viability testing of PDAC organoids upon MFH treatment revealed a highly significant cytotoxic effect of MFH. This could also be shown for MFH treated Mia PaCa-2 and Panc-1 cells. Further investigations of the underlying molecular mechanisms identified this cytotoxic effect to be apoptosis-based.

Conclusion:

Treatment with magnetic nanoparticles and MFH have a highly significant effect on pancreatic cancer in vitro. This supports the concept that MFH is a promising strategy in the treatment of pancreatic cancer. As PDAC organoids much better resemble in vivo conditions than conventional 2D cell lines, our organoid model holds great potential for further investigations, especially with regard to personalized treatment approaches.

Perioperative blood management of pre-operative anemia determines long-term outcome in patients with pancreatic surgery

(Abstract ID: 475)

F. Oehme¹, R. Knote¹, S. Hempel¹, B. Müssle¹, M. Distler¹, T. Welsch¹, J. Weitz¹, C. Kahlert¹

¹Universitätsklinikum Dresden

Background:

Pre-operative anemia in patients undergoing pancreatic surgery is an evident problem as these patients are suffering from malnutrition and partly chemotherapy-induced anemia. The patient blood management has become increasingly recognized to highlight pre-operative anemia and restricting blood transfusion as potential contributing factor in terms of improving post-operative morbidity and mortality. However, the current scientific evidence for pancreatic surgery is weak and partly inconsistent.

Here, we sought to examine the consequences of pre-operative anemia in terms of morbidity and mortality as well as on overall / recurrence free survival in patients with pancreatic diseases that need surgery.

Materials and methods:

A retrospective analysis was conducted of patients that required surgical exploration and treatment for pancreatic (pre)-malignancies or a chronic pancreatitis between 01/2012 and 06/2018 at the University Hospital Dresden, Germany. Primary endpoint analysis was defined by the pre-operative anemia workup. The overall blood transfusion rate differentiated for pre-, intra and post-operative transfusion was analyzed and compared to overall in-hospital morbidity and mortality. Overall- and recurrence free survival analyses were performed using the log-rank test.

Results:

Overall, 702 patients were included with 487 (69.4%) patients undergoing surgical procedures for pancreatic malignancies. Pre-operative anemia with a median HB-value of 7.3 mmol/l (IQR 1.4) was observed in a total of 318 (45.4%) patients. Patients with malignant pancreatic disease had significantly higher incidence of anemia (n= 248; 50.5%) pre-operatively (p-value < 0.001), which was significantly associated with the administration of blood pre-, intra- and post-operatively (p-value <0.001) and a CDC-complication > 2 (p-value < 0.01). Multivariate regression analyses confirmed post-operative blood transfusion as independent risk factor for post-operative complications (OR 6.7; p-value < 0.001) and survival analysis confirmed intra-operative blood transfusion as an independent factor associated with shorter overall survival (p-value < 0.01) but not with recurrence free survival (pvalue 0.57) in patients with pancreatic malignancies.

Conclusion:

Pre-operative anemia is a prevalent, independent and potentially controllable factor in pancreatic surgery that poses a significant risk for post-operative complications irrespective of the entity of the underlying disease(s). Patients undergoing surgical resection for a pancreatic malignancy are at higher risk for intra-operative red blood cell transfusions with increased rates of post-operative complications resulting in poor overall survival. Pre-operative anemia must be understood as a potential controllable factor rather than an indicator for the severity of the underlying disease.

Delayed surgery increases risk of postoperative complications in patients with preoperative biliary stenting – a single center retrospective study

(Abstract ID: 480)

F. Oehme¹, H. Götz¹, S. Hempel¹, B. Müssle¹, M. Distler¹, T. Welsch¹, J. Weitz¹, C. Kahlert¹

¹Universitätsklinikum Dresden

Background:

Therapy of choice for patients with a periampullary malignancy and synchronous cholestasis is the tumour resection without preoperative biliary stenting (PBS). Nevertheless, resection omitting PBS for patients with a cholangitis, neoadjuvant treatment protocol or considerable impairment of the liver cell function becomes virtually impossible. To date, a minority of evidence exists evaluating the appropriate preoperative stenting time. Primary aim was to contribute to an ongoing yet not solved discussion on the adequate preoperative stenting time.

Materials and methods:

A retrospective analysis was conducted of patients scheduled for pancreatic resection following biliary stenting between 01/2012 and 06/2018 at the University Hospital Dresden, Germany. Patients were eligible for inclusion regardless of the entity of the underlying disease. We assigned all patients to one of three different groups: preoperative stenting time period < 4 weeks, 4-8 weeks and > 8 weeks according to previous data from the FRAGERITA study group. Primary endpoint analysis was defined by overall morbidity and in hospital mortality. Ultimately, overall- and recurrence free survival was performed using the log-rank test.

Results:

Overall, 170 patients were included with 45 (25.3%), 66 (37.1%) and 59 (33.1%) being assigned to the short, intermediate and long term stenting group, respectively. Ductal adenocarcinoma and periampullary malignancies were equally distributed in between the groups (p-value 0.55), whereas patients operated for a pancreatitis tended to be more frequently in the long term stenting group (pvalue < 0.001).

Overall complications occured in 80 (47.1%) patients with significantly fewer complications in the short term stenting group (p-value 0.04). Overall mortality tended to be as high as 8.8% with no significant differences in between the groups. Employing a multivariate regression model, intermediate (unadjusted OR 3.29; 1.394 - 7.759) and long term preoperative stenting (unadjusted OR 3.761; 1.448 - 9.766) indicated to be an independent risk factor in terms of postoperative morbidity. Overall- as well as recurrence free survival did not differ significantly between the groups (p-value 0.11).

Conclusion:

PBS in patients scheduled for pancreatic surgery remains associated with a high postoperative mortality. Our results indicate, in contrast to the results presented by the FRAGERITA study group, that patients with PBS should be operated within four weeks after stenting. Respecting these contradictory results we advocate to perform a high quality prospective trial to answer this decisive question in such a highly vulnerable patient population.

Parenchymal-sparing hepatectomy for colorectal liver metastases reduces postoperative morbidity while maintaining equivalent oncologic outcomes compared to anatomic resection

(Abstract ID: 551)

A. Andreou¹, S. Knitter², D. Kradolfer¹, V. Banz¹, A. Lachenmayer¹, W. Schöning², M. Schmelzle², J. Pratschke², D. Candinas¹, G. Beldi¹

¹Inselspital Bern

²Charité - Universitätsmedizin Berlin

Background:

Colorectal liver metastases (CRLM) can be either resected using anatomy-oriented formal hepatectomy or atypical parenchymal-sparing procedure. The oncological differences between these two approaches remain unclear.

Materials and methods:

Clinicopathological data of patients who underwent liver resection for CRLM between 2012 and 2017 at two major hepatobiliary centers in Bern, Switzerland, and Berlin, Germany were assessed. Patients were stratified according to the recently introduced tumor burden score (TBS) in a lower and a higher tumor burden cohort, respectively, dichotomized by the median TBS. Postoperative outcomes und long-term survivals of patients following parenchymal-sparing resection (PSR) for CRLM were compared with those of patients undergoing anatomic resection (non-PSR).

Results:

A total of 283 patients underwent liver resection for CRLM with curative intent. The median TBS of all patients was 4. PSR was performed in 95 cases with TBS <4, and in 53 cases with TBS >=4. In patients with lower tumor burden (TBS <4), PSR was associated with lower complication rate (26% vs. 47%, p = 0.039), lower major complication rate (13% vs. 28%, p = 0.041), and shorter length of hospital stay (8 vs. 11 days, p = 0.005) in comparison to non-PSR. For TBS <4, PSR resulted in equivalent 5-year overall survival (OS, 48% vs. 61%, p = 0.830) and 5-year disease-free survival rates (DFS, 40% vs. 41%, p = 0.730) compared to non-PSR. For TBS >=4, PSR resulted in lower postoperative morbidity rate (38% vs. 58%, p = 0.015), lower length of hospital stay (8 vs. 12 days, p < 0.0001), equivalent 5-year OS (47% vs. 26%, p = 0.217), and equivalent 5-year DFS rates (46% vs. 26%, p = 0.332) compared to non-PSR.

Conclusion:

PSR for CRLM is associated with lower postoperative morbidity, shorter length of hospital stay and equivalent oncologic outcomes compared to non-PSR independently from TBS. Our findings suggest that PSR should be considered as the preferred method for the treatment of curatively resectable CRLM if allowed by tumor size and location.

Survival after hepatectomy for colorectal liver metastases is a function of intrahepatic recurrence but is not dependent of recurrence at the liver resection margin: A bicentric experience

(Abstract ID: 566)

A. Andreou¹, M. Schmelzle², S. Knitter², D. Kradolfer¹, M. Maurer¹, T. A. Auer², A. Lachenmayer¹, V. Banz¹, D. Candinas¹, J. Pratschke², G. Beldi¹

¹Inselspital Bern

²Charité - Universitätsmedizin Berlin

Background:

Resection margin status has been generally known to be associated with oncologic outcomes following liver resection for colorectal liver metastases (CLM). Previous studies however, did not differentiate between true local recurrence at the resection margin (TLR) and recurrence elsewhere in the liver. This study aims to determine if resection margin represents only a surrogate factor of advanced disease while not causally determining overall survival.

Materials and methods:

Clinicopathological data of patients who underwent curative hepatic resection for CLM between 2012 and 2017 at two major hepatobiliary centers (Bern, Switzerland, and Berlin, Germany) were assessed. Cross-sectional imaging following hepatectomy was reviewed by an independent radiologist in each center to identify the presence and location of recurrent disease. Intrahepatic recurrence was distinguished between TLR at the resection margin and intrahepatic recurrence elsewhere. The association between surgical margin status (R) and location of tumor recurrence was evaluated and the impact of TLR on overall survival was analyzed.

Results:

During the study period, 345 patients underwent liver resection for CRLM with curative intent. Histological surgical margins were positive for tumor cells (R1) in 66 patients (19%). After a median follow-up time of 34 months, tumor recurrence was identified in 154 patients (45%). TLR was independent from the R1 status (p = 0.555). TLR was not associated with worse overall survival compared to patients with intrahepatic recurrence elsewhere. Additionally, overall survival was equivalent between patients with TLR and patients with any intrahepatic and/or extrahepatic recurrence. In patients with intrahepatic recurrence oncologic outcomes improved if local hepatic therapy was possible (resection or ablation) in comparison to patients treated only with chemotherapy or best supportive care (3-year OS: 77% vs. 52%, p = 0.001).

Conclusion:

The incidence of TLR after hepatectomy for CRLM is independent of R1 resection margin status. Additionally, TLR at the resection margin is not associated with worse overall survival compared to any other intrahepatic or extrahepatic recurrence. Therefore, R1 status at hepatectomy seems to be a surrogate factor for advanced disease without influencing location of recurrence or oncologic outcomes. If local treatment for intrahepatic recurrence is feasible, long-term survival may be prolonged.

Influence of diabetes on short-term outcome after major hepatectomy – an underestimated risk?

(Abstract ID: 587)

J. Fuchs¹, A. Fischer¹, C. Stravodimos¹, U. Hinz¹, A. Billeter¹, M. Büchler¹, K. Hoffmann¹

¹Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg

Background:

Patient-related risk factors such as diabetes mellitus and obesity are increasing in western countries. At the same time the indications for liver resection in both benign and malignant diseases have been significantly extended in recent years. Major liver resection is performed more frequently in a patient population of old age, comorbidity and high rates of neoadjuvant chemotherapy. The aim of this study was to evaluate whether diabetes mellitus, obesity and overweight are risk factors for the short-term post-operative outcome after major liver resection.

Materials and methods:

Four hundred seventeen major liver resections were selected from a prospective database on liver resections performed at the Department of General and Transplantation Surgery, University of Heidelberg, which contained 1,619 liver resections. Exclusion criteria were prior liver resection in patient’s history and synchronous major intra-abdominal procedures. Overweight was defined as BMI >= 25 <= 30kg/m² and obesity as BMI > 30kg/m². Primary end point was 90-day mortality and logistic regression was used for multivariate analysis. Secondary end points included morbidity, Clavien-Dindo classification, unplanned readmission, bile leakage, and liver failure. Morbidity was defined as occurrence of a post-operative complication during hospital stay or within 90 days postoperatively.

Results:

Fifty-nine patients had diabetes mellitus (14.1%), 48 were obese (11.6%) and 147 were overweight (35.5%). In the multivariate analysis, diabetes was an independent predictor of morbidity, ClavienDindo grade IV complications, unplanned readmission and bile leakage. Additionally, it was associated with significantly higher rates of pneumonia, respiratory decompensation, acute renal failure and wound healing disorders in univariate analysis. Obese and overweight patients did not have an impaired post-operative outcome compared patients with normal weight.

Conclusion:

Major liver resection is a safe procedure in obese and overweight patients. Diabetes has direct influence on the short-term postoperative outcome with an increased risk of morbidity but not mortality. Preoperative identification of high-risk patients will potentially decrease complication rates and allow for individual patient counseling as part of a shared decision-making process.

Endoscopic versus Surgical Treatment for Infected Necrotizing Pancreatitis - a Systematic Review and Meta-Analysis of Randomized Controlled Trials

(Abstract ID: 624)

C. M. Haney¹, K.-F. Kowalewski¹, M. W. Schmidt¹, R. Koschny¹, E. A. Felinska¹, E. Kalium¹, P. Probst¹, M. Diener², B. P. Müller-Stich¹, T. Hackert¹, F. Nickel¹

¹Universitätsklinikum Heidelberg

²Chirurgiesche Universitätsklinik Heidelberg

Background:

Treatment of INP has changed in the last two decades with adoption of interventional, endoscopic and minimally invasive surgical procedures for drainage and necrosectomy. However, this relies mostly on observational studies.

Materials and methods:

We performed a systematic review following Cochrane and PRISMA guidelines and AMSTAR-2 criteria. Main outcomes were mortality and new onset multiple organ failure. Prospero registration ID: CRD42019126033

Results:

Three RCTs with 190 patients were included. Intention to treat analysis showed no difference in mortality, but higher frequency of new onset multiple organ failure in the surgical group (odds ratio (OR) confidence interval [CI]: 0.31 [0.10, 0.98]). There were significantly less incidents of a composite of perforations of visceral organs and enterocutaneous fistulae (OR[CI]: 0.31 [0.10, 0.93]), and less pancreatic fistulae (OR[CI]: 0.09 [0.03, 0.28]) in the endoscopic group. Patients with endoscopic treatment had a significantly shorter hospital stay (Mean difference [CI]: -7.86 days [-14.49, -1.22]). No differences in bleeding requiring intervention, incisional hernia, exocrine or endocrine insufficiency or ICU stay were apparent. Overall certainty of evidence was moderate.

Conclusion:

There seem to be possible benefits of endoscopic treatment procedure. Given the heterogenous procedures in the surgical group as well as the low amount of randomized evidence, further studies are needed to evaluate the combination of different approaches and appropriate timepoints for interventions.

Clinical management of gallbladder perforation - a single-center experience

(Abstract ID: 643)

S. Wehrmann¹, H. Rudolph¹, L. Mirow¹

¹Städtisches Klinikum Chemnitz

Background:

In 1934 O.W. Niemeier described for the first time the symptoms and therapy of acute gallbladder perforation. Furthermore he classified them in three types. Now, more than 80 years after Niemeier, the acute gallbladder perforation is still a life-threatening diagnosis with a high risk of mortality.

In most cases, open cholecystectomy is the state of the art to therapy this disease, although sometimes a percutaneous transhepatic gallbladder drainage is favorised- even in older and multimobide patients.

But times and therapy- strategies changed since Niemeier and so it makes sense to reevaluate the diagnostic and therapy-stategies of acute gallbladder-perforation. We present the experience of our single center in management of this disease.

Materials and methods:

From 01.01.2013 through 01.02.2019, all 110 patients with diagnosis of gallbladder perforation were identified and reevolved retrospectively. The type of perforation was clssified by Niemeier’s score. We collected all data including co-morbidities, postoperative or postinterventional complications, and analyzed them by using SPSS.

Results:

All 110 caes of gallbladder perforation at our surgical department were included in this study. Most of them (n=96) underwent primary operative treatment. But 14 patients were firstly treated conservative with percutneous drainage and bile-duct stenting because of multimorbidity or intake of new oral anticoagulants and became operated in a second step. 98 underwent a laparoscopic operation and 12 were operated conservative. Mean stay in hospital for primary operated patients was 10.32 days. The 14 conservative treated patients stayed in mean 14 days. Complications were postoperative bleeding, hepatic bilioma and sepsis. One patient died after surgery.

Conclusion:

Gallbladder perforation is still a life-threatenting situation, in which fast and sufficient handling is needed. Nevertheless, the diagnosis is not as easy as it seems. Sonography and CT are still the gold standard. But the therapy of this disease is still depending on patient`s individual clinical presence. In most cases fast operative treatment is preferred. But other strategies like percutaneous drainage and stenting the bile duct to garantee a sufficent gall-flow and operate the patient in a more stabile situation, seems to be also good strategy, even in multimorbide patients under oral antikoagulation. In our department of surgery we established a therapy-standard, based on the retrospective analyzed data, to treat patients with gallbladder- perforation.

Risk factors for treatment failure after surgical resection for chronic pancreatitis

(Abstract ID: 667)

A. Willner¹, A. Bogner¹, J. Weitz¹, T. Welsch¹

¹Universitätsklinikum Dresden

Background:

Frequently, patients with chronic pancreatitis (CP) pass through a step-up-approach with interventional/ endoscopic procedures as first-line treatment and surgery is postponed to later stages. The aim of the study was to identify predictive factors for short- and long-term surgical treatment failure (redo procedures), pain relief, and the quality of life after surgical treatment of CP

Materials and methods:

All patients operated for CP between September 2012 and June 2017 at our university clinic were retrospectively reviewed. A patient survey was conducted to identify the postoperative patients` quality of life (QoL). Primary endpoints were treatment failure and significant clinical improvement (SCI), defined as stable health status, positive weight development and complete pain relief without routine pain medication. Standard statistical analysis was performed, adding variables from univariate analyses with P<0.05 to a multivariate model. A P-value less than 0.05 was considered statistically significant.

Results:

The study cohort of the retrospective analysis included 89 patients. The median follow-up of the study was 38 months (IQR: 18-46 months). Complete responses for QoL assessment was obtained from 52 patients. The median age of the patients was 52.0 years (83.1% male). Eighty per cent had ³3 symptomatic episodes of CP and the median disease duration before surgery was 3 years (interquartile range [IQR] 1-7 years). At the time of surgery, 52.8% (n=47) of the patients have had endoscopic interventions; but portal vein occlusion and portovenous congestion were seen in 13.5% and 30.3%, respectively. In most cases a duodenum preserving pancreatic head resection or a pancreatoduodenectomy were performed (48 and 28 cases, respectively). Some 13 patients (14.6%) required redo surgery for progression of the disease. The absence of preoperative endoscopic interventions and of a postoperative pancreatic fistula were significantly associated with fewer redo surgeries (P=0.032; OR 12.6; 95%CI 1.2-127.7 and P=0.048; OR 7.2; 95%CI 1.02-49.9 respectively). Furthermore, smoking was protective (P=0.046; OR 0.145; 0.022-0.970) and the postoperative onset of insulin-dependent endocrine insufficiency as well an independent risk factor for redo-surgery (P=0.025; OR 10.1; 95%CI 1.3-75.2). Patients who had undergone surgery within 4 years of symptomatic CP had a significant clinical improvement (median follow-up: 15 months [IQR: 7-35 months], P=0.039). During follow-up, 96.2% of the patients had a complete or major pain relief on the visual analogue scale (0-10 [max]) with a medium reduction from 8.1 to 1.9 after surgery.

Conclusion:

The surgical therapy of CP should be considered at early stages and multiple interventions prior to surgery can negatively influence the postoperative course of the disease. Surgery can effectively reduce the postoperative pain intensity and enable rehabilitation.

Short-term Outcome of Primary/Elective and Rescue Total-Pancreatectomy

(Abstract ID: 673)

S. Hempel¹, E. Tahirukaj¹, F. Oehme¹, T. Welsch¹, J. Weitz¹, M. Distler¹

¹Universitätsklinikum Dresden

Background:

Postoperative mortality after pancreatic resection has improved significantly in recent decades. However, especially for total pancreatectomy high morbidity and mortality rates were reported although, due to the missing pancreatic anastomosis there is no risk for postoperative pancreatic fistula. The current study examined short-term outcome after primary (pTP), secondary elective (sTP) and rescue pancreatectomy (rTP).

Materials and methods:

Allpatients underwenting total pancreatectomy for malign and benign indications between 2008 - 2017 were retrospectively analyzed. Three subgroups were generated: pTP, sTP and rTP. Uni- and multivariate analyses were computed by employing stepwise binary and multifactorial regression models.

Results:

In total, 121 patients (76 pTP 31 rTP and 14 sTP) were included.In basic patient characteristics (e.g. sex, age, BMI, comorbidities) no relevant differences were observed. Major complications (at least Clavien-Dindo IIIa) occurred in 32.9% patients after pTP and 83.9% after rTP, respectively (P < 0.001). The overall mortality after pTP (n=10, 13.1%) was significantly lower (P = 0.001) than after rTP (n=13, 41.9%). In multivariate analysis, rTP was an independent risk factor for occurrence of major complications (OR 13.472, 95% CI 3.832 - 47.371, P < 0.001). Arterial resection during pTP did not impaired the incidence of major complications (29.4% vs. 41.7%, P = 0.294), however the overall mortality (5.9% vs. 29.2%) is significantly lower (P =0.01) without arterial resection.

Conclusion:

The morbidity and mortality after total pancreatectomy should not be underestimated, whereas the mortality without arterial resection decreases significantly. Avoiding a difficult pancreatic anastomosis by pTP might save the patient from rTP including its high morbidity and mortality.

Prognostic factors and survival after surgical resection of the primary tumor in metastasized pancreatic cancer

(Abstract ID: 698)

T. Pausch¹, X. Liu¹, J. Cui¹, T. Hackert¹

¹Universitätsklinikum Heidelberg

Background:

Previous studies revealed that surgical resection of the primary tumor can improve survival for pancreatic ductal adenocarcinoma (PDAC) patients with liver metastasis. This study aimed to investigate prognostic factors after surgical resection in PDAC patients with liver metastasis and to develop a prognostic score to predict survival in such patients.

Materials and methods:

Patients with microscopically confirmed hepatic metastases of PDAC who had received cancer directed surgery of the primary tumor were identified from the Surveillance, Epidemiology, and End Results database (SEER, 2010-2015). Kaplan-Meier curves and multivariate analysis using Cox proportional hazards models were used to identify prognostic factors. Subsequently a prognostic score was developed combining these factors to stratify patients into different risk groups.

Results:

A total of 259 PDAC patients with liver metastasis who underwent surgical resection of the primary tumor were included. Overall survival (OS) was 10 months and the 1-year, 2-year and 3-year survival rates were 39.6%, 22.4% and 12.7%, respectively. Multivariate analysis showed that age >= 70 (HR 1.65, 95% CI 1.11-2.43, p = 0.012), III-IV differentiation grade (HR 1.65, 95% 1.17-2.33, p = 0.004), and not receiving chemotherapy (HR 2.23, 95% CI, 1.60-3.11, P < 0.001) were independent prognostic factors for OS. A prognostic system was developed based on these factors, which categorized the patient into low, mediate and high-risk group, with an OS of 15, 10 and 3 months for the corresponding risk groups. A Harrell's C concordance statistic of 0.66 (95% CI 0.62, 0.70) indicated the prognostic score had moderate discriminatory power.

Conclusion:

Resection of the primary tumor in metastasized PDAC can result in reasonable survival dependent on the distinctive prognostic factors age at diagnosis, tumor differentiation grade, and receipt of adjuvant chemotherapy. Our subsequently developed prognostic score could help to select candidates for surgical resection of the primary tumor and to guide individualized treatment for metastazied PDAC patients.

Is Exploration Noteworthy after Conversion Chemotherapy in Patients with Locally Advanced Pancreatic Cancer: Case Report

(Abstract ID: 706)

S. Elhabash¹, I. Dimopoulus¹, M. Sorleto¹, B. Gerdes¹

¹Johannes Wesling Klinikum Minden, Univeristätsklinikum der Ruhr-Universität Bochum

Background:

pancreatic adenocarcinoma (PADC) with contact to the common hepatic artery (CHA) has been described as borderline resectable. An extended involvement of the celiac axis (CA) or other major surrounding arterial structures without the possibility of surgical reconstruction has been defined as locally advanced (LA-PADC) and priorly thought as irresectable. Recent advances in neoadjuvant chemotherapy made it possible to achieve tumor control with subsequent R0-Resection, despite the growing evidence that standard conventional imaging fails occasionally in demonstrating the actual response of the tumor during restaging after conversion chemotherapy. Surgical resection of tumors of the pancreatic body with contact to the proximal CHA or CA has been reported in many case reports to be technically feasible in terms of distal pancreatectomy with resection of CA (DP-CAR, modified Appleby procedure)

Materials and methods:

A 70-year-old male patient, presented initially in the department of gastroenterology in 06/2018 with progressive abdominal and back pain in the last 3 weeks. The computer tomography (CT) showed a tumor of the proximal pancreatic body with encasement of the splenic artery and the proximal CHA and high-grade stenosis of the portal vein confluence without distant metastasis. CA19-9 was 504 U/ml. A CT-guided biopsy confirmed a PADC and the patient underwent a neoadjuvant Chemotherapy with nab-paclitaxel and gemcitabine regimen. A restaging-CT showed downsizing of the tumor with a persistent contact to the above described major blood vessels. Therefore, operative exploration was recommended by the tumor board in 11/2018

Results:

upon exploration, a tumor infiltration of CHA directly at its origin from CA and proximal to gastroduodenal artery (GDA) was found. After a successful periarterial preparation along the superior mesenteric artery according to the artery first approach, the CHA was tightly clamped proximal to GDA. Upon which, a strong arterial pulse along the proper hepatic artery with sufficient liver perfusion by antegrade blood flow through GDA was palpated. Consequently, a modified Appleby DP-CAR with en block splenectomy was safely performed. The histologic examination showed a total remission of the primary tumor with free resection margins but with nodal infiltration (TNM: ypT0, ypN1 (5/37), R0). Postoperatively, a mild elevation of liver enzymes resolved spontaneously, and the patient was discharged on the 13th postoperative day with no major complications. After recovery, he underwent adjuvant chemotherapy using the same regimen and still until date free of recurrence

Conclusion:

LA-PDAC has been reported in up to 25-30% of patients at the time of diagnosis. Surgical resection remains the main stay of treatment with curative intention. Our report adds up to the case reports previously noted in the literature and describes an excellent efficacy of neoadjuvant Chemotherapy in achieving R0-resection of initially irresectable LA-PADC. An exploration with attempt to resection should be considered in such patients showing stable disease in the re-staging

Essential information prior to liver resection: liver function testing using Limax

(Abstract ID: 711)

J. P. Jonas¹, R. Lutz¹, R. Padickakudy¹, T. Grünberger¹

¹Kaiser Franz Josef Spital SMZ Süd, Wien

Background:

We see liver function tests as an essential tool prior to liver resection to prevent postoperative liver dysfunction in previously unknown injured livers. We used ICG-Clearance test in most of our liver resections until we introduced the Limax test. Here we report on our initial results using both tests prior to liver resection and on our current results using Limax only. Additionally, we describe our future aims and recommendations for the use of Limax.

Materials and methods:

Between 2014 and 2019 we performed 518 liver resections. Major liver resections were performed in 272 patients. In total, 171 patients were resected for primary tumors (HCC, CCC), 211 patients for CRCLMs and 136 patients for other lesions. Preoperative ICG clearance test results were available for 113 patients, Limax test results for 170 patients. Median PDR was 20 %/min (3,4 - 27. %/min), median R15 was 5 % (0,1 - 35%), median preoperative Limax test results were 392 (108 - 1083). Both liver function test were performed in 65 patients.

Results:

All HCC patients underwent HVPG measurements, which demonstrated portal hypertension (>5 mm Hg) in 55 patients, of which 2 had a value of 11 mmHg. The outcome of major hepatectomy patients in the HCC group (n=42) showed Dindo III-V in 15,6 %. Six HCC patients with major resection had both liver tests all of which showed adequate function and showed no major postoperative M&M. Here, Limax alone correlated in 93% with postoperative M&M.

21 out of the total 94 CCC patients were preoperatively icteric and had a biliary intervention prior to surgery. 66 CCC patients underwent major hepatectomy, their median Limax was 401. 10 CCC patients that underwent major surgery had both, Limax and ICG values. Of these, 8 patients showed adequate liver function (Limax > 315) and had good postoperative M&M with only one patient in the category Dindo III-V (interestingly, the ICG test was adequate as well in this patient). The remaining two patients without adequate Limax showed no postoperative M&M. Here, a possible explanation for a low liver function test is that one of those patients was a follow-up resection after explorative surgery a week before and liver function was assessed in between both surgeries and the other patient showed no radiological signs of liver damage (CT & Primovist MRI showed normal liver morphology). Here, Limax and ICG adequately predicted mortality and morbidity with only one major exception possibly explained by the timepoint of liver testing.

In the CRCLM patient group (n=211), all of which received induction chemotherapy, 93 major liver resections were performed. Of those, 26 patients had Limax tests alone and 11 patients had both, Limax and ICG tests. It is noteworthy, that all of those patients had Dindo O / I with only one exception where preoperative liver funtions tests did not correspond to the patient’s M&M. Limax correlated with severe morbidity in 91%.

Conclusion:

In conclusion, Limax is a very useful tool to determine liver function prior liver resection and combined with an additional volumetry the function of a future liver remnant can easily be calculated peroperatively. Therefore, the Limax test has replaced our previous liver function measurements. We strongly recommend using functional testing at least prior to major hepatectomies or after prolonged chemotherapy. Currently, we evaluate a Limax threshold for a minimum FLR without major M&M to reliably predict postoperative liver function.

Does Complexity of Laparoscopic Liver Surgery Reflect Postoperative Complications?

(Abstract ID: 712)

K. Jöchle¹, M. Menzel¹, S. Herrmann¹, S. Fichtner-Feigl¹, S. A. Lang²

¹Universitätsklinikum Freiburg

²Universitätsklinikum RWTH Aachen

Background:

Recently, a new difficulty score of laparoscopic liver resection was proposed only based on three intraoperative variables: operative time, conversion rate, and blood loss. Therefore, we aimed to verify its impact also on postoperative complications.

Materials and methods:

Laparoscopic liver resections from November 2016 to August 2019 at the University Medical Center Freiburg were included and divided into three groups based on their difficulty. Postoperative complications were defined according to the Dindo-Clavien classification with major complications >= grade 3 and scored with the comprehensive complication index (CCI).

Results:

76 patients underwent laparoscopic liver resection with low grade (group 1), intermediate grade (group 2) and high grade (group 3) difficulty in 75%, 7% and 18%. While the most complications were noted to occur in group 3 (group 1: 19%, group 2: 20%, Group 3: 57%; p=0.052), major complications (p=0.281) and mean CCI (p=0.148) were comparable between the different groups. 90-day mortality was 0%.

Conclusion:

While the complexity of laparoscopic liver surgery is associated with the occurrence of complications it might not reflect the severity of postoperative complications.

Influence of perioperative therapy with SSRIs affects outcome after liver resection for malignant tumors

(Abstract ID: 714)

J. Santol¹, D. Pereyra¹, G. Ortmayr¹, S. Najarnia¹, C. Köditz¹, P. Jonas², T. Grünberger², P. Starlinger¹

¹Medical University and General Hospital of Vienna

²Social Medical Center South, HPB Center Vienna Clinics

Background:

Intra-platelet serotonin has been implicated in the process of liver regeneration and in the development of disease recurrence after liver resection for malignant diseases. While the effect of serotonin on liver regeneration and tumor promotion were only observed in independent experiments, we recently demonstrated a bivalent association in patients undergoing liver resection. This raised the question whether pharmacologic modification of intra-platelet serotonin might be beneficial for this patient cohort.

Materials and methods:

497 patients were included out of our prospectively maintained institutional data base. Perioperative intake of selective serotonin reuptake inhibitors (SSRI) was recorded. Patients were followed up for postoperative liver dysfunction (LD), severe morbidity and disease recurrence.

Results:

52 patients (10.5%) were treated with SSRI during the perioperative course. Patients with SSRI intake showed a significantly higher incidence of severe morbidity (16.6%vs29.5%, p=0.031) and LD (10.4%vs25.0%,p=0.004). On the contrary, patients with SSRI intake showed a significantly decreased incidence of disease recurrence after 6 months (23.3%vs4.7%, p=0.005) and after 12 months (44.2%vs24.4%, p=0.015), which could also be confirmed in the subgroup analysis of patients with colorectal cancer liver metastases (p=0.024, p=0.048, respectively).

Conclusion:

Within this study, we present solid evidence for a central impact of serotonin modification on the surgical and oncological outcome of patients undergoing liver resection. Intriguingly, treatment with SSRI seems to exert a dual effect on patients’ outcome via disruption of both liver regeneration and tumor growth. Further, our data elucidates a potential pro-tumorigenic role of SSRIs, which clearly has to be confirmed in prospective trials.

Osteopontin affects Oncological Outcome after Liver Resection for Colorectal Metastasis

(Abstract ID: 721)

C. Köditz¹, D. Pereyra¹, G. Ortmayr¹, S. Gabbassova¹, F. Fritsch¹, T. Sorz¹, T. Grünberger², P. Starlinger¹

¹Medical University and General Hospital of Vienna

²Social Medical Center South, HPB Center Vienna Clinics

Background:

Osteopontin (OPN) - a chemoattractant and matrix protein - was previously described to be expressed by a variety of malignant tumors. As such, colorectal carcinoma was found to produce OPN. Further, a close relation of OPN to oncological outcome could be identified. Yet, OPN was not investigated in patients with colorectal cancer liver metastasis (CRCLM).

Materials and methods:

Within this analysis 48 patients undergoing liver resection for CRCLM were included. Circulating OPN was evaluated prior to the operation. Further, OPN was stained on tumor tissue gathered during liver resection. Patients were followed up for disease recurrence.

Results:

OPN expression in tumor tissue was tightly associated to circulating levels. Further, OPN was found to be significantly increased in patients that develop disease recurrence within two years after curative liver resection (median OPN no recurrence = 49.97 ng/mL vs median OPN recurrence = 72.38 ng/mL, p = 0.013). This difference was found to obtain a strikingly high predictive potential evaluated via receiver operating characteristics (AUC = 0.833, p = 0.015). Based on this analysis an optimal cut-off was identified at 60 ng/mL of OPN. Indeed, patients above this cut-off showed a significantly reduced disease-free survival when compared in a Kaplan-Meier analysis (difference in median disease-free survival = 1.3 years, p = 0.042).

Conclusion:

OPN is a marker for early disease recurrence in patients suffering from CRCLM. Thus, assessment of OPN might be a useful tool for preoperative patient evaluation and should hence be included in the work-up of this patient cohort.

Pathophysiology of Bile Acids Affects Liver Regeneration in Patients undergoing Liver Resection

(Abstract ID: 725)

S. Gabbassova¹

¹Medizinische Universität Wien

Background:

Bile acids (BAs) are known initiators of liver regeneration (LR) after partial hepatectomy. Previous data shows that BAs positively influence LR through induction of pro-regenerative proteins and via a direct effect on proliferation. However, BAs are known to be toxic in high concentrations. As the majority of the data regarding BAs during LR derives from experimental studies, the present investigation aimed to elucidate the influence of these effectors during human LR.

Materials and methods:

In our cohort[PD1] of 46 patients undergoing liver resection, circulating BAs were measured and profiled preoperatively and on the first postoperative day (POD1). Additionally, liver biopsies were taken at baseline and during LR in a subset of 8 patients. Postoperative liver dysfunction (LD) was prospectively recorded.

Results:

While BAs were found to increase significantly during early LR in liver tissue, they seem to decrease from prior to the operation to POD1 in circulation (p=0.001). Interestingly, higher levels were found in patients with LD on POD1. This difference was found to obtain a striking predictive potential with an area under the ROC-curve of 0,860. A cut-off for postoperative BAs was set at 7.[PD1] 7ng/mL, which could identify all patients with LD in the postoperative period (0% in BAs<7.7ng/mL vs 38% in BAs>=7.7ng/mL, p<0.001). Ultimately, not only concentration but also the profile of BAs in circulation differed markedly between the two groups.

Conclusion:

This data suggests that BAs are important initiators of LR, while a BA-overload might ultimately lead to liver toxicity and impaired LR after liver resection.

The preoperative score of apri + albi facilitates risk classification for patients undergoing liver surgery post neoadjuvant chemotherapy

(Abstract ID: 727)

T. Sorz¹, D. Pereyra¹, B. Rumpf¹, M. Ammann², P. Jonas³, F. Längle², T. Grünberger³, P. Starlinger¹

¹Medical University and General Hospital of Vienna

²State Hospital Wiener Neustadt

³Social Medical Center South, HPB Center Vienna Clincs

Background:

Today, the vast majority of patients with colorectal cancer liver metastases (CRCLM) receive neoadjuvant chemotherapy (NeoCTx). However, NeoCTx is known to induce chemotherapy-associated liver injury (CALI), which in turn might result in a poor postoperative outcome. Still, there is no clinically applicable and non-invasive tool to assess CALI before liver resection.

Materials and methods:

Routine blood parameters were assessed in 339 patients before and after completion of NeoCTx and before surgery. The study evaluated the prognostic potential of the aspartate-to-platelet ratio index (APRI), the albumin-bilirubin grade (ALBI), and their combinations. Furthermore, an independent multicenter validation cohort (n=161) was included.

Results:

Higher ALBI, APRI, and APRI+ALBI were found in patients with postoperative morbidity (P=0.001,P=0.064,P=0.001,respectively), liver dysfunction (LD) (P=0.009,P=0.012,P<0.001), or mortality (P=0.037,P=0.045,P=0.016), and the combination of APRI+AlBI had the highest predictive potential for LD (area under the curve [AUC]=0.695). An increase in APRI + ALBI was observed during NeoCTx (P<0.001). Patients with longer periods between NeoCTx and surgery showed a greater decrease in APRI + ALBI (P=0.006) and a trend for decreased CALI at surgery. A cut-off for APRI + ALBI at -2.46 was found to identify patients with CALI (P=0.002) and patients at risk for morbidity (P<0.001), LD (P<0.001), and mortality (P=0.021). Importantly, the predictive potential of APRI+ALBI for LD and mortality could also be confirmed in a multicenter validation cohort.

Conclusion:

A combination of APRI+ALBI can be used to determine the risk of liver resection in CRCLM patients who received NeoCTx. This knowledge could be a potent clinical tool for optimizing the waiting period after NeoCTx.

Early Detection of Patients Affected by Liver Dysfunction and Mortality after Liver Resection using the 3-60 Criteria

(Abstract ID: 729)

D. Ammon¹

¹Medizinische Universität Wien

Background:

Current definitions of liver dysfunction (LD) after liver resection focus on late time points during the postoperative course, which makes a supportive intervention likely unfeasible. Further, the parameters used for definition were shown to be potentially influenced by the clinical management. Thus, we aimed to evaluate an early and stable definition for postoperative LD.

Materials and methods:

Circulating parameters were assessed perioperatively in a cohort of 228 colorectal cancer patients with liver metastasis. Subsequently, a routine clinical set of 177 prospectively included patients was used as a validation cohort.

Results:

C-reactive protein (CRP,) and antithrombinIII-activiy (ATIII) on the first postoperative day (POD1) were found to predict postoperative LD (AUC=0.739,AUC=0.844, respectively). Clinically applicable cut-off values for CRP (3mg/dL) and ATIII (60%) were found to identify patients in risk for LD and mortality (P<0.001) on POD1 (i.e. 3-60 criteria). Compared to established definitions of LD the 3-60 criteria showed an increased sensitivity and specificity (3-60:70% mortality detected, odds-ratio(OR):48.8; ISGLS:70% mortality detected, OR:23.3; Peak7:30% mortality detected, OR:27.8; 50-50:30% mortality detected, OR:27.8). Ultimately, multivariable analysis was conducted to investigate independency of predictors of postoperative mortality and showed that only the 3-60 criteria (OR:50.4) and Peak7 (OR:10.3) were independent predictors for this hard outcome parameter.

Conclusion:

This analysis shows that the 3-60 criteria are able to predict postoperative LD and mortality with an equally good or even better accuracy than commonly used definitions of LD. Yet, the 3-60 criteria are met already on the first postoperative day and hence allow early identification of high-risk patients.

Implementation of a specific miRNA signature for risk assessment in patients prior to liver resection

(Abstract ID: 730)

F. Fritsch¹, D. Pereyra¹, H. Hackl², S. Skalicky³, E. Geiger³, C. Brostjan¹, T. Grünberger⁴, M. Hackl³, A. Assinger⁵, P. Starlinger¹

¹Medical University and General Hospital of Vienna

²Medical University of Innsbruck, Bocenter

³TAmiRNA GmbH, Vienna

⁴Social Medical Center South, HPB Center Vienna Clincs

⁵Medical University of Vienna

Background:

Postoperative liver dysfunction (LD) as a result of insufficient hepatic regeneration occurs in up to 30% of patients undergoing major hepatic resection, which concomitantly increases the incidence of morbidity and mortality. Still, treatment options and reliable predictive marker to determine patients at risk to develop LD after surgery are limited. Accordingly, there is an urgent need for an easily assessable preoperative test to predict postoperative liver function recovery, specifically as current markers are often expensive, time consuming and sometimes invasive. Emerging evidence suggests that microRNA (miRNA) signatures represent potent diagnostic, prognostic and treatment response biomarkers for several diseases.

Materials and methods:

Using next-generation sequencingas an unbiased systematic approach 554 miRNAs were detected in preoperative plasma of 21 patients suffering from postoperative LD after liver resection and 27 matched controls.

Results:

We identified a miRNA signature thathighly correlated with patients developing postoperative LD after liver resection. The predictive potential for postoperative LD was subsequently confirmed using realtime PCR in an independent validation cohort of 24 patients. Ultimately, a regression model of the peroperative miRNA pattern was found to reliably predict postoperative LD and associated complications with a remarkable accuracy, thereby outperforming established markers of postoperative LD.

Conclusion:

Given the clinical relevance of predicting potentially fatal postoperative clinical outcome after liver resection, our data demonstrate the clinical utility of a novel miRNA-based biomarker to support the selection of patients undergoing partial hepatectomy. Thereby, our data might help to tailor surgical strategies to the specific risk profile of individual patients.

The accumulation of dead cells in response to partial hepatectomy induces the secretion of regenerative mediators by phagocytes

(Abstract ID: 738)

D. Pereyra¹, V. Brandel¹, W. Schrottmaier², R. Öhler¹, A. Assinger², P. Starlinger¹

¹Medical University and General Hospital of Vienna

²Medical University of Vienna

Background:

Partial hepatectomy leads to the release of auxiliary and complete mitogens TNF, IL-6, SCF, HGF, TGFa and EGF, necessary for liver regeneration. However, no individual determinant seems to be solely responsible for the whole process of regeneration. Although the aforementioned factors hint at an involvement of the innate immune system in the initiation and progression of regenerative processes, the initial stimulus kick-starting the process is still subject of research. A recent study has shown that caspase-3 knock out in mice drastically reduces the number of proliferating cells after partial hepatectomy.

In our work, we have explored the role of apoptotic cell death, its effects on the innate immune system and thus consequential implications in liver regeneration.

Materials and methods:

Apoptotic and necrotic cell death in plasma of patients that have undergone partial hepatectomy was assessed in an immunoassay detecting un-cleaved and cleaved cytokeratine-18. Apoptotic bodies in patients after partial hepatectomy were analyzed by negative exclusion immunostaining and flow cytometry. UV-C irradiated, CFSE labeled apoptotic bodies derived from apoptotic Jurkat and HepG2 cells were co-cultured with whole blood, isolated monocytes or isolated neutrophils. Efferocytosis of apoptotic bodies was analyzed by ImageStreamXimaging flow cytometry. Re-distribution of surface molecules in response to dying cells was assessed by flow cytometry. Secretion of chemokines and growth factors was analyzed in a bead-based immunoassay.

Results:

Apoptotic, hepatic cell death increases significantly on post-operative day 1 and returns to normal values on post-operative day 5 (n=58, p<0.0001). Patients undergoing partial hepatectomy show a two-fold higher induction of apoptotic bodies as compared to patients undergoing colon or rectum resections (PHx: 0.3712∙10^6/ml; Ctrls: 0.172∙10^6/ml). ImageStreamX analysis showed that apoptotic bodies are cleared by neutrophils and that efferocytosis is associated with CD66b, CD45 and CD11b upregulation, as well as CD62L loss. On the contrast, large apoptotic cell remnants are exclusively cleared by monocytes and not neutrophils. Additionally, co-cultivation of apoptotic bodies with whole blood induces the secretion of SCF (6-fold increase), TGFαand HGF (100-fold increase) in comparison to pro-inflammatory stimuli or controls. Co-culture of apoptotic bodies with isolated white blood cells indicates that HGF is released by neutrophils in response to apoptotic bodies and necrotic cells, but not apoptotic cell remnants or living cells. Only the supernatant of monocytes incubated with apoptotic bodies was capable of inducing HGF release.

Conclusion:

Our datashows that partial hepatectomy is associated with massive cell death induction and that both apoptotic cells and their clearance are crucial for the production of pro-regenerative stimuli such as SCF, HGF and TGFα. Based on these data we propose that efferocytosis of dead cells represents one of the major triggers that initiate the process of liver regeneration.

Metabolic profiling allows risk stratification prior to liver resection

(Abstract ID: 741)

P. Jonas¹, D. Pereyra², H. Hackl³, J. Santol², B. Rumpf², D. Ammonn², F. Fritsch², T. Sorz², T. Grünberger¹, P. Starlinger²

¹Social Medical Center South, HPB Center Vienna Clincs

²Medical University and General Hospital of Vienna

³Medical University of Innsbruck, Biocenter

Background:

Postoperative liver dysfunction (LD) still represents a severe complication in patients undergoing liver resection and its incidence is estimated at 10-20%. As postoperative LD commonly develops as a result of delayed liver regeneration, it is most relevant to reach a comprising understanding of this process. Thus, we aimed to investigate the perioperative dynamic of circulating metabolites, as well as differences in the metabolic profile of patients with and without postoperative LD using an unbiased metabolomics approach.

Materials and methods:

Plasma from 95 prospectively included patients was collected preoperatively and on the first and fifth postoperative day (POD5). Per patient and time point 180 metabolites were assessed using the Biocrates p180-kit. Development of LD was prospectively recorded.

Results:

21 patients (19.95%) suffered from postoperative LD. We observed significant dynamics in the metabolic profile after liver surgery, that tended to normalize upon POD5. Further, we were able to document differences in the concentration of 120 metabolites between patients with and without postoperative LD. Interestingly, the family of sphinoglipids showed an evident accumulation of differentially abundant metabolites in patients with LD at several time points, while the total amount of sphingolipids did not differ.

Conclusion:

Within this study we present the first data on the metabolic profile in patients undergoing liver resection and in patients with delayed liver regeneration. While we found a plethora of potential markers for postoperative LD at various time points, we also present hypothesis generating data and the opportunity to characterize potentially targetable pathways for improvement of postoperative liver regeneration.

Bile-duct anastomosis is not inferior to endoscopic stenting of bile duct stenosis in non resectable pancreatic cancer

(Abstract ID: 751)

M. Bernhardt¹, L.-M. Schein¹, A. Azizian¹, F. Rühlmann¹, P. Jo¹, J. Gaedcke¹

¹Universitätsmedizin Göttingen

Background:

Pancreatic Head Cancer is very often associated with hyperbilirubinaemia due to bile duct obstruction. The standard oncological treatment is the pancreatic head resection. Unfortunately only 20 % of pancreatic tumors are primarily resectable curatively at the timepoint of diagnosis due to local irresectability or distant metastasis. In this case, treatment options are radiation, chemotherapy or a combination of both. All of this treatment options require a serum bilirubin level lower than 2.5 fold compared to the normal serum bilirubin level. Typically, there are surgical (bile-duct anastomosis) and non-surgical ways (stentimplantation via ERC) to reduce bilirubin.

The aim of this study is to compare the drop of bilirubin levels after stentimplantation via ERC vs. bile duct Anastomosis.

Materials and methods:

Retrospectively we analyzed medical records of patients treated at the university medical center Goettingen, Germany. Overall, we identified n=62 patients and divided these in three different groups (n=29 were treated with ERC, while n=33 patients were treated surgically; divided in pancreatic head resection n=24 and bile duct anastomosis n=9). To achieve comparability the initial bilirubin level was set on 100% and the ranges of the following 20 days were related to the initial value. Since bilirubin value was not checked every postinterventional day we grouped our data in sets of three days (days 0-2, days 3-5, days 6-8, days 9-11, days 12-14, days 15-17 and days 18-20) and formed the average in case of having more than one value for this time set.

Results:

Within the different groups, bilirubin levels decreased over time. The ERC-group decreased by 66% from 14.1 mg/dl to 5.6 mg/dl within 11 days. Bile duct anastomosis dropped by 78 % (from 13.5 mg/dl to 3.3 mg/dl) compared with 81 % after Pancreatic head resection (12.6 to 3 mg/dl).

Conclusion:

There is no statistically difference in serum bilirubin level decrease between bile duct anastomosis and ERC-Stentimplantation.

Using these data, bile-duct anastomosis seems to be a justified treatment option for bilirubin decrease prior to palliative care of pancreatic head cancer.

Laparoscopic salvage resection for patients with disease progression after transarterial chemoembolization: A new treatment algorithm in primary liver cancer?

(Abstract ID: 764)

E. Birgin¹, C. Reißfelder¹, N. Rahbari¹

¹Universitätsmedizin Mannheim

Background:

Primary liver cancer patients with disease progression after transarterial chemoemboliztion (TACE) have traditionally been considered candidates for palliative systemic treatment or best supportive care only. We herein report a clinical series of patients with progressive disease following TACE who underwent minimally-invasive salvage hepatic resection (HR) based on multidisciplinary board decision.

Materials and methods:

A retrospective review of patients who underwent salvage HR following non-responding TACE between 2018 and 2019 was performed. Clinicopathological outcomes were collected and presented as medians and ranges.

Results:

A total of seven patients (five males, two females) received a median of 4 (1-5) TACE treatments with a median dose of 55mg (15-90mg) epirubicin. Laparoscopic HR was performed at a median of 55 days (14-147 days) after the last TACE session. Conversion to a mini laparotomy was required in 1 patient. Apart from a superficial surgical site infection in 1 patient no further postoperative complications were observed. Histopathological examination revealed cholangiocarcinoma (CCC) on final diagnosis in 2 patients. The R0 resection rate was 86%. Median postoperative length of hospital stay was 5 days (4-12 days). After a median follow-up of 60 days (14-125 days) no patient had recurrent disease.

Conclusion:

Laparoscopic HR is safe and enables salvage treatment in patients with primary liver tumors and disease progression after TACE. Further studies are needed to evaluate the long-term outcomes of this novel treatment approach.

Resistant bacteribilia negatively affects survival for patients with periampullary cancer

(Abstract ID: 783)

T. Herzog¹, S. Homann¹, A. Luu¹, O. Belyaev¹, W. Uhl¹

¹St. Josef-Hospital - Unviersitätsklinikum, Bochum

Background:

In pancreatic surgery preoperative biliary drainage is associated with bacteribilia. Bacteribia is frequently caused by resistant microorganisms. Resistant microorganisms increase the risk for postsurgical complications, which may delay recovery and adjuvant therapy. The question if resistant microorganisms also reduce long term survival is not answered, yet.

Materials and methods:

We performed a prospective survival analysis for all patients with periampullary cancer who underwent pancreatic head resection or biliary bypass surgery at St. Josef Hospital, Ruhr University Bochum, from January 2011 until December 2015. The final date for survival evaluation was August 31st 2016. Intraoperative bile duct cultures were collected among all patients immediately after bile duct transection.

Results:

430 patients were included. The frequency of bacteribilia was 66 %, bacteribilia with resistant microorganisms was 17 %. In 41 % patients with resistant microorganisms had undergone preoperative antibiotic therapy, vs. 20 % in patients without resistant microorganisms (p<0.001). There were significantly more postsurgical infectious complications (33 % vs. 17 %; p=0.003), wound infections (10 % vs. 3 %; p=0.019) and sepsis (7 % vs. 2 %; p=0.049) among patients with resistant microorganisms. The overall survival was 35 % for patients with resistant microorganisms, vs. 51 % for patients without resistant microorganisms (p=0.024). After palliative bypass surgery the 3 year survival rate was 25 % for patients with resistant microorganisms, vs. 34 % for patients without resistant microorganisms (p=0.540). After R0 resection the 3 year survival rate was 33% for patients with resistant microorganisms, vs. 62 % for patients without resistant microorganisms (p=0.055).

Conclusion:

Bacteribilia with resistant microorganisms is associated with higher risk for postsurgical complications with reduced long term survival. Strategies to avoid bacteribilia with resistant microorganisms include avoidance of preoperative biliary drainage and rational use of antibiotics.

Microbiological colonization of the pancreatic tumor affects postoperative complications and outcome after pancreatic surgery

(Abstract ID: 836)

E. A. Biesel¹, O. Sick¹, S. Chikhladze¹, S. Fichtner-Feigl¹, U. Wittel¹

¹Universitätsklinik Freiburg

Background:

The patient´s microbiome turned in the focus of cancer research being suspected of having significant influence on tumor treatment and patient outcome. Even for pancreatic cancer, which is still one of the deadliest malignancies, alterations in the microbiome seem to influence cancer formation and progression. The aim of our single center analysis was the examination of microbiological colonization of pancreas tissue at the time of surgery and its potential influence on postoperative complications and patient outcome.

Materials and methods:

We prospectively evaluated our patients undergoing pancreatic surgery from 06/2018 to 05/2019 concerning microbiological colonization of pancreatic tissue which was acquired during pancreatic surgery. Tissue samples were cultivated for bacterial and fungal species at our institute of microbiology. Patients´ characteristics, complications and postoperative outcome were analyzed using a prospectively maintained SPSS database. After explorative analysis, statistical significance was calculated by Chi-square test and fisher´s exact test.

Results:

Between 06/2018 and 05/2019 we collected pancreatic tissue samples of a total of 60 patients undergoing pancreas resections due to different indications, mostly due to ductal adenocarcinoma (68.3 %). In the majority of cases patients underwent pancreatoduodenectomies (87 %). We could cultivate bacterial or fungal species in pancreatic tissue samples of 17 of our patients (28.3%), the remaining 43 samples remained sterile. Predominantly there was only proof of one microbiological species, but seven patients showed colonization with up to four different species in their tissue samples. Among the bacteria detected were E. faecium, E. faecalis, E.coli, S. aureus, E. cloacae, Klebsiella pneumoniae, Proteus and some other species.

We could find significantly more positive microbiological cultures in patients with a preoperative inserted biliary stent (62.5% vs. 7.9% in patients without stent, p < 0.001) and in patients that had undergone neoadjuvant chemotherapy prior to surgery (71.4 % vs. 23.1% in patients without chemotherapy, p = 0.017). Concerning postoperative complications we observed a trend towards more postpancreatectomy hemorrhage, more abdominal infections and more severe complications such as respiratory failure in patients with positive bacterial or fungal colonization at the time of surgery, but these differences were not statistically significant. Interestingly, patients with positive microbiological findings at the time of surgery required significantly more often interventional (47.1% vs. 19%, p = 0.033) or antibiotic treatment (76.5% vs. 38.1%, p = 0.008) following surgery.

Conclusion:

In our short-time analysis of our patient cohort we could show a bacterial or fungal colonization of pancreatic tumor tissue in almost a third of our patients. This seems to go along with more postoperative complications that often require further therapy. Further observation is needed to evaluate the influence of the vital tumor microbiome at the time of surgery on the long term oncological outcome.

Evaluating a clinical pathway in laparoscopic cholecystectomy – effective in reducing complications? A propensity-score matching analysis

(Abstract ID: 894)

D. Arabacioglu¹, A. Buia¹, E. Hanisch¹, A. Lehn², E. Herrmann²

¹Asklepios Klinik Langen

²Klinikum und Fachbereich Medizin der Goethe-Universität, Frankfurt am Main

Background:

Care pathways (synonyms: case management plans, critical pathways, clinical pathways, care map, integrated care pathway) were primarily aimed at decreasing length of stay and cut out unnecessary cost while maintaining or improving the quality of care. In laparoscopic cholecystectomy, there is insufficient evidence for proving an impact upon postoperative complications.

Materials and methods:

In this retrospective study logistic regression was used to calculate a propensity score for each patient from a pool of 696 patients (296 patients without and 400 patients with clinical pathway). After matching, 296 patients are analysed in both groups with regard to postoperative complications using the Clavien-Dindo classification system as a primary aim. In addition, secondary aims were the length of stay, compliance to and deviation from the care pathway with respect to the discharge of patients were analysed. Relative risk of the primary outcome was calculated and compared with the e-value as sensitivity testing approach.

Results:

After adjustment for potential factors, the relative risk when comparing Clavien-Dindo complication grading 0 versus 1-4 is 1.64 (95%CI 0.87; 3.11) which is not significantly different (p= 0.127). The corresponding e-value is 2.67.

After matching, length of stay is 3.69 days without and 3.26 days with the care pathway, respectively. Due to the mandatory part of the care pathway in the patients records compliance was 100 percent. Deviation from the care pathway with respect to planned patient’s discharge on day two postoperatively occurred in 16% of cases.

Conclusion:

Against the background of already implemented structured standard operation procedures a care pathway is not able to reduce postoperative complications. Against the background of already established risk management tools, it may be difficult to detect quality improvements of clinical pathways. Nevertheless, we consider our clinical pathway as a highly valuable tool for the interdisciplinary management of the patient’s hospital stay under the supervision of experienced expert surgeons.

Dormancy in synchronous and metachronous colorectal liver metastasis

(Abstract ID: 899)

K. Jaber¹, M. Wecker¹, R. Bobe¹, A. Rehders¹, W. T. Knoefel¹, G. Flügen¹

¹Universitätsklinikum Düsseldorf

Background:

Despite modern concepts in diagnosis and treatment, colorectal cancer (CRC) remains the third most common cancer worldwide. Although multimodal treatment is standard of care, the 5 years survival rate is just about 50%, most deaths resulting from metastatic spread. The Liver is the main organ in which those metastases disseminate. Even patients diagnosed with local disease (UICCI+II) will eventually develop CLM in 50% of the cases. In those patients, surgical therapy offers better survival and, in some cases, a total remission; yet even after total R0-resection, 60% of these patients will still suffer recurrent CLM within 2 years of initial treatment. Even after long periods of clinical remission, CLM can arise. In 2% of patients who have had successful treatment of M0 CRC and no recurrence or CLM in the following 5 years, CLM developed up to 10 years after initial therapy. This observed latency until overt CLM arise points to a clinically relevant pool of metastasis initiating cells in a dormant stage, present in the liver from an early stage. Currently, no treatment of these dormant disseminated tumor cells exists, as research into this phenomenon is lacking.

Materials and methods:

Using RNeasy FFPE Kit we isolated mRNA from FFPE sections of synchronous and metachronous CLM, as well as primary tumors (PT) (n=30 patients). After producing cDNA from the mRNA-samples, using qPCR (quantitative real time PCR), we looked for the expression of known dormancy factors NRF2F1, DEC2, p27 and TGFβ2. These factors have previously been implicated in dormancy, as well as cell-cycle arrest. The ΔΔC(t) method was used to analyze the qPCR results, statistics were carried out using two-tailed t-test with the Prism software (Version 6).

Results:

While observing interindividual variation, NR2F1 and TGFβ2 were not detectable in the majority of samples. Low sample acquisition of PT of patients with metachronous CLM has, so far, resulted in an insufficient number of samples of this group. Further recruitment is ongoing. Surprisingly, metachronous metastases so far showed a significantly lower expression of DEC2 than the synchronous CLM. We observed no significant difference in p27 expression between these two groups in the samples analyzed this far. Between PT and their synchronous CLM, we could not detect a significant difference in p27 expression, yet a trend toward higher expression in the CLM was observed. The DEC2 expression in the synchronous CLM was significantly lower than in the concurrent PT.

Conclusion:

While metachronous metastases have developed at a later time, compared to synchronous CLM, and the metastasis initiating cells may thus have gone through a dormancy-phase, all of the hepatic lesions included here were, at the time of resection, viable and proliferating metastases. Thus, the observed lower expression of the putative dormancy factors in metachronous metastases could be caused by a subclone that has been able to effectively exit dormancy. Following this hypothesis, heterogenous populations within synchronous metastases could express dormancy factors, as well. The ongoing recruitment of new samples will hopefully enable us to further unravel the connection between the established dormancy factors and the chronology of CLM. Tumor dormancy, especially in CLM, has not been extensively researched. Understanding dormancy is critical in developing treatment options for metastatic CRC and to stop metastasis in the first place.

Sarcopenia by CT scan reduces the kinetic growth of livers after portal vein embolization

(Abstract ID: 901)

J. Heil¹, B. Beck Schimmer², F. Heid², E. Schadde²

¹Universitätsklinikum Frankfurt am Main

²Universität Zürich

Background:

Portal vein embolization (PVE) increases the future liver remnant (FLR) to appropriate size prior to resection in only 60-70% of patients, mostly due to insufficient growth of the FLR. Kinetic growth rate (KGR) is used to estimate the speed of growth and depends on age, cirrhosis, diabetes and cholestasis. Malnutrition in patients with malignancy may be the only modifiable risk factor prior to PVE and can be measured at the time of volume assessment using sarcopenia indices. In this study we asked if sarcopenia correlates with kinetic growth after PVE.

Materials and methods:

All patients with colorectal liver metastasis requiring PVE and planned for liver resection at one center between 2010 and 2019 were retrospectively analyzed. Liver volumetry was assessed on pre- and postoperative CT and sarcopenia indices were assessed on preoperative scans using the software Osirix Lite, Version 10.0.4.. Sarcopenia indices skeletal muscle area (SMI), visceral adipose area (VAI) and subcutaneous adipose area (SAI) were measured at the third lumbar vertebra (L3) and were standardized to height (m2). Known factors impacting on kinetic growth were assessed and a multivariate analysis performed using stepwise regression and a p-value of <0.05.

Results:

Sixteen patients were included. Mean age was 61. Gender distribution was 10:6 (m:w). Kinetic growth was assessed at a median of 39,5 days after the procedure and resection was performed at a median of 52 days. All patients underwent resection. There were no perioperative mortality and no major complications (Clavien-Dindo >IIIa). Sarcopenia was assessed by BMI and SMI and correlated significantly with KGR (R2=0.28). P value SMI (p=0.0331) was more reliable than SAI (R2=-0.0298) and VAI (R2=0.0005).

Conclusion:

Sarcopenia should be assessed by your radiologist at the time of volume measurement when planning PVE. A prospective study should determine if nutritional interventional prior to PVE improves KGR and thereby increase resectability of patients undergoing regenerative procedures.

Case report – the rare case of abdominal pentastomiasis

(Abstract ID: 969)

V. Martini¹

¹Uniklinik Freiburg

Background:

Pentastomiasis is a zoonotic infection caused by pentastomids phylogenetically related to arthropods (Lavrov et al. 2004). Generally pentastomiasis infects animals; humans are defined of being an accidental dead-end host. The species Armilifer armilltaus and Linguatula serrata are the two most common ones in humans, with the first one making up the majority. The infection is rare and might develop when infective parasite ova are ingested. Parasites may be found in humans nasopharyngeal, in the lung, lymphnodes or visceral.Diagnosis is made histologically but most findings are made incidentally during autopsies (Böckeler et al. 2010). In most cases no medical treatment is necessary since the parasites degenerate over time and no effective antiparasitic therapy exists.

Materials and methods:

55 year old women presented to our outpatient clinic after routine abdominal sonography where a liver cyst had been detected. Due to a known BRCA2 mutation, routine scans had been applied every two years. Otherwise the patient presented in a good condition without any symptoms, only having experienced a laparoscopic ovarectomy and prophylactic mastectomy in her medical records. The laboratory values revealed no abnormalities.Following this liver finding a CT scan was performed detecting a cystic formation in Segment VII with central calcifications and a diameter of 1,2cm. A malignancy could not finally be denied either. According to the inconclusive imaging we scheduled the patient for an operation in terms of a laparoscopic atypical segment resection. This was performed without any complications. Intraoperatively a sonography was performed, detecting a lesion in Segment VIII; followed by the resection.

Results:

The cystic formation in liver segment VII of our patient was caused by Lingualatula serrata and belongs to the human pentostomiasis.The therapy with Albendazol was ended. The patient presented in a very good condition for postoperative control and did not receive any specific treatment since she showed no symptoms and the parasitic worms only have a live span of 2 years

Conclusion:

Pentastomiasis is a rare zoonotic disease first described in humans in 1847 by Prum in Egypt.In tropical Africa human pentastomiasis caused by Armilifer is relatively frequently reported. The visceral pentastomoiasis is generaly caused by the family of Armilifer armilatus mainly in Western and Central Africa. (Meyers et al, Guerrand et al). The species of Lingulatula is held responsible for nasopharyngal infections and only handful case reports for abdominal manifestation exist (Baird et al., Gardiner et al.)Case reports exist describing nasopharyngeal occurrence in humans (Yazdani et al., Hamid et al, Tappe et al.) often after the consumption of raw meat.But abdominal manifestation of this parasite is extremely rare. Over the last decade four cases are described in the USA and England naming a visceral pentastomiasis, affecting the liver.At the time of detection the nymphs are predominantly degenerated Linguatula serrata is identified by prominent spines histologically. Only a limited number of cases of pentastomiasis infections are reported around the world and even less affecting the liver caused by L. serrata ( Symmers and Valteris, Gardiner et al.).

Neodadjuvant therapy influences sceletal muscle mass after liver resection for malignancies

(Abstract ID: 1001)

D. Wagner¹, P. Kornprat¹, J. Waha¹, S. Wisiak¹, A. Tomberger¹, G. Werkgartner¹, P. Schemmer¹, H. J. Mischinger¹

¹Universitätsklinik für Chirurgie Graz

Background:

The prevalence of sarcopenia as surrogate for the frailty syndrome is often linked to worse outcomes after liver resection for hepatic malignancies. Recent research shows that sarcopenia also increases the toxicity of chemotherapy and lessens its effect. Sarcopenia is usually measured preoperatively.

We aimed to measure sarcopenia in the long term follow up after liver resection.

Materials and methods:

726 patients who underwent liver resection for hepatic malignancies were included into the presented analysis. Preoprative, 6 months follow up images and 12 months fullow up CT images were used to assess sarcopenia by measuring the total sceletal muscle mass at the level of the third lumbar vertebra image and normalizing for height squre. The lowest gender specific quartile was defined as sarcopenia. Cut offs for sarcopenia were cm2/m2 for female and cm2/m2 in male patients.

Results:

Overall prevalence of preoperative sarcopenia was 16% (n=124), at 6 months follow up 120% (n=119) and increased to 33% (n=240) at 12 months. 481 (66.3%) patients received neoadjuvant therapy with preoperative sarcopenia in 17% (n=82) patients. The prevalence of sarcopenia significantly increased after neoadjuvant therapy to 26% (125) at 6 months and 32% (154) at 12 months (p=0.01). The presence of sarcopenia had a significant impact on patient outcome: HR 1.69 (1.04-2.75), P = 0.036. Median OS was 20.5 (7.36-33.64) versus 52.1 (13.55-90.65) months in sarcopenic and nonsarcopenic patients, respectively. Sarcopenia was identified as an independent risk factor: HR 1.72 (1.049-2.83), P = 0.032.

Conclusion:

Patients who receive neoadjuvant therapy are at higher risk to develop postoperative sarcopenia even if preoperative muscle measurements are normal. This has a severe impact on their outcome.

Identification of the risk factors influencing the recurrence rate of HCC

(Abstract ID: 1021)

J. Li¹, O. Stueben¹, H. Wege¹, A. Heumann¹, J. Izbicki¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

Curative local treatment options are established for patients with early stage HCC. In patients with preserved liver function (normal liver parenchyma or Child-Pugh A cirrhosis) and without clinically significant portal hypertension, resection is the foremost curative therapy. In experienced centers, the 1-, 3-, and 5-year overall survival rates (OS) are 95%, 80%, and 61%, respectively, while the 1-, 3-, and 5-year disease-free survival rates (DFS) have been reported to be 77%, 41%, and 21%. Our study aimed at identifying the risk factor for tumor recurrence.

Materials and methods:

HCC Patients receiving liver resection from 2011 to 2018 were retrospectively studied. The patient demographics, operation approaches and histological findings were analyzed together with the DFS and OS.

Results:

From 167 patients, the 1-, 2- and 3-year OS were 82.5%, 75.3% and 71.4% respectively. The 1-, 2- and 3-year DFS were 59.3%, 49.1% and 45.4% respectively. Multifocality was the main risk factor for tumor recurrence, with 35% of patients with a singular tumor showing recurrence within the follow-up period, whilst 79.4% of patients with a multifocal tumor showing recurrence. Patient demographics (age, gender), liver parenchymal changes (cirrhosis vs non-cirrhosis), operation approaches (laparoscopic vs open surgery) were not recognized as a risk factor for the tumor recurrence.

Conclusion:

Multifocality of the HCC was the main risk factor for tumor recurrence after resection with curative intention. Thus, patients with multifocal HCC is the aimed population, in which either neoadjuvant or adjuvant therapy might help to reduce the early recurrence.

Picture:

Die Multifokalität und das Rezidiv

Trocar site HERnias after BAriatric Lparoscopic Surgery (HERBALS) - a prospective cohort study

(Abstract ID: 85)

I. Karampinis¹, E. Lion¹, S. Hetjens¹, C. Galata¹, G. Vassilev¹, M. Otto¹

¹Universitätsmedizin Mannheim

Background:

The exact incidence and morbidity related to trocar site hernias after bariatric procedures is not known yet. A recent metaanalysis data has indicated a very worrisome incidence reaching 25%. We conducted a prospective cohort study to estimate the trocar site hernia incidence and investigate the role of fascia closure in the development of trocar hernias.

Materials and methods:

361 patients (1805 trocar sites) who had been operated for obesity in our department between 2009 and 2018 were included in the study. All patients were invited to a follow-up sonography scan in order to detect abdominal wall defects. The role of intraoperative fascia closure in the development of trocar site hernias was evaluated and a multivariate analysis was performed to detect further potential risk factors.

Results:

The overall incidence of sonographically detected abdominal wall defects was 34.5 %. The incidence of abdominal wall defects in the group of patients who had had a fascia closure was 37% compared with 34 % in the group of patients who had not had a fascia closure (p=0.37). The only factor that was associated with a higher risk for trocar site hernias was high excessive weight loss (p=0.05).

Conclusion:

Trocar site hernias are an underestimated complication of minimally invasive, multiportal bariatric surgery and the incidence of asymptomatic hernias is probably even higher than initially expected. In this study fascia closure was not associated with fewer trocar hernias. However, it significantly prolongs the operating time and is potentially associated with cardiopulmonary complications. The role of fascia closure in preventing trocar hernias should be therefore analyzed in a prospective randomized setting.

Morphofunctional assessment of the mucous membrane of the small intestine after transit bipartition in the experiment

(Abstract ID: 183)

A. Okhunov¹, S. Razzakov¹, P. Azizova¹

¹Tashkent Medical Academy

Background:

It is known that in the treatment of type 2 diabetes mellitus, bariatric surgeries are becoming increasingly popular, in particular, transit bipartition reduces the level of postoperative side effects with its high effectiveness. Meanwhile, it remains unclear how much the transit bipartition meets the requirements of exposure to the incretin system directly in the intestine itself? The first step in the search for an answer to this question, in our opinion, should be a morphofunctional assessment of the intestinal mucosa.

Materials and methods:

We have conducted experiments on rats of both sexes. The first group consisted of rats that had received a transit bipartition, the second group included rats that were just doing laparotomy and wound closure. The study was conducted in the dynamics.

Results:

Comparative morphometry of the small intestinal mucosa of rats showed that the length and width of the villi in the experimental group exceed the corresponding control indicators. In the mucous membrane of the small intestine of the experimental group of animals on the tops of the villi, intense hyperplasia of the enterocytes into the intestinal lumen was observed. The average area of the villus enterocyte nuclei decreased by 32.0% (P<=0.05), and the cryocyte enterocyte nuclei increased by 27.8% (P<=0.05) compared to the control. In the experimental group, an increase in the number of goblet cells by 50.14% (P<=0.05) was observed, mainly in the villi, while their average area remained almost unchanged.

Conclusion:

Thus, as a result of research, changes in the hypertrophic and adaptive nature were detected in the wall of the small intestine of rats after the transit bipartition operation.

Effects of bariatric surgery vs. medical treatment on histologically proven non-alcoholic steatohepatitis: A meta-analytic approach

(Abstract ID: 231)

B. Reiners¹, A. Billeter¹, B. P. Müller-Stich¹, K. Scheurlen¹

¹Universitätsklinikum Heidelberg

Background:

Currently, the only approved therapy for non-alcoholic steatohepatitis (NASH) is lifestyle modification. Several medical therapies as well as bariatric surgery have been evaluated. However, no direct comparison of medical therapy with bariatric surgery has been performed. This meta-analytic approach aims to evaluate the effectiveness of bariatric surgery vs. medical intervention on liverhistology in patients with biopsy-proven NASH.

Materials and methods:

We searched PubMed, Central and Web of Science for clinical trials investigating improvement of NASH in adult patients with consecutive liver biopsies at baseline and evaluation of liver histology after mean 16 months. Out of 20 studies meeting the inclusion criteria of biopsy proven NASH (NAS>3) and re-liver biopsy, 7 prospective surgical trials and 6 RCTs were included in this analysis.

Results:

274 surgical patients and 480 patients in medical intervention groups had consecutive liver biopsies and biopsy-proven NASH. The medical intervention group included lifestyle interventions as well as a variety of drugs for the treatment of NASH. The pooled proportion of patients with resolution of NASH after surgery was 84,6% (95% CI: 0,765;0,927) and after medical intervention 36% (95% CI: 0,254;0,472). Ballooning improved in 78% of surgical patients and in 45% patients treated conservatively. Effects on lobular inflammation differed less with 69% after surgery vs. 53% after medication. 64% of surgical patients with fibrosis at baseline showed improvement compared to 24% in the medication group, however some surgical patients showed worsening of fibrosis despite other histological improvement. In patients with NAS>5, the mean decrease in NAS was -1,3 after medical intervention and -2,6 after surgery. We estimated a 70% relative risk reduction for NASH-persistence after surgery compared to medication. No relation between change in liver enzymes and improvement of histology could be observed. 28%-63% of surgical patients were diabetic at baseline, with postoperative remission in 50-80% compared to none after medical treatment.

Conclusion:

NASH resolution in >80% of patients was observed after bariatric surgery. A limitation of this analysis is the variety of medical treatments as well as surgical therapies. A RCT directly comparing surgery and medical therapy is urgently warranted.

Higher socioeconomic status of women does improve the outcome in Bariatric surgery in Germany

(Abstract ID: 326)

J. Wagner¹, N. Zanker¹, A. Duprée¹, A. Wöstemeier¹, O. Mann¹, J. Izbicki¹, S. Wolter¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

Access to health care can be a challenge for people with lower socioeconomic status (SES). People with a lower SES, according to various studies, have a worse outcome in different diseases. Some studies also found an inverse association between weight and SES. Therefore, we hypothesised that a lower SES leads to an inferior outcome after Bariatric surgery.

Materials and methods:

We retrospectively analysed patients, who underwent Bariatric surgery from our prospective collected database between 2012 and 2014. Since we did not have reliable information about every patient’s SES, we used the income/head/year from a certain region, namely the purchasing power index (PPI) as a surrogate parameter. The PPI is an important tool in determining the SES in several socioeconomic studies and economic calculations. As a cut-off we chose the commonly used 2000€/head/month to distinguish between higher and lower income classes. As primary outcome we analysed the development of the body mass index (BMI), weight and the excess weight loss (EWL).

As a secondary outcome we examined the course of other weight associated medical conditions.

Results:

We included 559 patients at time of the operation in this study, 388 (69,4%) women and 171 (30,6%) men. 303 (54%) patients had an estimated income lower than 2000 €. The follow up rates were 67% after 1 year, 68% after 2 years, 60% after 3 years and 31% 5 years after the operation.

At the time of Bariatric surgery, patients in the upper income group had a significantly lower initial BMI and weight (BMI: 49,25 kg/m2 ± 9,2 vs. 51,26 kg/m2 ± 10,3; weight 146,2 kg ± 30,8 vs 152,7 kg ± 35,4). Although these values were in the upper income group constantly below the other group (BMI after 1 year 35,8 kg/m2 vs 37,4 kg/m2, after 2 years 34,9 kg/m2 vs 36,3 kg/m2; after 3 years 35 kg/m2 vs 37 kg/m2; after 5 years 35,4 kg/m2 vs 37,5 kg/m2), no significant difference between the groups was observed. Consistent with these findings was that no difference in the %EWL was observed.

When looking at the differences between sexes, it turned out that women with a higher income showed a significantly better outcome, which lead to a significantly lower BMI and weight 3 and 5 years after the operation. In men no difference was observed.

Overall there was no difference in remission of overweight associated diseases.

Conclusion:

All in all, the outcome after Bariatric surgery in this study was good for all the patients regardless of the income.

To our knowledge, no study examined the outcome after obesity surgery in Germany with regard of the SES. By doing so, we found that patients with a high income had a lower weight and BMI when presenting themselves for the operation. This could be because patients with a higher SES have a better access to health care or are more sophisticated in terms of understanding their medical condition.

In conclusion the SES seems to have an effect on the time of which an individual chose an operation. Furthermore, the higher income can be regarded as a positive influence, especially for women after Bariatric surgery. Measures should be developed to give people on lower incomes, better access to adequate Bariatric measures.

Preoperative upper-GI endoscopy prior to bariatric Surgery: Imperative or Optional?

(Abstract ID: 350)

Y. Moulla¹, O. Lyros¹, M. Mehdorn¹, G. Lange¹, H. Hamadeh¹, A. Hoffmeister¹, B. Jansen-Winkeln¹, I. Gockel¹, A. Dietrich¹

¹Universitätsklinikum Leipzig

Background:

The role of preoperative upper-gastrointestinal (GI) gastroscopy is still a field of debate between bariatric surgeons. The aim of this study was to evaluate the incidence of upper-GI pathologies detected via endoscopy prior to bariatric surgery along with their clinical significance for patients’ management.

Materials and methods:

In a prospectively-established database of obese patients, who underwent bariatric operation from 01/2011 to 12/2017 in our center, we retrospectively analyzed the perioperative endoscopic findings along with their influence of patients’ management. According to the endoscopic and histologic findings as well as their direct clinical consequences in the perioperative management, patients were divided into three groups (Group 1: No change of the peri-operative strategy, Group 2: change of the perioperative strategy and Group 3: change the final operative strategy). The incidence of GIpathologies and possible correlations between clinical, endoscopic and histological findings were assessed for each group.

Results:

In total, 636 obese patients with median BMI (body mass index) of 49 kg/m2 [range 31-92] received upper-GI endoscopy prior to bariatric procedure. The bariatric procedures were laparoscopic gastric bypass (72.6%, 462), laparoscopic sleeve (20.1%, 128) and Re-Do operations (6.6%, 42). A lot of pathological findings were detected endoscopically [Peptic ulcer: 3.5% (22/636), HP-Gastritis: 18.6% (111/598[YM1] ), Gastric & duodenal /Polyp: 6.8% (43/636)]. Reflux esophagitis could be detected in 212/636 patients (33.3%). Although, endoscopic findings were confirmed by histology in most of the cases. Barrett’s esophagus was histologically diagnosed in 94 cases (14.9%), whereas only in 75 cases (11.3%) was endoscopically suspected. Esophageal adenocarcinoma was detected in 3 cases (0.5%). Change of the operative strategy due to endoscopically or histologically detected pathologic findings had to be performed in 10 cases (1.6%). No major complications were associated with perioperative upper-GI endoscopy.

Conclusion:

Preoperative upper-GI endoscopy identifies a wide range of abnormal endoscopic findings in obese patients, which may have significantly impact on decision making, particularly regarding the most suitable bariatric procedure and an appropriate follow-up. Therefore, preoperative upper-GI endoscopy should be considered in all obese patients prior to bariatric procedure.

Picture:

Change of peri- operative strategy in our center according to preoperative Gastroscopy

Impact of resection volume/stapler firings-ratio on postoperative complications and outcome after laparoscopic sleeve gastrectomy

(Abstract ID: 573)

F. Hönes¹, A. Della Penna¹, J. Lange¹, R. Archid¹, A. Königsrainer¹, M. Quante¹

¹Universitätsklinikum Tübingen

Background:

Since major postoperative morbidity after laparoscopic sleeve gastrectomy (LSG) is often related to staple line leakage, many efforts have been made to better understand pathophysiological and technical aspects related to its onset. Of note, a recent study suggested a central role of the absolute numbers of stapler firings as a predictive factor for postoperative morbidity due to staple line leakage. In addition, a larger gastric remnant volume could be responsible for lower weight loss after LSG, and nevertheless, the gastric resection volume (GRV) is strictly related to the residual volume. Thus, we retrospectively analyzed the impact of the number of stapler firings and GRV on postoperative complications and weight loss results after LSG.

Materials and methods:

Prospectively collected data of 380 consecutive patients with complete follow-up at 12 months after LSG at our institution were retrospectively analyzed. Patients were stratified according to three different variables (i.e. number of stapler firings, GRV and GRV/stapler firings-ratio), and impact on postoperative complications and weight loss was analyzed.

Results:

Higher absolute number of stapler firings was associated with higher intraoperative and postoperative bleeding and prolonged hospitalization, but was not associated with staple line leakage, transfusion rate or revisional procedures. Absolute GRV showed no impact on both, complications and outcome after LSG. Interestingly, higher ratio of GRV/stapler firings was not only linked to lesser intraoperative bleeding and shorter hospital stay, but also to higher EBMIL at 12 months after LSG.

Conclusion:

Here, we introduce resection volume/stapler firings-ratio as a simple predictive factor for identifying patients at high risk for postoperative complications and impaired weight loss, that is superior compared to absolute number of stapler firings or GRV alone.

Effect of intraoperative blood pressure enhancement on postoperative hemorrhage after bariatric surgery

(Abstract ID: 811)

G. Marjanovic¹, S. Stock¹, G. Seifert¹, F. Fink¹, C. Laessle¹

¹Uniklinik Freiburg

Background:

Postoperative hemorrhage after laparoscopic bariatric surgery is a common early complication. The aim of this study was to analyze if intraoperative enhancement of systolic blood pressure in order to detect silent bleedings would reduce postoperative hemorrhage.

Materials and methods:

In this retrospective 4-year analysis we have included 403 consecutively operated patients with a gastric bypass (n=202) or a sleeve gastrectomy (n=201). We especially focused on the incidence of postoperative hemorrhage with the need for early reoperation. The patients operated in the first two years serve a control group (no blood pressure enhancement; gastric bypass n=72; sleeve n= 146). In all patients of the second two years (gastric bypass n=130; sleeve n=55) the systolic blood pressure was raised up to 150mmHg at the end of the operation and clips were applied were necessary. The operative technique was unchanged throughout the time span.

Results:

In the control group there were 8/218 patients with a postoperative hemorrhage who needed reoperation (3.7%) whereas there were no patients in the intervention group (0/185). Of these 8 patients five had gastric bypass and three a sleeve gastrectomy. The bleeding could be localized to the staple line in four patients and in one to the abdominal wall. No active bleeding but hematoma was found in the upper abdomen in the last three patients.

Conclusion:

Intraoperative blood pressure enhancement seems to reduce postoperative hemorrhage in patients after laparoscopic bariatric surgery and could be implemented in standardized protocols.

Superobese and High-risk Patients - clinical experience with Endoscopic Sleeve Gastroplasty with Apollo Overstich

(Abstract ID: 841)

R. Zorron¹, R. Li¹, C. Grande¹, B. Ruschen¹, M. Specht¹

¹Klinikum Ernst von Bergmann Potsdam

Background:

Bariatric surgery for morbid obesity can induce important excess weight loss (EWL) during years after surgery, and co-morbidities often improve or resolve. As many patients with surgical contraindications for formal bariatric surgery have no alternative besides conservative management, new endoscopic procedures can be currently applied to these cases. This study describes the preliminary german clinical experience with Endoscopic Sleeve Gastroplasty- Endosleeve in this set of patients.

Materials and methods:

Primary endoscopic sleeve gastroplasty was performed for a series of 28 patients using the fullthickness suturing device Apollo Overstich. All selected patients were ASA III classified, due to cardiopulmonary high-risk, liver/renal transplant candidates, or BMI over 50kg/m2. Technical steps included general anesthesia, insertion of an Overtube, full-thickness suturing of the corpus and fundus with interrupted nonabsorbable sutures, sizing the gastric tube. The patients were followed and documented regarding complications, weight loss and co-morbidities.

Results:

All patients were submitted to the procedure without intraoperative complications. Mean operative time was 87 min. Mean preoperative BMI was 61kg/m2, Highest BMI was 100.8, highest body weight was 310kg. One patient with postoperative bleeding was treated with endoscopic clips, no other complications were documented. Follow-up showed satisfactory weight loss with no weight regain after 12 months. Co-morbidities were ameliorated with reduction of medications in all patients.

Conclusion:

Endoscopic primary sleeve gastroplasty using Apollo Overstich is a new less invasive procedure for morbid obesity, satisfactory early results and few complications for this set of high-risk patients.

Cell adhesion molecules are related to adipose tissue signatures in individuals with insulin sensitive or resistant obesity

(Abstract ID: 854)

Y. Moulla¹, A. Dietrisch¹, M. Blueher¹

¹Universitätsklinikum Leipzig

Background:

A subgroup of obese individuals seems to be protected from metabolic and cardiovascular disorders. To elucidate potential mechanisms underlying this protection, differences in circulating adhesion molecule serum concentrations between insulin sensitive (IS) and insulin resistant (IR) individuals with morbid obesity were studied. A subgroup of obese individuals seems to be protected from metabolic and cardiovascular disorders. To elucidate potential mechanisms underlying this protection, differences in circulating adhesion molecule serum concentrations between insulin sensitive (IS) and insulin resistant (IR) individuals with morbid obesity were studied.

Materials and methods:

Based on glucose infusion rate during euglycemic-hyperinsulinemic clamps, 60 individuals with a BMI of 45.0±1.3 kg/m² were divided into an IS and IR group matched for age, gender and body fat. Serum concentrations of soluble intracellular adhesion molecule (sICAM-1), soluble vascular cell adhesion molecule (sVCAM-1), soluble endothelial leukocyte adhesion molecule-1 (sE-selectin) and parameters of fat distribution, lipid metabolism and inflammation were measured. In addition, omental visceral and subcutaneous adipose tissue mRNA expression was investigated using an Illumina gene array.

Results:

IS compared with IR obese individuals have significantly lower sICAM-1 (174±39 versus 211±45 ng/ml) and sE-selectin (20.5±5.2 versus 31.4±2.9 ng/ml) serum concentrations, whereas no significant difference was found regarding sVCAM-1. The strongest significant predictors of sICAM-1 and sEselectin are insulin sensitivity (sICAM-1: r=-0.42, sE-selectin: r=-0.44; both p<0.01), circulating chemerin (sICAM-1: r= 0.36, sE-selectin: r= 0.34; both p<0.01) and adiponectin (sICAM-1: r=-0.25, sEselectin: r=-0.28: both p<0.05). In addition, adhesion molecules correlate with adverse adipose tissue gene expression signatures and markers of inflammation and cellular stress.

Conclusion:

Lower sICAM-1 and sE-selectin concentrations are associated with IS obesity. This suggests that mechanisms such as inflammation and adipokine release determine the risk of metabolic disturbances in obese individuals.

Influence of BMI and gender on stigmatization of obesity

(Abstract ID: 872)

E. A. Felinska¹, C. Tapking², L. Benner¹, M. Hackbusch³, D. Tran⁴, G. B. Ottawa³, K. Krug³, B. P. Müller-Stich¹, L. Fischer¹, F. Nickel¹

¹Universitätsklinikum Heidelberg

²BG Klinik Ludwigshafen

³Universitätsklinikum Heidelberg

⁴University of Texas Medical Branch, Galveston, TX

Background:

Stigmatization and discrimination of obese people due to their weight is a common problem that may lead to additional weight gain. The objective of the present study was to evaluate the stigmatization of obesity and the influence of demographic parameters.

Materials and methods:

Participants of six groups (general population, obese patients, medical students, physicians, nurses in training and nurses; n=490) answered the short form fat phobia scale (FPS) between August 2016 and July 2017. The influence of body mass index (BMI), gender and other factors on total scores and single adjective pairs were analysed using linear regression models.

Results:

A total of 490 participants were evaluated. The total mean FPS rating was 3.5 ± 0.6. FPS was significantly lower (more positive) in obese (3.2 ± 0.7) compared to non-obese participants (3.5 ± 0.5, p < 0.001). Obese individuals and those suffering from diabetes mellitus rated the FPS significantly lower (more positive). Obese participants linked other obese individuals more often with good selfcontrol (p < 0.001), being shapely (p = 0.002), industrious (p < 0.001), attractive (p < 0.001), active (p < 0.001), strong (p = 0.004), self-sacrificing (p < 0.001), fast (p < 0.001), having more willpower (p < 0.001) and endurance (p < 0.001) than the non-obese participants. Female participants rated more positive in shapely versus shapeless (p = 0.038) and attractive versus non-attractive (p < 0.001) than male participants.

Conclusion:

The present study shows that people affected by obesity characterized other obese people more positively (e.g. attractive or active), whereas non-obese people linked negative characteristics and attitudes with obesity. Other demographics such as gender have an influence on the attitude towards obesity in some subcategories.

Update on gastroesophageal cancer risk following OAGB-MGB

(Abstract ID: 875)

A. Plamper¹, K. P. Rheinwalt¹

¹St. Franziskus-Hospital

Background:

Bile reflux and gastroesophageal cancer risk have repeatedly been regarded to be serious concerns in One Anastomosis Gastric Bypass - Mini Gastric Bypass (OAGB-MGB). Although this procedure is being performed for more than 22 years, this timespan might be too short to draw final conclusions concerning the actual risk for the development of gastroesophageal cancer after OAGB-MGB. Up to now, only three cases have been published. Conclusions can therefore so far only be deducted from knowledge coming from studies regarding gastric resection due to peptic ulcer or distal gastric carcinoma as well as experimental studies.

Materials and methods:

A review of the literature (Pubmed) was performed and 741 studies were identified. The most important studies on this issue were evaluated and will be presented.

Results:

741 studies were evaluated. In summary, the discussion about the existence of the so-called gastric stump cancer after gastric resection appears to be very controversial. It is unclear whether biliary reflux into the stomach (induced by the procedure) or whether other pre-existing disorders (such as gastroduodenal ulcers or other (pre-)malignant conditions) attribute to what degree to the development of gastric cancer after such a long timespan. On the other hand, it appears to be widely accepted that biliary reflux into the esophagus represents a substantial risk factor for the development of adenocarcinomas of the gastroesophageal junction.

Conclusion:

For the daily routine in clinical practice, regular endoscopic follow-up after OAGB-MGB should be recommended, as already recommended after other bariatric procedures such as sleeve gastrectomy.

Multimerization of adiponectin is modified by site-specific phosphorylation of Casein kinase 1 in vitro

(Abstract ID: 889)

P. Xu¹, D. Henne-Bruns¹, U. Knippschild¹

¹Universitätsklinikum Ulm

Background:

Adiponectin, an adipocytokine with anti-inflammatory, antidiabetic, anti-atherogenic, and anti-cancer features, is mainly secreted by adipose tissue. Human adiponectin has an N-terminal collagenous domain and a C-terminal globular domain and builds characteristic homomeres including trimers, hexamers and high molecular weight (HMW) 12-18-mers. The beneficial effects of adiponectin in humans are primarily mediated by its HMW isoform. Posttranslational modifications play an important role in regulating activity and complex formation of adiponectin. Phosphorylation is considered to be another most common posttranslational modification that may alter the activity, life span, or cellular localization of proteins. Casein kinase 1 (CK1) family, protein kinase family of serine/threonine kinases, are involved in the regulation of various signaling pathways. In this study, complex formation and biological activity of adiponectin after phosphorylation are indicated.

Materials and methods:

Gene expression levels and their correlations in adipose tissue from morbid obese (MO) patients were analyzed by immunohistochemistry, RT-PCR and Immunoprecipitation. Next, in vitro kinase assays, phosphopeptide analysis and phosphoamino acid analysis provided evidence that adiponectin is phosphorylated . To investigate the influence of site -specific phosphorylation on complex formation of adiponectin omental adipose tissue or serum either treated with or without protein phosphatase 1 and SGBS adipocytes cells treated with CK1 inhibitor and analyzed by Western blot analysis for changes in adiponectin complex formation. For glucose uptake, SGBS cells at day 14 of the differentiation process were grown in the absence or presence of IC261 and stimulated with or without insulin for 15 min before 2-deoxy-D-[14C]-glucose (0.2 μCi/well) was added for another 15 min. Cells were washed twice in ice-cold PBS, harvested with 100 mM NaOH and incorporation of 2-deoxy-D-[14C]-glucose was measured on a β-counter.

Results:

CK1Δ is expressed in adipose tissue and correlates with adiponectin expression levels. Furthermore, adiponectin coimmunoprecipitates with CK1Δ and is phosphorylated by CK1Δ at serine 174 and threonine 235, thereby influencing the formation of adiponectin oligomeric complexes. Furthermore, inhibition of CK1Δ in human adipocytes by IC261 leads to an increase in basal and insulin-stimulated glucose uptake.

Conclusion:

Site-specific phosphorylation of adiponectin, especially at sites targeted by CK1Δ in vitro, provides an additional regulatory mechanism for modulating adiponectin complex formation and function.

Revealing the ergonomic crisis of upper gastrointestinal robotic surgery – still a lot to improve in minimally invasive surgery

(Abstract ID: 180)

B. Babic¹, D. T. Müller¹, E. Schulte¹, L. Knepper¹, C. Fuchs¹, L. Schiffmann¹, F. Ahn², C. Höfler², J. Leers¹, W. Schröder¹, C. J. Bruns¹, H. Fuchs¹

¹Uniklinik Köln

²International School of Design, Köln

Background:

Minimally invasive technologies have improved outcomes after esophagectomy and the use of robotic technology in Europe is rapidly increasing. Even if robotic technology was developed to improve minimally invasive surgery, many robotic surgeons complain about ergonomics when using existing devices. Aim of this study is to evaluate the ergonomics of the newest robotic technology in a center of excellence for upper gastrointestinal surgery

Materials and methods:

Starting 02/2017 the latest available robotic system (davinci xi) was introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n>300 esophageal cases/year). Surgeons ergonomics were studied using a standardized video capture and touch sensor protocol (Fig 1 & 2). Data recorded were analyzed to study whether the new robotic system was used in an ergonomic fashion troughout robotic esophageal surgery.

Results:

From 02/2017 - 09/2019, a total of 105 mainly upper gastrointestinal robotic cases including 52 Esophagectomies for cancer and 25 Heller Myotomies were performed. All cases were performed safely without operation-associated intraoperative complications. Even though experienced robotic console surgeons used the robotic device, the davinci xi arm rest was used in less than 25% of surgery time (Fig. 3) Video documentation using the new technology is provided to showcase the dilemma.

Conclusion:

Robotic technology allows for safe minimally invasive upper gastrointestinal operations. Further development in robotics should focus on improvement of surgeons ergonomics.

Picture:

 

The hunger games: The feeling of hunger can affect laparoscopic performance in novice surgeons

(Abstract ID: 431)

F. von Bechtolsheim¹, F. Oehme¹, N. Oppermann¹, C. Reissfelder², S. T. Mees³, C. Yang², J. Weitz¹

¹Universitätsklinikum Carl Gustav Carus Dresden

²Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim

³Städtisches Klinikum Dresden Friedrichstadt

Background:

Food deprivation is a common condition for visceral surgeons due to complex and highly specialized surgeries lasting several hours. Especially laparoscopic approaches require high levels of concentration without refreshing breaks. The current literature does not provide adequate answers whether intraoperative breaks, especially food intake, might influence the quality of the surgical skills. Thus, the primary aim of this trial was to analyze the influence of food deprivation on the laparoscopic performance of surgeons.

Materials and methods:

37 laparoscopic novices participated from October 2017 to April 2018 in this single center, prospective-randomized trial. Students were trained during laparoscopic training sessions until they reached a predefined level of proficiency.

Subsequently, participants were randomized into three different groups: food deprivation of 8 hours, 4 hours or carbohydrate loading directly prior to the laparoscopic exam. The exam comprised four tasks: PEG-transfer, precise cutting, gallbladder resection and surgical knot. Task performance was evaluated by the dimension of time and accuracy.

Results:

Completion time for PEG-transfer, precise cutting, gallbladder resection and surgical knot overall students was 63 s, 139 s, 192 s and 272 s respectively. Participants starving for 8 hours performed 3 of 4 tasks more slowly whilst participants starving for 4 hours performed 3 of 4 tasks faster than the average.

Analyzing the self-reported level of appetite revealed that students with an intermediate level were significantly faster (P<0.05) during more complex procedures compared to participants that reported hunger prior to performing these tasks (192 s vs. 307 s). Additionally, hungry students had been more inaccurate during the surgical knot (P<0.05) whilst students with intermediate appetite level tend to be most accurate (7,1% vs. 53,3% inaccuracy of the first stitch, p-value 0.012).

Conclusion:

The subjective level of appetite rather than the absolute number of fasting hours influences the laparoscopic performance. Thus, any extreme level of appetite, hunger or the feeling of satiation, should be avoided and surgeons may achieve the best performance when they have an intermediate level of appetite. In consequence, heavy meals should be omitted immediately prior to demanding laparoscopic procedures and surgeons should have access to mini-breaks and refreshers during major procedures.

Training of minimally invasive surgery: A prospective randomized crossover study between robotic versus laparoscopic cholecystectomy

(Abstract ID: 815)

E. Willuth¹, F. Lang¹, C. Haney¹, E. A. Felinska¹, K.-F. Kowalewski¹, S. Hardon², T. Horeman-Franse², B. P. Müller-Stich¹, F. Nickel¹

¹Chirurgische Klinik, Universitätsklinikum Heidelberg

²Delft University of Technology

Background:

The Da Vinci operating system provides theoretical advantages compared to conventional laparoscopy. Features have been developed to reduce eye strain, improve the ergonomic outcomes for surgeons, so both the mental and the physical workload can be reduced. On the other hand, the da Vinci system lacks haptic feedback and therefore requires surgeons to learn visual haptics during the learning curve to compensate for the lack of tissue feeling and avoid tissue damage. The objective of this study is to compare robotic surgery and conventional laparoscopy for the early learning phase.

Materials and methods:

This was a prospective monocentric randomized cross-over study in the training center of minimally invasive surgery (MIS) at Heidelberg University Hospital. It was conducted within a voluntary elective module for medical students in their 3rd to 6th year of medical school without prior laparoscopic or robotic experience. The participants (n=40) were randomized in a 1:1 ratio and stratified by gender to group 1 (G1) and group 2 (G2). G1 started with the robotic assisted cholecystectomy (RAC) and then afterwards performed laparoscopic cholecystectomy (LC), G2 started with LC and then performed RAC. All cholecystectomies were performed on porcine livers. Before performing the first cholecystectomy, the participants received practical and theoretical instructions. The theorical part included a catalogue and instructional videos, containing the key steps of cholecystectomy, showing the laparoscopic and the robotic version. Participants also had a standardized basic skill training for robotic surgery and conventional laparoscopy. The primary endpoint was the complication rate (damage to the liver, gallbladder perforation and force applied to the tissue). The outcomes were statistically tested using chi-square and Wilcoxon test. P-values under 0.05 were deemed to be significant.

Results:

Complication rates between the two groups showed that students from G1 injured the liver significantly less than students from G2 during the first cholecystectomy (Major liver damage: G1=5 (25%) vs G2=11 (57%), p-value=0.037). After transitioning, we observed that students from G1 damaged the liver significantly more than students from G2 while performing the second cholecystectomy. (Major liver damage: G1=9 (45%) vs G2=1 (5%); p-value=0.005). There was no statistically significant difference in operating time for cholecystectomy between G1 and G2 or between LC and RAC.

Conclusion:

The results indicate that the robotic system helps students to learn cholecystectomy safer than conventional laparoscopy at the beginning of the learning curve, resulting in less liver damage. The experience from laparoscopic surgery seems to transfer skills when transitioning to robotic system, while the robotic experience did not transfer to conventional laparoscopy. This should be considered when designing training curricula.

Picture:

Cholecystectomy on Da Vinci with ForceSense Device

The effect of introducing a coping role model on efficacy and quality of training in laparoscopic knot tying - a randomized-controlled trial

(Abstract ID: 835)

A. S. Gerhäuser¹, F. Lang¹, C. Wild¹, M. W. Schmidt¹, B. P. Müller-Stich¹, F. Nickel¹

¹(Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Heidelberg

Background:

OBJECTIVE: The aim of this study was to examine whether efficiency in learning laparoscopic knot tying can be increased by shifting focus towards solution orientation and development of coping strategies, and how such an approach affects learning motivation.

BACKGROUND: Previous studies have indicated that observational learning using a coping model instead of the previously established mastery model could achieve better learning results. However, the coping model according to Lazarus has not yet been specifically tested for its efficiency as a fundamental instruction model in minimally invasive surgical training.

Materials and methods:

METHODS: 55 laparoscopically naive medical students learned a standardized knot tying technique by means of an instructional video. The control group was only offered a mistake-free mastery video. The intervention group, instructed on active error analysis, additionally watched freely selectable coping videos showing typical beginner errors including solution strategies. The primary endpoint of the study is the number of attempts to reach a predefined proficiency level, defined by time, Knot Quality- and OSATS-Score. Secondary endpoints include regularly raised scores on current motivation (FAM), satisfaction with the performance and self-efficacy expectations (ASKU).

Results:

RESULTS: Face and content validity and reliability of the coping videos were established. Preliminary statistical analysis showed a lower mean number of attempts until proficiency was reached with 18.8±5.5 for intervention group vs. 21.3±6.5 for control group without reaching statistical significance (p=0.142). However, there was a trend with higher fraction of good knots in the intervention group with 0.56±0.12 vs. 0.50±0.15 (p=0.078). Over the whole period, 3 out of 4 motivational subscores of FAM (challenge, interest, probability of success) were significantly higher for the intervention group (p<0.005), as well as subjective learning benefit (p=0.002) and error-awareness (p<0.001).

Conclusion:

CONCLUSION: Using a coping role model improves learning motivation and understanding of the technique with a positive trend but no significant difference in its implementation in the current setting. The ability to think in a solution-oriented, independent way is necessary in surgery in order to recognise, understand and adequately deal with technical difficulties and complications.

Operative time and age predict surgical morbidity after laparoscopic liver surgery

(Abstract ID: 865)

D. Heise¹, J. Bednarsch¹, A. Kroh¹, G. Lurje², U. P. Neumann¹, F. Ulmer¹

¹Uniklinik RWTH Aachen

²Charité – Universitätsmedizin Berlin

Background:

Laparoscopic liver resection has emerged as a considerable alternative to conventional liver surgery in recent years. While complex liver surgery with vascular resections or hepaticojejunostomies is usually carried out conventionally, even major liver resections appear technically feasible with a laparoscopic approach. This particular patient selection results in low mortality figures after laparoscopic liver resection and brings postoperative morbidity to the center of attention of the hepatobiliary surgeon. Thus, we here aim to assess risk factors for increased surgical morbidity in patients undergoing laparoscopic liver resection.

Materials and methods:

All consecutive patients which underwent laparoscopic liver resection between 2015-2019 at our institution were analyzed for postoperative complications. Associations between general morbidity (defined as the presence of any postoperative deviation) and complications (defined as the presence of any postoperative minor complication ranked >2 and major complication ranked >3a according to the Clavien-Dindo-Scale) with demographics, clinical and operative characteristics were assessed using univariate and multivariable logistic regression analyses.

Results:

Our cohort comprised 156 patients with a mean age of 60±14 years and mean BMI 26±6. While perioperative mortality rarely occurred in the cohort (2.6%, 4/156), general morbidity and minor complications were observed in 19.9% (31/156) and 9.6% (15/156) of the patients, respectively. Major complications appeared in 3.2% of the patients (5/156). Multivariable analysis identified age>65 years (Odds Ratio(OR)=2.56, p=0.028) and operative time>180 min (OR=4.49, p=0.001) as the two independent predictors of general morbidity and operative time>180 min (OR=23.25, p=0.003) as the single independent predictor of complications.

Conclusion:

Laparoscopic liver resections are safe in experienced high-volume centers. Surgical morbidity is based on patient- (age) and procedure-related (operative time) characteristics. Therefore, sophisticated patient selection is the key to improve postoperative outcomes after laparoscopic liver resection.

Robotic-assisted liver resection – early experience during introduction at a tertiary center

(Abstract ID: 891)

R. Wahba¹, H. Fuchs¹, G. Dieplinger¹, A. Damanakis¹, R. Datta¹, M. Thomas¹, C. J. Bruns¹, D. Stippel¹

¹Uniklinik Köln

Background:

Robotic-assisted liver resection (RL) is an advanced robotic procedure. It might have benefits compared to laparoscopic liver resection regarding visualization, ergonomics and instrument movement. Nevertheless worldwide RL is still not widespread due potential complications and limitations in parenchyma dissection. This study describes early experience during introduction of RL.

Materials and methods:

Prospective observational study during introduction of robotic-assisted liver resection

Results:

Following robotic-assisted cholecystectomies the first RL was performed in February 2019 (HCC in Seg 3, CHILD A liver cirrhosis, atypical resection). Since then 12 patients were operated with RL. Diagnosis were HCC in cirrhosis (n=5), metastases (n=4), non-parasitic liver cysts (n=2) and adenoma (n=1). In one patient a robotic left pancreatectomy was combined with RL. Three or four robotic arms with one assist trocar were used. Resection plane was always identified by robotic-assisted ultrasound. Parenchyma dissection was performed by crush-clamp technique (fenestrated bipolar scissors, bipolar maryland scissors) or with the vessel sealer. Larger vascular structures were dissected between robotic-assisted clips or robotic staplers. 5 atypical, 3 segmental-oriented and 4 anatomical left-lateral RL were performed. Skin-to-skin time was 186 ± 77 minutes. There was one conversion due to bleeding and one due to cardiac arrhythmia during dissection of the left triangular ligament. Morbidity rate was 0%. 1 patient with cirrhosis died after liver failure.

Conclusion:

Robotic-assisted liver resection is feasible. Optimization of parenchyma dissection seems to be crucial in the future.

Da Vinci Single-Port robot-assisted transanal mesorectal excision – a preclinical experience

(Abstract ID: 961)

W. Kneist¹

¹St. Georg Klinikum Eisenach

Background:

Introduction: Robotic single-port platforms represent a viable option for advanced surgical procedures. This preclinical study investigated the dual-field, single-port, robot-assisted transanal total mesorectal excision (taTME).

Materials and methods:

Technique: In a male human cadaver, we employed the novel da Vinci® SP™ Surgical System, sequentially, to realize the transanal and abdominal parts of the taTME procedure. We evaluated the feasibility of the one-team approach.

Results:

We showed that single-port access for the taTME was technically feasible with the current da Vinci® SP™ Surgical System in both surgical fields. The total console times were 189 min, for the juxta-anal purse-string suture placement, partial intersphincteric resection, and bottom-up mesorectal dissection to where it meets the peritoneal reflection, and 43 min for the abdominal procedure. A good quality specimen was achieved with a high level of comfort during the simulated surgery. The task load was highly acceptable (NASA-TLX global score: 35), even though it was the surgeon’s first use of this platform.

Conclusion:

This preclinical study demonstrated that the robotic, single-port, TaTME was feasible and could be performed with the da Vinci® SP™ Surgical System, beginning at the level of the dentate line. Further simulations are necessary to confirm this promising approach.

Development of a suture training model for open, laparoscopic and robotic pancreatic surgery

(Abstract ID: 985)

E. Karadza¹, K.-F. Kowalewski¹, E. Wennberg¹, F. Lang¹, E. A. Felinska¹, C. M. Haney¹, M. W. Schmidt¹, A. Studier-Fischer¹, E. F. Limen¹, F. Köppinger¹, H. G. Kenngott¹, T. Hackert¹, B. P. Müller-Stich¹, F. Nickel¹

¹Universitätsklinikum Heidelberg

Background:

Due to fragile nature of pancreatic tissue, the reconstruction with pancreaticojejunostomy or pancreatogastrostomy in pancreatoduodenectomy is demanding and requires adequate training to ensure low complication rates. Especially in minimally invasive and robotic surgery the pancreatic anastomosis should be trained outside the operating room before performing on patients. A realistic suturing model with adaptive tissue properties for soft and hard pancreas with different duct sizes that can be used for training open, laparoscopic, and robotic surgery was developed. To complete the training setup for surgical reconstruction a small bowel, stomach and a biliary duct model were added for performing gastrojejunostomy and hepaticojejunostomy.

Materials and methods:

The pancreatic models were produced with different silicone mixtures and additives, using 3D-printed molds that were generated out of patient data. Soft and hard pancreatic models, simulating the remaining healthy pancreatic tail after pancreatic head resection and chronically inflamed pancreatic tissue were developed for evaluation. Two commercially available pancreatic training models, soft and hard tissue, were used for comparison. A two-layered model for small bowel, stomach and a bile duct were developed. Ten highly experienced pancreatic surgeons evaluated the different models for realism of haptic properties and suturing. The evaluation criteria involved haptic realism, rigidity, fragility of tissue and duct, as well as the realism of suture behavior. Likert scales and qualitative analysis were used. After the first evaluation phase the models were improved for further evaluation steps performed with congress participants at the German Society of Surgery (DGCH) Congress 2019 in Munich/Germany and at the Austrian Surgeons Congress 2019 in Innsbruck/Austria.

Results:

The first evaluation round showed high haptic realism and superiority of all four of the developed soft pancreatic models (Likert scale with scores 1 to 5 where 5 represents high realism compared to human pancreas.) over the commercially available model (Means: 3.3±0.8, 3.5±1.6, 3.9±1.6, 3.2±1.6 vs. 1.8±1.4; p-values: p1= 0.039, p2=0.008, p3=0.002, p4=0.039). The hard pancreatic models were rated superior in tissue behavior (Means: 4.5±0.5 vs. 3.5±1.7). Following the evaluation process the small bowel and the stomach were modified in wall thickness and tissue properties, the pancreas was modified by adding a pancreatic capsule. The modifications of small bowel and stomach resulted in higher haptic realism (small bowel means: 4.4±0.8 vs. 3.1±1.2, p=0.0314; stomach means: 4.1±0.9 vs. 2.6±1.5, p=0.0052), optimal wall thickness (Likert scale from -2 to 2 where 0 represents the optimum. Small bowel means: 0.2±0.7 vs. -0.8±0.9 and 0.6±1.2, p=0.007; stomach means: 0.1±0.5 vs. -1.6±0.7, p<0.0001) and optimal suture behavior (small bowel means: 0.1±0.5 vs. 0.6±0.5 and 1.4±0.8, p= 0.046 and p=0.0001; stomach means: 0.06±0.5 vs. 0.5±1.1 and 0.6±1) compared to the first evaluation round. Overall the developed pancreas models performed better than the commercially available products.

Conclusion:

The different modifications improved haptic realism and suture behavior. The developed organ models show very high realism in all evaluation criteria compared to human organs and are therefore highly suitable for realistic surgical training. They will be implemented in the surgical training routine and used for translational research to show surgeons and patients benefits.

Picture:

Pancreaticojejunostomy performed during robotic training with soft pancreas model

Robot-assisted versus conventional laparoscopic fundoplication: A 12 years follow up assessment of quality of life

(Abstract ID: 1015)

F. Lang¹, A. Huber¹, K.-F. Kowalewski², C. Gutt³, L. Fischer⁴, V. Bintintan⁵, B. P. Müller-Stich¹, F. Nickel¹

¹Universitätsklinikum Heidelberg

²Universitätsmedizin Mannheim

³Klinikum Memmingen

⁴Klinikum Mittelbaden, Baden-Baden

⁵Clinica Vasculara, Cluj-Napoca

Background:

Numerous reports have addressed the feasibility and safety of using robot-assisted (RALF) and conventional laparoscopic fundoplication (CLF). However, evaluation of patient satisfaction and quality of life data in long-term follow up remains still unclear. Therefore, the aim of the study was to assess disease specific symptoms and quality of life in patients with GERD treated with either robot-assisted (RALF) or conventional laparoscopic fundoplication (CLF) in long-term follow up.

Materials and methods:

The present study was a randomized controlled trial comparing RALF and CLF in patients, who intended undergoing laparoscopic Nissen fundoplication at our institution for treatment of GERD between August 2004 and December 2005. Twelve years after surgery, all patients who underwent this treatment were sent a standardized questionnaire concerning the psychometric characteristics of the Gastrointestinal Symptom Rating Scale (GSRS, seven-graded Likert type scale, 1 represents absence of bothersome symptoms) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD, seven-graded Likert type scale, the lower the value the more severe the impact on the daily functioning) which illustrates the impact of reflux and dyspepsia symptoms and satisfaction on the patient’s daily life.

Results:

Forty patients received intervention (n(RALF)=20, n(CLF=20)). All of them were given the questionnaires and 30 ((n(RALF)=15, n(CLF=15)) of them replied. The mean (range) GSRS score was in long-term follow up 2.1 (1.1-3.3) in the RALF group versus 2.2(1.0-5.9) in the CLF group (p=0.740). As well there was no significant difference in GSRS, neither in reflux syndrome specific subscale, heartburn and acid regurgitation (RALF, 1.6 (1.0-5.0); CLF, 1.7 (1.0-4.5), p=0.818). In addition, the mean difference in QOLRAD score at 12 years´ follow up was similar with 5.4 (2.4-7.0) in the RALF group versus 5.4 (1.0-7.0) in the CLF group (p=0.656). Both procedures were not significant different in improving emotional distress, food/drink problems, physical/social functioning, sleep disturbance and vitality in long-term follow-up.

Conclusion:

In accordance with previous short term studies, our long-term results showed no difference twelve years after laparoscopic Nissen fundoplication in the postoperative symptom evaluation, patient satisfaction and quality of life in reflux and dyspepsia questionnaires between the conventional laparoscopic and robotic groups. Noticeable was the high amount of (very) positive feedback about the rare appearance of gastroesophageal reflux disease symptoms and high life quality in this long-term study. This lead to the assumption that both, RALF and CLF seemed to be satisfying methods.

The decrease of BMI and albumin levels influences the rate of anastomotic leaks in patients following reconstruction after emergency diverting esophagectomy

(Abstract ID: 41)

K.-F. Karstens¹, B. O. Stüben¹, T. Ghadban¹, F. G. Uzunoglu¹, M. Bockhorn¹, J. Izbicki¹, M. Reeh¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

Diverting esophagectomies in cases of benign esophageal perforations remain rare but potentially life saving procedures. Usually, an esophagostoma and a feeding jejunostomy or gastrostomy are created and patients are given time to recover from the emergency situation. However, little is known about morbidity and mortality as well as the optimal timing for a staged reconstruction.

Materials and methods:

Patients with benign esophageal perforations were selected from our retrospective database. Perforations in esophageal malignancies were excluded to avoid bias on patients’ general outcome. Clinical parameters and especially the influence of the nutritional status indicated by the BMI (Body Mass Index) as well as serum albumin levels (g/l) were analyzed.

Results:

A total of 24 patients with diverting esophagectomies were identified. Of these, 13 (54.2%) patients received a staged reconstruction after a median of 143.0 days. Patients presenting for their staged reconstruction demonstrated a significantly decreased level of their BMI (p=0.026) as compared to their prior hospitalization. Interestingly, the relative decrease of BMI (8.5kg/m2 vs. 4.3kg/m2) and albumin levels (6.5 g/l vs. 0.0 g/l) was significantly different in patients with or without anastomotic leaks between both surgeries (p=0.021; p=0.034, respectively). In addition, higher rates of overall complications were associated with an increased rate of malnutrition.

Conclusion:

The relative amount of malnutrition indicated by BMI or serum albumin levels influences the rate of anastomotic leaks and general complications in patients with staged reconstruction after diverting esophagectomy for non-malignant esophageal perforations. Hence, reconstruction should be done as fast as possible to reduce the amount of malnutrition and a frequent assessment of the nutritional status must be done during recovery from the emergency surgery.

Note:

The full manuscript has been published in Esophagus. 2019 Nov 28. doi: 10.1007/s10388-019-00703-x

Decompressive laparotomy in patients with an extracorporeal membrane oxygenation suffering from abdominal compartment syndrome

(Abstract ID: 255)

C. S. Nitschke¹, M. Schulte¹, C. Burdelski¹, S. Kluge¹, J. R. Izbicki¹, K. Bachmann¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

Abdominal compartment syndrome is a life threatening situation, most commonly found after a major abdominal trauma or surgery and often leads to severe organ dysfunctions and is thereby predicting mortality for patients at the Intensive Care Unit. A decompressive laparotomy intends to improve the elevated intra-abdominal and peak airway pressures, inadequate ventilation with hypoxia and hypercarbia and a disturbed renal function.This study aims to evaluate the benefit of an emergency decompressive laparotomy looking at mortality and organ function improvement after the operation in patients with an extracorporeal membrane oxygenation (ECMO), who are suffering from abdominal compartment syndrome.

Materials and methods:

All available data from all adult patients being treated at the University Medical Center HamburgEppendorf between 2011 and July 2019 was included for collection. Data from surgical reports, intensive care unit parameters and administrative data was collected.

Results:

71 ECMO patients with an abdominal compartment syndrome were identified. The mortality rate of these patients was 82 % with a median survival of one day. Those, who survived were discharged after 64 days on average. The laparotomy of these patients resulted in an immediate improvement of the organ functions in 11% only.

Conclusion:

Mortality among ECMO patients suffering from abdominal compartment syndrome is extremely high and the median survival short - despite receiving a decompressive laparotomy, which only leads to an immediate improvement in a tenth of these patients. Therefor the indication for this procedure should be evaluated critically.

Community, hospital acquired and postoperative peritonitis – outcome of ICU treated patients

(Abstract ID: 288)

B. Glaser¹, V. Justin¹, S. Kriwanek¹

¹SMZ-Ost, Donauspital, Wien

Background:

Complicated intra-abdominal infections (C-IAI) represent challenging diseases with high mortality rates. Depending on different selection criteria and therapy strategies the reported mortality rates vary between 7.6 and 36 percent. Usually a distinction between community (CAP) and hospital acquired peritonitis (HAP) is made. HAP can further be classified as postoperative peritonitis (POP) or nonpostoperative peritonitis (HAP-non-POP). This classification is essential due to the varying causes, patient characteristics and management strategies. Although the treatment options have improved over time, the survival rates have not. Hence we conducted a retrospective analysis of patients with complicated intra-abdominal infections requiring intensive care therapy representing the most challenging cases in abdominal surgery.

Materials and methods:

All patients with C-IAI requiring surgery and intensive care treated at the Danube Hospital in Vienna from January 2010 to August 2018 were retrospectively analyzed. A total of 195 patients where included into the study and grouped as CAP, HAP-non-POP or POP. Data concerning patient history, comorbidities, performed operations, ICU stay, complications and outcome was collected. For patient scoring the postoperative values were gathered from the ICU database. For each group comorbidity and patient characteristics, source and cause of infection, hospital and ICU stay, APACHE II, SAPS II and SOFA-Scores, mortality and outcome were calculated and compared to each other, using fisher exact test or Mann-Whitney-U-test. This study is a part of the "Donauspital Peritonitis Study - DSPPS" (Study Register DRKS00016165).

Results:

A total of 195 C-IAI were treated, consisting of 37.3% CAP, 12.7% HAP-non-POP and 50% POP. Concerning the patient characteristics and comorbidities no significant differences were seen between the groups, except for malignant diseases which were significantly higher in POP. The postoperative (Source control) APACHE II and SAPS II values did not differ between CAP and POP (APACHE II: mean CAP 13,5 /-6,99, mean POP 13,29 /-6,16) whereas both were significantly higher in HAP-nonPOP (APACHE II mean: 16,32 /- 8,0). Mortality rates were not significantly different in CAP and POP (34,2% vs. 36,26%): however, HAP-non-POP was complicated by a nearly doubled death rate (57,14%). ICU stay and overall hospital stay was significantly longer in the POP group (ICU mean 24,45 /- 24,96, overall 54,08 /- 53,73).

Conclusion:

Although patients with POP are described to have a higher mortality in the literature, this could not be shown in our study. Postoperative survival was comparable between CAP and POP patients. HAPnon-POP demonstrated a significantly higher mortality. This could be due to the preexisting comorbidities of these patients. Our study shows that postoperative peritonitis may have similar results as community acquired complicated intra-abdominal infection if complications are detected and treated at an early stage of peritonitis.

Microbiology of community, hospital acquired and postoperative peritonitis

(Abstract ID: 289)

V. Justin¹, B. Glaser¹, S. Kriwanek¹

¹SMZ OST - Donauspital, Wien

Background:

Secondary peritonitis is a severe and life threating surgical emergency with high morbidity and mortality rates. Usually a distinction between community (CAP) and hospital acquired peritonitis (HAP) is made. HAP can further be classified as postoperative peritonitis (POP) or non-postoperative peritonitis (HAP-non-POP). In addition to rapid source control and possible follow-up interventions (relaparotomy, planned or on demand; open abdomen, etc.) adequate antimicrobial therapy is essential to improve outcomes. Delay of appropriate antibiotic administration has been shown to negatively affect outcomes. Thus empiric antimicrobial therapy has to take suspected germ spectrum as well as possible resistance rates into account. Microbial selection and development of resistances pose problems during the usually prolonged administration of antibiotics for peritonitis. However, a possible negative effect of multi-resistant germs on mortality has not yet been clarified. Furthermore, the choice of a suitable antibiotic and the relevance of its efficacy on isolated germs from intraabdominal smears (infection vs. colonization) as well as the relationship between germ spectrum and clinical condition of the patients need to be clarified.

Materials and methods:

Bacteriological smears from 195 consecutive patients treated at a single institution from 2010 to 2018 requiring intensive care due to secondary peritonitis were evaluated retrospectively. 116 of those underwent open abdominal treatment. Patient characteristics and outcomes as well as germ spectrum and antimicrobial resistance rates were collected. Initial germ spectrum, changes over the course of therapy and possible development of resistance as well as potential influences on the clinical course were analyzed. Potential differences between CAP, POP and HAP-non-POP were evaluated. This study forms part of the "Donauspital Peritonitis Study - DSPPS" (Study Register DRKS00016165).

Results:

Microbial intraabdominal swabs of 195 (75 CAP, 90 POP, 28 HAP-non-POP) patients were analyzed Patient characteristics and outcomes between CAP and POP did not differ statistically, HAP-non-POP however showed significantly higher mortality rates. At index operation 77.7% of positive swabs identified a polymicrobial flora with E. coli (26%), Bacteroides spp. (18%) and Enterococcus spp. (15%) being the most common bacteria. We found no influence of the site of perforation on the composition of the microbial flora. At index operation 35.4% of tested bacteria were resistant to Ampicillin/Sulbactam (POP 44.2%; CAP 22.3%; HAP-non-POP 39.5%) while 29.0% were resistant to second generation cephalosporins (POP 29.5%; CAP 31.2%; HAP-non-POP 21.4%). As expected the microbial spectrum in patients with open abdomen shifted over time: after 7 to 30 days of open abdominal treatment Enterococcus spp. (37%) and Candida spp. (33%) were the most common germs identified.

Conclusion:

In this study we described the microbial flora of severe intraabdominal infections at a medium sized Central European acute care hospital. High rates of resistance against certain antibiotics should be taken into account for guiding empirical therapy in peritonitis.

Simple Wound Irrigation in the Postoperative Treatment for Surgically Drained Spontaneous Soft Tissue Abscesses - a Prospective, Randomized Controlled Trial

(Abstract ID: 509)

A. Rühle¹, F. Oehme², S. Hempel², K. Börnert³, B.-C. Link⁴, R. Babst⁴, J. Metzger⁴, F. Beeres⁴

¹Uniklinik Heidelberg

²Universitätsklinikum Dresden

³Kantonsspital Obwalden, Sarnen

⁴Kantonsspital Luzern

Background:

Soft tissue abscesses are among the most frequently encountered medical problems treated by different surgeons. Standard therapy remains incision and drainage with sterile saline irrigation during postoperative wound healing period. Aim of this prospective randomized controlled trial was to compare sterile irrigation versus nonsterile irrigation.

Materials and methods:

A single center randomized controlled trial was performed to investigate postoperative wound irrigation. The control group used sterile irrigation, and the intervention group used nonsterile irrigation. Primary endpoints were reinfection and reintervention rates, assessed during follow-up controls for up to two years. Secondary endpoints were the duration of wound healing, inability to work, pain and quality of life.

Results:

Between 04/2016 and 05/2017, 118 patients were randomized into two groups, with 61 allocated to the control- and 57 to the intervention group. Reinfection occurred in a total of 4 cases (6.6%) in the sterile protocol and 4 (7%) in the nonsterile protocol. Quality of life and pain values were comparable during the wound healing period, and patients treated according to the nonsterile irrigation protocol used significantly fewer wound care service teams. Despite equal wound persistence rates, a substantially shorter amount of time off from work was reported in the nonsterile protocol group (pvalue 0.086).

Conclusion:

This prospective, randomized trial indicates that a nonsterile irrigation protocol for patients operated for soft tissue abscesses is not inferior to the standard sterile protocol. Moreover, a nonsterile irrigation protocol leads to a shorter period of inability to work with comparable pain and quality of life scores during the wound healing period.

Acute mesenteric ischemia – is there a possibility for an early anastomosis? A retrospective cohort study

(Abstract ID: 984)

V. Martini¹, A.-K. Lederer¹, J. Fink¹, S. Utzolino¹, R. Huber¹, S. Fichtner-Feigl¹, L. Kousoulas¹

¹Uniklinik Freiburg

Background:

Acute mesenteric ischemia (AMI) is a fatal and prevalently lately diagnosed interruption of the small intestinal blood circulation, resulting ultimately in bowel necrosis. AMI is a rare diagnosis and can often only be proven by exploratory surgery. Typical treatment is composed of an early revascularization followed by an operative exploration for resection of necrotic areas. So far, it is not clarified what kind of surgical technique might be the most promising and whether an anastomosis might be a safe and feasible procedure in these patients.

Materials and methods:

A retrospective cohort analysis was conducted, aiming to evaluate the impact of surgical techniques on patient’s survival with proven AMI

Results:

54 patients were identified with the proven diagnosis of AMI. Overall hospital mortality was 61%. 19 patients presented with a complete ischemia intraoperatively and had unfavorable prognosis. 13 resectable patients received discontinuity resection, in another 20 patients anastomosis was performed. Patients with anastomosis had a similar mortality than patients with discontinuity resection (38% vs. 35%). The type and localization of anastomosis, respectively, had no influence on mortality. Pre- and postoperative hyperlactatemia was a risk factor for fatal outcome.

Conclusion:

AMI remains a fatal acute abdominal emergency with high mortality, but an early anastomosis might be performable in suitable patients.

Therapeutic approach of esophago-tracheal and -bronchial fistula

(Abstract ID: 988)

C. Mann¹, P. Grimminger¹, H. Lang²

¹Universitätsmedizin Mainz

²Universitätsmedizin der Johannes Gutenberg-Universität, Mainz

Background:

Esophago-tracheal or -bronchial fistulas are severe complications accompanied by high mortality. The therapeutical management remains challenging.

Materials and methods:

We analyzed the therapeutic approach of 15 patients in the course of 10 years which presented with esophago-tracheal or -bronchial fistula.

Results:

The data reflect the progression towards interventional approaches as first option. However, about 60% of the patients primarily treated interventionally required surgical treatment afterwards. Surgically direct closure with resorbable sutures or reconstruction with alloplastic or allogenous materials was the preferred method. In larger defects or high esophago-tracheal fistulas local transposition of muscular flaps or free muscular flaps played a major role. During operative reconstruction of high intrathoracic or cervical fistulas intraoperative neuromonitoring can be useful to prevent nerval damage. Operation was successful in 85% of the cases. 90-day mortality was 12,5% (n=1).

Conclusion:

Surgical intervention should be evaluated after unsuccessful endoscopic treatment or primarily, if endoscopic treatment is not feasible.

Motility disorders of the esophagus - a risk factor for the development of Barrett's esophagus?

(Abstract ID: 17)

L. Knepper¹, A.-K. Bär¹, D. T. Müller¹, H. Fuchs¹, C. Fuchs¹, S. Brinkmann¹, S.-H. Chon¹, W. Schröder¹, C. J. Bruns¹, J. Leers¹

¹Uniklink Köln

Background:

The Barret´s esophagus is becoming even more important against the background of an increasing incidence of adenocarcinoma of the esophagus. The question as to why only a few patients with gastroesophageal reflux disease (GERD) develop a Barrett's esophagus has not been clarified. This study aims to investigate the extent to which esophageal motility affects the development and progression of Barrett's mucosa in GERD patients.

Materials and methods:

A cohort of 315 GERD patients with and without Barrett's esophagus who received High Resolution Manometry (HRM) as part of their regular diagnostics was therefore examined in this study. The evaluation of the HRM results was based on the Chicago classification version 3.0 and was compared with endoscopic and histological findings.

Results:

Out of the 315 GERD patients, 67 had a Barrett's esophagus. The two patient groups (GERD without Barrett and GERD with Barrett) did not differ in demographic data and risk profile (hiatal hernia 71.4% vs 70.2%). In pH metry, both groups achieved a comparable DeMeester score as well as a similar fraction time (49.6 vs 44.2, 13% vs 11.7%). In both groups, approximately 40% of patients showed motility disorders. The mean basal pressure and the mean DCI also showed comparable values (21.2 vs 21.3, 1189.2 vs 1249.2). However, when comparing patients within the Barrett cohort with a long and a short segment Barrett (LSB, SSB), differences in peristalsis and pressure build-up of the distal esophagus become clear. Patients with an LSB showed a lower basal pressure of the lower esophageal sphincter (LES) and lower mean DCI (12.9 vs 25.0, 1230.0 vs 1389.3). In addition, they presented a hypotonic LES more frequently (54.6% vs 17.4%). Patients with LSB also showed motility disorders more often (54.6% vs 39.1%), especially ineffective motility and fragmented peristalsis (18.2% vs 10.9%, 9.1% vs 2.2%).

Conclusion:

The differences in motility disorders between Barrett and non-Barrett patients already described in other publications could not be confirmed in this study, despite the large cohort of 315 patients. However, the differences between LSB and SSB patients suggest that esophageal motility disorders can at least influence the severity of this disease.

Postoperative morbidity and failure to rescue in surgery for gastric cancer: A single-center analysis of 1107 patients from 1972 to 2014

(Abstract ID: 81)

C. Galata¹, U. Ronellenfitsch², S. Blank¹, C. Reißfelder¹, J. Hardt¹

¹Universitätsmedizin Mannheim (UMM)

²Universitätsklinikum Halle (Saale)

Background:

The aim of this study was to evaluate postoperative morbidity, mortality, and failure to rescue following complications after radical resection for gastric cancer.

Materials and methods:

A retrospective analysis of the surgical database for patients with gastroesophageal malignancies at the University Hospital Mannheim, Mannheim, Germany, was performed. All consecutive patients undergoing R0 gastrectomy for T1-4 M0 gastric adenocarcinoma between October 1972 and February 2014 were eligible for this analysis. Patients were divided into two groups according to the date of surgery, an early cohort operated on from 1972-1992 and a late cohort operated on from 1993-2014. Both groups were compared regarding patient characteristics and surgical outcomes.

Results:

A total of 1107 patients were included. Postoperative mortality was more than twice as high in patients operated on from 1972-1992 compared to patients operated on from 1993-2014 (6.8% vs. 3.2%, p=0.017). Between both groups, no significant difference in failure to rescue after major surgical complications was observed (20.8% vs. 20.5%, p=1.000). Whereas, failure to rescue after other surgical and non-surgical complications was 38.1% in the early cohort compared to 3.2% in the late cohort (p<0.001). Non-surgical complications accounted for 71.2% of lethal complications between 1972 and 1992 but only for 18.2% of lethal complications between 1993 and 2014 (p=0.002).

Conclusion:

In the course of four decades, postoperative mortality after radical resection for gastric cancer has more than halved. In this cohort, the reason for this decrease was reduced mortality due to nonsurgical complications. Major surgical morbidity after gastrectomy remains challenging.

Progression of thoracoscopic esophagectomy - evaluation and future perspective

(Abstract ID: 239)

T. Kamei¹

¹Tohoku University Hospital, Sendai

Background:

Thoracoscopic esophagectomy has been performed for two decades and becomes widely spread. We evaluate our cases whoundergone the thoracoscopic esophagectomy and consider the future prospective of this operation.

Materials and methods:

735 patients who received thoracoscopic esophagectomy in our institute from March 1995 to October 2018 were enrolled andstudied retrospectively. Operative indication is an all of the clinically resectable cases including with a neoadjuvant treatment ordefinitive chemoradiotherapy before surgery. Long term outcome of the patients with thoracoscopic esophagectomy was comparedto the result from comprehensive registry of esophageal cancer in Japan. Short term results of the perioperative parameters wereanalyzed between left lateral decubitus position and prone position

Results:

5year survival without neoadjuvant treatment was 88.9% (pStageI), 71.5%(pStageIIA), 68.1%(pStageIIB), 40.9%(pStageIII),respectively. 5 year survival rate of cStageII and III with neoadjuvant chemotherapy was 65.7% and 5 year survival rate of thesalvage esophagectomy after failure of definitive chemoradiotherapy was 31.4%. Every outcome is as good as any reported resultsin esophagectomy. In the comparison of the lateral position with the prone position, total blood loss was significantly lower in proneposition. Inflammatory response after surgery was improved more rapidly in prone group, therefore, prone position is recommendedas a minimally invasive procedure for thoracoscopic esophagectomy.(Technical progression)Not only operative positioning in prone esophagectomy but also 3D-CT imaging, intraoperative nerve monitoring, high definitionimage or total management has been made a progression for this operation

Conclusion:

Thoracoscopic esophagectomy will develop further as a standard operation for esophageal cancer. Robot assisted esophagectomywill probably spread quickly and reduction of postoperative complications is expected

Influence of peritoneal carcinomatosis on perioperative outcome in palliative gastric bypass for malignant gastric outlet obstruction

(Abstract ID: 249)

J. Bednarsch¹, Z. Czigany¹, D. Heise¹, H. Zimmermann¹, J. Böcker¹, T. F. Ulmer¹, U. P. Neumann¹, C. Klink¹

¹UK Aachen

Background:

Malignant gastric outlet obstruction (GOO) is commonly associated with the presence of peritoneal carcinomatosis (PC) and preferably treated by surgical gastrojejunostomy (GJJ) in patients with good performance. Here, we aim to investigate the role of PC as a risk factor for perioperative morbidity and mortality in patients with GOO undergoing GJJ.

Materials and methods:

Perioperative data of 72 patients with malignant GOO who underwent palliative GJJ at our institution between 2010 and 2019 were collected within an institutional database. To compare perioperative outcomes of patients with and without PC, extensive group analyses were carried out.

Results:

A set of 39 (54.2%) patients was histologically diagnosed with concomitant PC while the remaining 33 (45.8%) patients showed no clinical signs of PC. Inhouse mortality due to surgical complications was significantly higher in patients with PC (9/39, 23.1%) than in patients without PC (2/33, 6.1%, p=.046). Considerable differences were observed in terms of surgical complications such as anastomotic leakage rates (2.8% vs. 0%, p=.187), delayed gastric emptying (33.3% vs. 15,2%, p=.076), paralytic ileus (23.1% vs. 9.1%, p=.113) and pneumonia (17.9% vs. 12.1%, p=.493) without reaching the level of statistical significance.

Conclusion:

This is the first report directly investigating PC as a risk factor for impaired surgical outcome in GOO. In this context, PC is an important predictor of perioperative morbidity and mortality patients undergoing GJJ for malignant GOO.

Distribution of lymph node metastases in locally advanced adenocarcinomas of the esophagogastric junction (cT2-4): Comparison between Siewert-type I and selected Siewerttype II tumors

(Abstract ID: 261)

A. Sakaki¹, J. Kanamori¹, K. Ishiyama¹, D. Kurita¹, J. Oguma¹, H. Daiko¹

¹National Cancer Center Hospital, Tokyo

Background:

The distribution of lymph node metastases in locally advanced Siewert-type I and II AEG (adenocarcinoma of the esophagogastric junction) remains unclear. The diversity of data in the literature reflects the non-uniformity of tumor stages and surgical procedures in previous studies.

Materials and methods:

Based on a retrospective analysis from our single-center database, we examined distributions of lymph node metastases in types I and II cT2-4 AEG. The dataset comprised 44 patients; 19 and 25 patients had type I and type II, respectively. All patients underwent subtotal esophagectomy and total mediastinal lymphadenectomy, which included dissection of the upper mediastinal lymph nodes. Patients with AEG type I underwent this surgical procedure routinely. The indication for patients with AEG type II was either a tumor diameter of more than 4cm or a suspected mediastinal lymph node metastasis. The histological data of the surgical specimens were analyzed to evaluate metastasis rates in each lymph node station according to the Japanese Esophageal Society (JES)- and American Joint Committee on Cancer (AJCC)-guidelines.

Results:

Lymph node metastases were observed in 75,0% cases (n=33/44). There was no significant difference in the total lymph node metastasis rate between the two groups (type I: 73,7% versus type II: 76,0%). On comparing each lymph node region separately, no statistically significant differences were noted between the groups: upper mediastinal (type I: 31,6% versus type II: 24,0%), middle and lower mediastinal (type I: 31,6% versus type II: 44,0%), paragastric (type I: 61,1% versus type II: 76,0%), and celiac lymph nodes (type I: 16,7% versus type II: 25,0%).

Conclusion:

In advanced clinical stages, the metastasis rate is high at all mediastinal lymph node regions in both type I and II AEG. This result may reflect a possible tendency of AEG type II with a diameter of more than 4cm or a suspected mediastinal lymph node metastasis behaving biologically similar to the AEG type I regarding lymph node metastasis to the upper mediastinum.

Perioperative FLOT-chemotherapy and surgical resection for limited metastasized esophagogastric adenocarcinoma: Surgical Outcome and Overall Survival

(Abstract ID: 283)

M. Runkel¹, R. Verst¹, J. Spiegelberg¹, S. Fichtner-Feigl¹, J. Höppner¹, T. Glatz¹

¹UNIVERSITÄTSKLINIKUM FREIBURG

Background:

Current guidelines do not recommend surgical resection for patients with limited metastatic disease from esophagogastric adenocarcinomas, although some studies suggest a more favourable survival. We analysed the outcome of patients receiving FLOT chemotherapy followed by surgical resection for EGAC with limited metastatic disease.

Materials and methods:

The data of patients with limited metastatic EGAC were extracted from a prospective database of a single cancer centre during the 2009-2018 period. Forty-eight consecutive patients were identified who had been treated by FLOT chemotherapy followed by surgical resection of the primary and secondary lesions.

Results:

No patients died perioperatively. The overall 5-year survival was 18.7%. 12 patients, who had no histologic evidence of metastases after neoadjuvant FLOT chemotherapy and surgical resection, had a survival rate of 48.1% compared to a 11.1% survival rate of 36 patients, who had histologic metastatic evidence after FLOT chemotherapy and surgical resection (p=0.012). The survival rates after R0, R1 and R2 resection were 21,3%, 0% and 17%, respectively (p=0,273). Postoperative pathologic T-staging showed survival rates of 60% for T0 staging, 26,7% for T1-2 and 0% for T3-4 (p=0,047).

Conclusion:

Limited metastatic EGAC is associated with poor overall survival; however the subgroup of patients with good clinical response to neoadjuvant FLOT that show no histologic evidence of metastases has a favorable prognosis similar to published survival rates of patients with non-metastatic EGAC. The outcome remains low for non-responders despite resection. Our data do not challenge current guideline recommendations.

The effect of age on short-term and long-term outcomes after minimally invasive Ivor Lewis esophagectomy: A propensity matched analysis

(Abstract ID: 294)

D. Kröll¹, F. Martin¹, S. Knitter¹, M. Schmelzle¹, S. Chopra¹, C. Denecke¹, C. Benzing¹, T. Hofmann¹, J. Pratschke¹, M. Biebl¹

¹Charité - Universitätsmedizin Berlin

Background:

The number of elderly patients diagnosed with esophageal cancer rises due to increased incidence of esophageal adenocarcinoma and growing life expectancy. Current information about outcomes in elderly patients undergoing minimally invasive Ivor Lewis esophagectomy (MIE) is limited.

The aim of this study is to evaluate the influence of age on short- and midterm outcomes after MIE.

Materials and methods:

A retrospective review of 169 consecutive esophagectomy cancer patients undergoing MIE between August 2014 and July 2019 was performed. The study population was divided into patients aged >= 75 years (elderly group (EG), N=27) and patients <= 75 years (younger group (YG), N=142). Baseline patient characteristics, postoperative outcomes, 30- and 90-day mortality, and DFS and overall survival with a median FU of 12 months (95% CI [8.0-16.0]) were compared. After correction for baseline comorbidity, a 1:1 propensity-matched analysis was performed for inter-group comparison. Data are reported as median (range), with a p<0.05 considered significant.

Results:

In the total population, the distribution of baseline characteristics was different for preoperative chemotherapy (less in EG), cardiovascular- and renal diseases (more frequent in EG). Postoperatively, no significant differences in major complications, 30- and 90-day mortality, diseasefree or overall survival up to three years after surgery were noted.

In the case-matched cohort, the preoperatively noted differences subsided, with a mean age of EG (N= 27) 78 years (range 76-88), and YG (N=27) 54 years (38-74). The majority of patients were diagnosed with adenocarcinoma (67% and 63%, p = 0.750) of the lower third esophagus (70% and 59%, p = 0.393) for EG and YG patients, respectively.

Postoperatively, no significant differences in complications (67% vs. 41%, p = 0.056), 30- (4% vs. 4%, p = 1) and 90-day mortality (15% vs. 4%, p = 0.316) for EG vs YG, respectively, was noted.

In the elderly group, the median hospital length of stay was significantly longer compared to the younger group (23 vs. 14 days, p= 0.008), and postoperative pneumonia occurred in 56% (EG) vs. 33% (YG) of patients (p = 0.100).

Three-year DFS was 36% vs. 57% (p = 0.719) and 3-year OS 46% vs. 56% for EG vs YG, respectively (p = 0.741).

Conclusion:

Minimally invasive Ivor-Lewis esophagectomy resulted in acceptable postoperative morbidity and mortality, and good long-term survival in elderly compared to younger patients with esophageal cancer. However, older patients suffered more pulmonary complications, which resulted in a longer length of hospital stay. Intensive respiratory prehabilitation and postoperative rehabilitation is warranted in elderly patients undergoing MIE.

Impact of diameter of the circular stapled esophagogastric anastomosis on the incidence of postoperative leakage in minimally invasive esophagectomy (MIE)

(Abstract ID: 303)

D. Kröll¹, F. Martin¹, S. Knitter¹, M. Schmelzle¹, S. Chopra¹, C. Denecke¹, C. Denecke¹, T. Hofmann¹, U. Fehrenbach¹, J. Pratschke¹, M. Biebl¹

¹Charité - Universitätsmedizin Berlin

Background:

Anastomotic leakage (AL) remains a major cause for morbidity and mortality after esophageal cancer surgery. In minimally invasive esophagectomy with intrathoracic anastomosis, the use of a circular stapler (CS) has been widely accepted as a simple and convenient method. Several stapler sizes are in use, with no evidence available regarding potential differences in outcome between these staplers. The objective of this study was to compare the leakage rates of small diameter (25mm) versus large diameter (29mm) circular stapled esophagogastric anastomoses in MIE.

Materials and methods:

Retrospective review of all consecutive patients undergoing minimally invasive esophagectomy between 08/2014 and 07/2019 with a circular stapled thoracic oesophagogastric anastomosis within 1cm of the vena azygos were analyzed. Patients were divided according to the CS size: small-sized (25 mm, SM) and large-sized (29 mm, LA). Patient demographics, data regarding morbidity and clinical outcomes were compared. Primary outcome measure was anastomotic leakage rate (AL) during hospital stay.

Results:

A total of 119 patients were included (SM n=63, LA n=56). Demographics were similar in each group. Overall, anastomotic leakage were observed in 11.8 % (n=14). Upon univariate analysis, the incidence of anastomotic leakage was significantly lower in the LA group compared to the SM group (5 % vs. 18%, p< 0.04). There were no significant differences in duration of surgery, postoperative pulmonary complications, mortality, time of hospitalization and overall survival between the two groups. By univariate analysis, pneumonia, cardiovascular disease, renal insufficiency, pulmonary complications and small size stapler diameter were significant risk factors for AI. Only pulmonary complications (OR 5.3, 95 % CI= 1.0-27.3; p< 0.04) were identified as an independent risk factor for anastomotic leakage in multivariate analysis.

Conclusion:

In this retrospective analysis, for standard E/S circular stapled esophagogastrostomy at the level of the vena azygos, the use of a 29 mm stapler is preferable to a 25mm stapler.

A rare case of a trans-esophageal endoluminal gastric pull-up operation with cervical anastomosis

(Abstract ID: 429)

N. Emmanouilidis¹

¹Sankt Elisabeth Hospital Gütersloh

Background:

We report about a case of a persistent congenital esophago-tracheal fistula with multiple adverse coconditions, including: a severed gastro epiploic artery, multiple thoracotomies, an esophageal stent and a complete scarring encapsulation of the thoracic cavity without a possibility for a standard esophageal resection or a cervical pull-up through the upper thoracic aperture.

Materials and methods:

We report about a 22 year old patient with history of esophagus atresia Vogt Type IV and an open thoracotomy with a temporary gastrostomy catheter for nutrition when he was an infant. During childhood and adolescence he was repeatedly hospitalized and received about 25 endoscopic dilatation treatments of a recurrent stenosis of the esophagus.

Due to repeated dilatations the fistula reopened and the patient suffered from recurrent fluid aspirations and his health conditions deteriorated. Finally he was planned for an esophagus resection and reconstruction by a gastric conduit.

During the laparotomy it was discovered that the gastroepiploic artery had been severed. The plan for a gastric conduit reconstruction was withdrawn. As ultima ratio a covered expanding stent was implanted. However, the fistula and aspirations persisted and the patient's health conditions deteriorated further.

The patient was then transferred to our Abdominal Surgery Department.

Results:

The fistula was located above the level of the tracheal bifurcation and the stent was not removable due to an incarceration of the upper stent's tulip into a scarring ring of inflammatory tissue.

We planned for a retrosternal colon pull-up operation with a cervical anastomosis. During laparotomy we confirmed that the continuity of gastro-epiploic's artery had been severed. However, we decided to try a gastric conduit preparation and to evaluate the conduit after an interval 72 hours. The left gastric artery was dissected, the lesser curvature resected and a conduit of about 3-4cm width was stapled.

Three days later the gastric conduit had a normal arterial perfusion. We decided to proceed with the thoracotomy, but blundered into most severe pleural adhesions. The esophagus was merely identifiably and the upper thoracic aperture was not explorable at all, as there were no visible or palpable inter-tissue layers. The esophagus was opened by a longitudinal incision and the stent was extracted. The esophagus was incised and the fistula was closed by direct suture. The gastric conduit was pulled to the thoracic cavity, but due to non-existent inter-tissue layers it was impossible to dissect the esophagus from the dorsal part of the right and left bronchus or the trachea and thus it was impossible to perform an esophago-gastrostomy at the thoracic level.

A gastric catheter was forwarded orally and then connected to the end of the gastric conduit. The conduit was then pulled inside the esophageal lumen and upwards into the cervical portion of the esophagus.

A left sided cervicotomy was performed and the cervical part circumcised. The end of the gastric conduit was resected and a standard end-to-end esophago-gastrostomy was performed by continuous running suture.

The postoperative course was uneventful and the young man recovered to full health and enjoys a normal life to date.

Conclusion:

1. In case of impossible passage through the upper thoracic aperture it is possible to guide a gastric conduit through the esophagus itself, circumcise the cervical portion of the esophagus an perform a safe standard end-to-end esophago-gastrostomy.

2. A missing or dissected gastro-epiploic artery does eliminate the possibility for a gastric pull-up operation.

Picture:

Gastric conduit during endoluminal transesophgeal pull-up

Longterm-results of interventional sphincteraugmentation in GERD – is laparoscopic fundoplicatio obsolete?

(Abstract ID: 510)

A. Jell¹, N. Hüser¹, H. Feußner¹

¹Klinikum rechts der Isar, München

Background:

There is a significant therapeutic gap in the treatment of gastro-esophageal reflux disease (GERD) between medical therapy (PPI, H2, Antacida, …) and antireflux surgery. In the early 1980s first endoluminal antireflux procedures were described, appeared in the market and were further on tested in clinical routine. Although these endoluminal therapies seemed promising only little of them could show great long-term results and were removed from the market due to complication risks and unsatisfactory benefits. The aim of this study was to evaluate the efficiency as well as complication rate on applying endoluminal sphincteraugmentation in patients with gastro-esophageal reflux disease.

Materials and methods:

Patients with gastro-esophageal reflux disease who were referred to the Chirurgisches Gastrolabor at Klinikum rechts der Isar inbetween 2008 and September 2019 underwent fully gastrointestinal functional diagnostics for their symptoms (e.g. pH/impedance, manometry studies, endoscopy, videofluoroscopy, FEES). After completing diagnostics we performed 72 endoscopic sphincteraugmentations on patients with chronic reflux disease and absence of hiatal hernia. Besides diagnostics the peri- and post-interventional data was evaluated and all these patients had a follow-up using standardized questionnaires for quality of life, GERD-related symptom scores and measurement of anti-acidic medication.

Results:

During November 2008 and September 2019 we performed 74 endoscopic sphincteraugmentations in 67 patients with gastro-esophageal reflux disease. In 17 patients the EsophyX® device and in 50 patients the GERDx® device was used. Of the 17 patients originally assigned to the EsophyX procedure 2 patients had to be excluded due to procedure failure during sphincteraugmentation while none of the GERDx procedures showed technical problems. Of the remaining patients 80% completed the follow-up. Among the GERDx-patients 5 received a second GERDx-sphincteraugmentation due to a relapse of symptoms, while 3 patients treated with EsophyX and 5 patients treated with GERDxsphincteraugmentation underwent laparoscopic fundoplication due to a relapse of symptoms. Both procedures turned out to be safe as no severe complications did occure. On the long run 9 patients (75%) who underwent EsophyX-procedure could cut down on PPI-medication on at least 50 percent, while it was slightly lower in GERDx-patients. Both groups showed significantly improved quality of life and GERD-related symptom scores (p < 0,05).

Conclusion:

Interventional sphincteraugmentation turned out to be a very safe procedure in patients with chronic gastro-esophageal reflux disease that can even be repeatedly applied of necessary. On a long-time follow up on to 10 years a significant reduction on PPI-medication and concurrently increase of quality of life and a GERD-related symptom score could be shown.

Nevertheless as interventional sphincteraugmentation can only be performed in patients without hiatal hernie which is very likely to be coincident in patients with GERD laparoscopic fundoplicatio is not (yet) obsolete. But there are first good long-term results that have to be further investigated in larger prospective randomized trials to show if these positive results can be maintained on the long run.

RefluxStop™: 1-year Results of a Novel Procedure to Address Gastroesophageal Reflux Disease

(Abstract ID: 547)

Y. Borbély¹, T. Haltmeier¹, M. Bjelovic²

¹Universitätsspital Inselspital Bern

²University Hospital for Digestive Surgery, Belgrad

Background:

Gastroesophageal Reflux Disease (GERD) is one of the most common gastrointestinal disorders that not only impedes quality of life (QoL) but can also lead to Barrett’s esophagus. Traditional antireflux surgery is effective and safe but carries the burden of possible long-term consequences such as dysphagia, bloating and diarrhea. Novel methods seek to provide the same efficacy whilst having lesser side-effects.

RefluxStop™ is a new implantable medical device not compromising the food passageway. It is based on restoring and reinforcing the angle of His secured by implantation of a silicon ball into the fundus.

Hence, it mechanically prohibits the Lower Esophageal Sphincter from moving into the thorax.

Materials and methods:

In this multicenter, single arm and prospective trial to gain CE-certification, data from patients undergoing a RefluxStop™-procedure were collected and analyzed. At baseline and in the follow-up, demographic, subjective (GERD-Health Related-QoL (HRQL)-questionnaires; every 6 months) and objective data (after 6 months: routine off-proton pump inhibitor (PPI)-24-pH-manometry; barium swallows and upper endoscopies in case of subjective improvement <50%) were recorded.

Included were patients >18 years with GERD symptoms and esophageal pH <4 in more than 6%, excluded were patients with prior esophagogastric procedures, hiatal hernias >3cm, major esophageal motility disorders and Body Mass Index >35kg/m2.

Operative steps consisted of laparoscopic esophageal mobilization, posterior hiatoplasty, restoration of the angle of His and fundo-esophagopexy of 5 cm followed by implantation and invagination of RefluxStop™ in the upper gastric fundus.

Results:

50 patients were included, 1-year follow-up was available for 47 (94%).

Mean GERD-HRQL (max 50 points) at baseline was 28.8±7.3, after 6 months 3.5±5.9 and after 1 year 4.0±6.9. Improvement of >50% in GERD symptoms compared to baseline was reported in 44 subjects (94%); mean score improvement was 89%. 34 patients (72%) had moderate (3-4/day) or severe (³5/day) episodes of regurgitation preoperatively. After 1 year, 1 patient (2%) had moderate regurgitation, 44 (94%) had no symptoms. There were no patients with de novo dysphagia.

At baseline, all patients needed daily PPI, after 1 year one patient (2%).

Esophageal acid exposure (n=45, 96%) was reduced from 16.35%±16.6 at baseline to 0.80±1.56 after 6 months (p<0.001). Of the 5 patients refusing control pH-metry, 4 (9%) had a GERD-HRQL score of 2; one patient (2%) had less than 50% subjective improvement, barium swallow showed an implant positioned too low.

Conclusion:

Restoring and reinforcing the angle of His using the novel RefluxStop™-device resulted in excellent subjective GERD symptom control and normalization of esophageal acid exposure. There was no de novo dysphagia whilst regurgitation was normalized in the vast majority. Further prospective studies with longer follow-up are needed to confirm these results.

Literature-based approach identifies rs10423674, rs10419226, rs1979654 and rs9936833 as significant SNPs for oncologic outcome in upper GI surgery

(Abstract ID: 580)

J.-O. Jung¹, H. Nienhüser¹, L. Peters¹, B. P. Müller-Stich¹, M. Büchler¹, T. Schmidt¹

¹Universitätsklinikum Heidelberg

Background:

Cancers of the upper gastrointestinal tract are devastating diseases with a rising incidence worldwide. In the Western World, gastroesophageal reflux disease (GERD) and Barrett’s esophagus (BE) caused by obesity have led to increasing rates of adenocarcinomas in the upper gastrointestinal tract, especially in the region of the cardia and gastroesophageal junction. Various SNPs have been identified in the past which are associated with either GERD and BE or directly with esophageal and gastric adenocarcinoma (AC). The goal of this study was to find clinically relevant SNPs by correlating these with survival data.

Materials and methods:

In a prospective database, data of 211 patients with gastric or esophageal adenocarcinoma was collected who underwent oncologic resection between 2008 and 2017 at Heidelberg University Hospital, Department of General Surgery. The collected data included preoperative characteristics, perioperative course and survival data which was recently updated in June 2019.

We genotyped all patients with Infinium OmniExpress, Infinium OmniExpressExome and Infinium Omni2.5Exome BeadChips (by Illumina®) according to manufacturer’s protocol. Quality control was performed by PLINK v1.90b6.6 and samples with genotype call rates less than 97%, discrepancies in sex, divergent ancestry from the CEU HapMap 2010 population and related samples were excluded. Imputation was performed with IMPUTE2 and on high standards (SNP call rate > 95%, MAF >1% and HWE > 0.001). Post-imputation quality control led to further exclusion following additional criteria (INFO-score < 0.8, HWE < 0.001, MAF < 1% and SNP missing rate > 5%).

We selected SNPs out of the existing literature introduced as being relevant for either BE, GERD or esophagogastric cancer by searching the PubMed database. We extracted the genotype information for each SNP by Gtool v0.7.5 and eventually correlated it with survival data by performing Mantel-Cox comparisons on STATA/SE 15.0 for Mac.

Results:

We selected 32 SNPs from literature review with four SNPs showing significant survival differences on a significance level of a = 0.05: For rs10423674, 19 patients belonged to group GG, 93 to group TG and 99 to group TT (p = 0.0009). For rs10419226, 58 patients were classified as AA, 103 as AC and 50 as CC (p = 0.0350). rs9936833 was divided into 24 patients belonging to group CC, 108 to group CT and 79 to group TT (p = 0.0337). Regarding rs1979654, 65 patients were classified as group CC, 109 as group GC and 28 as group GG (p = 0.0338). All SNP IDs, genetic information and median survival times in months are summarized in Table 1 and Figure 1.

Conclusion:

rs10423674 as well as rs10419226 have been shown to be involved in BE and AC according to metaanalysis of several GWAS. The loci each map to an intron of CRTC1 which has been identified as a candidate gene since it has oncogenic potential and is regulated by tumor suppressor LKB1. rs9936833 is located on chromosome 16q24 with its closest protein-encoding region being FOXF1 which is involved in esophageal development and structure. rs1979654 was found to be in strong linkage disequilibrium with rs9936833 with simultaneous association with risk of Barrett’s esophagus. rs1979654 lies in a DNase 1 hypersensitive cluster (DHSs) and probably affects binding of transcription factors such as STAT3, MYC and FOXA1.

By correlating above-mentioned SNPs with our survival data, we achieved further narrowing of many available SNPs down to clinically relevant ones and thus a potentially individualized treatment for the future.

Picture:

Figure 1

Impact of splenectomy in the surgical treatment of gastric cancer – results of a prospective multicenter observational study

(Abstract ID: 592)

I. Gastinger¹, K. Heine², R. Otto², F. Meyer¹, S. Wolff¹, R. S. Croner¹

¹Otto-von-Guericke University with University Hospital at Magdeburg

²Otto-von-Guericke University at Magdeburg

Background:

Splenectomy can be associated with an increase of postop. complications but a worse 5-yr survival.

Materials and methods:

From 01/01/2007-12/31/2009, all patients (nin total=2,897; surgical depts., n=141) with primary gastric Ca/Tu lesion of the esophagogastric junction (AEG-Tu) who underwent surgery were registered.

Results:

Overall, 2,545 patients (=group[gr.] 1) underwent Tu resection. Gr.2/3/4/5: AEG-Tu (n=475)/distal gastric Ca (n=2,070)/intraop. spleen injury (n=127)/splenectomy (n=94) due to Tu infiltration vs. injury.

Splenectomy rate was 11.1 % (n=283) with the highest proportion in AEG-Tu (19.4%; no signif. differences among the groups regarding age, sex ratio & ASA).

Surgical procedures: The highest splenectomy rate was found in transhiatally ext. gastrectomy (in total, 30.2 %; AEG-Tu, 27.3 %; distal gastric Ca, 38.6 %).

Morbidity in case of splenectomy was higher overall & depending on Tu site (the same in general postop. complication rate; specific postop. complication rate, no difference).

Lethality post-splenectomy: Only in AEG-Tu, it was signif. higher (15.2 vs. 5.0 %).

All splenectomized patients showed a shorter long-term survival (p<0.001; 18 vs. 36 months with preservation of the spleen).

The lowest 5-yr-survival rates were observed in splenectomized AEG-Tu patients (25 %) & in those with splenectomy due to Tu infiltration (20 %).

Logistic regression: Spleen preservation - signif. independent variable regarding lower postop. morbidity whereas splenectomy was associated with higher postop. complication rate. Overall, splenectomy did not provide a signif. impact onto lethality. However, splenectomy as part of resection in AEG-Tu was associated with a signif. higher lethality. A tendential impact of splenectomy onto a lower overall survival was only seen in the group of AEG-Tu.

Conclusion:

Splenectomy - negative predictor for a worse early postop. & long-term oncosurgical outcome; therefore, it can only be justified by direct Tu infiltration or irreparable spleen injury.

Minimally invasive robot-assisted resection of submucosal esophageal tumors

(Abstract ID: 754)

S. Chopra¹, M. Biebl¹, P. Grimminger², D. Perez³, J. Pratschke¹, T. Becker⁴, H. Lang⁵, J. Izbicki³, J.-H. Egberts⁴

¹Charité - Universitätsmedizin Berlin - CVK

²Universitätsmedizin Mainz

³Universitätsklinikum Hamburg-Eppendorf

⁴Universitätsklinik Schleswig-Holstein, Kiel

⁵Universitätsmedizin der Johannes Gutenberg-Universität, Mainz

Background:

Minimally invasive enucleation is the treatment of choice for benign mesenchymal tumors of the esophagus. Indications for surgery are symptomatic tumors or lesions larger than 3-5cm. Robotassisted esophageal surgery potentially offers a further refinement to minimally-invasive organpreserving resection. Aim of the study was the evaluation of the DaVinci robotic system for minimally invasive resection of benign esophageal tumors.

Materials and methods:

A retrospective review of the robotic cases entered in the individual institutional electronic databases was conducted. All consecutive robotic resected submucosal tumors of the esophagus between 2015 to 2019 were analyzed for indication, operative and postoperative parameters. To approach the esophagus, a right-sided thoracoscopic access in single-lung ventilation was used. Using either a Si or Xi system, one camera port, 2-3 8mm robotic ports and on assist port were used. Suturing of the muscularis of the esophagus after resection was left to the surgeons discretion. At the end of the operation, a 20 CHR chest tube was placed in the pleural cavity. Data are presented in a descriptive manner as median (range) or total numbers (%).

Results:

A total of 15 patients (8 female, age 49 (28-67) years) were identified. Performance status was excellent (Karnofsky index 100% (90%-100%)), ASA-score 2 (1-3) in all patients. Location of the tumor was mainly the distal esophagus (distance from incisions 31 (25-40) cm). Duration of surgery was 136 (48 - 276) min with 1 (7%) conversion to open surgery for a bronchial lesion from the tubus, and successful resection of the lesions in all cases. Intraoperative blood-loss was 0 (0 - 150 ml), with one mucosal lesion to the esophagus (sutured intraoperatively) and no thoracic duct or pulmonary lesion recorded. Operation time decreased from 227 (108 - 276) min before 2018 to 119 (48 - 140) min thereafter. Size of the resected lesion ranged from 46 (25 - 120)mm, histology confirmed complete resection in all cases. Histology revealed leiomyoma (67%), GIST (13%), schwannoma, bronchiogenic cyst and myxoide mesenchymal tumor (7% each). Postoperatively, the chest tube was removed on POD 3 (2-6). No leakages, dysphagia, recurrences or esophageal stenoses were encountered. Length of stay was 7 (3 - 28) days. Postoperative morbidity was 14% (1x Dindo II, 1x Dindo IIIb).

Conclusion:

The robotic approach allows a selective and safe removal of even large and lobulated tumors from the esophageal wall. A learning curve effect in procedural time was noted after the first 3-4 procedures.

Quantification of the micoperfusion of gastric tube using fluorescence angiographie (FA) with Indocyanine green (ICG)

(Abstract ID: 829)

P. H. von Kroge¹, D. Russ², D. Perez¹, J.-R. Izbicki¹, O. Mann¹, S. H. Wipper¹, A. Duprée¹

¹Universitätsklinikum Hamburg-Eppendorf

²Universität Ulm

Background:

The incidence of esophageal cancer is increasing. Surgical treatment continues to be the therapy of choice in resectable stages of esophageal cancer. Despite technical improvement with minimal invasive therapeutic approaches, anastomotic leakage remains a prevalent and threatening complication after esophagectomy.

The evaluation of gastric tube perfusion using fluorescence imaging (FI) with indocyanine green (ICG) has been published in several studies and is a promising tool regarding the reduction of anastomotic leakage. However, the described use of technology is merely subjective.

In a previous study our group investigated and validated the quantification of microperfusion of the gastric tube using FA (fluorescenceangiography) with ICG in a porcine model. Now we have started a pilot study to transfer the data into clinical usage.

Materials and methods:

In six patients with esophageal cancer a thoracoabdominal esophagectomy was performed. For reconstruction, a gastric tube was created.

Intraoperatively, a FA with ICG of the gastric tube using SPY Elite (NOVODAQ) was performed. The FA was evaluated postoperatively. The whole gastric tube was divided into ten regions of interest (ROI) starting at the prepyloric region and ending at the tip of the tube. In every ROI a fluorescence intensity curve was created. From this curve, three parameters were calculated: The slope of fluorescence intensity (SFI), the background substracted fluorecence intensity (BSFI) and the background substracted peak fluorescence intensity (BSPFI). In addition, the prepyloric region was set as a baseline. The remaining values were set in relation to this baseline value, to calculate a ratio.

Results:

We were able to validate the quantification of microperfusion of the gastric tube in humans. The expected perfusion pattern with decreasing perfusion with increasing distance to the pylorus was confirmed. SFI-Ratio at the tip of the gastric tube in relation to baseline was 0,11 0,12, BSPFI-Ratio was 0,18 0,14 and BSFI was 0,4 0,49. The values in between showed also a declining trend. In almost every case the postpyloric region showed good perfusion up to a line of demarcation. After that line the intensitiy was decreasing up to the tip of the tube. The value adjacent to the line showed a difference. The mean SFI-ratio proximal of the line was 0,65 compared to 0,18 in the distal ROI. For the BSFI the ratio in the proximal ROI was 0,67 and 0,29 in distal region. BSPFI values were 1,06 and 0,9 around the line of demarcation.

Conclusion:

The quantifcation of the microperfusion of the gastric tube is feasible using FA with ICG. The calculated parameters SFI, BSPFI and BSFI confirmed the expected perfusion pattern, and therefore can predict the local intensity of circulation.

FA with ICG might be a promising tool in evaluation of anastomotic perfusion after esophagectomy.

Picture:

FA of gastric tube with line of demarcation and Parameters

Tumor response and proliferation index ki-67 as predictors for overall survival in patients with peritoneal metastases of gastric cancer treated by complete cytoreduction and hyperthermic intraperitoneal chemotherapy

(Abstract ID: 855)

A. Brandl¹, U. Fehrenbach¹, A. Arnold¹, M. Jara¹, L. Feldbrügge¹, J. Pratschke¹, P. Thuss-Patience¹, B. Rau¹

¹Charité - Universitätsmedizin Berlin

Background:

Patients with peritoneal metastases of gastric cancer have a poor prognosis and a median survival of 7 months. Cytoreductive surgery (CRS) in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) showed promising results in selected patients. The aim of this study was to determine preoperative predictors for overall survival in these patients in order to improve patient selection beyond Peritoneal Cancer Index (PCI).

Materials and methods:

This retrospective analysis included patients with synchronous peritoneal metastases of gastric cancer treated between March 2008 and December 2017 with CRS & HIPEC and complete cytoreduction at our institute. Preoperative factors like regression grade (pathologic and radiologic) were as well included as histopathologic markers. The statistical analysis included Log rank test and Cox regression analysis.

Results:

A total of 52 patients (29 female) with a mean age of 54.2±9.4 years, and a mean PCI of 7.0±5.5 were included in this analysis. The median overall survival was 14.0 months, the median recurrence free survival 9.8 months. Cox regression analysis revealed ki-67 >40% (HR 2.89; 1.24 - 6.74; p=0.014) as a predictor for overall survival. Regarding the tumor regression analysis, the presence of ascites after preoperative chemotherapy was the strongest predictor for overall survival (5.4 months) compared to patients with no ascites (21.3 months; p=0.008) at the time of CRS & HIPEC.

Conclusion:

Ki-67 >40% and the presence of ascites after preoperative chemotherapy seem to be strong predictors for deteriorated overall survival in patients with peritoneal metastasis of gastric cancer treated with complete cytoreduction and HIPEC. The analysis of larger cohorts (e.g. multicenter trial) are necessary to confirm this hypothesis.

Postoperative Diaphragmatic prolapse after transthoracic esophagectomy

(Abstract ID: 858)

I. Bartella¹, H. Fuchs¹, L. Knepper¹, C. J. Bruns¹, J. Leers¹, W. Schröder¹

¹Uniklinik Köln

Background:

Diaphragmatic transposition of intestinal organs is a major complication after esophagectomy and can be associated with significant morbidity and mortality. This study aims of to analyze a large series of patients with this condition in a single high-volume center for esophageal surgery and to suggest a novel treatment algorithm.

Materials and methods:

Patients who received surgery for post-esophagectomy diaphragmatic prolapse (PEDP) between October 2003 and December 2017 were included. Retrospective analysis of demographic, clinical and surgical data was performed. Outcomes of measure were initial clinical presentation, postoperative complications, in-hospital mortality and prolapse recurrence.

Results:

39 patients who had surgery for PEDP were identified. PEPD occurred after a median time of 259 days following esophagectomy with the highest prevalence between one and 12 months. 84.6% of the patients had neoadjuvant radiochemotherapy prior to esophagectomy. The predominantly effected organ was the transverse colon (87.2%) prolapsing into the left hemithorax (81.6%). 20 patients required emergency surgery. Surgery always consisted of reposition of the intestinal organs and closure of the hiatal orifice; a laparoscopic approach was used in 25.6%. Major complications (DindoClavien >=IIIb) were observed in 35.9%, hospital mortality rate was 7.7%. Three patients developed recurrent PEDP during follow up.

Conclusion:

PEDP is a functional complication of the late postoperative course and predominantly occurs in patients with locally advanced adenocarcinoma having chemoradiation before Ivor-Lewis esophagectomy. Due to a high rate of emergency surgery for PEDP with life-threatening complications not a ,wait-and-see’ strategy but early surgical repair appears to be indicated when PEDP is diagnosed.

Gastrointestinal stromal tumors (GIST) of the Upper Gastrointestinal Tract - Data from the German Cancer Registries

(Abstract ID: 912)

M. Thomaschewski¹, U. Wellner¹, L. Pieper¹, Y. Keck¹, T. Keck¹, R. Hummel¹

¹Universitätsklinikum Schleswig-Holstein (UKSH), Lübeck

Background:

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors and represent approximately 25% of all sarcomas. The Association of German Tumor Centers e.V. (ADT) is working to merge the regional clinical cancer registries in order to better map the treatment of various tumor diseases in Germany. The aim of this work was to evaluate GIST of the upper gastrointestinal tract (OGI) using ADT register data.

Materials and methods:

Between 2000 and 2016, 101,559 records with the diagnosis C15 (gastric carcinoma) and C16 (esophageal carcinoma) were reported from 19 registries in 12 federal states. This corresponds to approximately 25% of patients nationwide in this period. 1.7% of these cases (n=1,696) are GIST tumors of the esophagus, cardia and stomach. The data were analyzed with regard to epidemiology, tumor stages, therapy and survival.

Results:

Men are slightly more frequently affected with 54%. The peak age is between 71-75 years, the median age of onset is 69 years. Women are affected much more frequently with increasing age. The reporting rate increased steadily from 2,000 (0.2% of all OGI tumours) to 3.5% by 2016. GIST of the stomach are most common in the OGI tract, with men showing almost twice the incidence of tumors at the cardia (6.6% vs. 3.5%) and in the esophagus (3.7% vs. 1.9%) compared to women. Metastases were described more frequently in men (13.2% vs. 10.1%) and were more frequent with increasing age and higher localization (stomach vs. cardia vs. oesophagus: 11% vs. 15% vs. 25%). Detailed treatment information was available for 570 patients. Of these, 24.4% were treated conservatively. However, the proportion of conservative treatment decreased steadily between 2000 and 2016. Women show a significantly better long-term survival, which also correlates with age and tumor localization. Interestingly, tumor size does not correlate with survival.

Conclusion:

Data from the German Cancer Registries allow a detailed analysis of the current treatment of GIST of the OGI-tract in Germany.

Signet ring cell carcinoma of the stomach and the young cancer patient - Data from the German Cancer Registries

(Abstract ID: 915)

M. Thomaschewski¹, U. Wellner¹, Y. Keck¹, L. Pieper¹, T. Keck¹, R. Hummel¹

¹Universitätsklinikum Schleswig-Holstein (UKSH), Lübeck

Background:

In gastric cancer patients there is a subgroup of young patients with very aggressive tumors. The Association of German Tumor Centers (ADT) is aiming to merge the regional clinical cancer registries in order to better map the treatment of various tumor diseases in Germany. The aim of this work was to use the ADT registry data to investigate and characterise the subgroup of young patients with gastric cancer.

Materials and methods:

Between 2000 and 2016, 101,559 records with the diagnosis C15 (gastric carcinoma) and C16 (esophageal carcinoma) were reported from 19 registries in 12 federal states. This corresponds to approximately 25% of patients nationwide in this period. 56,776 of these patients are patients with gastric cancer. The data were analysed with regard to demography, tumor characteristics, therapy and survival.

Results:

Initially, there is only a single peak age in patients with gastric carcinoma at about 75 years. However, an analysis of the histological subtypes showed that the proportion of patients with signet ring cell carcinoma increased steadily with decreasing age and reached a rate of >50% in patients under 60 years of age. This corresponded to 20% of the patients in the total collective. This subgroup of patients presented significantly more advanced tumor stages (T3/4: 51% vs. 48%; N0: 43% vs. 47%; M0: 64% vs. 68%) as well as worse differentiations (G3: 73% vs. 59%) compared to the remaining older 80% of patients and could be treated significantly less frequently in a curative intent (36% vs. 49%). Interestingly, the overall survival of the young patients was still better compared to the older patients. A further analysis of the patients with signet ring cell carcinomas also showed a similar biological behaviour as in patients with diffuse tumours. Intestinal tumors differed significantly. Diffuse tumors and signet ring cell carcinoma showed much more frequently metastatic cancer to the peritoneum than intestinal tumors, which showed to over 50% metastatic cancer to the liver. The response to neoadjuvant therapy also differs significantly; the rate of complete responders in signet ring cell carcinomas in this collective is 0%.

Conclusion:

Data from the German cancer registries allow detailed analysis and characterization of patient subgroups that are clinically relevant.

Reduction of surgical trauma leads to better result after esophagectomy: A comparison of four surgical approaches

(Abstract ID: 919)

P. C. van der Sluis¹, B. Babic¹, E. Uzun¹, E. Tagkalos¹, F. Berlth¹, E. Hadzijusufovic¹, F. Corvinus¹, M. Hoppe-Lotichius¹, S. Heinrich¹, H. Lang², I. Gockel³, P. Grimminger¹

¹Unimedizin Mainz

²Universitätsmedizin der Johannes Gutenberg-Universität, Mainz

³Universitätsklinikum Leipzig

Background:

With the introduction of minimally invasive esophagectomy, postoperative complications rates have decreased. There are 3 surgical strategies for minimally invasive esophagectomy; hybrid esophagectomy (HE), conventional minimally invasive esophagectomy (MIE) and robot assisted minimally invasive esophagectomy (RAMIE). In this study, the 3 different strategies for minimally invasive esophagectomy (HE, MIE and RAMIE) are compared to open transthoracic esophagectomy (OTE).

Materials and methods:

Between 2008 and 2019, 422 consecutive patients underwent thoraco-abdominal esophagectomy with gastric conduit reconstruction. Patient characteristics and postoperative results were recorded in a prospective database. Four different surgical approaches (OTE, HE, MIE and RAMIE) were compared.

Results:

Four different esophagectomy techniques; open (n=107), hybrid (n=101), conventional minimally invasive (n=91) and robot-assisted minimally invasive (n=123) technique were evaluated. An uncomplicated postoperative course was observed in 27% (OTE), 34% (HE), 53% (MIE) and 63% (RAMIE) of patients (p<0.001). Pulmonary complications were observed in 57% (OTE), 44% (HE), 28% (MIE), and 21% (RAMIE) of patients (p<0.001). Cardiac complications were observed in 25% (OTE), 23% (HE), 9% (MIE), and 11% (RAMIE) of patients (p<0.001). Median hospital stay after esophagectomy was 20 days (OTE), 17 days (HE), 13 days (MIE) and 12 days (RAMIE) (p<0.001). A radical resection was observed in 95% (OTE), 96% (HE), 96% (MIE), and 93% (RAMIE) (p=0.651). A median number of 21 (OTE), 23 (HE), 23 (MIE), 31 (RAMIE) (p<0.001) were harvested.

Conclusion:

Compared to open transthoracic esophagectomy and hybrid esophagectomy, conventional minimally invasive esophagectomy and robot assisted minimally invasive esophagectomy were accompanied with less postoperative complications and shorter hospital stay without a compromise in short term oncological results. In esophagectomy, avoiding thoracotomy resulting in a reduction of surgical trauma, results in better postoperative results and shorter hospital stay. Robot assisted minimally invasive esophagectomy might results in improved lymph node dissection.

CRP levels after esophagectomy are associated with increased surgical trauma and complications

(Abstract ID: 930)

P. C. van der Sluis¹, B. Babic¹, I. Gockel², F. Corvinus¹, E. Tagkalos¹, E. Hadzijusufovic¹, M. Hoppe-Lotichius¹, H. Lang³, P. Grimminger¹

¹Unimedizin Mainz

²Universitätsklinikum Leipzig

³Universitätsmedizin der Johannes Gutenberg-Universität, Mainz

Background:

With the introduction of minimally invasive esophagectomy, postoperative complications rates have decreased. Daily laboratory tests are used to screen patients for postoperative complications. The course of inflammatory parameters after esophagectomy following different surgical approaches has not been described yet. The aim of the study was to describe the postoperative CRP and leukocyte levels after different surgical approaches for esophagectomy and relate it to postoperative complications.

Materials and methods:

Between 2010 and 2018, 217 consecutive patients underwent thoraco-abdominal esophagectomy with gastric conduit reconstruction. Blood tests regarding C-reactive protein (CRP) and leukocytes were performed daily in all patients. Differences between treatment groups were analyzed with a linear mixed model. All postoperative complications were recorded in a prospective database. Prognostic factors were analyzed using a multivariate logistic regression modeling.

Results:

Four different esophagectomy techniques; open (n=57), hybrid (n=53), totally minimally invasive (n=52) and robot-assisted minimally invasive (n=55) technique were evaluated. The increase of inflammatory parameters was significantly higher after open esophagectomy on the first two postoperative days compared to the 3 minimally invasive procedures (p<0.001). Postoperative CRP values >200mg/l on the 2nd postoperative and open esophagectomy were independently associated with postoperative complications.

Conclusion:

Open esophagectomy results in significantly higher CRP and leukocyte values compared to the hybrid, minimally invasive and robot assisted minimally invasive esophagectomy. Open esophagectomy and a CRP increase on the 2nd postoperative day above 200mg/l are independent positive predictors for postoperative complications in multivariate analysis.

A Structured Training Pathway to Implement of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE): The Learning Curve Results from a High Volume Center.

(Abstract ID: 933)

P. C. van der Sluis¹, F. Kingma², E. Hadzijusufovic¹, H. Lang³, J. Ruurda², R. van Hillegersberg², P. Grimminger¹

¹Unimedizin Mainz

²UMC Utrecht

³Universitätsmedizin der Johannes Gutenberg-Universität, Mainz

Background:

A structured proctoring program was developed to safely and effectively train surgeons in robotassisted minimally invasive esophagectomy (RAMIE). The aim of this study was to describe the results of this structured training pathway in a high volume center for esophageal cancer surgery.

Materials and methods:

Consecutive patients who underwent RAMIE by a single surgeon who followed the structured training pathway were included from the trainee center’s prospective database. Cumulative sum (CUSUM) learning curves were plotted for thoracic operating time and intraoperative blood loss. Perioperative outcomes were compared between patients who underwent surgery before and after a learning curve plateau occurred.

Results:

Between 2017-2018, the trainee team adhered to the structured training pathway and a total of 70 patients were included. The learning curves showed plateaus after 22 cases. In cases 23-70, the operating time was shorter for both the thoracic phase (median 215 vs. 249 minutes, P=0.001) and overall procedure (median 394 vs. 440 minutes, P=0.005), intraoperative blood loss was less (median 210 vs. 400 milliliters, P=0.029), and lymph node yield was higher (median 32 vs. 23 nodes, P=0.001) when compared to the first 22 cases. No significant differences were found between these groups regarding conversion rates, postoperative complications, length of hospital stay, radicality, or mortality.

Conclusion:

The structured RAMIE training pathway results in a short learning curve and is a safe and effective way to introduce RAMIE without compromising the oncological outcomes and complication rates. The pathway is therefore advised to surgeons who are willing to adopt this technique.

The diameter of the circular stapler used for creating an intrathoracic esophagogastric anastomosis following esophagectomy for esophageal cancer does not affect the postoperative course

(Abstract ID: 938)

E. Tagkalos¹, P. C. van der Sluis¹, E. Uzun¹, F. Berlth¹, H. Lang², P. Grimminger¹

¹Unimedizin Mainz

²Universitätsmedizin der Johannes Gutenberg-Universität, Mainz

Background:

Esophagectomy with intrathoracic anastomosis (Ivor-Lewis procedure) is associated with substantial trauma as well as potentially lethal complications with mortality rates described between 0-15%. Creation of the anastomosis is crucial for the postoperative outcome of the patient. Discrepancies are reported in literature whether to use 25 mm or 28 mm circular stapler for a esophagogastric anastomosis.

Materials and methods:

Between January 2008 and June 2019, 349 consecutive patients underwent thoraco-abdominal esophagectomy for esophageal carcinoma with intrathoracic end-to-side circular stapled gastric conduit reconstruction. A 25-mm (EEA; Covidien) or a 28-mm (EEA; Covidien) stapler were used.

Patient characteristics and postoperative results were recorded in a prospective database.

Results:

A 25-mm stapler was used in 222 patients and a 28-mm stapler was used in 127 patients. The patient demographics did not differ statistically (p>0.05). Anastomotic leakages occurred in 27 patients (12.2%) of the 25-mm group and in 14 patients (11%) of the 28-mm group (p=0,751). Anastomotic stricture occurred in 30 patients (13.5%) treated with 25-mm stapler in comparison to 18 patients (14.2%) in the 28-mm group (p=0,867). The median dilatation procedures needed to treat the stricture were 2 (range 0-19) for the 25-mm group vs 1,5 (range 0-5) for the 28-mm group (p=0.573). The median time of strictural occurrence was 89,5 days (range 27-938) and 78 days (range 12-243) for the two groups respectively (p=0.412). Mortality rates were low (30-d (1.4% vs 3.1%) as well as 90-d (5.9% vs 4.7)) and did not differ statistically between the groups (p=0.249 and p=0.654 respectively).

Conclusion:

The use of the circular stapler for the creation of the esophagogastric anastomosis provides a safe and feasible procedure and is irrelevant of the diameter in use. In our study, which encloses one of the biggest cohorts worldwide, anastomotic leakages as well as postoperative stricture-formation occur in rates comparable to the literature and do not affect the long-term outcome of the patient.

Gastric stump carcinoma: Frequency, multimodal treatment and prognosis

(Abstract ID: 980)

M. Korenkov¹, A. Pamuk¹, A. Barutcu¹, A. Hölscher², S. P. Mönig³, E. Bollschweiler¹, A. Quaas¹, S.-H. Chon¹, P. Plum¹, C. J. Bruns¹, H. Alakus¹

¹Uniklinik Köln

²Agaplesion Markus Krankenhaus, Frankfurt am Main

³Hôpitaux universitaires de Genève

Background:

Several studies showed an increase in the risk of developing GSC in those with a Billroth-II (B II) reconstruction for benign diseases such as ulcers, but surgery is gradually being abandoned as a treatment option for gastric ulcer. The aim of this study was to evaluate the clinicopathologic features, multimodal treatment and surgical therapy of GSC compared to primary gastric cancer.

Materials and methods:

Patients undergoing (sub)total gastrectomy with or without transhiatal extension for gastric or gastroesophageal junction adenocarcinoma at the University Hospital of Cologne between 1996 and 2019 were collected into a prospectively maintained database. Patients receiving gastrectomy for GSC were identified and analysed in correlation to perioperative and surgical treatment, clinicopathology and survival.

Results:

Of 735 patients, 30 (4.1%) patients were presented with GSC. GSC occurred in 23/30 (76.7%) after receiving a B-II resection for ulcer, in 4/30 (13.3%) after B-II resection for previous gastric adenocarcinoma and in 1/30 (3.3%) after B-I resection for previous gastric adenocarcinoma. 2 (6.7%) patients had incomplete data. The median interval between partial gastrectomy and total gastrectomy for GSC was 38 years. Patients with GSC were slightly older (72 vs 65 years; p=0.04) than primary gastric cancer. 30- (0% vs 2.3%; p=0.644) and 90-day (6.7% vs 4.7%; p=0.650) mortality was similar. The proportion of stage (y)pT0-T2, (y)pT3 and (y)pT4 tumors in the GSC group was 39.3%, 28.6% and 32.1% versus 34.5%, 40.4% and 25.1% in the primary cancer group (p=0.441). R-status (p=0.828) and complications according to Dindo-Clavien (p=0.520) were also similar in both groups. GSC was associated with less nodal involvement ((y)pN0: 72.4% vs 42.9%; p=0.013) and less patients receiving neoadjuvant therapy (6.7% vs 43.2%; p<0.001). Signet ring cell and mucinous type carcinoma were more present in GSC (p=0.015). Median overall survival rates did not differ between GSC and primary gastric cancer (43 months vs 55 months; p=0.954). The 5-year survival rate did not differ between GSC and primary gastric cancer (48.5% vs 47.5%; p=0.954).

Conclusion:

Clinically GSC can be viewed as a subset of gastric adenocarcinoma with a similar prognosis. GSC seem to occur in older patients. Signet ring cell and mucinous type carcinoma seem to be more present in GSC.

Viable tumor cells as a measure for histological tumor regression after neoadjuvant chemotherapy in gastric adenocarcinoma

(Abstract ID: 1026)

A. Pamuk¹, A. Barutcu¹, M. Korenkov¹, Y. Zhao¹, A. Hölscher², S. P. Mönig³, E. Bollschweiler¹, A. Quaas¹, S. Chon¹, C. J. Bruns¹, H. Alakus¹

¹Uniklinik Köln, Köln

²Agaplesion Markuskrankenhaus Frankfurt am Main

³Hopitaux Universitaires de Geneve,

Background:

One of the commonly examined prognostic factors for the survival of patients with gastric adenocarcinoma is the tumor response after neoadjuvant chemotherapy. In order to assess the tumor response, besides analysing the ypT and ypN status, the proportion of viable tumor can be determined. The aim of this work was to examine the impact of histological tumor regression measured by viable tumor cells in patient survival.

Materials and methods:

Patients undergoing (sub)total gastrectomy for gastric or gastroesophageal junction adenocarcinoma with or without transhiatal extension at the University Hospital of Cologne are collected into a since 1996 prospectively maintained database. In patients who underwent neoadjuvant chemotherapy the histological tumor regression was recorded in four grades: Grade 1 (>50 % viable tumor), Grade 2 (<50 % viable tumor), Grade 3 (<10 % viable tumor) and Grade 4 (complete response).

Results:

737 patients (67.2% male, 32.8% female) with a median age of 65 years and a median follow-up of 27.5 months for patients still alive were eligible for analysis. 308 (41.8%) patients received neoadjuvant therapy before surgery and 429 (58.2%) received surgical tumor resection primarily . 89.6% of the pre-treated patients received neoadjuvant chemotherapy and 10.6% neoadjuvant radiochemotherapy. 47.4% had neoadjuvant chemotherapy according to FLOT regime, 19.1% were treated with ECF, 9.2% with PLF and in 13.9% the chemotherapy regime was unknown.

The Tumour Regression Grade (TRG) was determined and documented in 174 patients (56.5%). Grade 1 was recorded in 88 (50.6%) patients, Grade 2 in 45 (25.9%), Grade 3 in 29 (16.7%) and Grade 4 in 12 (6.9%) patients.

There was no association between the choice of neoadjuvant treatment and the grade of tumor response (p=0.63). Especially the distribution of the two most commonly used chemotherapy regimes FLOT and ECF was similar between patients with various grades of histological tumor regression (FLOT: Grade 1: 45.1%, Grade 2: 30.5%, Grade 3: 13.4%, Grade 4: 11,0% and ECF: Grade 1: 54.5%, Grade 2: 27.3%, Grade 3: 12.1%, Grade 4: 6.1%, p=0,827)

Lymphonodular invasion (ypN) (p=0.01) and T-stage (ypT) (p<0.001) were significantly higher in patients with Grade 1/ 2 compared to Grade 3/4.

Tumor localisation (p=0.59), the distribution of histological subtype according to Laurén´s classification (p= 0.677), R- Status (p= 0.075) and postoperative complications according to Dindo- Clavien (p=0.759) were similar regardless of the grade of histological tumor response. There was no difference in 30-day mortality (p=0.383) and 90-day mortality (p=0.23)

In Kaplan-Meier survival curve, the median overall survival (OS) was significantly higher in the patient groups with less vital tumor cells. The 3-year overall survival in Grade 1 was 37%, in Grade 2 58.4%, in Grade 3 74.1% and in Grade 4 no death was documented (p< 0.001).

In multivariate analysis ypT-status and ypN-status had a significant association with OS (p=0.004 and p=0.027, respectively) while tumor regression failed to reach statistical significance (p=0.352).

Conclusion:

Our results show that the histological tumor regression seems to have a subordinate prognostic value in OS compared to ypT and ypN-status but it can be used as a complementary tool for estimating survival. The choice of given neoadjuvant pretreatment did not have an impact on histological tumor regression.

Screening and Interdisciplinary Perioperative Management of Delirium in Geriatric Patients: Development and Implementation

(Abstract ID: 371)

I. Klingenhegel¹, E. Karakas¹, J. Westphal¹, K. Engelbrecht¹, B. Luther¹, R. Ihl¹

¹Krankenhaus Maria Hilf, Alexianer GmbH, Krefeld

Background:

Elderly patients show an increasing risk of postoperative delirium, with prevalence from 8% up to 80% depending on clinical field and operationalisation. Consequences are cognitive and functional impairment, often irreversible, thus complex care needs, and tripled mortality. Considering demographic change, medical and economical efficacy is needed in the management of delirium.

Most approaches to improve prevention and therapy of delirium focus on depth of sedation, nursing and environment, according to the S3-guideline. The Interdisciplinary Perioperative Management of Delirium (IDA) chooses a multi professional approach, relying on its surgical and psychiatric departments "under the same roof".

Materials and methods:

Additional diagnostic, preventive and curative modules are being integrated into somatic standard care as depicted in the flowchart.

Note: Flowchart of the interdisciplinary perioperative management of delirium for geriatric patients (s. jepg).

Both modules of environment and individual-related care contribute to the whole process. In a continuous therapeutic relationship, trained staff supports patients with proven interventions. Infrastructure is adapted to be more soothing and helpful for reorientation.

The preoperative module identifies somatic, psychiatric and psychosocial risk factors. A session with experienced geriatric psychologists is added. Risk is reduced individually where tractable. Remaining high risk patients will be treated in a specialized ward.

Intraoperatively, anaesthesia is planned accordingly and avoids too deep and long sedation. Procedure, depth of sedation and vital parameters are recorded.

Postoperatively, regular screenings based on the confusion assessment method for the intensive care unit (CAM-ICU) are assessed. Patients are treated with maximum effort in psychiatric, environmental and patient-centred care, wherever possible avoiding invasive and pharmacological interventions. For sustainable relief, the geriatric psychiatric Complete Support Network (CSN) is available.

Scientific evaluation of predictive power, impact and treatability of all risk factors and symptoms will be provided based on voluntary patient participation and a positive vote by the responsible ethics committee.

Results:

Since February 2019, screening has been conducted for 118 patients. Prevalence of postoperative delirium is 8.16%. Delirious patients show increased age (M=79.9), and long duration of general anaesthesia (M=258.4). Preoperative cognitive impairment has an OR of 9.8 for delirium and accurately can be determined with the screening tool TE4D. Further major risk results from vascular diseases and cancer. Other factors have not yet shown significance. Interactions remain to be evaluated.

Preventive and curative measures are being introduced on a step-by-step basis mostly with positive response. Staff acceptance and sensitivity will be raised by regular trainings starting in October 2019.

Conclusion:

While IDA shows promising results, obstacles remain. Additional expenses are considered with scepticism, leading to temporary limitations in staff and infrastructure. Long-term benefits need to be proven. Especially, the early psychiatric involvement is unfamiliar and being addressed by information and specialized conversational skills. With an increasing data base and the inclusion of further risk factors like environment etc. more new insights are expected.

Picture:

Note: Flowchart of the interdisciplinary perioperative management of delirium for geriatric patients

Resection of esophageal carcinoma: Analysis of risk factors predicting early results

(Abstract ID: 409)

R. Konopke¹, S. Kersting², H. D. Saeger³

¹Elblandklinikum Riesa

²Chirurgische Klinik, Erlangen

³Universitätsklinikum Dresden

Background:

Background: Despite advances in diagnosis and treatment, the rate of medical and surgical problems after resection for esophageal carcinoma remains high. Identification of risk factors for these complications is essential in order to reduce morbidity and mortality.

Materials and methods:

Methods: A total of 273 patients undergoing conventional esophageal resection for carcinoma, collected prospectively between 1995 and 2015, were included in a single center observational trial. Uni- and multivariate logistic regression analysis of 32 factors was performed to identify independent predictors for the length of hospital stay, complications and mortality.

Results:

Results: Operations included en-bloc esophageal resection with lymphadenectomy via combined transthoracic and abdominal access (n=209; 76.6%), additional cervical access (n=36; 13.2%) and abdominocervical access (n=28; 10.2%).

The median length of hospital stay was 28 days (5-203 days). Severe surgical morbidity and 30-daymortality rates were 27.5% and 4.4%, respectively.

Preoperative risk score of Bartels et al. (1998) > 1 (HR: 2.37, p=0.022), perioperative blood loss > 800ml (HR: 2.06, p=0.009), chronic bronchitis (HR: 1.94; p=0.034) and postoperative ventilation > 24h (HR: 1.88, p=0.003) were found to be significant parameters for a prolonged hospital stay in multivariate analysis.

Postoperative ventilation > 24h (HR: 3.98, p=0.001), abdominotransthoracic esophagectomy (HR: 2.65, p=0.020) as well as abdominotransthoracocervical esophageal resection (HR: 2.60, p=0.033) were independent risk factors of postoperative morbidity.

Independent risk factors of mortality were necessity of postoperative ventilation for more than 24 hours (HR: 3.24, p=0.001) and Bartels preoperative risk score > 1 (HR: 2.03, p=0.021).

Conclusion:

Conclusions: Esophageal cancer resection is a complex procedure with a multitude of factors influencing postoperative early results. Especially high risk patients according to the score of Bartels, operation with transthoracic access and necessity of postoperative ventilation > 24h leads to a higher risk of morbidity and mortality.

The “Bonn Inhibitor Model” enables safe surgeries for haemophiliac adolescents with inhibitors

(Abstract ID: 555)

N. P. Sommer¹, V. Lüder¹, S. Horneff¹, J. Dohmen¹, J. Oldenburg¹, J. C. Kalff¹, G. Goldmann¹, P. Lingohr¹

¹Universitätsklinikum Bonn,

Background:

Surgeries in patients with Haemophilia A are at high risk of perioperative bleeding complications. Up to 20 % of patients develop antibodies against the clotting factors. This considerably complicates the usual therapeutic regimen, as standard therapy, replacing Factor VIII, might not be sufficient. By the example of port catheter implantations in adolescents, this study investigates the safety of the "Bonn Inhibitor Model", an immunotolerance therapy, where patients with antibodies were treated with additional Factor VIIa (NovoSeven ®).

Materials and methods:

In a retrospective comparison at the University Hospital Bonn 35 of 50 patients with haemophilia met the inclusion criteria, 25 non-haemophiliacs served as controls. All included patients were younger than 18 years. Duration of surgery, length of hospital stay, time to explantation, complications, haemoglobin-concentration and rate of infections were compared. Mann Whitney-U-Test (significance level p = 0.05) and Pearson’s Chi-squared-test (significance level p = 0.05) were used for statistical analysis.

Results:

No significant differences were found in the duration of surgery (p = 0.824) and the time to explantation of the port catheter (p = 0.517). Postoperative and overall length of hospital stay were significantly longer (p < 0.001; p < 0.001) in the haemophiliac group. Pre- and postoperative haemoglobin concentrations were significantly higher in the control group (p < 0.001; p = 0.002). The overall complication rate according to the Clavien-Dindo classification remained unchanged between the groups (p = 0.067). Of note, no difference in postoperative haemorrhage (p = 0.110) was seen.

Conclusion:

Immunotolerance therapy with additional administration of Factor VIIa aligns the complications rate of haemophiliac adolescents with inhibitors with non-haemophiliacs. In standardized operations the "Bonn Inhibitor Model" enables a safe surgery for these patients. Nonetheless, the perioperative management and treatment of haemophiliac patients with acquired inhibitors remain an interdisciplinary challenge.

Do graduated compression stockings really prevent postoperative symptomatic or fatal pulmonary embolism? A propensity matched retrospective analysis in 24 273 patients

(Abstract ID: 902)

K. Suna¹

¹Asklepios Klinik Langen

Background:

The recommendation for venous thromboembolism (VTE) prophylaxis using graduated compression stockings (GCS) is historically based and has been critically examined in current publications. Existing guidelines are inconclusive as to recommending the general use of GCS. The aim of this observational case-control study is to examine the change of relative risk for symptomatic or fatal pulmonary embolism (PE) using/not using GCS.

Materials and methods:

24 273 in-patients undergoing surgery between 2006 and 2016 were retrospectively analysed in the study. From 01/2006 to 01/2011 postoperative GCS was employed and from 02/2011 to 03/2016 patients received no GCS. According to guidelines all patients received VTE prophylaxis with weightadapted low molecular weight heparin. The risk stratification for developing a pulmonary embolism was based on the German S3 guideline and the guideline of the American College of Chest Physicians. Data analysis was performed before and after propensity matching (PM). The defined primary endpoint was the incidence of symptomatic or fatal pulmonary embolism.

Results:

After PM two groups of 11 312 patients each, one with and one without GCS application, were formed. When comparing the two groups, the relative risk (RR) for the occurrence of a pulmonary embolism was: Risk Score 1 - 0.99 [CI95% 0.998-1.000]; Risk Score 2 - 0.999 [CI95% 0.95-1.003]; Risk Score 3 - 0.996 [CI95% 0.992-1.000] (p>0.05). The incidence of pulmonary embolism in the group without GCS was 0.1% (n=16). In the group using GCS, the incidence was 0.3% (n=29). The RR after PM was

0.999 [CI95% 0.998-1.00].

Conclusion:

After PM, this study shows that abstaining from GCS-use does not increase the incidence of pulmonary embolism.

Liver Transplantation versus Watchful-Waiting in Hepatocellular Carcinoma Patients with Complete Response to Bridging-Therapy

(Abstract ID: 58)

M. Schoenberg¹, J. Bucher¹, D. Koch¹, N. Börner¹, H. Nieß¹, U. Ehmer², M. Seidensticker¹, E. De Toni¹, J. Andrassy¹, M. Angele¹, J. Werner¹, M. Guba¹

¹Klinikum der Universität München

²Technische Universität München

Background:

During the waiting period for liver transplantatiuon (LT), patients with hepatocellular carcinoma (HCC) are at risk for tumor progression and therefore bridging therapy is recommended. In some patients the treatment results in a long-lasting complete tumor response (CR). In these cases, the risk of tumor progression must be weighed against the risk of transplantation. This observational study examines whether HCC patients with preserved liver function and complete response after bridging-therapy should be transplanted or managed by a watchful waiting strategy.

Materials and methods:

We performed an intention-to-treat analysis of overall and recurrence free survival from the time of listing in this patient group. Patient data listed for transplantation from January 1st 2007 until December 31st 2018 was collected and analyzed. Bridging therapy included RFA, resection and combinations with TACE. In this analysis sustained Complete Response (CR)was defined as: CR for at least 6 months after treatment.

Results:

Altogether 166 cases were reviewed in this retrospective analysis. 39 (23.49%) patients achieved sustained CR. 17 patients were not transplanted (CR-WW) and 22 patients received liver transplantation (CR-LT). Overall survival in both groups was similar (at 5 years: 83.9% vs 75.4%; p=0.97)(Figure). Recurrence free survival was lower in the CR-WW group (53.3% vs. 84.0%; p=0.0.49). 5 (29.4%) out of the 17 CR-WW patients received a rescue transplantation because of recurrence.

Conclusion:

A Watchful-waiting strategy for patients with preserved liver function and CR after bridging is feasible in highly selected patients. Combined with a rescue transplant concept in case of tumor recurrence, it leads to acceptable overall survival compared to primary transplantation (CR-LT).

Picture:

Overall Survival for Watchful-waiting (CR-WW) and liver transplantation (CR-LT) Strategy Patients

Liver grafts with major extended donor criteria - an alternative for patients with hepatocellular carcinoma

(Abstract ID: 63)

V. Lozanovski¹, L. Kerr¹, E. Khajeh¹, O. Ghamarnejad¹, K. Hoffmann¹, O. Strobel¹, A. Mehrabi¹

¹Universitätsklinikum Heidelberg

Background:

The major extended donor criteria (maEDC; steatosis > 40%, age > 65 years and cold ischemia time > 14 hours) influence graft and patient outcome after liver transplantation (LT). Despite organ shortage, maEDC organs are often considered unsuitable for transplantation and discarded. We investigated the outcomes of maEDC organ LT in patients with hepatocellular carcinoma (HCC).

Materials and methods:

Risk factor analysis was performed for EAD, PNF, 30-day and 90-day graft failure, and 30-day, 90-day and 1-year patient mortality. Cox regression analyses of donor and recipient factors associated with 1year patient mortality were performed and recipient age, gender, BMI > 30 kg/m2, tumor grade, labMELD score, LC cause, Milan criteria, Child-Pugh score, and maEDC were analyzed.

Results:

One-year graft survival was higher in recipients of no-maEDC grafts. One-year patient survival did not differ between the recipients of no-maEDC and maEDC organs. The univariate and the multivariate analyses revealed no association between maEDC grafts and 1-year patient mortality. Graft survival differed between the recipients of no-maEDC and maEDC organs after correcting for a labMELD score with a cut-off value of 20 and patient survival did not. Also, patient survival did not differ between recipients who did and did not meet the Milan criteria and who received grafts with and without maEDC. Tumor recurrence rates and recurrence-free survival were unaffected by the maEDC.

Conclusion:

Instead of being discarded, maEDC grafts may expand the organ pool for patients with HCC without impairing the patient survival or the recurrence-free survival.

The influence of bridging procedures on patient survival after liver transplantation for HCC

(Abstract ID: 112)

A. Bauschke¹, A. A. Altendorf-Hofmann¹, H. Kißler¹, M. Tautenhahn¹, M. Ardelt¹, U. Settmacher¹

¹Universitätsklinikum Jena

Background:

We evaluated the influence of bridging procedures on our patient survival after liver transplantation for HCC.

Materials and methods:

Data of patients with HCC in cirrhosis who underwent liver transplantation (LT) between 1996 and 2017 were extracted from our prospectively maintained tumor register. Patients who died within three months after LT were excluded.We analyzed the tumor load pre transplant, α-Fetoprotein (AFP) (ng/ml) level, Child Stage, use of bridging therapy and type of LT. Starting point for survival calculation was the date of LT.

Results:

76 out of 163 patients hat no bridging therapy. The other 87 patients (54%) had - multiple and/or combined - transarterial chemoembolization, radiofrequency ablation, yttrium 90 radioembolization. In 20 cases this resulted in a complete regression of the tumor before LT. Median follow-up-time was 55 months (range 4-264). Median observed survival time was 106 months. By now, 71 patients died, 37 of them of recurrence of tumor, 34 of other causes.

Observed 5- and 10- year survival rates with bridging were 67±5% and 47±7%, without bridging 56±5% and 46±7%, respectively. In contrast tumor related 10- year survival rates showed a statistically significant difference (81±5% versus 59±7%). Bridging, number and diameter of lesions, Milan score and AFP level were included in a COX-procedure. Here bridging, number of lesions, and α-Fetoprotein level showed an independent statistically significant influence on tumor related survival.

Conclusion:

Bridging therapy is able to reduce tumor recurrence and death of tumor in transplanted HCC patients.

Impact of sarcopenia on the outcome after liver transplantation

(Abstract ID: 175)

D. Kniepeiss¹, H. Mayr¹, S. Janout¹, M. Eibisberger², H. Schrem¹, F. Iberer¹, K.-H. Tscheliessnigg¹, H. Müller¹, P. Schemmer¹

¹Universitätsklinik für Chirurgie, Graz

²Universitätsklinik für Radiologie, Graz

Background:

The decrease of sceletal muscle mass also known as sarcopenia, is a syndrome associated with adverse outcomes and a higher risk of mortality for patients undergoing surgery. A higher prevalence of sarcopenia is described in liver transplant candidates. In this study we analysed the impact of sarcopenia on the outcome after liver transplantation.

Materials and methods:

Between 2008 and 2017, 132 patients, undergoing liver transplantation at the University Hospital of Graz were included to this retrospective study. Sarcopenia was evaluated by measuring muscle mass through CT scans at third lumbal vertebra. This area highly correlates with the whole body skeletal muscle mass. Therefore, sex specific cut-points were given (<= 38,5cm2/m2 for women, <= 52,4 cm2/m2 for men). As parameters for the outcome following liver transplantation 30-d-mortality, 1-yearsurvival, 5-year-survival, early and late complications according to the Clavien-Dindo score, the length of ICU-stay and postoperative hospital stay were analysed.

Results:

A statistically significant (p=0,019) correlation between sarcopenia and the 1-year-survival and the length of ICU stay (p=0,037) was found. Furthermore a sex specific correlation (p= 0,003) was observed. In male individuals, sarcopenia was more likely to occur. Sarcopenia did not show a statistically significant impact on complication rates, 30-d-mortality, 5-year-survival and the length of postoperative hospital stay.

Conclusion:

This study shows that the depletion of muscle mass has an impact on the outcome of liver transplantation.

Gender discrimination via MELD-based liver allocation in solid organ transplantation

(Abstract ID: 266)

P. Ritschl¹, L. Wiering¹, M. Jara¹, T. Dziodzio¹, D. Eurich¹, F. Aigner¹, W. Schöning¹, M. Schmelzle¹, I. Sauer¹, J. Pratschke¹, R. Öllinger¹

¹Charité - Universitätsmedizin Berlin

Background:

MELD was implemented to guarantee urgency-based and fair organ allocation. Nonetheless men are outnumbering women as liver transplant recipients. The aim of this study was to analyze gender disparities in liver transplantation particularly with regard to organ allocation in the US and Germany.

Materials and methods:

All liver transplantations - excluding pediatric recipients, combined organ transplantation and living donors - from 2005 to 2015 in Germany and from 1999-2016 in the US were assessed retrospectively using the data record of Eurotransplant (ET) respectively of the United Network for Organ Sharing (UNOS) . Additionally, data by the German Federal Statistical Office (‘Statistisches Bundesamt’) and the American Centers for Disease Control and Prevention were analyzed.

Results:

Between 2005 and 2015 the ratio of males to all liver associated cause of death was 64.8% in Germany. This number was quite stable, varying only between 64.1% and 65.7%.

In the investigated period 9832 liver transplantations fulfilled all criteria. Nearly two thirds (6466; 65.8%) of all recipients were male. This percentage was even higher in patients allocated with regular allocation status without high urgency status (male 68.7%). While gender proportions of liver associated cause of death remained stable over time, the ratio of female liver recipients decreased after the implementation of MELD-based organ allocation, from 37.0% before MELD to 33.7% afterwards. In the US liver associated cause of death show a similar distribution, with 63.9% males between 1999 and 2016 and stable proportions over the years. However, also the American liver transplant program experienced a decrease of female liver transplant recipients after the implementation of MELD, from 36.1% in the last three years before to 32.6% during the MELD-era.

Characteristics of male and female recipients differ. Latest laboratory MELD score as well as matchMELD score were higher in women compared to male recipients (23 vs. 18; p<0.001 and 28 vs. 26, <0.001, respectively). Men on the other side were more likely to have an exceptional status compared to women (30.9% vs. 23.4%; p<0.001) as 80% of all transplantations for hepatocellular carcinoma occurred in men. In contrast, common indications for women are not considered for standard exceptions (e.g. PBC - 77% females). Besides this discrimination in indications laboratory values of the MELD score diverged by gender. Although women showed better serum creatinine values (1.38mg/dl vs. 1.6mg/dl; p<0.001) eGFR was significantly lower (65.9 vs. 69.2; p<0.001). Despite being sicker, women do not generate high MELD scores due to lower muscle weight. Therefore, their Bilirubin (11.02 vs. 8.77; p<0.001) and INR (2.02 vs. 1.72; p<0.001) had to achieve higher values before getting organ offers. The mean difference in creatinine values corresponded to approximately two points in the labMELD score.

Also in the US female recipients had higher laboratory MELD scores (19 vs. 22; p<0.001), were less likely to have an exceptional status (27.0% vs. 35.7%; p<0.001), showed significantly higher Bilirubin and INR values and a lower GFR (all p<0.001).

Conclusion:

There is a significant gender inequity in liver transplantation recipients. Probably this can be partially explained by varying incidences of liver diseases, but MELD based allocation seems to aggravate the injustice. A critical analysis whether access to liver transplantation is equal seems necessary.

Graft tolerance and immunological consequence following a combined THI / Certican^® substitution after liver transplantation in the rat: A novel immunsuppresant drug

(Abstract ID: 680)

D. Andrade¹, D. Koliogiannis¹, J. Werner¹, M. Guba¹, E. Matevosjan¹

¹Klinikum der Universität München

Background:

Acute rejection is still a common complication of liver transplantation (LTx). The mechanism of allograft rejection or tolerance induction is a competitive, complex process that presumably involves interactions between multiple subpopulations of T lymphocytes. CD4+/CD8+ T cells represent a subpopulation of T lymphocytes, and are a marker for allograft rejection. The acute blood lymphocyte reduction after reperfusion of a liver allograft seems to be an early intraoperative marker for poor graft preservation and function. The deposit of CD4+/CD8+ cells provides evidence of activation of humoral immunity. The allograft rejection has generally been considered a T-cell-dependent immune process.

It is known that lymphocyte regress after allograft transplantation depends on sphingosine 1phosphate (S1P) receptor-1. Treatment with 2-Acetyl-4-tetra-hydroxybutyl imidazole (THI), a potentially immunosuppresant drug, inhibits the S1P-degrading enzyme and plays a fundamental role in the immune response. The component of Caramel Colour III that is responsible for these immunological effects has been shown to be THI.

The aim of this experimental study is to evaluate the protective effects with mono-therapy after LTx in a rat model, or Certican®-combined THI treatment of the recipients. An understanding of this preconditioning of the allograft is essential for the design of therapeutic strategies as well as an improvement of survival after LTx for recipients with relevant immunosuppressant toxicity.

Materials and methods:

orthotopic arterialised LTx in a rat model. The recipients are divided into 4 groups:

group I (controls without THI or Certican® pre-/treatment/immunosuppression of therecipients, n=6);

group II (immunsuppression of the recipients (day 0-28 after LTx) with high-dose Certican®, n=10);

group III (pre-/treatment of the recipients (day 0-14 after LTx) with THI, n=10);

group IV (pre-/treatment and immunosuppression of the recipients (day 0-28 after LTx) with low-dose Certican® and day 0-14 after LTx with THI, n=10).

Results:

Our preliminary data (histopathological findings and FACS) with application of a single THI-injection 60 minutes before liver transplantation show a significant decrease of CD4+/CD8+ populations of the Tlymphocytes in the recipients` peripheral blood and liver allograft. These results indicate that lymphopenia in the peripherial blood compartment is caused by a rapid sequestration after THI treatment, and gives credence to the theory that the reduction of T-lymphocytes with THI alone or in combination with low-dose Certican® before reperfusion will prevent or reduce acute rejection episodes in liver allografts.

Conclusion:

The study is of considerable interest as it draws attention to the modulation of immune function after solid organ transplantation.

Von Willebrand Factor allows risk stratification in patients listed for liver transplantation

(Abstract ID: 718)

B. Rumpf¹, D. Pereyra¹, G. Györi¹, H. Hachkl², C. Köditz¹, G. Ortmayr¹, G. Berlakovich¹, P. Starlinger¹

¹Medical University and General Hospital of Vienna

²Medical University of Innsbruck, Biocenter

Background:

Today, Model of End-Stage Liver Disease (MELD) is commonly used for decision making and organ allocation in orthotopic liver transplantation (OLT). Still, recent reports suggest that MELD may underestimate complications arising from portal hypertension or infection. In this context, von Willebrand factor antigen (vWF-Ag) - previously introduced as a robust surrogate parameter for portal venous pressure - was shown to be associated to adverse outcome in patients with cirrhosis while being independent from portal hypertension. Accordingly, this study aimed to evaluate the value of vWF-Ag as an auxiliary marker for risk stratification on the waitlist for OLT.

Materials and methods:

MELD and vWF-Ag at time of listing were assessed in 269 patients. Patients were followed up for mortality on the waitlist and overall survival.

Results:

Patients dying within three months on the waitlist displayed elevated levels of vWF-Ag (p<0.001). Interestingly, MELD and vWF-Ag showed a similar predictive potential for three-month mortality (AUC: vWF-Ag=0.739; MELD=0.770). Yet, a cut-off for vWF-Ag at 413% was found to harbor a higher risk for patients when compared to the previously used cut-off for MELD at 15 points (vWF-Ag: OR=10.873, 95%-confidence interval: 3.160-36.084, p<0.001; MELD: OR=6.527, 95%-confidence interval: 2.21619.227, p=0.001). Ultimately, combination of vWF-Ag and MELD significantly improved prediction of three-month waitlist mortality (AUC: vWF-Ag+MELD=0.836).

Conclusion:

A single measurement of vWF-Ag at listing for OLT was found to increase the predictive potential for early mortality on the waitlist. Thus, introduction of vWF-Ag evaluation into the allocation process for patients listed for OLT might lead to a decrease in waitlist mortality.

The effect of recipient-donor size mismatching on short-term outcome after pediatric kidney transplantation

(Abstract ID: 787)

O. Beetz¹, R. Nogly¹, C. Weigle¹, F. Oldhafer¹, M. Kleine¹, K. Timrott¹, J. Klempnauer¹, L. Pape¹, N. Richter¹, F. W. R. Vondran¹

¹Medizinische Hochschule Hannover

Background:

Recipient-donor size matching is a formidable challenge in pediatric kidney transplantation due to an ongoing lack of size-matched grafts. In this study, we investigated postoperative complications and their influence on short-term graft and patient survival in pediatric kidney transplantation with respect to recipient-donor-ratios (RDR).

Materials and methods:

This was a retrospective monocentric analysis of all pediatric kidney transplantations at our institution from 2005 until 2018. Pediatric recipients were defined as under the age of 18.

Results:

A total of 231 pediatric kidney transplantations were performed, with a rate of living donation of 35.9%. Median recipient age and weight were 10.9 years (0.3-17.9) and 30.0 kg (3.0-118.0) with a RDR for weight and height of 0.62 (0.05-8.00) and 0.89 (0.29-2.27), respectively. Median cold ischemia and operating times were 621.5 min (90.0-1761.0) and 129.0 min (60.0-441.0). Postoperative complications requiring surgical intervention were mainly vascular complications (thrombosis or stenosis) (7.6%), hemorrhage (6.7%) and ureteral complications (4.3%). Early graft loss was observed in 9 patients (4.3%). Median serum creatinine at discharge was 64 µmol/l (11-535). Initial non-function (INF), defined as need for dialysis after transplantation, occured in 23 cases (10.1%). The 1-year-graftsurvival rate was 96.4%. Severe weight or height RDR mismatches (<0.5) did not significantly alter the incidence of postoperative complications, INF or 1-year-graft loss.

Conclusion:

Pediatric kidney transplantation can be achieved with excellent early clinical outcome despite severe size-mismatch of recipient and donor.

Current status of liver Machine-Perfusion in the Eurotransplant Region

(Abstract ID: 859)

J. Bucher¹, M. Schoenberg¹, H. Nieß¹, J. Andrassy¹, D. Koliogiannis¹, J. Werner¹, M. Guba¹

¹Klinikum der LMU München

Background:

Machine perfusion (MP) of liver grafts before transplant has gained wide acceptance in the field for its beneficial effects on graft survival and function. However, the demand for- and the actual availability of MP systems in the Eurotransplant (ET) region is currently not known. Since this new treatment has the potential to revolutionize the standard of care, we feel that the current need for- and availability of Machine-Perfusion programs in the ET region needs to be evaluated.

Materials and methods:

We performed an online-survey (Qualtics®) addressed to the program leaders in all ET liver transplant (LT) centers. 27 Questions were asked concerning the general attitude towards MP, the state of MP- programs and characteristics of obstacles that were encountered in the process of implementation. Additionally we performed personal interviews with selected program directors to showcase different implementation and management strategies.

Results:

23 of 38 transplant centers answered the survey (60 %). 7 centers reported a total of 50 normothermic and 92 hypothermic and 25 subnormothermic clinical MPs performed. All 3 centers in Austria, 2 of 6 centers in Belgium and 2 of 13 centers in Germany reported active MP programs. While 65 % of the participants predicted MP to become the standard of care in LT in the near future, 14 of 16 centers without a currently active program have the plan to implement MP in their centers. 6 of these centers have already started the implementation process. Generally the high costs for machines and disposable were viewed as a main problem of MP. Accordingly, centers without active programs reported the main obstacle in the implementation process to be monetary.

Conclusion:

Generally, LT program leaders in the ET region seem to have a positive perspective on MP. While the vast majority of the transplant centers have at least the plan to implement an MP program, only 30 % already have an active program and further 35 % have started the implementation process. Within the ET region, Austrian centers are furthest in including MP in their LT programs, likely as a result the centralistic nature of their national transplant strategy. Aside from this intuitive conclusion, we have noted that the implementation of MP to date still requires major individual commitment. Funding and management strategies differed between centers. With our survey, we hope to further stimulate the dialogue and cooperation between LT centers in the ET region.

Myosteatosis and its impact on graft- and patient survival in adult recipients of deceased donor liver transplantation

(Abstract ID: 900)

Z. Czigany¹, W. Kramp¹, J. Bednarsch¹, G. van der Kroft¹, P. Strnad¹, K. Hamesch¹, P. Bruners¹, M. Zimmermann¹, G. Wiltberger¹, U. P. Neumann¹, G. Lurje²

¹Uniklinik RWTH Aachen

²Charité – Universitätsmedizin Berlin

Background:

The significance of preoperative body composition (BC) is in the spotlight of interest in various diseases. Recently our group could demonstrate the role of myosteatosis in inferior perioperative outcomes (Czigany et al. Am J Transplant 2019) in recipients of orthotopic liver transplantation (OLT).

Here we aimed to investigate the effects of BC on long-term graft- and patient survival following OLT.

Materials and methods:

The data of 225 consecutive OLT recipients from a prospective database were analyzed retrospectively (05/2010-01/2018). Computed tomography-based lumbar skeletal muscle index-SMI, and mean skeletal muscle radiation attenuation-SM-RA were calculated using a segmentation tool (3DSlicer). Patients with sarcopenia (low SMI), and myosteatosis (low SM-RA) were identified using predefined cutoff values.

Results:

The cutoff values of myosteatosis resulted in a good stratification of patients into low- and high-risk groups in terms of graft- and patient survival. The overall graft- and patient survival rates were significantly lower in myosteatotic patients compared to the subgroup of patients with higher SM-RA values (p=0.011, p=0.001, respectively). Sarcopenia alone was not associated with significant differences in graft- and patient survival rates (p=0.273, p=0.278, respectively). Dividing the patient cohort into quartiles, based on the values of SMI and SM-RA, resulted in significant differences between the SM-RA quartiles in terms of patient survival but not of graft survival (p=0.011). Accordingly, myosteatosis was identified as an independent predictor of inferior patient survival in our cohort (Hazard ratio: 2.260, Confidence interval: 1.177-4.340, p=0.014).

Conclusion:

Our study identified preoperative myosteatosis as an important factor of inferior graft- and patient survival in liver transplant recipients. These findings underline the clinical significance of preoperative body composition assessment in potential OLT recipients.

Long-term survival after curative colorectal cancer resection in a rural australian surgical center

(Abstract ID: 33)

M. Wichmann¹

¹Mount Gambier General Hospital, Mount Gambier

Background:

Colorectal cancer is one of the leading causes of cancer related deaths in Australia and the developed world. The incidence of colorectal cancer in Australia is among the highest in the world (57/100000 population/year).

The long-term results of colorectal cancer care in Australian non-metropolitan rural treatment centers are underreported.

Materials and methods:

This study investigates the long-term results (up to 10 years postoperative follow-up) after curative resection of colorectal cancer in a rural treatment center. Follow-up data were prospectively collected over a 13-year period (since February 2006) in a single institution. A total of 298 patients (Male N=164, Female N=134) met the inclusion criteria: surgery for cure, UICC Stages 1 to 3.

Results:

All results are reported as median unless indicated otherwise. Patient age at time of operation was 71 years. The BMI and ASA were 26 and 3, respectively. Length of surgery was 136.5 minutes with 200 ml intraoperative blood loss. Postoperative length of stay was 7 days with a 30-day mortality rate of 1.3% (N=4). 27% of the patients (N=80) were operated for rectal cancer. 35% of the patients (N=103) underwent laparoscopic resection. Lymph node yield was 13.5. Stage distribution was UICC I 32% (N=95), UICC II 35% (N=105) and UICC III 33% (N=98) with significant survival differences between cancer stages (Log Rank p=0.003). Median follow-up is 36 months. 36% of the patients have reached 5-years and 6% have reached 10 years follow-up after surgery. Overall survival after 5 and 10 years is 80% and 60%, respectively. Cancer specific survival after 5 and 10 years is 90% and 80%, respectively.

Conclusion:

Elective and emergency surgery for colorectal cancer is commonly performed in non-metropolitan/rural surgical centers throughout Australia. Long-term results for these patients are rarely reported. The results of this study indicate that colorectal cancer care can be safely provided in the rural nonmetropolitan environment with low perioperative mortality (1.3%). The long-term overall survival of patients after curative resection is high with 60% surviving until 10 years after surgery. Cancer specific survival after 10 years of follow-up is as high as 80%.

Surgical care for colorectal cancer can be safely provided in rural non-metropolitan centers with excellent long-term survival and low 30-day mortality. Based on these results centralization of surgical care for colorectal cancer far away from the patients’ families and homes is not justified.

Impact of postoperative complications on long-term prognosis following surgery for colorectal carcinomas

(Abstract ID: 124)

S. Merkel¹, C. Beck¹, K. Weber¹, M. Brunner¹, A. Agaimy¹, S. Semrau¹, R. Grützmann¹, V. Schellerer¹

¹Universitätsklinikum Erlangen

Background:

The influence of postoperative complications (POCs) on long-term prognosis in patients with colorectal carcinomas was analyzed with respect to the severity of complications according to the Clavien-Dindo classification (CDC).

Materials and methods:

The data of 2158 consecutive patients with curative elective resection of a colorectal carcinoma (CME or TME/PME) without distant metastases between 1995 and 2014 were analyzed. POCs were documented in a standardized form and retrospectively assigned to the Clavien-Dindo classification. Patients who died postoperatively (CDC grade V, 1.7%) were excluded. The influence of CDC on locoregional and distant recurrence, disease-free and overall survival was examined.

Results:

990 patients with colon carcinoma and 1168 with rectal carcinoma were analyzed. 467 patients (21.6%) had POCs: CDC I (slight deviation from the normal postoperative course) 141 (6.5%), CDC II (requiring pharmacological treatment) 162 (7.5%), CDC III (requiring surgical, endoscopic or radiological intervention) 112 (5.2%) and CDC IV (life-threatening complication requiring critical care management) 52 (2.4%). A higher rate of POCs and a higher grade of CDC were found in men, ASA III-IV patients, rectal carcinomas, after abdominoperineal excisions and multivisceral resections.The 5year rate of locoregional recurrences was 5.6% and was highest in CDC grade III patients (12.9%). The 5-year rate of distant metastases was 16.7% and increased continuously to 23.7% in CDC grade IV patients. In disease-free survival, the 5-year rate was 73.4% and decreased to 55.4% in CDC grade IV patients. In overall survival, the 5-year rate was 81.3% and decreased to 63.1% in CDC grade IV patients. This was confirmed in multivariate Cox regression analysis. We found a significantly higher risk for locoregional recurrences (HR 2.2; p=0.005) and distant metastases (1.7; p=0.020) in CDC III patients, while patients with CDC grade IV were associated with significantly worse disease-free (HR 1.8; p=0.002) and overall survival (HR 1.9; p=0.001).

Conclusion:

Patients with Postoperative complications after colorectal surgery have worse long-term prognosis. With increasing Clavien-Dindo classification grade, survival deteriorates.

Impact of preoperative body mass index on long-term prognosis in patients with colon carcinoma

(Abstract ID: 126)

S. Merkel¹, J. Fuchs¹, V. Schellerer¹, M. Brunner¹, C. Geppert¹, R. Grützmann¹, K. Weber¹

¹Universitätsklinikum Erlangen

Background:

Obesity is an established risk factor for a number of chronic diseases, including diabetes, cardiovascular diseases and cancer with an unfavorable influence on life expectancy. A crude measure of obesity is the body mass index (BMI). Here, we analyze the impact of the preoperative BMI on long-term prognosis in patients with colon carcinomas who underwent complete mesocolic excision.

Materials and methods:

The data of 694 consecutive patients with curative resection of a colon carcinoma (CME, complete mesocolic excision), no distant metastases, between 2003 and 2014 were analyzed. The preoperatively measured BMI was categorized according to the proposal of the WHO: <18.5 underweight, 18.5-24.9 normal weight, 25.0-29.9 overweight, >=30.0 obesity.

Results:

13 patients (1.9%) were underweight, 221 patients (31.8%) were normal weight, 309 patients (44.5%) were overweight and 151 patients (21.8%) were obese. Men were found to be significantly more frequently overweight or obese (p<0.001). The 5-year rate of locoregional recurrences was 2.1%. No influence of any risk factor including BMI was found. The 5-year rate of distant metastases was 13.4%. It was significantly higher in advanced stage and emergency patients, but was not influenced by the patients’ BMI. The 5-year rate of disease-free survival was 72.4%, the 5-year rate of overall survival was 78.1%. Both were significantly influenced by age, ASA classification, emergency presentation, tumor site, stage and preoperative BMI. Obese patients had a significantly better 5-year disease free survival than normal weight patients (78.5% vs 69.8%; p=0.045). This could be confirmed in multivariate Cox regression analysis (HR 0.7; p=0.034). In addition, obese patients had a significantly better overall survival than normal weight patients (82.4% vs 73.4%; p=0.027), which also could be confirmed in multivariate Cox regression analysis (HR 0.6; p=0.019).

Conclusion:

In a cohort of 694 colon carcinoma patients treated with CME, obese patients at the time of surgery were not found to have worse prognosis than normal weight patients.

Impact of disease severity on postoperative quality of life after elective sigmoidectomy for diverticulitis

(Abstract ID: 221)

M. Sohn¹

¹Städtisches Klinikum München - Bogenhausen

Background:

To identify the impact of disease severity on long-term quality of life (QoL) in patients, who undewent elective sigmoidectomy for diverticulitis.

Materials and methods:

Data of consecutive patients were prospectively collected in a multicentric approach. Disease severity was graded according to CT-findings at the acute inflammation and by histopathologic analysis in the resected specimen: G1=Diverticulosis; G2=Diverticulitis with peridiverticulitis; G3=Diverticulitis with peridiverticulitis and abscess; G4=Diverticulitis with peridiverticulitis, abscess and peritonitis, -/+ perforation. Results were compared with pre- and postoperative QoL, assessed 1 day preoperatively and 6 month postoperatively by use of SF36 and GIQLI-questionnaires. Moreover, SF36 results were compared to a German normative sample. The SF36 contains 36 items in eight domains: general health (GH), physical functioning (PF), social functioning (SF), bodily pain (BP), role physical (RP), mental health (MH), role emotional (RE), and vitality (VT). Scores range from 0 to 100. Higher scores indicate better results. GIQLI consists of 36 questions addressing QoL with five possible answers. Maximum score is 144. A difference of 10 points is considered to show clinically significant differences in both questionnaires. Complicated diverticulitis (CD) was defined in accordance to the German CDDclassification: presence of extraluminal air -/+ abscess at the initial CT-scan. Indication for surgery was made in accordance to the German S2K-guidelines and individualized. Patients with free perforation and acute peritonitis were excluded. Trial Registration Number: NCT03527706.

Results:

From 11/2017 to 6/2019 44 patients were included. SF 36 results within the preoperative assessment were superior in 6 of 8 SF36 domains, favoring CD. Results were statistically and clinically significant in 4 of 8 domains (GH, RE, RP, VT). The same was shown by GIQLI with statistical and clinical superiority in case of CD (102,9 vs. 89,1; p=0,001). No differences were found within the comparison between QoL and histopathological grading of the inflammation. Six months follow-up was available in 26 patients. An improvement of QoL was shown in all SF36 domains as well as in the GIQLI-scoring. Results were statistical relevant in 4 of 8 domains of SF36 (RP, RE, BP, SF) and within GIQLI. Evidence of an abscess at the initial CT-scan were without influence. Preoperatively, patients with diverticulitis had worse QoL in comparison to the normative sample in 7 of 8 domains, clinically relevant in 4 domains (RE, RP, BP, SF). After sigmoidectomy results were equal in 2 and better in 5 of 8 domains, comparing to the normative sample.

Conclusion:

Diverticulitis of the colon has a relevant impact on QoL. Therefore, the identification of the best treatment strategy is of significant interest. QoL is partially better in patients with complicated disease. The authors hypothesize, that uncomplicated and complicated disease might be different disease entities. Since the risk for complicated recurrence as well as associated emergency surgery is low, quality of life constitutes as central outcome parameter. Therefore, we recommend an individualized approach within the decisionmaking for surgery, favoring patients with impaired QoL due to symptoms of the disease, such as persisting abdominal pain or frequent recurrencies. Complicated disease should not automatically lead to elective sigmoidectomy.

Is there a benefit of secondary resection of metastasis in patients with initial palliative therapy for colorectal cancer

(Abstract ID: 271)

V. Schellerer¹, J. Baecker¹, S. Kersting¹, R. Grützmann¹, S. Merkel¹, A. Wein¹

¹Universitätsklinikum Erlangen

Background:

Patients with unresectable metastatic colorectal carcinoma (CRC) receiving palliative chemotherapy and biological agents after expanded RAS-analysis are regularly restaged by imaging with subsequent tumor board decision every 2 months to identify patients becoming secondary resectable (IVOPAK II study). The aim was to analyze the benefit for the patients.

Materials and methods:

Between 7/2016 and 7/2019, 40 patients were included into the study. 50% (n=20) had a RAS mutation, 50% (n=20) an all-RAS wild-type. To date, 14 patients received a secondary curative therapy, including 9 patients with liver metastases only (HEP), 1 patient with resection of HEP and primary tumor (PT), 2 patients with resection of HEP and pulmonary metastases (PUL) and PT, 1 patient with resection of PUL, 1 patient with peritoneal metastases.

Results:

Median age of the 12 patients with HEP was 65 years (range: 56-72), including 10 men and 2 women. RAS wild-type was diagnosed in 67% (n=8), RAS mutations in 33% (n=4). In median 6 months after starting palliative treatment (range 3-18) patients underwent secondary curative surgery. The 12 patients with HEP ( /- PUL) were treated by surgical resection (n=7), radiofrequency ablation (n=3) or both (n=2). Liver resections included 2 atypical and 4 segmental resections, 2 right hemihepatectomies and 1 extended right hemihepatectomy. Postoperatively, the following complications occurred after liver-resection (Clavien-Dindo classification): Grade 0 (n=2), Grade I (n=1), Grade II (n=1), Grade III (n=2), Grade IV (n=3). Median follow-up of the 12 patients is currently 6 months (0-28). 11 of 12 patients are still alive. 4 patients (30%) remain with no evidence of disease. Patients with lung metastases (n=2) received a resection but suffered from further recurrence of the lung metastases. In one case a further resection was performed and the patient is currently without evidence of disease. The patient with peritoneal metastases received a hyperthermic intraperitoneal chemoperfusion after cytoreductive surgery without any complications and is currently without any evidence of disease. Results of a longer follow-up will be presented at the meeting.

Conclusion:

Even in patients with unresectable metastatic CRC receiving palliative therapy, regularly restaging for evaluation of secondary curative treatment options is meaningful. The high response rate of all-RAS wild-type population is important for secondary resection. If possible, a secondary resection of metastases should be performed, as patients benefit, even in case of postoperative complications.

Conclusion after 1956 mostly laparoscopic appendectomies for appendicitis: Strengthening the indication for an early operation

(Abstract ID: 368)

J. W. Heise¹, J. Witte¹, M. Schreck¹, J. Tomczak¹, N. Tosuncuk-Ari¹, C. Baron¹, J. M. Ewodo Beyeme¹

¹BETHLEHEM Gesundheitszentrum Stolberg gGmbH, Department of Surgery

Background:

Until recent years early appendectomy was the treatment of choice if appendicitis was suspected. But lately in actual publications conservative treatment with antibiotics in presumed non-complicated cases was applied to avoid an operation in a majority of patients. Consecutively an open discussion for the need of an operation in such instances with the patient, in case a child´s parents, was recommended. Aim of this analysis was, to provide evidence for this discussion on circumstances and risks of an appendectomy in the year 2019.

Materials and methods:

For the period of August 2004 to July 2019 all appendectomies in a community hospital with a general surgical (1/2/4) and a pediatric departement were identified through the hospital information system. Simultaneous appendectomies and cases with missing information were excluded. In minimalinvasive operations always a linear stapler was used to divide the appendix from the cecum. Beside administrative data the start of symptoms, operative technique (open, converted, laparoscopic), if initially perforated (free or covered), histology (degree of inflammation) and postoperative complications (reoperation, abscess drainage, readmission, wound infection) were of interest. In order to look for changes over time three groups for 5 years each were defined (2004-2009: Gr. I, 20092014: Gr. II, 2014-2019: Gr. III). Significance (p<0,05) for parametrics was tested using the U-test, for non-parametrics by Fisher´s exact-test.

Results:

Over a period of 15 years 1956 patients suspected for having appendicitis were operated by a number of 26 surgeons. The average age was 26 ± 19 (2-91) years.There was no mortality. In Table 1 the most important results are displayed:

Conclusion:

One of six patients in our study group had perforated appendicitis. In spite of the technical challenge, meanwhile 98% oft all cases were laparoscopically finished. Especially in the non-perforated situation the rate of complications is extremely low. Even if perforated, cases are managed mostly minimalinvasively with amazing success, there is still a considerable morbidity and a prolonged postoperative hospital stay in these instances. Taking this into account, early operation seems to be the favourable therapeutic principle especially in suspected uncomplicated appendicitis, compared to conservative treatment with antibiotics. Very low complications and the definitve solution of an otherwise pending problem are strong arguments for an early operation in the discussion with our patients.

Comparison of different lymph node staging systems in R0 resected colorectal cancer patients

(Abstract ID: 390)

D. Prassas¹, A. Rehders¹, W. T. Knoefel¹, A. Krieg¹

¹Universitätsklinikum Düsseldorf

Background:

Aside from the standard TNM staging system, lymph node ratio (LNR) and log odds of metastatic lymph nodes (LODDS) staging methods have been introduced for cancer staging. We compared the prognostic performance of the above mentioned lymph node staging systems (LNS) in patients with colorectal cancer.

Materials and methods:

Data from 655 patients with non-metastatic colorectal cancer (M0) that were radically resected (R0) in our department between the years 1996 and 2017 were included. Kaplan-Meier methods and multivariable Cox regression analysis were used to evaluate the prognostic value of different LNS. To build a multivariable-adjusted model we used cut-off values generated in a test set including cases (n=197) operated before 2004 and applied them in a validation set including cases (n=458) operated after 2004. LN involvement (N) was classified according to the AJCC (8th edition). LODDS was stratified by quartiles. LNR cut-off values proposed by Calero et al. (LNRC) and Guglielmi et al. (LNRG) were applied in our data set. Various patient subgroups (rectal cancer cases only, colon cancer cases only, UICC III cases only, at least 12 resected lymph nodes only) were formed to further investigate the prognostic value of the above variables. The predictive power of the different LNS methods was estimated by calculating the receiver operating characteristic (ROC) curve at 1, 3 and 5 years after surgery, respectively.

Results:

Univariate analysis showed that N, LODDS, LNRC and LNRG were significant prognostic factors for overall patient survival (OS) in all patient sets (p<0.001). In multivariate analysis N, LODDS, LNRC and LNRG remained significant prognostic factors for overall survival in all data sets and patient subgroups. LODDS classification and LNRG classification demonstrated the highest HR values in the UICC III patient subgroup [LODDS: p<0.001, HR=1.791 (95%CI: 1.287-2.492)], [LNRG: p<0.001, HR=2.077 (95%CI: 1.405-3.072)]. LNRG demonstrated comparable HR values across all data sets and patient subgroups (HR range: 1.755-1.904). The standard N classification was also found to have comparable HR values between all data sets and subgroups (HR range: 1.688-1.830). LNRC and LNRG demonstrated higher HR values compared to N in all test sets and patient subgroups. The results of the ROC curve analysis demonstrated that LODDS (AUC: 0,62; 0,64 and 0,63) was the most predictive factor during the 5 years of postoperative follow up, followed by LNRG, LNRC (both AUC: 0,59; 0,62 and 0,62) and N (AUC: 0,58; 0,62 and 0,62).

Conclusion:

Our results indicate that novel LNS may be better predictors of OS in patients undergoing radical surgery for UICC III stage colorectal cancer. Further studies are needed to investigate the differences regarding model discrimination for each LNS parameter.

Laparoscopic and open resection of rectal cancer — is age an effect modifier for short- and long-term survival?

(Abstract ID: 396)

V. Völkel¹, T. Draeger¹, M. Klinkhammer-Schalke², M. Gerken², S. Benz³, A. Fürst¹

¹Caritas Krankenhaus St. Josef, Regensburg

²Tumorzentrum Regensburg

³Kliniken Böblingen

Background:

Various studies proofed the oncologic safety of laparoscopic resection of rectal carcinoma. However, there does not exist a clear recommendation on whether age should influence the choice of the surgical approach.

Materials and methods:

This population-based retrospective cohort study compared outcomes of laparoscopic and open surgery in rectal cancer patients. Perioperative mortality, 5-year overall, relative, and recurrence-free survival rates were analyzed separately for three age groups (< 60 years, 60-69 years, 70-79 years). Data originate from 30 regional German cancer registries that cover approximately one quarter of the German population. All primary nonmetastatic rectal adenocarcinoma cases with surgery between 2005 and 2014 were eligible for inclusion. To compare survival rates, Kaplan-Meier analysis, a relative survival model, and multivariable Cox regression were used; a sensitivity analysis assessed bias by exclusion.

Results:

10,754 patients fulfilling all inclusion criteria without missing data in important variables were included in the analysis. The mean laparoscopy rate was 23.0% and increased over time. Uni- and multivariable regression analysis of 30-day postoperative mortality revealed advantages for laparoscopically treated patients, although the significance level was not reached in any age group (for age group 70-79, it was missed only slightly: odds ratio, OR 0.559; 95% confidence interval, 95% CI 0.296-1.058). Regarding 5-year overall survival, laparoscopy generally seems to be the superior approach, whereas for recurrence-free survival patients under 60 years benefited more from the minimally invasive approach than older patients (< 60 years: hazard ratio, HR 0.703, 60-69 years: HR

0.787, 70-79 years: HR 0.923).

Conclusion:

Laparoscopy shows similar results to the open approach in terms of postoperative mortality in all age groups. Concerning long-term outcomes, younger patients benefitted most from the minimally invasive approach. Increased use of laparoscopy for rectal cancer should be considered in this group.

Surgical treatment of rectal cancer patients aged 80 years and older - a German nationwide analysis comparing short- and long-term survival after laparoscopic and open tumor resection

(Abstract ID: 398)

V. Völkel¹, T. Draeger¹, M. Gerken², S. Benz³, M. Klinkhammer-Schalke², A. Fürst¹

¹Caritas Krankenhaus St. Josef, Regensburg

²Tumorzentrum Regensburg

³Kliniken Böblingen

Background:

Minimally invasive removal of rectal tumors has proven to be a safe alternative to the open approach. Despite increased use of laparoscopy, its eligibility for patients aged 80 years and older requires further exploration.

Materials and methods:

This study compares perioperative mortality and 5-year overall, disease-free, and relative survival after laparoscopic and open surgery in rectal cancer patients aged 80 years and older. Data derive from 30 German regional cancer registries covering approximately one quarter of the entire German population. All primary nonmetastatic rectal adenocarcinoma cases with surgery between 2005 and 2014 were eligible for inclusion. To compare survival rates, Kaplan-Meier analysis, a relative survival model, and multivariable Cox regression were applied; a sensitivity analysis assessed bias by exclusion.

Results:

1,532 patients were included, of whom 17.1% underwent laparoscopic procedures. 30 days after surgery, 2.7% of the laparoscopy patients had died compared to 7.0% in the open surgery group. The multivariable analysis confirmed that minimally invasive procedures are followed by a lower 30-day postoperative mortality risk (odds ratio, OR, 0.352; 95% confidence interval, CI, 0.161e0.771; p =0.009). With a 5-year disease-free survival rate of 52.0 vs. 47.6% (p = 0.557), only a nonsignificant long-term advantage of the minimally invasive approach was observed.

Conclusion:

Given the results of this study, older rectal cancer patients are likely to benefit from the laparoscopic approach in the short term, while there are no disadvantages in terms of long-term survival. Therefore, laparoscopy should be considered as standard procedure for patients aged 80 and older as well.

Secondary Cancers in Colorectal Cancer Patients: Incidence, Survival and Risk Factors

(Abstract ID: 465)

J. Lemke¹, P. Glück¹, S. Sander¹, M. Kornmann¹, D. Henne-Bruns¹

¹Universitätsklinikum Ulm

Background:

Due to improvement in diagnosis and therapy, today long-term survival can be achieved in most colorectal cancer patients. In addition to the extended live expectancy in general, this fact accounts for an increased risk to develop secondary cancers. In this study we analyzed the incidence and survival of patients developing secondary cancers after or simultaneously to colorectal cancer.

Materials and methods:

Between January 2000 and December 2012 1144 patients diagnosed with colorectal cancer were treated in our clinic. All patients were postoperatively followed up in our clinic. Here, we analyzed the incidence and survival of patients that developed secondary cancers.

Results:

Of all 1144 patients, 137 patients (12%) developed secondary cancers. 67 patients ( 49%) were diagnosed with synchronous secondary cancer, whilst 70 patients (51%) developed a secondary malignancy postoperatively. Secondary cancers developed included, colorectal, other gastrointestinal, urological, and gynecological tumors. Interestingly, in general, the development of secondary cancers was not associated with impaired survival. Moreover, we identified risk factors for the development of secondary cancers.

Conclusion:

In conclusion, secondary cancers are commonly encountered in colorectal cancer patients. Moreover, our study suggests, that several factors may contribute to the development and prognosis of secondary cancers in these patients.

Functional outcome of robotic and transanal total mesorectal excision

(Abstract ID: 626)

J.-K. Graß¹, R. Persiani², F. Tirelli², C.-C. Chen³, M. Caricato⁴, A. Pecorino⁴, I. J. Lang¹, C. Diehm¹, P. Sconamiglio¹, T. Ghadban¹, J. Izbicki¹, D. Perez¹

¹Universitätsklinikum Hamburg-Eppendorf

²IRCCS, Rome

³National Yang-Ming University, Taipei

⁴Catholic University, Rome

Background:

Improved long-term survival moves functionality after LAR to the fore of rectal cancer care. Urogenital and anorectal dysfunction are frequently reported after conventional low anterior resection (LAR). Advanced minimal invasive techniques as robotic (RoTME) and transanal total mesorectal excision (TaTME) could optimize functional results facilitating the preservation of autonomic nerves. This multicenter study aims to compare outcomes after TaTME and RoTME.

Materials and methods:

All Patients, who have been operated in four participating centers by RoTME or TaTME, were included. Functional outcome was assessed by validated self-administered scores 12 months after surgery and compared to preoperative score values. Anorectal (Wexner and LARS Score), urinary (IPSS, ICIQ-MLUTS, ICIQ-FLUTS ) and sexual (IIEF, FSFI) outcome were compared to preoperative score values. Results were calculated with validated scoring systems and statistically analyzed. Clinicopathological parameter and short-term outcome were collected.

Results:

120 patients (55 RoTME / 65 TaTME) were included. RoTME revealed a better preserved fecal function (0.7 ± 3.9 vs. 3.2 ± 3.8, p= 0.006). Bladder function was comparable with mild postoperative impairment in both groups (male: 13.2 ± 12.6 vs. 7.1 ± 19.9, p=0.181; female incontinence: 1.4 ± 0.5 vs. 1.6 ± 1.1 p=0.790). TaTME demonstrated a better preserved male sexual function, especially for orgasmic function and overall satisfaction (orgasmic function -2.1 ± 4.4 vs. 0.1 ± 1.0, p= 0.038). Female sexual function was equal between both groups (-0.3 ± 19.5 vs. -06. ± 2.9, p=0.959).

Conclusion:

Both, RoTME and TaTME result in only mild functional impairment after rectal resection. RoTME leads to better fecal results potentially induced by sphincter dilatation or damage of the internal sphincter whiles TaTME, which demonstrates better male orgasmic function.

Morbidity and Mortality of Colorectal Surgery in Patients with Liver Cirrhosis – a retrospective Analysis of 54 cases

(Abstract ID: 773)

C. van Beekum¹, C. Beckmann¹, J. Dohmen¹, M. von Websky¹, B. Stoffels¹, T. Glowka¹, J. C. Kalff¹, T. Vilz¹

¹Universitätsklinikum Bonn

Background:

Mortality of patients with liver cirrhosis is predicted by different scoring systems such as MELD and Child-Pugh. Despite existing data on the impact of liver cirrhosis on morbidity and mortality of patients undergoing non-hepatic surgery, studies evaluating the outcome of patients suffering from cirrhotic liver disease undergoing colorectal surgery are rare. Purpose of this study was to elucidate perioperative morbidity and mortality of these patients. We hereby aim to clarify on possible pitfalls of colorectal surgery in patients with cirrhotic liver disease.

Materials and methods:

A review of 54 patients in different stages of liver cirrhosis, who underwent colorectal surgery (right hemicolectomy, resection of the transverse colon, left hemicolectomy, resection of the sigmoid colon, colectomy, reversal of an end colostomy, creation of a colostomy) between 1996 and 2018 in an elective or emergency setting was conducted. Perioperative morbidity and mortality were evaluated as well as type and quality of complication.

Results:

Medium patient age was 61±14 years. 38.9% of procedures were performed electively, 61.1% in an emergency setting. Child-Pugh A cirrhosis was found in 53.7%, B in 24.9% and C in 12.1% of cases. In 9.3% no Child-Pugh stage could be evaluated due to missing data. 37% of patients died during or within 30 days after the operation (Dindo/Clavien V). Major complications (Dindo/Clavien >IIIb) were seen in 23.1% of cases. Patients whose procedures were performed in an emergency setting, patients with ASA score >IV as well as patients with Child-Pugh B or C cirrhosis experienced significantly worse complications (p=0.0023, p=0,013, p=0.04 respectively). All patients suffering from Child-Pugh C liver cirrhosis died during the procedure or in the postoperative course. A primary anastomosis was established in 53.7% of patients. Anastomotic leakage was seen in 11.1% of these patients. Bleeding requiring blood transfusion (51.1%) and hemodynamic instability due to bleeding or inflammation (44.4%) were the most common complications. Hydropic decompensation of cirrhotic liver disease was seen in 24% of patients.

Conclusion:

Mortality of colorectal surgery in patients with liver cirrhosis is high, especially if the operation is performed in an emergency setting. Severity of complications increases with worsening liver function. In Child-Pugh C cirrhosis non-operative treatment has to be preferred if possible. Morbidity is not only influenced by liver function (especially by ascites refractory to treatment), but also by surgical variables such as necessity of blood transfusions and urgency of surgery. Due to the high rate of anastomotic leakage, creation of diverting ileostomy must be considered. Colorectal surgery in patients with cirrhotic liver disease should be performed only in experienced institutions and in cooperation with hepatologists and hemostaseologists.

Sacral nerve stimulation for the treatment of fecal incontinence in patients with ileal J-pouch – a retrospective study

(Abstract ID: 776)

C. E. Degro¹, N. Slavova¹, M. E. Kreis¹, B. Weixler¹

¹Charité, Campus Benjamin Franklin, Berlin

Background:

Functional results after panproctocolectomy and ileal pouch anal anastomosis (IPAA) are usually promising. A relevant proportion of patients however experiences continence disorders with high stool frequency and fecal incontinence. The treatment of these patients is challenging and requires a combination of dietary modifications, medication and pelvic floor rehabilitation and yet results often remain unsatisfactory. Sacral nerve stimulation (SNS) could provide a therapeutic alternative to conventional treatment in these patients but indication for this operation is reserved as related studies are almost entirely lacking. The aim of this study was to assess the duration of postoperative incontinence as well as the effectiveness of SNS implantation after IPAA.

Materials and methods:

Patients undergoing SNS implantation after panproctocolectomy with IPAA (J-pouch) for ulcerative colitis or familiar adenomatous polyposis between 1994 - 2019 were included in this retrospective study. IPAA was either performed as a two or three step approach with removal of ileostomy (ISR) as the last step. Demographic and follow-up data as well as functional results were obtained from the hospital database.

Results:

SNS for high stool frequency or fecal incontinence was performed in 11 patients (8 male). Mean age at timepoint of IPAA was 43.7 years (standard deviation [SD] 10.5 years). Mean time from IPAA to ISR was 0.6 years (SD 0.5 years). Mean time with high stool frequency or fecal incontinence (ISR to SNS implantation) was 6.5 years (SD 4.9 years). Continence after SNS was decent in all patients with a mean St. Marks score for anal incontinence of 10.0 (SD 6.6).

Conclusion:

SNS implantation for high stool frequency or fecal incontinence after panproctocolectomy with IPAA is used hesitantly, exposing patients to unnecessarily long suffering, although postoperative function after SNS implantation is consistently good.

Awareness of the positive impact of SNS in patients with IPAA should rise amongst physicians involved in the treatment of these patients.

Impact of Surgical Site Infection on Postoperative Outcome

(Abstract ID: 788)

J. C. Lauscher¹, R. M. Strobel¹, F. Speichinger¹, K. Neumann², M. E. Kreis¹

¹Charité - Unversitätsmedizin Berlin - CBF

²Charité Universitätsmedizin Berlin

Background:

Surgical site infection (SSI) is a common complication after visceral surgery. Irrespective of prevention strategy it is seen in up to 25% after laparotomy causing increased morbidity. The economic burden for the department and the health system rises due to prolonged hospital stay, duration of disease and input of personal and financial resources.

Materials and methods:

Within the scope of the RECIPE trial we analyzed the 30-days postoperative outcome of SSI in a single-centre, prospective, randomized-controlled trial comparing subcutaneous wound irrigation with Serasept® (0.04 % Polihexanide) to irrigation with saline 0.9% after elective laparotomy for visceral surgery. All patients were followed for 30 days postoperatively and SSIs were detected respectively the criteria of the Centers for Disease Control (CDC). Furthermore, duration of hospitalization, costs of inpatient treatment, postoperative pain and satisfaction with the cosmetic result were documented.

Results:

Between November 2015 and May 2018, 456 patients were recruited. Follow-up was completed by 393 patients (86.2%). The overall rate of SSI was 28.2%. More than half of the SSIs (59.5%) were detected during inpatient treatment. Median duration of hospitalization was longer in patients with SSI than in patients without SSI: 18.0 days vs. 12.0 days; p<0.001. Preliminary, the median overall costs of inpatient treatment of patients treated in 2015 and 2016 (n=184) were higher in the study population with SSI: 13575€ vs. 10834€ (p=0.01). Furthermore, there were higher median treatment costs for patients with SSI on surgical ward (median 7325€ vs. 4561€; p=0.004) and higher median costs for medication (median 762€ vs. 458€; p=0.005). Patients with SSI had more postoperative pain at the scar after 30 days (1.3 ± 1.7 mean on NAS) than patients without SSI (0.6 ± 1.4 mean on NAS; p<0.001). Satisfaction with the cosmetic result (rated 8-10 out of 10) of the scar was achieved in

27.0% of patients with SSI and 60.7% of patients without SSI (p<0.001).

Conclusion:

SSI after elective laparotomy is causing increased morbidity 30 days postoperatively. The duration of hospitalization is longer and costs of inpatient treatment are higher. Patients with SSI have more postoperative pain and are less satisfied with the cosmetic result 30 days postoperatively. Therefore, prevention of SSI is crucial.

Surgical Resections Of Colorectal Cancer In Patients With Liver Dysfunction not necessarily lead to a worse perioperative or oncological outcome

(Abstract ID: 892)

M. Neuberger¹, T. Schiergens¹, N. T. Beger¹, A. Sint¹, P. Zimmermann¹, F. Kühn¹, U. Wirth¹, J. Werner¹, M. Rentsch¹

¹Klinikum der Universität München

Background:

It is well known that patients with advanced liver disease - especially in a cirrhotic liver - have a high perioperative risk and more surgical complications due to hepatic dysfunction. Hence, especially in patients with greater degree of liver cirrhosis larger abdominal operation is mostly not indicated, although patients with colorectal cancer often meet conditions for liver diseases. Nevertheless, perioperative risk and surgical contraindications in patients with non-cirrhotic liver disease or moderate forms of liver insufficiency are poorly understood although risk stratification in situations with potentially higher perioperative complications should be required. Therefore, we performed this study to investigate the perioperative risk in patients with liver dysfunction undergoing resection of primary colorectal cancer.

Materials and methods:

A total of 1062 patients undergoing curative-intended resection for colon (n=501) or rectal cancer (n=561) were recruited in this prospective trial between January 2009 to December 2018. 24 Patients (14 females, 10 males) identified with moderate or severe liver dysfunction by using anamnestic and diagnostic tools were assessed by the Charlson comorbidity index. Using univariate and multivariate analysis, the aim of this study was to evaluate the perioperative morbidity and tumor recurrence rate in patients with or without liver dysfunction.

Results:

Patients with moderate and severe liver dysfunction undergoing surgery for colorectal cancer showed comparable, statistically not significant, perioperative morbidity to patients with regular liver function regarding perioperative requirement of blood transfusion (15.8 vs. 19.4%), anastomotic insufficiency (0 vs. 6.4%), secondary bleeding (4.3 vs. 3%), peritonitis (4.3 vs. 2%), intraabdominal abscess (0 vs. 2%), sepsis (0 vs. 6%), and wound infection (8.7 vs. 11.9%). The rate of revision surgery was comparable with 21 vs. 16% in both groups. There were no significant differences in recurrence rate in both groups (13.6 vs. 18.5%) and time to recurrence was 15 months in both groups. Charlson Score was 5.3 and 4.2, respectively. Patient characteristics were comparable in both groups with regard to sex, age, body mass index, American Society of Anesthesiologists score and tumor stage.

Conclusion:

In patients undergoing resection for colorectal cancer, moderate or severe liver dysfunction is not necessarily associated with a higher perioperative morbidity although this is well investigated in cirrhotic liver diseases. However, patients with liver dysfunction need an especially careful perioperative setting and further studies are required to assess specific risk factors and further classify types of liver dysfunction in these patients.

Combination of mechanical bowel preparation with oral antibiotics reduced postoperative morbidity in elective colorectal surgery

(Abstract ID: 918)

J. Presl¹, P. Schredl¹, S. Mitterwallner¹, S. Ciftci¹, A. Dinnewitzer¹, K. Emmanuel¹, T. Jäger¹

¹Universitätsklinik für Chirurgie Salzburg

Background:

The optimal bowel preparation strategy to reduce postoperative morbidity in elective colorectal surgery is currently under discussion. The aim of our study was to investigate the effect of three different bowel preparation strategies on postoperative morbidity in elective colorectal surgery.

Materials and methods:

This is a retrospective study with prospectively collected data. All patients (N=272) who underwent an elective colorectal surgery between January 2017 and December 2018 were analyzed. Primary outcome was postoperative complication rate (Clavien/Dindo 1-5). Three groups: no preparation (None, N=81), mechanical bowel preparation only (MBP, N=83), and MBP with oral antibiotics (MBP+AB, N=108) were compared with the Kruskal-Wallis test.

Results:

Baseline characteristics of patients in this study were mostly balanced between the groups (except BMI P=0.01). In total 85 (31%) patients, had 75 surgical(s) and 24 none surgical complications. Clavien-Dindo 3b - 5 complications occurred in 32 patients (12%).

Statistically lowest complication rate was observed in the MBP+AB group when compared with the None and MBP group (surgical: P=0.004 and nonsurgical: P=0.002).

Conclusion:

Mechanical bowel preparation with additive oral antibiotics prior to elective colorectal resection significantly reduced the postoperative surgical and non-surgical complication rates and was associated with decreased hospital stay. Our results suggest that this bowel preparation strategy in elective colorectal surgery is the best and should be recommended as the standard.

A prospective phase I/II open label trial of Hyperthermic Intraperitoneal Chemotherapie (HIPEC) following macroscopic complete resection (R0/R1) of pancreatic adenocarcinoma (PanHIPEC)

(Abstract ID: 24)

C. Yurttas¹, P. Horvath¹, A. Königsrainer¹, S. Beckert², M. Löffler¹

¹Universitätsklinikum Tübingen

²Schwarzwald Baar Klinikum Villingen-Schwenningen

Background:

Context: Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal disease, even in spite of macroscopically complete surgical resection. Unfavorable outcomes, frequently observed after surgery, including local recurrence and lymph node metastasis are attributed to minimal residual disease and undetected local dissemination. To address this issue and to increase the rate of patients benefiting from this high-risk surgical intervention, accessory hyperthermic intraperitoneal chemotherapy (HIPEC) application has been suggested as a promising therapeutic modality.

Objective: Since both pancreas resection and HIPEC are established as procedures associated with relevant morbidity and mortality, the primary end point of this prospective interventional clinical trial was to assess the 30 day mortality rate under the combination treatment. Further this trial aimed to assess the feasibility and safety and toxicity of the treatment in a controlled prospective manner for the first time.

Materials and methods:

Design, Setting, and Participants: The PanHIPEC trial was designed as a single arm open-label phase I/II trial for patients with macroscopically complete resection for PDAC (R0/R1), without neo-adjuvant pretreatment. The sample size of 16 evaluable patients was estimated to prospectively establish a critical event (death and/or severe adverse event) profile <10 % with a power of >80 %.

Interventions: Consenting patients undergoing surgery with confirmed PDAC and successful surgical treatment (R0/R1) received intraoperative HIPEC treatment with gemcitabine dosed at 1000 mg per m² body surface area at 42 °C for one hour.

Main Outcome Measure: Primary endpoints include 30 days mortality rate of treated patients as well as assessment of feasibility, safety and toxicity of the intervention assessed by common toxicity criteria (CTCAE; V4.0).

Results:

Between 12/2015 and 07/2017 20 patients were screened for eligibility. HIPEC treatment proved feasible in 16 of 18 included patients (89%) after Whipple’s procedure (n=10), distal (n=3) or total pancreatectomy (n=3). Treatment according to protocol was performed in all patients. During the immediate postoperative course (32 days post intervention) none of the patients died or experienced a severe adverse event. Except for one patient (94%) all patients experienced at least one adverse event with at least possible relation to HIPEC treatment in two patients. Toxicity assessed according to CTCAE resulted to grade 3 (severe nausea) in one patient, whereas the toxicity profile was mild in all other patients and frequently (n>1) encompassed nausea and vomiting, diarrhea, stomatitis.

Conclusion:

The combinatorial treatment of pancreas resection together with HIPEC using gemcitabine can be regarded as a safe procedure in experienced centers and is not correlated with a significant immediate postoperative increase in morbidity and/or mortality. The planned procedure was shown feasible in about 90% of patients and produced a well-manageable toxicity and adverse event profile. Against this background we conclude there are no substantial grounds precluding further clinical testing.

Recurrence of lymph node metastases of a malignant melanoma - an interdisciplinary surgical therapy

(Abstract ID: 77)

K. Keller¹, J. De Deken¹, M. Steffen¹, A. Gharbi¹, G. A. Stavrou¹

¹Klinikum Saarbrücken

Background:

The malignant melanoma is the skin tumor with the highest metastasis rate and is responsible for more than 90% of all deaths caused by skin tumors. The Saarland cancer registry shows an increase in mortality rates of over 200% in the past 30 years. According to literature, almost 15% of all patients develop lymph node metastases. Previously, the prognosis was considered infaust when metastases occurred.

Materials and methods:

The patient presented with a swelling in the groin. An MRI showed a fist-sized lymph node metastasis recurrence in the left groin of a known malignant melanoma, with infiltration of the communal femoral vein and questionably the femoral artery. An interdisciplinary surgery including a visceral and vascular surgeon was performed. The patient underwent radical lymphadenectomy of the left groin and a resection of the inguinal ligament, the femoral vein and the external iliac vein. In addition, the vessels were covered by a Sartorius muscle flap and the inguinal canal was reconstructed with the Lichtenstein technique.

Results:

The histological examination confirmed that the tumor was a metastasis of the malignant melanoma. It could be resected in sano with 1 mm distance. After an uncomplicated perioperative recovery the patient could be discharged after one week. Thereafter an adjuvant chemotherapy with Nivolumab was administered.

Conclusion:

Despite extensive tumor infestation, RO resection was achieved thanks to an interdisciplinary surgical approach. Due to the different manifestations of lymph node metastases of a malignant melanoma, no clear standard for resection can be proposed. Therefore, the extent of resection should be planned individually.

Picture:

operative site after removal of the tumor

CT-guided ethanol 95% ScleroTherapy (ST) to cure postoperative Lymphatic Leakage (LL) after clinically ineffective transpedal lymphangiography

(Abstract ID: 160)

C. Sommer¹, F. Pan¹, M. Loos¹, T. Do¹, G. Richter², H. Kauczor¹, T. Hackert¹

¹University Hospital Heidelberg

²Stuttgart Clinics

Background:

To analyze safety and efficacy of CT-guided ethanol 95% ScleroTherapy (ST) in the treatment of postoperative Lymphatic Leakage (LL) after clinically ineffective transpedal lymphangiography.

Materials and methods:

Between 04/2004-09/2018, 13 patients met the inclusion criteria. Study goals included patient demographics, technical and clinical success as well as complications.

Results:

From the included patients, n=4 patients (30.8%) presented with chylothorax, n=6 patients (46.2%) with inguinal lymphatic fistula/lymphocele, and n=3 patients (23.1%) with lymphatic fistula in the thigh. The lymphatic drainage volume was 670±494ml/day. After a mean time of 25±16 days after causal surgery, TL with curative intent was performed with iodized oil, and under fluoroscopy, radiography and/or CT the leakage site and the lymphatic feeder could be identified in all patients. Due to clinical failure after TL, ST was indicated as lymphatic second-line intervention and performed after a mean time of 17±13 days after TL. The technical success rate of ST was 100.0%. An average of 2.9±1.3ml ethanol 95% as the sclerosant was injected in/around the lymphatic feeder under CT-guidance after simulation of the sclerosant distribution pattern. Clinical success was observed in 10 of 13 patients (76.9%) after a mean time of 6±6 days. There were no complications.

Conclusion:

CT-guided ethanol 95% ScleroTherapy (ST) in the treatment of postoperative Lymphatic Leakage (LL) after clinically ineffective transpedal lymphangiography is safe and effective. Although transpedal lymphangiography alone shows a clinical success rate of 42.6%, one cannot emphasize enough the important role of lymphatic second-line interventions such as ST, and others.

Picture:

Patient with postoperative chylothorax (drainage volume of 1130 ml/day) [A, B] undergoing CT-guided ethanol 95% ScleroTherapy (ST) after clinically ineffective transpedal lymphangiography [C-G]; cure of chylothorax within 8 days after ST [H].

Identification and differentiation of visceral tissue types with hyperspectral imaging in an experimental model

(Abstract ID: 177)

A. Studier-Fischer¹, I. Camplisson², C. M. Haney¹, K. F. Kowalewski¹, E. A. Felinska¹, B. P. Müller-Stich¹, F. Nickel¹

¹Universitätsklinik Heidelberg

²California Institute of Technology, Pasadena

Background:

The proper identification and differentiation of visceral tissue types during surgery is a defining factor for patient outcome. This is a proposition of diverse complexity reaching from the unsophisticated identification of different organs to the much more complex identification of different organ subunits. These subunits include physiological appearances such as cysts or scarring as well as pathological elements such as malignancies, infections or distant metastases. A tool for the sound identification of these elements might yield a high benefit for the patient reaching from the improvement of conventional surgery to the possibility of intraoperative diagnostics systems and even use in autonomous robotic surgery.

Materials and methods:

Visceral organ mobilization was performed in a total number of 12 pigs under general standardized anesthesia with extensive monitoring. Stomach, liver, gallbladder, pancreas, spleen, kidney, jejunum, colon and bladder were consecutively exposed and recordings were obtained using the TIVITA Tissue Hyperspectral Camera System from Diaspective Vision GmbH including StO2 (HSI Oxygenation), NIR (HSI Perfusion), THI (HSI Tissue Haemoglobin) and TWI (HSI Tissue Water) channels. With a specifically designed python code these three-dimensional data cubes were processed to obtain the optical spectrum and histogram of their reflectance and absorbance values in arbitrary units. After noncontrast recordings, different dyes including ICG and Toluidine Blue were applied and recorded.

Results:

Due to the capabilities of hyperspectral imaging it was possible to obtain characteristic spectral signatures of visceral tissue including but not limited to the two spikes in gastric absorbance at 550 and 580 nm, the decreasing tendency of gallbladder reflectance from 640 to 850 nm as well as the hyperbolic appearance of splenic reflectance between 700 and 1000 nm with a local minimum at 870 nm. When applying different dyes their additional characteristic changes appeared in the spectral curves allowing for further differentiation.

Conclusion:

Hyperspectral imaging is a novel technique capable of contributing significantly to patient safety and innovative techniques by providing an elaborate possibility of tissue detection. There are two fields of possible future applications: The first comprises the area of organ identification that can complement the surgeon’s capabilities and is essential to enable development of autonomous robotic surgery. The second field of future applications comprises the entirety of areas in which the surgeon experiences naturally given limitations such as the evaluation of oncological resection margins or the identification of lymphatic metastasis in adipose tissue. Conclusively, these concepts are well suited for machine learning algorithms and bear a great potential to improve future patient outcome.

Picture:

Hyperspectral Tissue Identification. a, Hyperspectral recordings of an in-vivo porcine stomach. Recordings were obtained with the TIVITA Tissue Hyperspectral Camera System from Diaspective Vision GmbH including StO2 (HSI Oxygenation), NIR (HSI Perfusion), THI (HSI Tissue Haemoglobin) and TWI (HSI Tissue Water); b, Spectral information of the reflectance signal and the distribution of reflectance values in its histogram. c, Spectral information of the absorbance signal and the distribution of absorbance values in its histogram. Scale bar equals 5 cm.

Effect of combined cell salvage and retrograde autologous priming on blood transfusion rate in elective coronary artery bypass grafting and aortic valve replacement - a prospective single center study

(Abstract ID: 224)

T. Puehler¹

¹Universitätsklinik Schleswig-Holstein, Kiel

Background:

In a prospective, observational study, we investigated the impact of the combined use of retrograde autologous priming (RAP) in combination with cell salvage (CS) on the intraoperative usage of red blood cell concentrates (RBC) during elective coronary bypass surgery (CABG) and aortic valve replacement (AVR).

Materials and methods:

200 patients underwent surgery at our institution (CABG or AVR) by using local standard of care without cell salvage and RAP (control group, CG), followed by 200 patients with cell salvage and RAP (study group, SG). Both groups were defined by elective surgery with hemodynamically stable patients prior to the onset of the cardiopulmonary bypass (CPB).

Results:

Prevalence of preoperative anemia did not differ significantly between the groups (SG, 35% and CG, 38%). In the SG, cell salvage was performed in all patients, RAP in 84%. Pre-CPB hemoglobin (Hb) in the SG was 13.5 ± 1.9 g/dl, compared to 13.3 ± 1.7 g/dl in the CG. The mean amount of blood gained by RAP in the SG was 343 ± 217 ml, with a mean Hb of 9.6 ± 1.7 g/dl after initiation of CPB. On average 0.81 RBCs were administered intraoperatively in the SG with a transfusion trigger of 7.2 ± 0.7 g/dl, compared to 1.51 RBCs in the CG, with a transfusion threshold of 7.1 ± 0.6 g/dl. Mean Hb value before admission to ICU in the SG was 9.8 ± 1.0 g/dl vs 9.9 ± 0.9 g/dl in the CG.

Conclusion:

The use of CS in combination with RAP in patients scheduled for isolated elective CABG and AVR seems to be a meaningful approach with respect to patient blood management. We were able to show an intraoperative reduction in RBC transfusion of approximately 50%. These first preliminary results are promising but further and differentiated analyzes are needed in order to verify these effects with respect to postoperative short- and long-term outcome.

Single Anastomosis Duodeno-Ileal bypass (SADI) compared to One Anastomosis Gastric bypass (OAGB) for insufficient weight loss or weight regain after Laparoscopic Sleeve Gastrectomy (LSG)

(Abstract ID: 348)

M. de la Cruz¹, M. Büsing², M. Reiser³, A. Torres²

¹Klinikum Vest-Knappschaftskrankenhaus Recklinghausen

²Knappschaftkrankenhaus Recklinghausen

³Paracelsus Klinik Marl

Background:

Patients with inadequate weight loss or weight regain after laparoscopic sleeve gastrectomy (LSG) as well as super-obese patients (BMI > 50 kg/m2) may benefit from additional surgical therapy. Single Anastomosis Duodeno-Ileal bypass (SADI) and the One Anastomosis Gastric Bypass (OAGB) are two revisional procedures to address the problem of weight recidivism. Whether the SADI or OAGB is the more efficient procedure hast not been systematically investigated. Moreover, differences in complications and conversion rates compared to Roux-Y-Gastric Bypass (RYGB) for persistent reflux symptoms are unkown.

Materials and methods:

We assesed outcomes in 90 initially mainly superobese patients (BMI > 50 kg/m2) who had undergone revisional bariatric surgery (RBS) after a previous LSG (n=45 SADI, n=45 OAGB) between July 2013 and April 2018. The mean BMI prior to the SLG was 56.1 kg/m2 with the SADI- and 55.2 kg/m2 with the OAGB-Patients. Indications for RBS were insufficient weight loss or weight regain (100% SADI, 64% OAGB), de novo or progressive gastro-oesophageal reflux (20% SADI, 55% OAGB), worsening of glycemic control (7% SADI, 2% OAGB) or proximal anastomotic leaks after SLG (7% OAGB). The data were collected prospectively with follow up [1] examinations (FE) on fixed dates (1/6/12/24/36 months after revisional surgery). The following variables were analyzed:,Time between primary LSG and RBS, weight, body mass index (BMI), excess weight loss (%EWL), total body weight loss (%TBWL), operation time, complications and effects on comorbidities.

Results:

The mean time interval between the primary LSG and RBS was 43.9±21.2 (11-101) and 40.9±24.9 (4108) for SADI and OAGB respectively. At the time of RBS, the mean body mass index (BMI) was 43.3±7.8 (28-66) kg/m2 in the SADI-group and 43.1±9.9 (21.6-67.7) kg/m2 in the OAGB-group. The %EWL at the given FE time points was 49±14.4 / 65.6±16.4 / 74.5±15.7 / 77.9±16.7 / 81.9±17.2 for SADI and 52.2±19.1 / 59.8±17.8 / 67.4±19.1 / 72.9±21.2 / 75±13.2 for OAGB. %TWL was 27.8±9.8 / 36.5±10.1 / 41±10.4 / 43.2±12.2 / 45.8±13.3 for SADI and 29.2±10 /33.6±9.8 /37,7±10.9 / 40.2±11.3 / 39.7±6.3 for OAGB.

The FE-rate (in %) with the SADI at each time point was 97.8 /88.9 / 80 / 57.8 / 33.3. It has to be mentioned, that 24.4 % (11 patients) have not reached the 2 years and 51.1 % (23 patients) the 3 years FE-timepoint yet.

In case of the OAGB the FE-rate (in %) after the above named timeline was 97.8 / 80 /71.1 / 44.4 / 24.4.

26.7 % (12 patients) and 37.8 % (17 patients) haven´t reached the 2 years, respectively the 3 years FE-timepoint yet.

The mean operating time for SADI was 140±42 (78-223) minutes and 125±40 (70-270) minutes for OAGB.

The mortality rate after both bypass procedures was 2.2[AT1] %. Three patients in the SADI-group and one patient in the OAGB-group developed a major complication within the first 30 postoperative days. Minor complications were observed in 6,7% and 8,9% and re-admission rates were 22,2% and 40% for SADI and OAGB respectively. 8 (18%) patients in the OAGB-group were eventually converted to a RYGB due to persistent reflux symptoms.

Conclusion:

Both SADI and OAGB were effective and safe second-step procedures for further weight reduction after LSG in superobese patients. There was a trend towards higher %EWL and %TWL for SADI, though this did not reach statistical significance. Gastro-esophageal reflux symptoms were more often observed after OAGB necessitating further conversion to RYGB in 18% of patients.

Perineal/pelvic reconstruction with the pedicled anterolateral thigh flap - is it time to consider the VRAM flap a secondary choice?

(Abstract ID: 444)

A. Momeni¹

¹Stanford University Medical Center, Palo Alto

Background:

Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. These procedures result in defects that are characterized by a non-collapsible pelvic dead space, skin defect, as well as occasionally vaginal defect. Primary closure of these defects is associated with a high rate of wound complications. Historically, the workhorse flap for reconstruction has been the vertical rectus abdominis myocutaneous (VRAM) flap. This, however, is associated with abdominal wall morbidity including bulge and hernia formation. In this study we investigated whether the anterolateral thigh flap is a suitable alternative for perineal/pelvic reconstruction, which avoids the abdominal morbidity associated with the VRAM flap.

Materials and methods:

Patients who underwent abdominoperineal resection (with or without vaginal resection) or pelvic exenteration between 2017 and 2019 were retrospectively analyzed. Only patients who underwent soft tissue reconstruction with pedicled ALT flaps were included in the study. We included patients with rectal cancer, anal squamous cell carcinoma, inflammatory bowel disease, and Paget’s disease. Patient age, gender, body mass index (BMI), comorbidities, history of radiation, extent of ablative surgery, and postoperative complications were recorded. Complications were categorized as either major, i.e. requiring admission and/or return to the operating room, or minor, i.e. managed in the outpatient setting. Differences in age, gender, BMI, comorbidities, history of radiation, and extent of ablative surgery were compared between patients with and without wound complications. Continuous variables were converted to categorical variables, specifically, age was categorized as less than or greater than 65 years and BMI was categorized as less than or greater than a BMI of 25.

Results:

Twenty-three patients (16 male and 7 female) with a median age of 66 (IQR: 49-71) years were included in the study. Median BMI was 24.9 kg/m2 (IQR: 24.2-26.7). Comorbidities included diabetes (N=7), hypertension (N=9), coronary artery disease (N=4), COPD (N=2), and chronic liver disease (N=1). Thirteen patents presented with rectal cancer, 5 with anal SCC, 4 with Crohn’s disease, and 1 with Paget’s disease. Nineteen underwent neoadjuvant radiation. The ALT flap provided sufficient soft tissue coverage in all patients.

There were no operative or 30-day mortalities. Nine patients experienced 11 complications (2 major and 9 minor). Two patients experienced major complications including sacral osteomyelitis and perineal wound dehiscence from a urinary leak. The most common complication was partial dehiscence of the recipient site (N=6). Two patient’s experienced donor site complications, including temporary leg weakness (N=2) and seroma (N=1). One patient developed a postoperative DVT. There was no significant difference in the age, gender, BMI, primary disease, comorbidities, and history of radiation in those with or without complications.

Conclusion:

The ALT flap is a reliable option for perineal/pelvic reconstruction following oncologic ablation. The main advantage is avoidance of abdominal wall morbidity, which is particularly relevant in patients undergoing pelvic exenteration. In light of an increasing number of laparoscopy-assisted resections being performed, the morbidity associated with the VRAM flap appears to negate the benefits of the minimally-invasive approach used by our colorectal surgery colleagues. Hence, we propose the ALT flap as an alternative that should be given consideration before the VRAM flap.

Hypo-fractionated interstitial High-Dose-Rate Brachytherapy (iBT) of very large or confluent growing colorectal liver metastases: Feasibility, safety and efficacy

(Abstract ID: 557)

P. Hass¹, O. Großer¹, I. Steffen¹, T. Bretschneider¹, M. Walke¹, M. Seidensticker², C. Willich¹, F. Meyer¹, R. Damm¹, C. Wybranski³, T. Brunner¹, J. Ricke², K. Mohnike⁴

¹University Hospital at Magdeburg

²Ludwig-Maximilian University of Munich with University Hospital at Munich

³Uniklink Köln

⁴Diagnostic and Therapeutic Center, Berlin

Background:

To investigate feasibility, safety and efficacy of a hypo-fractionated interstitial high-dose-rate brachytherapy (HDR-BT) in single large (>= 6 cm) or confluent growing oligo-metastases of the liver in patients with colorectal cancer.

Materials and methods:

Eleven patients with unfavorable prognostic factors (Fong score: °3-5) with non-operable, single large or confluent oligo-metastases (6.1-13.5cm) of the liver were enrolled in this prospective single-center single-arm phase-II study. The hepatic tumors showed either progression during chemotherapy and alternative regimes were not available or contraindicated because of comorbidity of the patients or the patients did not agree with further systemic approach. After CT-guided percutaneous implantation of the applicators, interstitial HDR-BT with 3 fractions within 48 hours was applied intention: 10Gy/fraction, total prescribed dose: 30Gy). Primary endpoints of the study were safety and local effect, secondary endpoint was progression-free survival (PFS). The endpoints were checked by clinical, laboratory and MRI-based follow-up at 1.5, 3, 6, 9 and 12 months after irradiation. Overall survival (OS) was determined at the 12-month control.

Results:

During the 12 months follow up, no grade III/IV complication according to CTCAEv4.03 was observed. In 9 patients, partial response of the tumor was found at the time point of the last MRI control. The median PFS was 6 months, median OS was 14.5 months.

Conclusion:

Hypo-fractionated interstitial HDR-BT is a feasible, safe and effective therapeutic approach in patients with single large or confluent colorectal oligo-metastases of the liver.

Impact of autophagy modulation on premature intra-acinar zymogen activation in caerulein hyperstimulated mice

(Abstract ID: 744)

T. Wartmann¹, R. Fischer¹, F. Meyer¹, H. Faber-Zuschratter², M. Lerch³, J. Mayerle⁴, H. Algül⁵, R. S. Croner¹

¹Universitätsklinik für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Magdeburg

²Universitätsklinikum Magdeburg

³Universitätsmedizin Greifswald

⁴Klinikum der Universität München (LMU)

⁵Klinikum rechts der Isar der Technischen Universität München

Background:

Intra-acinar zymogen activation is an early and critical event in the pathogenesis of acute pancreatitis. Chymotrypsinogen activation appears prematurely in subcellular fractions that are enriched with zymogen granules and dense lysosomal vesicles but lacking in the autophagosomal marker LC3B-II. Recently we found that zymogens are activated initially in dense lysosomal vesicles independent of Atg5-related autophagy. Here we analyzed effects of autophagy modulation in terms of zymogen activation and its subcellular distribution in relation to lysosomal protease cathepsin B in caerulein hyperstimulated murine pancreas.

Materials and methods:

NMRI mice were pre-treated with autophagy inducer rapamycin or inhibitors bafilomycin A1, 3methyladenine (3-MA) or vinblastine by i.p. injection for up to 27hours. After caerulein hyperstimulation for 30min pancreata were homogenized and subcellular fractionated by Percoll gradient centrifugation and subsequently portioned in 46 fractions. Distribution of enzyme activities and marker proteins in percoll gradient were determined by colour- and fluorometric measurement or by Western blotting

Results:

Whether blocking of autophagosome formation by 3-MA nor inhibition of autophagosome-lysosome fusion by Bafilomycin (V-ATPase-inhibitor) or autophagy induction by rapamycin affected the intrapancreatic chymotrypsinogen activation in caerulein hyperstimulated mice. However inhibition of microtubule formation and associated blocking of autophagosomal fusion events with lysosomes by vinblastine treatment decreased significantly chymotrypsinogen activation in caerulein hyperstimulated mice.

Conclusion:

The early zymogen activation occurs in a dense lysosomal compartment in an ATG5-independent process which requires microtubules formation. Our results give evidence that the activation compartment seems to be generated by fusion events of dense granular vesicles with lysosomes and/or autolysosomes.

Is the mesenterico-portal vein resection and reconstruction an independent risk factor for the occurence of a type C fistula or delayed postoperative recovery?

(Abstract ID: 877)

S. Sauseng¹, A. Imamovic¹, S. Gabor², T. Niernberger², H. Rabl³

¹Universitätsklinikum Graz

²LKH Oberwart

³Lkh Leoben

Background:

After pancreatic head resections a postoperative pancreatic fistula (POPF) occurs with an incidence of 15 - 35%. Following the 2016 ISGPS Definition the POPF are split up to different Types. The graduation is based on the clinical severity and the procedures needed to treat those fistulas. First biochemical leakage, second Type B and third Type C Fistulas.

In particular the latter represents a severe complication with a high amount of intensive care medicine needed and a raised mortality. Patients with these complications show a longer postoperative recovery time and do of course need much more resources to get back to normal life.

Within the usual opinion the probability of a type C fistula or major complication raises with the increasing radicality of the surgical procedure. To achieve this surgical radicality in some cases a venous resection and reconstruction is crucial.

Materials and methods:

With a retrospective data - analysis taken from a prospective data collection we want to show whether a mesenteric - portal vein reconstruction is a surrogate parameter for an occurrence of a type C fistula /major complication or not.

Therefor we matched the pancreatic head resections with venous resection to the ones without such a reconstruction.

Results:

Within 8 years (2010 - 2017) 201 patients underwent a pancreatic head resection for oncological reasons (all patients had been treated with a Kausch Whipple or PPPD procedure).

72 patients needed a venous reconstruction while 129 where operated without.

For the resection / reconstruction group type C fistula rate was 8,33 compared to 6,97% in the non resected group and the length of hospital stay corresponds with 31,35 days vs. 26,8 days.

Conclusion:

Even though the hospital stay showed to be longer within the reconstruction group the difference showed no statistically significance whether for the fistula rate nor for the length of hospital stay.

In summary the need for a mesenteric or portal vein resection and reconstruction during an oncological pancreatic head resection is not a predictive factor for the occurrence of a type C fistula or a delayed postoperative recovery due to a major complication.

Predictors of 30-day mortality for acute mesenteric ischemia: A retrospective analysis of 216 surgically treated patients.

(Abstract ID: 989)

P. Storz¹, W.T. Knoefel¹, A. Krieg¹

¹Universitätsklinikum Düsseldorf

Background:

Acute mesenteric ischemia (AMI) is associated with a very high and early mortality up to the present day. The objective of this retrospective analysis was to identify preoperative parameters connected to a 30-day mortality.

Materials and methods:

A total number of 216 patients who underwent surgery because of AMI during a period of 10 years in our department including our interdisciplinary surgical intensive care unit were examined. Clinical and laboratory parameters as well as CT morphologic findings were evaluated for their prognostic value using Kaplan-Meier curves, log rank tests and multivariate cox regression analysis. In addition, the predictive power of continuous parameters was estimated by calculating the receiver operating characteristic (ROC) curves.

Results:

Concerning identifiable causes of AMI, 24.07% of the patients had a thrombembolic event, 4.63% had a vessel stenosis, 30.56% suffered from non-occlusive disease (NOD), 20.83% had a mechanical cause and 8.33% had an ischemic colitis. 105 patients (48,61%) died within 30 days after surgery. Concerning preoperative assessable clinical parameters, COPD, acute kidney failure and myocardial infarction in the patient’s history showed a significantly elevated 30-day mortality. So did elevated lactate, creatinine, CK, AST, ALT and bilirubin values and the CT morphologic finding of pneumatosis intestinalis and vascular occlusion. In the cox regression analysis of each parameter group, patients with acute kidney failure had a 1.85 fold risk of 30-day mortality (95%CI 1.19-2.87; p=0.006), patients with elevated bilirubin levels had a 2.0 fold risk (95%CI 1.11-3.70; p=0.022) and patients with the finding of pneumatosis intestinalis had a 1.77 fold risk (95%CI 1.07-2.93; p=0,028). ROC analysis of the continuous laboratory values revealed an AUC of 0.72 for AST and 0.71 for lactate values, 0.69 for creatinine, 0.66 for bilirubin, 0.65 for ALT and 0.59 for CK values.

Conclusion:

Acute kidney failure, elevated bilirubin levels and the finding of pneumatosis intestinalis in the CT scan seem to be strong predictors for 30-day mortality. Whilst acute kidney failure has already been suspected to have a strong effect on survival in literature, elevated liver values, especially bilirubin levels, might be another interesting independent predictor. An elevation above normal values regardless the extent of elevation seems to be sufficient to predict a higher 30-day mortality.