Development of postbiotics by whey bioconversion with Enterococcus faecalis M157 KACC81148BP and Lactococcus lactis CAU2013 KACC81152BP for treating periodontal disease and improving gut health

This study developed postbiotics with whey bioconversion product produced by Enterococcus faecalis M157 KACC 81148BP, and mixed whey bioconversion products produced by E. faecalis M157 KACC 81148BP and Lactococcus lactis ssp. lactis CAU2013 KACC 81152BP to alleviate periodontitis (PD) and to improve gut health. The powdered whey bioconversion product (EF) produced by E. faecalis M157 KACC 81148BP, mixed whey bioconversion products (EF+LL) from E. faecalis M157 KACC 81148BP and L. lactis CAU2013 KACC 81152BP, and phosphate-buffered saline (PBS; control) were administered orally to PD-induced rats for 8 wk. Infiltration of inflammatory cells and epithelial proliferation in periodontal tissue were found in control, but the lesions were reduced in PD+EF group (administration of EF to PD-induced rats), and no lesions were observed in PD+EF+LL group (administration of EF+LL to PD-induced rats). The bone loss volumes in PD+EF and PD+EF+LL groups were lower than in control. Cytokine production levels related to inflammation were lower and antioxidative stress markers were higher in PD+EF and PD+EF+LL groups than in control for both periodontal tissue and gut. The ratios of Lactobacillus spp. in gut microbiome of PD+EF and PD+EF+LL groups were higher than in control. These results indicate that the whey bioconversion product produced by E. faecalis M157 KACC 81148BP, and mixed whey bioconversion products produced by E. faecalis M157 KACC 81148BP and L. lactis CAU2013 KACC 81152BP are effective on relieving periodontitis and improving the gut health.

Coronavirus viability in surgical plume and methods for safe disposal: a preclinical model

Smoke generated by cautery devices used during surgery may contain infective particles and may cause transmission of airborne viruses. This study determines whether live viruses are present in surgical smoke and evaluates the effectiveness of several proposed methods of removal so as to improve safety of healthcare workers.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Stress echocardiography and outcomes after cardiac surgery in patients with ischemic mitral regurgitation

Background

Ischaemic mitral regurgitation (IMR) is a frequent complication of coronary artery disease. This is generally associated with double mortality rates. Poor prognosis could be observed despite successful cardiac surgery. There is a gap about predictors of further negative outcomes after surgical treatment. Owing to the dynamic nature of IMR, we hypothesize that multiparametric stress echocardiography (SE) would be helpful in assessing risk stratification. Aim: To evaluate the relationship between multiparametric SE parameters and outcomes after cardiac surgery in patients with IMR.

Methods

We prospectively enrolled 30 patients (62.7±8.5 yrs, 18 men), who have severe IMR by ESC classification, referred for coronary artery bypass grafting (CABG) with or without mitral surgery. Before cardiac surgery, the patients performed semi-supine bicycle multiparametric SE. Wall motion abnormalities, systolic and diastolic volumes of left ventricle, B-lines (lung congestion feature), left atrium volume, pulmonary pressure, mitral regurgitation volume, and effective regurgitation orifice area (EROA) were assessed before and during exercise. Ejection fraction (EF) and left contractile reserve were calculated. All-cause death was an endpoint.

Results

All patients had indications for CABG due to severe three-vessel disease. Before exercising, EF was 42±12%, end-diastolic volume was 167±49 ml, systolic volume of left ventricle was 86±39 ml, left atrium was 103±37 ml, global longitudinal strain was 12±4%, index of wall motion abnormality was 1.83±0.48, EROA was 0.39±0.22 cm2, regurgitation volume was 58±27 ml, systolic pulmonary pressure was 43±16 mmHg, and B-lines were 2.4±2. During exercise, EF was 44±17%, end-diastolic volume was 148±54 ml, systolic volume of left ventricle was 98±44 ml, index of wall motion abnormality was 2.30±0.49, EROA was 0.45±0.2 cm2, regurgitation volume was 70±32 ml, systolic pulmonary pressure was 51±14 mmHg, and B-lines were 5.4±3.3. A median follow-up time was 332 days (224–335). ROC analysis demonstrated that left ventricle end-diastolic volume during exercise (the cut-off value 192 ml, area under the ROC curve 0.77, p<0.03), EROA during exercise (the cut-off value 0.37 cm2, the area 0.86, p<0.0003), regurgitant volume during stress (the cut-off value 82 ml, the area 0.79, p<0.02), the difference between stress and rest B-lines (the cut-off value 6 lines, the area 0.83, p<0.0001), the difference between stress and rest EROA (the cut-off value 0.15 cm2, the area 0.77, p=0.05) were associated with death.

Conclusion

The stress echocardiographic parameters were associated with increased mortality after cardiac surgery in patients with IMR over the 1-year follow-up. B-lines (objective evidence of severe congestive heart failure), EROA, regurgitation volume (severity of mitral regurgitation during exercise) were all associated with worse outcome. These preliminary results should be confirmed in the larger studies.

Funding Acknowledgement

Type of funding sources: None.

Micropattern platform promotes extracellular matrix remodeling by human PSC-derived cardiac fibroblasts and enhances contractility of co-cultured cardiomyocytes

In native heart tissue, cardiac fibroblasts provide the structural framework of extracellular matrix (ECM) while also influencing the electrical and mechanical properties of cardiomyocytes. Recent advances in the field of stem cell differentiation have led to the availability of human pluripotent stem cell-derived cardiac fibroblasts (iPSC-CFs) in addition to cardiomyocytes (iPSC-CMs). Here we use a novel 2D in vitro micropatterned platform that provides control over ECM geometry and substrate stiffness. When cultured alone on soft micropatterned substrates, iPSC-CFs are confined to the micropatterned features and remodel the ECM into anisotropic fibers. Similar remodeling and ECM production occurs when cultured with iPSC-CMs in a co-culture model. In addition to modifications in the ECM, our results show that iPSC-CFs influence iPSC-CM function with accelerated Ca2+ transient rise-up time and greater contractile strains in the co-culture conditions compared to when iPSC-CMs are cultured alone. These combined observations highlight the important role cardiac fibroblasts play in vivo and the need for co-culture models like the one presented here to provide more representative in vitro cardiac constructs.

Structured Training for Lap Appendectomy for Residents (STAR Trial)-A Randomized Pilot Study

OBJECTIVE

Laparoscopic appendectomy is a common operation that is frequently performed by junior surgical residents. We investigated the effect of a structured training program on the proficiency of junior residents in acquiring skills necessary in this operation.

DESIGN AND PARTICIPANTS

This is a randomized pilot trial. Between December 2014 and July 2018, twenty junior residents were recruited for this study. 11 were randomized to receive a structured training program of supervised, task-specific training. Each resident subsequently performed ten cases of laparoscopic appendectomy with their performance assessed for the last 5. The GOALS scale was used as the primary endpoint. Secondary endpoints were perioperative outcomes. The effect of intervention on these outcomes were evaluated assuming a linear mixed effect multi-level model. The study was single-blinded as the assessors did not know which group each resident belonged to.

RESULTS

There were no statistically significant differences in the total GOALS score or any of its individual domains. After adjusting for the number of operations done within the trial, the mean difference between the total GOALS score was 0.07 (95% CI -0.76 to 0.90, P=0.866). Blood loss, hospital stay and postoperative complication rates were similar. There was suggestion of a shorter operative time (effect estimate -9.03, 95% CI -19.56 to 1.50) in the intervention arm although statistical significance was not achieved. No avoidable adverse events due to this study were recorded.

CONCLUSION

Structured training program did not significantly improve surgical performance and outcomes in laparoscopic appendectomy in this pilot trial. Despite these findings, residents can still potentially mount their learning curves in laparoscopy earlier in a safe environment with such a program which is especially important in the era of minimally invasive surgery.

Increased salivary syndecan-1 level is associated with salivary gland function and inflammation in patients with Sjögren's syndrome

Objectives: Syndecan-1 (SDC-1), a transmembrane heparin sulphate proteoglycan predominantly expressed on epithelial cells, also exists in a soluble form through ectodomain shedding. SDC-1 expression and shedding may be modulated in the inflammatory milieu of primary Sjögren's syndrome (SS). We investigated SDC-1 expression in minor salivary glands (MSGs) and analysed the association between salivary or plasma levels of SDC-1 and clinical parameters in SS.Method: We measured salivary and plasma SDC-1 levels via an enzyme-linked immunosorbent assay and assessed the salivary flow rates (SFRs) in 70 patients with SS and 35 healthy subjects. Disease activity indices, serological markers, salivary gland scintigraphy, and MSG biopsy were evaluated in patients with SS.Results: SDC-1 expression was upregulated on ductal epithelial cells in inflamed salivary glands. Salivary SDC-1 levels in patients significantly exceeded those in healthy subjects [median (interquartile range) 49.0 (20.7-79.1) vs 3.7 (1.7-6.3) ng/mL, p < 0.001] and inversely correlated with SFRs (r = -0.358, p = 0.032) and ejection fractions of the parotid (r = -0.363, p = 0.027) and submandibular (r = -0.485, p = 0.002) glands in salivary gland scintigraphy. Plasma SDC-1 levels were significantly correlated with the EULAR Sjögren's Syndrome Disease Activity Index (r = 0.507, p < 0.001) and EULAR Sjögren's Syndrome Patient Reported Index (r = 0.267, p = 0.033). Focus scores were correlated with salivary SDC-1 levels (r = 0.551, p = 0.004).Conclusion: Salivary and plasma SDC-1 levels may constitute potential biomarkers for salivary gland function and disease activity, respectively, in SS.

OP0268 TREATMENT STATUS AFFECTS HOW PULMONARY BIOMARKERS PREDICT PROGRESSION OF SYSTEMIC SCLEROSIS-RELATED INTERSTITIAL LUNG DISEASE

Background:

The course of interstitial lung disease (ILD) varies considerably in patients with systemic sclerosis (SSc), and no biomarkers have been found to consistently predict ILD progression in this population. Treatment may affect how a candidate biomarker correlates with improvement/worsening of SSc-ILD. We hypothesized that specific proteins recovered from bronchoalveolar lavage (BAL) would differentially predict progression of SSc-ILD based on whether a patient was receiving ILD therapy.

Objectives:

(1) To assess the relationship between 68 unique BAL proteins measured in participants of Scleroderma Lung Study (SLS) I1 and changes in radiographic extent of SSc-ILD; (2) To determine if treatment affects whether a specific protein predicts improvement or worsening of SSc-ILD.

Methods:

Bronchoscopy was performed on 144 of the 158 participants in SLS I (Cyclophosphamide [CYC] vs. placebo) with 103 BAL samples available for analysis. BAL was lyophilized, concentrated 10X and used in a multiplex protein analysis of 68 distinct cytokines, chemokines and growth factors. Quantitative imaging analysis (QIA) was used to calculate the extent of radiographic fibrosis (QLF) in the whole lung using HRCT of the chest at baseline and 12 months. Multivariable linear regression models were created to determine the key BAL proteins associated with change in QLF scores using a backward selection process adjusting for treatment arm and ILD severity. The bootstrap procedure was employed for internal validation.

Results:

A number of BAL proteins were significantly associated with change in QLF scores at 12 months; however, the directionality of these associations was often based on the presence/absence of treatment. For example, increased levels of granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin (IL)-1, monocyte chemoattractant protein (MCP)-3, chemokine ligand (CCL)-5, transforming growth factor (TGF)-β, hepatocyte growth factor (HGF), stem cell factor (SCF), IL-4, TGF-α, were associated with worse QLF scores in patients who received placebo; whereas, increased levels of these same proteins were associated with improved QLF scores in patients who received CYC (Figure). Increased levels of Fractalkine were associated with worse in QLF scores, and increased levels of IL-7 were associated with improved QLF scores, regardless of treatment arm. In the multivariable model adjusting for treatment arm and baseline severity of ILD, IL-1, MCP-3, surfactant protein C, IL-7, and CCL-5 were independently associated with change in QLF scores.

Figure 1.

Example of a specific BAL protein (GM-CSF) that predicts worse QLF scores in patients receiving placebo (Group B, Red dotted line) and improved QLF scores in patients receiving CYC (Group A, Blue solid line). Shaded areas represent 95% confidence intervals.

Conclusion:

Proteins that mediate both inflammation and fibrosis differentially affected progression of SSc-ILD based on treatment status. Higher levels of certain proteins predicted worsening of ILD in patients receiving placebo, but improvement in patients receiving CYC. Measuring these proteins could help to identify patients who: (1) are at risk for ILD progression, and (2) may preferentially benefit from treatment with immunosuppression.

References:

[1]Tashkin DP, et al. NEJM 2006.

Disclosure of Interests:

Elizabeth Volkmann Consultant of: Boehringer Ingelheim, Grant/research support from: Corbus, Forbius, Donald Tashkin: None declared, Mei Leng: None declared, Ning Li: None declared, Grace Kim: None declared, Jonathan Goldin: None declared, Airi Harui: None declared, Michael Roth Grant/research support from: Genentech/Roche

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

OP0267 SHORT-TERM CHANGES IN THE RADIOGRAPHIC EXTENT OF INTERSTITIAL LUNG DISEASE PREDICT LONG-TERM MORTALITY IN SYSTEMIC SCLEROSIS

Background:

The forced vital capacity (FVC) is often used as the primary endpoint in treatment trials for systemic sclerosis-interstitial lung disease (SSc-ILD), and while trends in FVC have been found to predict mortality in SSc-ILD,1,2 FVC measurements are also influenced by extra-pulmonary factors, such as cutaneous sclerosis, myopathy, and patient/technician effort. Change in the quantitative extent of ILD (QILD) on HRCT is an emerging endpoint in clinical trials; however, no studies have evaluated whether changes in radiographic extent ILD predict mortality in SSc-ILD.

Objectives:

To evaluate the relationship between changes QILD in the whole lung (WL) and long-term survival in patients who participated in the Scleroderma Lung Study (SLS) I3 and II.4

Methods:

SLS I randomized 158 SSc-ILD patients to 12 months of cyclophosphamide (CYC) vs. placebo. SLS II randomized 142 SSc-ILD patients to 12 months of CYC, followed by 12 months of placebo vs. 24 months of mycophenolate (MMF). QILD-WL scores were calculated at baseline and 12 months (SLS I) and 24 months (SLS II). Participants were followed for up to 12 (SLS I) and 8 years (SLS II). Using landmark survival analysis, Kaplan Meier curves were generated to compare survival between participants who had worse QILD-WL scores (≥2% increase) and those who had stable/improved QILD-WL scores (<2% increase). Cox proportional hazards models were created to determine whether the change in QILD-WL scores predicted survival after controlling other variables found to affect survival in these cohorts.

Results:

Among all the SLS I and II participants, 82 and 90 had follow up HRCT scans, respectively, and were included in these analyses. SLS I participants with an increase in QILD-WL scores of ≥2% at 12 months had significantly worse long-term survival (P= 0.01; Figure). Similarly, SLS II participants with an increase in QILD-WL scores of ≥2% at 24 months had significantly worse long-term survival (P= 0.019; Figure). After adjusting for baseline FVC, age, and modified Rodnan skin score (mRSS), an increase in QILD-WL scores of ≥2% remained associated with worse long-term survival in SLS I (trend: P=0.089) and SLS II (P=0.014).

Conclusion:

Progression of the radiographic extent of ILD of ≥2% was associated with worse long-term survival in two independent SSc cohorts with extensive long-term follow up. The findings provide compelling evidence that short-term changes in the radiographic extent of ILD may serve as a surrogate endpoint for mortality in patients with SSc.

References:

[1]Goh NS, et al. Arthritis Rheum 2017.

[2]Volkmann ER, et al. Ann Rheum Dis 2019.

[3]Tashkin DP, et al. NEJM 2006.

[4]Tashkin DP, et al. Lancet Resp Med 2016.

Disclosure of Interests:

Elizabeth Volkmann Consultant of: Boehringer Ingelheim, Grant/research support from: Forbius, Corbus, Donald Tashkin: None declared, Michael Roth Grant/research support from: Genentech/Roche, Jonathan Goldin: None declared, Grace Kim: None declared

Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants

BACKGROUND

Metabolic-bariatric surgery delivers substantial weight loss and can induce remission or improvement of obesity-related risks and complications. However, more robust estimates of its effect on long-term mortality and life expectancy-especially stratified by pre-existing diabetes status-are needed to guide policy and facilitate patient counselling. We compared long-term survival outcomes of severely obese patients who received metabolic-bariatric surgery versus usual care.

METHODS

We did a prespecified one-stage meta-analysis using patient-level survival data reconstructed from prospective controlled trials and high-quality matched cohort studies. We searched PubMed, Scopus, and MEDLINE (via Ovid) for randomised trials, prospective controlled studies, and matched cohort studies comparing all-cause mortality after metabolic-bariatric surgery versus non-surgical management of obesity published between inception and Feb 3, 2021. We also searched grey literature by reviewing bibliographies of included studies as well as review articles. Shared-frailty (ie, random-effects) and stratified Cox models were fitted to compare all-cause mortality of adults with obesity who underwent metabolic-bariatric surgery compared with matched controls who received usual care, taking into account clustering of participants at the study level. We also computed numbers needed to treat, and extrapolated life expectancy using Gompertz proportional-hazards modelling. The study protocol is prospectively registered on PROSPERO, number CRD42020218472.

FINDINGS

Among 1470 articles identified, 16 matched cohort studies and one prospective controlled trial were included in the analysis. 7712 deaths occurred during 1·2 million patient-years. In the overall population consisting 174 772 participants, metabolic-bariatric surgery was associated with a reduction in hazard rate of death of 49·2% (95% CI 46·3-51·9, p<0·0001) and median life expectancy was 6·1 years (95% CI 5·2-6·9) longer than usual care. In subgroup analyses, both individuals with (hazard ratio 0·409, 95% CI 0·370-0·453, p<0·0001) or without (0·704, 0·588-0·843, p<0·0001) baseline diabetes who underwent metabolic-bariatric surgery had lower rates of all-cause mortality, but the treatment effect was considerably greater for those with diabetes (between-subgroup I² 95·7%, p<0·0001). Median life expectancy was 9·3 years (95% CI 7·1-11·8) longer for patients with diabetes in the surgery group than the non-surgical group, whereas the life expectancy gain was 5·1 years (2·0-9·3) for patients without diabetes. The numbers needed to treat to prevent one additional death over a 10-year time frame were 8·4 (95% CI 7·8-9·1) for adults with diabetes and 29·8 (21·2-56·8) for those without diabetes. Treatment effects did not appear to differ between gastric bypass, banding, and sleeve gastrectomy (I² 3·4%, p=0·36). By leveraging the results of this meta-analysis and other published data, we estimated that every 1·0% increase in metabolic-bariatric surgery utilisation rates among the global pool of metabolic-bariatric candidates with and without diabetes could yield 5·1 million and 6·6 million potential life-years, respectively.

INTERPRETATION

Among adults with obesity, metabolic-bariatric surgery is associated with substantially lower all-cause mortality rates and longer life expectancy than usual obesity management. Survival benefits are much more pronounced for people with pre-existing diabetes than those without.

FUNDING

None.

Admission discipline and timing of admission may influence outcomes for gastrointestinal bleeding patients

BACKGROUND

Bleeding of the gastrointestinal tract (BGIT) is a common gastrointestinal emergency. There is no consensus whether this condition should be admitted to medical or surgical discipline. Timing of presentation may also impact patient outcomes due to differences in healthcare resource availability. This study thus aims to investigate the impact of admitting discipline and timing of admission on patient outcomes in BGIT.

METHODS

A 2-year tertiary institution database was retrospectively reviewed. Outcome measures included 30-day mortality, 30-day readmissions and rebleeding requiring repeat endoscopic, angiographic or surgical interventions. Secondary outcome measures included time to endoscopy, percutaneous angiographic interventions and surgery. The effect of admission discipline (medical versus surgical) and time of admission (office-hours versus after office-hours) were analysed using a propensity-score-adjusted estimate.

RESULTS

A total of 1384 patients were included for analysis, medical (n = 853), surgical (n = 530); during office-hours (n = 785) and after office-hours (n = 595). After propensity-score-adjusted analysis, no significant differences in mortality or readmissions were noted between medical or surgical admissions. Patients admitted under surgery were less likely to sustain rebleeding (P = 0.004) for lower BGIT and had an earlier time to endoscopy for upper BGIT (P = 0.04). Patients admitted after office-hours had similar outcomes with those admitted during office hours apart from a delay in time to endoscopy (P = 0.02).

CONCLUSION

For BGIT patients, admission to a surgical discipline compared to a medical discipline appeared to have at least equivalent patient outcomes. Patients presenting with BGIT after office-hours were more likely to experience a delay to endoscopy, although it did not affect patient mortality.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Dynamics of right ventricle contractility after cardiac surgery of tricuspid valve

Funding Acknowledgements

Type of funding sources: None.

Background

The function of right ventricle (RV) is an independent prognostic factor for patients with valvular heart disease. However, changes in RV function parameters in patients with and without tricuspid valve operations after cardiac surgery are lack known. The aim of the study was to define changes in RV parameters after cardiac surgery in patients with left-sided valve diseases.

Methods

Fifty-five consecutive patients (33 men, 61 ± 10 years old), who were referred for the repair and/or replacement of left-sided valves, were included in the study. A transthoracic echocardiography assessment before and an average of 109 days (91-114) following the operation was performed. Tricuspid annular plane systolic excursion (TAPSE), fractional area change RV (FAC), strain of the RV free wall (SRV), and right atrial volume were assessed in groups of patients with and without tricuspid valve repair.

Results

Valve repair for secondary tricuspid regurgitation was performed in nineteen patients undergoing left-sided valve surgery. Thirty-six patients had repair and/or replacement of left-sided valves without a tricuspid valve operation. There was a strong correlation between TAPSE, FAC, and RV strain before the operation (R = 0.62-0.77, p &lt; 0.000002). However, there was no correlation between TAPSE and FAC; TAPSE and RV strain after the operation. TAPSE and RV strain significantly decreased after the operations and were below the normal range in both the groups of patients with and without tricuspid valve repair. TAPSE was 21 ± 5mm before the operation vs. 14 ± 4 mm after operation, p &lt; 0.0000001 for all patients (20 ± 5mm vs. 13 ± 3 mm, p &lt; 0.0003 for the group which underwent tricuspid valve repair; 22 ± 4mm vs. 14 ± 4 mm, p &lt; 0.000001 for tricuspid valves which were not operated on). RV strain was -19 ± 6 mm before operating vs. -16 ± 5mm after operating, p &lt; 0.0004 for all patients (-20 ± 6mm vs. -15 ± 5mm, p &lt; 0.006 for tricuspid valve repair; -19 ± 6mm vs. -16 ± 4 mm, p &lt; 0.02 for the tricuspid valves which were not operated on).  There was no difference in TAPSE and SRV among patients with and without tricuspid valve repair. Decreased longitudinal function parameters (TAPSE and SRV) didn’t correlate with patients’ clinical status or with normalized right chambers volumes. FAC was 39 ± 11% before operating vs. 41 ± 9% after the operation, p = 0.45 for all patients (37 ± 13% vs. 40 ± 8%, p = 0.69 for the group which underwent tricuspid valve repair; 40 ± 10% vs. 41 ± 9%, p = 0.52 for the group with tricuspid valves which were not operated on). An increase in FAC correlated with a decrease in right chamber sizes after operations (R=-0.37, p &lt; 0.03).

Conclusion

Longitudinal right ventricle parameters (TAPSE, SRV) significantly decrease after valve operations in groups with and without tricuspid valve repair. However, there is no correlation with the clinical status of patients. Global function parameters (FAC) correlates with the normalization of right chamber size after cardiac operation.

Design modifications to Rotating Modulation Collimators for extended field-of-view

Rotating Modulation Collimators (RMC) are devices that can be used to determine the location of a radiation source. In this work, a design with extended field-of-view (FOV) is proposed to allow faster measurements by providing a wider scanned area. Monte Carlo simulations were used to calculate the response of the RMC system, system matrix and modulation profiles. The Maximum Likelihood Expectation Maximization algorithm was used for image reconstruction. The proposed design provides a FOV up to 60° with a maximum error of 5° or up to 70° with a maximum error of 15°.

Frailty in Elderly Gastric Cancer Patients Undergoing Gastrectomy

INTRODUCTION

There is a dearth of literature on frailty specifically in elderly (aged ≥65 years) gastric cancer patients undergoing gastrectomy. We aim to assess the effects of frailty on postoperative outcomes.

METHODS

A review of a prospective database was performed from November 2011 to April 2019. Frailty was assessed by multidimensional frailty score (MFS). Outcomes assessed were early postoperative complications and mortality, and length of stay.

RESULTS

289 patients were included. The mean age was 77.3 (range 66-94) years. 183 (63.3%) were males and 172 (59.5%) had early cancer. 275 (95.2%) underwent minimally invasive gastrectomy. 79 (27.3%) patients suffered early postoperative complications, with 47 (16.3%) suffering from Clavien-Dindo grade ≥2 complications. One-year, 90-day, 30-day, and inhospital mortality were 6.6, 1.4, 0.7, and 0%, respectively. 111 (38.4%) of patients were classified as "frail" based on MFS > 5. "Frail" patients were associated with higher 1-year mortality (odds ratio (OR) 4.51, 95% CI 1.57-12.98, p = 0.005) on univariate analysis. On multivariate analysis, "frail" patients did not have significantly increased 1-year mortality. However, when definition of "frail" was changed from MFS > 5 to MFS > 6, frailty was significantly associated with increased 1-year mortality (OR 3.73, 95% CI 1.11-12.53, p = 0.033).

CONCLUSIONS

Elderly gastric cancer patients undergoing gastrectomy with MFS > 5 do not have increased mortality risk. The influence of frailty on postoperative outcomes may vary based on the risk of the surgical procedure.

Anaesthesia considerations and techniques for Pressurised IntraPeritoneal Aerosol Chemotherapy (PIPAC)

Pressurised IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a novel surgical technique to administer aerosolized chemotherapy into the abdominal cavity as treatment for peritoneal metastasis from various cancers. As the surgery is unique and there are concerns about occupational hazards, specific anaesthetic setup and techniques are required. Notably, our institution’s experience with PIPAC has enlightened us that anaesthesia requirements during PIPAC are generally uncomplicated and that the majority of the patients undergoing PIPAC do not require invasive monitoring, advanced intra or postoperative analgesia like epidurals or PCA. The need for postoperative intensive unit care is also not required in routine PIPAC cases. We describe the anaesthetic considerations involved and the detailed preparation of staff, space, anaesthetic equipment and drugs to facilitate the appropriate modifications for anaesthesia monitoring and maintenance for an elective set up as well as our standard operating procedure for an emergency situation should it arise.

PIPAC-OX: A Phase I Study of Oxaliplatin-Based Pressurized Intraperitoneal Aerosol Chemotherapy in Patients with Peritoneal Metastases

PURPOSE

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel laparoscopic, intraperitoneal chemotherapy delivery technique aiming to improve drug distribution and tissue penetration to treat peritoneal metastases. Thus far, PIPAC oxaliplatin is conducted at an arbitrary dose of 92 mg/m². We conducted a phase I study to establish safety and tolerability.

PATIENTS AND METHODS

We used a 3+3 dose-escalation design of PIPAC oxaliplatin for patients with peritoneal metastases from gastrointestinal tumors, after failure of at least first-line chemotherapy. Dose levels were planned at 45, 60, 90, and 120 mg/m².

RESULTS

This study included 16 patients with 24 PIPAC procedures (8 gastric; 5 colorectal; and 1 gallbladder, pancreas, and appendix cancer each). Median age and peritoneal cancer index (PCI) score were 62 years and 17, respectively. Two patients developed pancreatitis (grade 2 and 3) at 45 mg/m², necessitating cohort expansion. Another patient developed grade 2 pancreatitis at 90 mg/m². There were no other dose-limiting toxicities, and the highest-dose cohort (120 mg/m²) tolerated PIPAC well. Pharmacokinetic analyses demonstrated good linearity between dose and maximum concentration (r ² = 0.95) and AUC (r ² = 0.99). On the basis of RECIST, 62.5% and 50% had stable disease after one and two PIPAC procedures, respectively. A total of 8 patients underwent two PIPAC procedures, with improvement of median PCI and peritoneal regression grade score from 15 to 12 and 2.5 to 2.0, respectively.

CONCLUSIONS

The recommended phase II dose is 120 mg/m². Future studies should further delineate the efficacy and role of PIPAC oxaliplatin for peritoneal metastases.See related commentary by de Jong et al., p. 1830.

Safety, pharmacokinetics and tissue penetration of PIPAC paclitaxel in a swine model

INTRODUCTION

Peritoneal carcinomatosis is difficult to treat. Pressurized Intra-Peritoneal Aerosolised Chemotherapy (PIPAC) is a novel method of delivering chemotherapy to the peritoneal cavity, aiming for homogenous and deeper drug distribution. To date, limited chemotherapeutics have been used with promising results. Here, we evaluate the pharmacokinetics, peritoneal tissue drug concentration, penetration, and short-term safety of PIPAC using solvent-based paclitaxel in swine to guide clinical trials.

MATERIALS AND METHODS

PIPAC solvent-based paclitaxel was administered at 60, 30, and 15mg/m² for 3 cohorts. Each PIPAC procedure was followed by intravenous (IV) administration of the same dose of solvent-based paclitaxel on Day 7, serving as control for pharmacokinetic comparison in the same pig. Safety and toxicity were evaluated by clinical assessment, blood counts and biochemistry. Blood samples were taken for pharmacokinetic analysis. Peritoneal biopsies were taken to measure tissue paclitaxel concentrations and distribution.

RESULTS

12 Yorkshire x Landrace pigs underwent trial procedures. With PIPAC, there was linear pharmacokinetics and lower systemic exposure to paclitaxel compared to IV administration. MALDI-MSI demonstrated concentration of paclitaxel at the peritoneal surface, with estimated 2 mm penetration. PIPAC paclitaxel had favorable toxicity profile. The most significant adverse event was neutropenia which was dose dependent, with absolute neutrophil count <1.0 × 10³/μL seen at the highest dose. One pig developed grade 2 hypersensitivity reaction during IV infusion and one death occurred during the PIPAC procedure, likely from anaphylaxis; these are known potential adverse events mandating standard precautions and monitoring.

CONCLUSION

PIPAC paclitaxel at 15mg/m² may be considered for a Phase I study.

SAT0286 BIOLOGICAL CORRELATES OF RADIOGRAPHIC FEATURES OF INTERSTITIAL LUNG DISEASE IN SYSTEMIC SCLEROSIS: AN IN DEPTH ANALYSIS OF BRONCHOALVEOLAR PROTEINS OF SCLERODERMA LUNG STUDY I PARTICIPANTS

Background:

Systemic sclerosis-related interstitial lung disease (SSc-ILD) involves a combination of inflammation, fibrosis and vascular pathology that is typically assessed on CT imaging as a mixture of ground-glass opacification (GGO) and fibrotic changes. We hypothesized that proteins recovered from bronchoalveolar lavage (BAL) could be used to probe the underlying pathobiology associated with GGO and fibrotic changes.

Objectives:

(1) To assess the relationship between 68 unique BAL proteins measured in participants of Scleroderma Lung Study (SLS) I1and radiographic and physiologic measures of ILD; (2) To identify inter-correlations among specific proteins to enlighten our understanding of how specific biological pathways contribute to SSc-ILD.

Methods:

Bronchoscopy was performed on 144 of the 158 participants in SLS I with 103 BAL samples available for analysis. BAL was lyophilized, concentrated 10X and used in a multiplex protein analysis for 68 different cytokines, chemokines and other factors. Kendall tau correlations were performed to assess the relationship between individual proteins and baseline measures of pulmonary function and quantitative CT scores for fibrosis, GGO and total ILD. Those proteins found to correlate significantly with at least 2 clinical measures of ILD were entered into a cluster analysis with inter-correlations expressed as a heatmap.

Results:

Significant correlations were observed between fibrosis scores and several biologic pathways including pro-fibrotic factors (transforming growth factor beta [TGF-β], platelet-derived growth factor [PDGF]), proteins involved in tissue remodeling (Matrix metallopeptidase [MMP]-1,7,8,9; Hepatocyte growth factor [HGF]), and those involved in monocyte/macrophage migration and activation (Monocyte chemoattractant protein [MCP]-1,3; macrophage colony-stimulating factor [MCSF]). These same pathways correlated with the diffusing capacity for carbon monoxide (DLCO). In contrast, GGO scores correlated primarily with immune and inflammatory mediators (interleukin [IL]-5,8,13,15, IL-1 receptor antagonist and interferon gamma) with only limited overlap to proteins that related to fibrosis. Vascular endothelial growth factor (VEGF) levels were lower in patients with more extensive GGO, fibrosis and diffusion impairment, suggesting that vascular changes are a central feature of SSc-ILD. Specific proteins were highly correlated with one another in a pattern suggesting biologically-related networks (Figure) that might provide additional insight regarding disease pathogenesis.

Conclusion:

Combining a diverse analysis of BAL proteins with the rich dataset available from SSc-ILD patients participating in SLS I, the study findings suggest the involvement of distinct biologic pathways, inter-related networks, and specific biologic signatures associated with unique radiographic features of ILD. The relationship of these factors to other SSc disease features, patient outcomes and as predictors of treatment responses will be studied in future analyses.

References:

[1]Tashkin DP, et al. NEJM 2006.

Figure.

Correlation heatmap of BAL proteins associated with at least 2 clinical measures of ILD in SSc patients. Absolute correlations are depicted, and darker colors signify stronger correlations.

Disclosure of Interests:

Elizabeth Volkmann Grant/research support from: Forbius, Corbus Pharmaceuticals, Consultant of: Boehringer Ingelheim, Forbius, Speakers bureau: Boehringer Ingelheim, Donald Tashkin: None declared, Ning Li: None declared, Grace Kim: None declared, Jonathan Goldin: None declared, Airi Harui: None declared, Michael Roth Grant/research support from: Genentech/Roche

Comparison of neutron and secondary gamma dose assessment using polygon mesh and voxel computational phantoms

The newly developed mesh-type reference computational phantoms (MRCPs) represent the evolution of the previous reference phantoms and a more detailed description of the human body, addressing the voxel reference phantom limitations. These allow for a more accurate dose calculation in the human body, which in some cases results in a significant difference of the calculated quantities. In this work, the absorbed dose calculation due to neutrons and gammas was calculated using a voxel and a mesh-type computational phantom. The goal was to understand how a more accurate description of the human body affects the estimated neutron dose. The phantoms were tested in a real-case scenario: they were placed in front of a neutron Howitzer container model using PHITS. This model corresponds to the neutron Howitzer container at the Neutron Measurements Laboratory of the Energy Engineering Department of the Polytechnic University of Madrid (UPM), and at the time of measurement it was equipped with a ²⁴¹Am-Be neutron source of 74 GBq in its center. The container allows the source to be in either the irradiation or the storage position. Results show that when dealing with neutrons, the dose deviation when using GOLEM or the MRCP leads to a general 20%-30% deviation that goes up to above 400% in small thin structures such as the eye.

1105 A Randomized Controlled Trial of a Psychological Intervention for Decreasing Bedtime Procrastination: The BED-PRO Study

Introduction

Bedtime Procrastination (BP) is defined as the behavior of going to bed later than intended, without having external reasons for doing so. Previous studies have shown that BP has a negative effect on sleep and health, and there is a need to develop interventions to decrease BP. This study (BED-PRO) is an ongoing study evaluating a behavioral intervention to reduce BP.

Methods

Fifteen participants who scored higher than 33 on the Bedtime Procrastination Scale were randomized to either the treatment (TRT, n=6) or control group (CTRL, n=9). Treatment consisted of four face-to-face individual sessions. All participants completed self-report questionnaires on Bedtime Procrastination Scale (BPS), Epworth Sleepiness Scale (ESS), Positive Affect and Negative Affect Schedule (K-PANAS-R) and completed the 7-day sleep diary. Data was analyzed using two-way mixed Measures Analysis of Variance (ANOVA).

Results

Mean age of the participants was 21.78 (±1.8) years and 80% (n=12) were females. Group by time interactions from repeated measures analyses revealed significant post intervention improvements in the TRT group compared to the CTRL group on all bedtime procrastination duration and scores, sleep efficiency, refreshment after waking, daytime sleepiness and negative affect of K-PANAS-R. Specifically, bedtime procrastination duration in the TRT group measured by sleep diaries decreased significantly from 75.30 (±58.57) min to 14.83 (±7.83) min, while the CTRL group did not change from 57.60 (±32.01) to 54.36 (±40.82) min (p=0.019). In addition, the TRT group reported significant improvements in bedtime procrastination scores from 36.00 (±4.05) to 22.50 (±6.72).

Conclusion

Based on results, the behavioral intervention used in this study looks promising in improving bedtime procrastination and sleep.

Support

This work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea(NRF-2018S1A5A8026807)