929 The Incidence and Outcomes of Delayed Laparoscopic Cholecystectomy and Bile Duct Exploration on a Unit Adopting Index Admission Surgery for All Comers. a Review of 5750 Patients

Aim

The timing of laparoscopic cholecystectomy (LC) for emergency biliary admissions remains inconsistent with national and international guidelines. The perception that LC is difficult in acute cholecystitis and the popularity of the two-session approach to pancreatitis and suspected choledocholithiasis result in delayed management.

Method

Analysis of prospectively maintained data in a unit adopting “intention to treat” during the index admission. The aim was to study the incidence of previous biliary admissions and compare the operative difficulty, complications, and postoperative outcomes with index admission LC.

Results

Of 5750 LC performed 20.8% had previous biliary admissions; one in 93% and two or more in 7%. Most presented with biliary colic (39.6%) and acute cholecystitis (27.6%). A previous biliary history was associated with increased operative difficulty (p<0.001), longer operating times (86.9 v 68.1 minutes, p<0.001), more post-operative complications (7.5% v 5.2%, p=0.002) and longer hospital stay (8.1 v 5.5 days, p<0.001). However, conversion and mortality rates showed no significant differences.

Conclusion

Index admission LC is superior to interval cholecystectomy and should be offered to all patients fit for general anaesthesia regardless of presenting complaints. Subspecialisation should be encouraged as a major factor in optimising resource utilisation and post-operative outcomes of biliary emergencies.

Evaluation of Alternative Power Sources for Operating CDC Mosquito Surveillance Traps

Several portable, rechargeable lithium-ion (Li-Ion) cell phone power banks were compared with standard 6-V gel lead-acid batteries as alternative power sources for operating mosquito surveillance equipment. In laboratory trials, ToughTested® (TT)16000 and 24000, Goal Zero Venture™ 70, and Griffin Survivor® units either met or exceeded that of sealed 6-V batteries when operating the Centers for Disease Control and Prevention (CDC) suction light traps (with incandescent light on) for an average of 24 h. No significant difference was found when continually operating traps powered by either the TT16000 or Goal Zero Venture 70 units compared with 6-V batteries (at approximately 57 h). The TT24000 unit was the only Li-Ion power bank that exceeded this threshold at an average of approximately 73 h. In field studies, there was no significant difference in species diversity or abundance of mosquitoes among the above 4 power sources when operating CDC light traps for 24 h compared with 6-V batteries. Our results indicate that portable Li-Ion cell phone power banks ≥10,050 mAh may be suitable replacements for 6-V gel lead-acid batteries when operating these light traps, especially if weight and size constraints influence the extent of mosquito surveillance during deployments.

Renal engineering: strategies to address the problem of the ureter

Current techniques for making renal organoids generate tissues that show function when transplanted into a host, but they have no ureter through which urine can drain. There are at least 4 possible strategies for adding a ureter: connecting to ta host ureter; inducing an engineered kidney to make a ureter; making a stem-cell derived ureter; and replacement of only damaged cortex and outer medulla, using remaining host calyces, pelvis and ureter. Here we review progress: local BMP4 can induce a collecting duct tubule to become a ureter; a urothelial tube can be produced directly from pluripotent cells, and connect to the collecting duct system of a renal organoid; it is possible to graft ES cell-derived ureters into host kidney rudiments and see connection, smooth muscle development and spontaneous contraction, but this has not yet been achieved with all components being derived from ES cells. Remaining problems are discussed.

1134 Incidence of Bile Acid Diarrhoea Post-Cholecystectomy - A Single Centre Cohort

Aim

Bile acid diarrhoea (BAD) can occur as a result of enterohepatic circulation interruption following cholecystectomy. Although up to 57.2% of patients are reported to develop post-cholecystectomy diarrhoea, this is not always because of BAD. The aim of this study was to determine the incidence of post-cholecystectomy BAD diagnosis and evaluate the current practices.

Method

This study was conducted as part of BADCAP study. The electronic records of patients underwent cholecystectomy operation at Oxford University Hospitals between January 2013 and December 2017 were retrospectively analysed. Records were matched with patients who underwent 75SeHCAT testing during the same time period. A positive 75SeHCAT testing was defined as a seven-day retention time of < 15%.

Results

A total of 4327 patients underwent cholecystectomy operation. 2.05% (N = 89) investigated for diarrhoea by 75SeHCAT. Alongside 75SeHCAT, 69.7% (N = 62) had colonoscopy, 37.1% (N = 33) had CT abdomen and pelvis and 3.4% (N = 3) had MRCP/MRE. Gender wise statistics revealed females were 74.5% (N = 73) and males were 19.1% (N = 17). Median time from cholecystectomy to 75SeHCAT test was 780 days (SD +/-510 days). 70.8% (N = 63) had a positive 75SeHCAT test for BAD. IBD was confirmed in 2.2% (N = 2).

Conclusions

A small number of patients were investigated and only 1.5% were diagnosed with post-cholecystectomy diarrhoea. There was a significant time delay from operation to diagnosis. The true prevalence of BAD after cholecystectomy may be much higher and clinicians need to have an increased awareness of this condition. 75SeHCAT is a useful tool for diagnosis of bile acid diarrhoea.

Connection of ES Cell-derived Collecting Ducts and Ureter-like Structures to Host Kidneys in Culture

Work toward renal generation generally aims either to introduce suspensions of stem cells into kidneys in the hope that they will rebuild damaged tissue, or to construct complete new kidneys from stem cells with the aim of transplanting the engineered organs. In principle, there might be a third approach; to engineer renal tissue 'modules' in vitro and to use them to replace sections of damaged host kidney. This approach would require the urine collecting system or ureter of the new tissues to connect to those of the host. In this report, we demonstrate a method that allows collecting duct trees or ureters, engineered from ES cells, to connect to the collecting duct system or ureter, respectively, of fetal kidneys in culture.

O15: DISRUPTION OF THE BLOOD-SPINAL CORD BARRIER PREDICTS PERMANENT PARAPLEGIA AFTER THORACOABDOMINAL AORTIC ANEURYSM REPAIR

Introduction

Paraplegia post-thoracoabdominal aortic aneurysm (TAAA) repair remains both a devastating and poorly understood complication. We related temporal changes in cellular and protein composition of cerebrospinal fluid (CSF) to neurological outcomes after TAAA repair to gain mechanistic insights driving paraplegia.

Method

Patients undergoing TAAA repair (open or endovascular) with a CSF drain were prospectively recruited between 2016-2018. CSF was collected pre-operatively and 24-hourly until removal. Daily neurological examinations were performed by blinded neurologists to the study. CSF cell content was characterised by flow cytometry and proteome analysed by tandem-mass-tag proteomics. An in-vivo rat model was modified using 15 minutes of aortic occlusion to produce consistent paraplegia. Rats were analysed neuro-behaviourally and histologically.

Result

CSF was analysed from 52 patients (age: 70.27+/-11.4; 66% male; open (n=9), endovascular (n=43)). 12 developed paraplegia of whom 5 remained permanently-paraplegic. Demographics were comparable between paraplegics, those who recovered and without post-op neurology. Permanent paraplegia was associated with a significant infiltration of CSF CD45+ leucocytes (P<0.0001). Levels of ADVS-1 was >3-fold higher in permanent-paraplegics CSF versus those who recovered (P=0.0008). ADVS-1 >15ng/ml predicted permanent paraplegia with 100% specificity. Pre-treatment with ADVS-1 inhibition significantly improved walking (<0.001) and increased astrocytic staining in the lateral corticospinal, reticulospinal and rubrospinal tracts versus controls (P=0.03, 0.04, 0.04 respectively).

Conclusion

Permanent paraplegia is associated with shedding of ADVS-1 from parenchymal cord into CSF and blood/spinal-cord barrier disruption leading to cord oedema/leucocyte infiltration. Pre-treatment with ADVS-1 inhibition led to neurobehavioural and histological improvements offering translational hope for this devastating complication.

Take-home message

ADVS-1 is a novel biomarker of paraplegia where accurate biomarkers have proven challenging but more importantly it has proven a therapeutic target with genuine translational potential.

Differentiation of a Contractile, Ureter-Like Tissue, from Embryonic Stem Cell-Derived Ureteric Bud and Ex Fetu Mesenchyme

BACKGROUND

There is intense interest in replacing kidneys from stem cells. It is now possible to produce, from embryonic or induced pluripotent stem cells, kidney organoids that represent immature kidneys and display some physiologic functions. However, current techniques have not yet resulted in renal tissue with a ureter, which would be needed for engineered kidneys to be clinically useful.

METHODS

We used a published sequence of growth factors and drugs to induce mouse embryonic stem cells to differentiate into ureteric bud tissue. We characterized isolated engineered ureteric buds differentiated from embryonic stem cells in three-dimensional culture and grafted them into ex fetu mouse kidney rudiments.

RESULTS

Engineered ureteric buds branched in three-dimensional culture and expressed Hoxb7, a transcription factor that is part of a developmental regulatory system and a ureteric bud marker. When grafted into the cortex of ex fetu kidney rudiments, engineered ureteric buds branched and induced nephron formation; when grafted into peri-Wolffian mesenchyme, still attached to a kidney rudiment or in isolation, they did not branch but instead differentiated into multilayer ureter-like epithelia displaying robust expression of the urothelial marker uroplakin. This engineered ureteric bud tissue also organized the mesenchyme into smooth muscle that spontaneously contracted, with a period a little slower than that of natural ureteric peristalsis.

CONCLUSIONS

Mouse embryonic stem cells can be differentiated into ureteric bud cells. Grafting those UB-like structures into peri-Wolffian mesenchyme of cultured kidney rudiments can induce production of urothelium and organize the mesenchyme to produce rhythmically contracting smooth muscle layers. This development may represent a significant step toward the goal of renal regeneration.

Serum 25-OH vitamin D level in treatment-naïve systemic lupus erythematosus patients: Relation to disease activity, IL-23 and IL-17

Objectives The aim of this study was to assess the vitamin D status in treatment-naïve SLE patients and its association with clinical and laboratory markers of disease activity, including serum levels of IL-17 and IL-23. Methods Fifty-seven treatment-naïve SLE patients along with 42 matched controls were included. SLEDAI score was used to estimate disease activity. Serum levels of 25(OH) D, IL-17 and IL-23 were measured. Results The median level of 25(OH) D in SLE patients (40.8; 4-70 ng/ml) was significantly lower than in the controls (47; 25-93 ng/ml) ( P = 0.001). A total of 38.6% of SLE cases had 25 (OH) D levels < 30 ng/ml (hypovitaminosis D) vs. 4.8% of the controls ( P < 0.0001). Apart from thrombocytopenia, vitamin D was not associated with clinical signs of SLE. There were negative correlations between serum 25(OH) D and serum levels of IL-17, IL-23 and ANA (rho = -0.5, -0.8, -0.5, P ≤ 0.05) in SLE patients. Conclusion Hypovitaminosis D is prevalent in treatment naïve SLE patients. It contributes to ANA antibody production and is associated with high serum levels of IL-23 and IL-17; thus they may trigger the inflammatory process in SLE.

Predictors of re-occlusion after successful recanalization of chronic total occlusion

The objective of this study was to highlight the incidence and predictors of re-occlusion after successful recanalization of chronic total coronary occlusions.

METHODS AND RESULTS

Following successful recanalization and stent implantation in 716 coronary lesions (665 patients) with chronic total occlusion, four hundred and five (56.6%) lesions (375 patients) underwent repeat angiography within 6 months. Restenosis (> or = 50% lumen narrowing) was observed in 151 (37.3%) lesions; forty-three (10.6%) of these lesions had complete re-occlusion and constituted the study population. In this group, final angiographic minimal lumen diameter (MLD) was 2.6 +/- 0.51 mm and final percent diameter stenosis was 18 +/- 11. Univariate analysis revealed significant correlation between re-occlusion and restenotic lesions, final balloon diameter, final percent diameter stenosis, final angiographic MLD, number of stents per lesion and total stent length. By multivariate analysis, the only independent predictor of re-occlusion was total stent length (OR = 1.46, 95% CI = 1.12-1.82; p = 0.0069).

CONCLUSION

Re-occlusion occurs in about 11% of cases after stenting chronic total occlusion. The most important predictor of re-occlusion seems to be stent length.

The preoperative use of cimetidine in reducing acidity of gastric secretion

Cimetidine, SKF 92334, 1-Cyano 2-methyl -3-2 (Methylimidazole -4- ylmethylthio) ethyl guanidine, C10 H16 N6 S, a competitive antagonist of H2 histamine receptors was given as a single dose orally before induction of anaesthesia in elective and emergency surgery. The volume and pH of the gastric juice were measured in 260 patients of either sex. Cimetidine was given at different times between 0 and 6 hours and was compared with control Group A who received I.M. injection of diazepam 10 mg. and atropine sulphate 0.6 mg, and control Group B who received oral diazepam 10 mg. 1-11/2 hours preoperatively. Cimetidine had maximum effect in reducing the acidity of the gastric secretion when given 2-4 hours preoperatively. Atropine had no substantial effect in reducing the pH and volume of gastric juice when administered with cimetidine.

Safety in the use of pesticides

The need for coordination between the Egyptian Ministries of Agriculture, Health, and Manpower in order to reduce the potential hazards from pesticides is discussed. A consolidated code of safety regulations is required for the handling and use of pesticides. Regular updates of the regulations to reflect changes in techniques or information is required. Precise evaluation of environmental exposures must be made. Finally, efforts must be made to develop the proper safety attitude in each individual.

Acute upper gastrointestinal tract bleeding and recent alcohol ingestion

Alcohol ingestion is a reason for hospital admission for what may be termed trivial or even spurious gastrointestinal bleeding. This clinical entity can be recognized and hospital admission avoided. It is suggested that in the case of men under the age of 40 who present with a history of hematemesis and who are intoxicated to a variable degree but without a history of recent salicylate ingestion or previous dyspepsia, and in whom the hemoglobin level is above 13.0 g/dl it is acceptable management to send them home with instructions to seek help only if there is fresh, authenticated bleeding. This attitude is further supported by a normal blood volume measurement and the absence of blood from a gastric aspirate.

Pulmonary hypertension due to micro-thromboembolism from splenic and portal veins after portacaval anastomosis

This is a presentation of a unique case of pulmonary hypertension in a 15-year-old girl, due to micro-thromboembolism from splenoportal veins through a portacaval anastomosis.