Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study

BACKGROUND

In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level.

METHODS

All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD.

RESULTS

In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma.

CONCLUSIONS

This series provides a real-life picture of elective sigmoidectomy for SDD at a national level.

TRIAL REGISTRATION

Comité National Information et Liberté (CNIL) (n°920361).

Assessing causality in the association between neurocognitive gains and fasting

Fasting is associated with improvements in cognitive function, and triggers weight loss in human and animal models. In recent years, the connection between fasting, brain health, and cognitive function has increasingly proven deserving of attention from researchers. The objective of this review work is to highlight evidence supporting a positive association between fasting and enhanced cognition. We looked at the following database sources "The Cochrane Library, PubMed, EMBASE, Web of Science and Google Scholar" for present review article. All the studies based on the key words "impact of fasting", or "cognitive function" or "brain stimulation". Much of this evidence demonstrates that fasting results in enhanced performance in cognitive tests of memory and visuospatial processing, which rely heavily on hippocampal function. The mechanisms responsible for the cognitive improvements associated with fasting are not fully understood, although current evidence suggests neuroplasticity plays an important role. Maintaining the health and the functionality of neurologically and cognitively impaired individuals can be extremely costly. Higher life expectancy and ageing populations globally is anticipated to increase the prevalence of many non-communicable, chronic, progressive conditions including neurological disorders.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

1611 Significant Epistaxis Secondary To COVID-19 Nasopharyngeal Swab

Aim

This case highlights the need for appropriate training when adopting new techniques, even for relatively simple procedures.

Method

we report a rare complication of the innovative COVID-19 nasopharyngeal swab which is a new skill for many healthcare professionals and frequently performed with little or no training.

Results

We describe a case of iatrogenic epistaxis after a diagnostic nasopharyngeal swab was taken during the COVID-19 pandemic. The epistaxis was significant, causing haemodynamic and respiratory compromise. In a frail patient who is susceptible to epistaxis, the potenial for further harm is significant. After initially presenting with shortness of breath, this patient (who had no previous nasal pathology) underwent routine naso- and oro- pharyngeal swabbing to test for COVID-19. He felt immediate discomfort in his nasopharynx and epistaxis ensued. The bleeding persisted for several hours; bilateral anterior and posterior nasal packing was required to eventually cease the bleed. He was compromised with a falling haemoglobin, and aspiration of blood compounded his shortness of breath.

Conclusions

Epistaxis is a potentially serious side effect of nasopharyngeal swabbing; a procedural skill dramatically increasing in prevalence during the COVID-19 pandemic. We advocate for formal training of this procedure for all healthcare staff required to undertake it. Presenting such a case report can help us in understanding the complications of this procedure, and better thus inform the patient consenting process.

247 Single-Photon Emission Computed Tomography (SPECT) In Predicting Localisation of Parathyroid Adenomas: A Closed-Loop Prospective Study

Aim

to measure the sensitivity of SPECT in localising parathyroid adenomas particularly whilst attempting minimally invasive parathyroidectomy.

Method

2-cycles prospective study correlating SPECT and operative findings was conducted. All patients underwent ultrasound and SPECT, those with concordant findings on both modalities underwent minimally invasive parathyroidectomy, whilst patients with discordant findings on both modalities had central neck exploration. Following operative findings, recommendations of changing the SPECT reporting method such as surgically relevant structures adjacent to the lesion, such as the thyroid, were implemented. Following which, a second prospective study assessed the outcome of change.

Results

In the first cycle, 20 patients underwent partial parathyroidectomy, either by open (n = 13), or minimally invasive (n = 7) approach. SPECT sensitivity was 85% (n = 17) in identifying the adenoma. Out of all histologically confirmed adenomas, SPECT identified all adenomas (n = 17) on the correct side and 41% (n = 7) on the correct level (superior vs. inferior parathyroid). In the second cycle following recommendation, 14 patients had surgery, 9 as minimally invasive and 5 as open approach. SPECT sensitivity was 79% (n = 11) for adenoma identification. Of all confirmed adenomas, SPECT identifying adenomas at the correct side increased to 91% (n = 10) and correct level to 91% (n = 10).

Conclusions

SPECT alone is not yet regarded as gold standard in parathyroid adenoma localisation. The study has demonstrated that feedback to the radiologist of the operative findings may enhance its usefulness, particularly in attempting to proceed with a minimally invasive parathyroidectomy.

1640 Stridor in An Infant with Double Aortic Arch

Conclusions

Although foreign body aspiration is the commonest cause of stridor in infants and young children, external compression of the trachea, particularly with vascular rings, should be considered in children with otherwise unexplained stridor.

P14.76 Bevacizumab (BEV) alone or in combination with chemotherapy in recurrent Glioblastoma Multiforme (GBM): A real world experience

BACKGROUND

Patients with glioblastoma multiforme (GBM) have a median survival of about 14 months. In recurrent GBM no active intervention has shown improvement in survival. Clinical trials has shown that bevacizumab (BEV) alone or in combination with chemotherapy is associated with better progression free survival (PFS). The current study aims to assess efficacy of BEV in real-world setting.

MATERIAL AND METHODS

Population-based retrospective cohort study patients with recurrent GBM diagnosed in the province of Saskatchewan during 2008–2018 and received BEV alone or in combination with chemotherapy were evaluated. Survival was compared with historic control.

RESULTS

43 eligible patients with GBM treated with BEV with or without chemotherapy. 25 patients were treated with Bev alone and 18 patients treated with chemotherapy+ BEV. Median age of the patients were noted to be 53 years. 28 male, and 15 female. 80% of patients treated with single agent BEV had a performance status of either 2 or 3 compared to 33% of patient treated with BEV+ chemotherapy.

Median PFS was 4.6 months with 95% CI 2.9–6.9. Median Overall survival (OS) from the time of diagnosis was 17.5 month. Median OS from the time of start of BEV was 5.4 months with 95% CI 3.4–6.8. Partial response (PR) was noted in 3 patients (7%) with stable disease (SD) in 6 patients (14%). 33 (77%) had progressive disease (PD). We were unable to confirm response status in one patient (2%). No statistically significant difference in response rate for patients treated with BEV and BEV+ Chemotherapy. From the start of Bev to the best response, 11 patients (30.56%) noted decrease in the dose of steroids, 14 patients (38.89%) dose remained unchanged. 7 patients (19.44%) required increase in the dose of steroids. 4 patients (11.11%) were not on steroids. For 7 patients we did not have the information on use of steroids. PFS was better for patients treated with chemotherapy + BEV with median PFS of 6.9 months, 95% CI 3.2- 22.3 verses BEV alone with median PFS 3.53 months 95% CI 1.4–5.3, P-value 0.0449. The Cox regression model for PFS to test comparing Bev with chemotherapy vs. Bev alone with the co-variables of sex, age, and ECOG performance status (PS). The model showed that patient with higher ECOG PS were noted to have inferior PFS with a Hazard ratio of 1.92 95% CI 1.09–3.37. P value of 0.2. Patient treated with BEV+ chemo had better PFS with a HR of 6.44 95% CI 1.86–22.28. P value of 0.003.

CONCLUSION

Retrospective real world study confirms that, patients with recurrent GBM, treatment with BEV is associated with similar PFS as reported in literature. Our study showed similar overall survival from the diagnosis compared to historic control. However the Median OS from Start of BEV was noted to be inferior to what is reported in EORTC EH1.3. Better ECOG performance status is associated with better PFS. Higher number of patients with ECOG 2 and 3 received BEV alone.

229 Uncomplicated Diverticulitis: A Proposed Diagnostic Algorithm

Introduction

Covid-19 has changed surgical practice. Infection risk and hospital pressures means appropriate patient ambulation is paramount. Uncomplicated diverticulitis can be managed as an outpatient. Clinical differentiation of uncomplicated and complicated diverticulitis remains challenging. This study aims to develop a diagnostic algorithm to differentiate complicated from uncomplicated disease prior to imaging.

Method

A single-centre retrospective review of 177 patients referred as diverticulitis between Sept-Dec 2018, was performed. Data collected included clinical presentation, biochemistry and imaging. Complicated diverticulitis was defined as occlusion, perforation, abscess formation, fistula and/or bleeding. Inferential parametric analysis was performed to ensure predictive value.

Results

Of 177 patients referred, 71 received a consultant diagnosis of diverticulitis. 60 were confirmed and differentiated on CT scan. LIF/lower abdominal pain (P < 0.01) and bowel habit change (P < 0.05) was significantly higher in patients with diverticulitis compared to other pathology. In complicated diverticulitis, symptoms occurred < 4days (P < 0.05), fever was present (P < 0.001) and CRP was > 75.

Conclusions

Once diverticulitis diagnosis is made based on pain localisation and change in bowel habit, complicated disease can be predicted by symptom duration (< 4 days), presence of fever and a CRP > 75. Plans to assess these findings prospectively in a Surgical Admissions Unit are currently in development.

Hemorrhagic Posterior Reversible Encephalopathy Syndrome as a Manifestation of COVID-19 Infection

We describe 2 hospitalized patients with confirmed coronavirus 19 (COVID-19) infection in whom brain imaging showed hemorrhagic posterior reversible encephalopathy syndrome, and we discuss the possible reasons for these findings and their relationship to the infection.

Use of esophageal stents to relieve dysphagia during neoadjuvant therapy prior to esophageal resection: a systematic review

Esophageal cancer stenting offers symptomatic relief for patients suffering from dysphagia. There are limited data to support their use to relieve dysphagia and improve nutrition during neoadjuvant therapy with some concern that they may negatively impact oncological outcomes. The aim of this systematic review was to quantify the impact of esophageal stents on outcomes prior to resection with curative intent. A literature search was performed using Embase, Medline, PubMed, PubMed Central, the Cochrane library for articles pertaining to esophageal stent use prior to or during neoadjuvant chemotherapy or chemoradiotherapy in patients planned for curative esophagectomy. Data extracted included basic demographics, clinical, nutritional and oncologic outcomes. A total of 9 studies involving 465 patients were included. Esophageal stent use resulted in a significant improvement in mean dysphagia scores in the immediate post stent period but failed to demonstrate any positive changes in weight, body mass index (BMI) or albumin. Only 33% of stented patients ultimately progressed to potential curative surgical resection and stents were associated with reduced R0 resection rates and lower overall survival. This systematic review shows that, although esophageal stenting is associated with improvements in dysphagia during neoadjuvant therapy, their effect on improving patient nutritional status is less clear and they may be associated with poorer long-term oncological outcomes. Stents should be used with caution in patients who are being considered for potentially curative resection of esophageal malignancies and other strategies of nutritional supplementation should be considered.

P2831Safety of atrial fibrillation catheter ablation in the elderly

Background

Catheter ablation for drug refractory, symptomatic atrial fibrillation (AF), is becoming increasingly common and can be beneficial in alleviating symptoms. However, in the elderly, there are concerns about the risks an invasive procedure poses, with limited published data available in those aged over 80 years.

Purpose

To determine the complication risk of AF catheter ablation in the elderly

Methods

Complications were identified from patient records in 3156 consecutive patients who underwent radiofrequency catheter ablation for AF, at a tertiary cardiology centre between 2013–2017. All cases were performed under general anesthesia.

Results

In this cohort of 3156 patients (mean age= 62.9±11.0 years, female = 29.9%), 90 (2.85%) (mean age= 66±10.0 years, female = 49.5%) complications were identified. In patients aged ≥80 years, complications occurred in 5 out of 99 patients (5.05%) (mean age= 82.6±1.2, female=100%), compared to 85 out of 3057 patients (2.78%) in those aged <80 years (mean age= 65±10.3, female = 49.4%). The difference was not significant p=0.18. Complications in the elderly all occurred acutely, and included groin haematoma (2.02%), pneumonia (2.02%) and pericardial effusion (1.01%).

Conclusion

Catheter ablation for AF in patients ≥80 years of age, is not associated with a significant increase in complication risk, compared to those who are younger.

Genetic depletion of Soat2 diminishes hepatic steatosis via genes regulating de novo lipogenesis and by GLUT2 protein in female mice

Depletion of the cholesterol esterifying enzyme acyl-Coenzyme A: cholesterol acyltransferase 2 (ACAT2, encoded by Soat2) protects mice from atherosclerosis, diet-induced hypercholesterolemia, and hepatic steatosis when fed high-cholesterol diet. The glucose transporter 2 (GLUT2) represents the main gate of glucose uptake by the liver. Lipid synthesis from glucose (de novo lipogenesis; DNL) plays a pivotal role in the development of hepatic steatosis. Inhibition of DNL is a successful approach to reverse hepatic steatosis, as shown by different studies in mice and humans. Here we aimed to investigate whether depletion of Soat2 per se can reduce hepatic steatosis, also in the presence of very low levels of cholesterol in the diet, and the underlying mechanisms. Female Soat2-/- and wild type mice were either fed high-fat or high-carbohydrate diet and both contained <0.05% (w/w) cholesterol. Analysis in serum, liver, muscles and adipose tissues were performed. We found Soat2-/- mice fed high-fat, low-cholesterol diet to have less hepatic steatosis, decreased expression of genes involved in DNL and lower hepatic GLUT2. Similar findings were found in Soat2-/- mice fed high-carbohydrate, low-cholesterol diet. CONCLUSION: Depletion of Soat2 reduces hepatic steatosis independently of the presence of high levels of cholesterol in the diet. Our study provides a link between hepatic cholesterol esterification, DNL, and GLUT2.

Audit of PPI Prescribing Practices: A Risk to Patient Safety?

Aim Proton pump inhibitors (PPIs) are frequently prescribed to surgical patients (50-60%) to prevent gastrointestinal bleeding. However, most surgical patients are at low risk of significant bleeds. The aim of this audit was to identify inappropriate PPI prescribing, if any, in a cohort of surgical inpatients. Methods This was a prospective analysis completed over a 4 month period. Data was collected via review of clinical notes and drug charts. The audit standard was the consensus guideline on indications for PPI use issued by Scarpignato et al (2016). Results In total 89 patients were included (n = 89). 73% were on PPI therapy. 30% had a documented indication for therapy which was concordant with recommendations. However, the majority of PPI prescriptions (70%) were inappropriate. Conclusion PPIs are frequently prescribed to surgical patients without an appropriate indication. Indiscriminate use of these drugs has implications in the form of costs and potential complications.