Martius flaps for low rectovaginal fistulae: a systematic review and proportional meta-analysis

BACKGROUND

Rectovaginal fistulae (RVF) are notoriously challenging to treat. Martius flap (MF) is a technique employed to manage RVF, among various others, with none being universally successful. We aimed to assess the outcomes of RVF managed with MF interposition.

METHODS

A PRISMA-compliant meta-analysis searching for all studies specifically reporting on the outcomes of MF for RVF was performed. The primary objective was the mean success rate, whilst secondary objectives included complications and recurrence. The MedCalc software (version 20.118) was used to conduct proportional meta-analyses of data. Weighted mean values with 95% CI are presented and stratified according to aetiology where possible.

RESULTS

Twelve non-randomized (11 retrospective, 1 prospective) studies, assessing 137 MF were included. The mean age of the study population was 42.4 (±15.7), years. There were 44 primary and 93 recurrent RVF. The weighted mean success rate for MF when performed for primary RVF was 91.4% (95% CI: 79.45-98.46; I2  = 32.1%; P = 0.183) and that for recurrent RVF was 77.5% (95% CI: 62.24-89.67; I2  = 58.1%; P = 0.008). The weighted mean complication rate was 29% (95% CI: 8.98-54.68; I2  = 85.4%; P < 0.0001) and the overall recurrence rate was 12.0% (95% CI: 5.03-21.93; I2  = 52.3%; P = 0.021). When purely radiotherapy-induced RVF were evaluated, the mean overall success rate was 94.6% (95% CI: 83.33-99.75; I2  = 0%; P = 0.350).

CONCLUSIONS

MF interposition appears to be more effective for primary than recurrent RVF. However, the poor quality of the data limits definitive conclusions being drawn and demands further assessment with randomized studies.

Prospective Longitudinal Assessment of Quality of Life After Stereotactic Ablative Radiotherapy for Oligometastases: Analysis of the Population-based SABR-5 Phase II Trial

AIMS

To evaluate longitudinal patient-reported quality of life (QoL) in patients treated with stereotactic ablative radiotherapy (SABR) for oligometastases.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases, conducted in six regional cancer centres in British Columbia, Canada from 2016 to 2020. Prospective QoL was measured using treatment site-specific QoL questionnaires at pre-treatment baseline and at 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. Patients with bone metastases were assessed with the Brief Pain Inventory (BPI). Patients with liver, adrenal and abdominopelvic lymph node metastases were assessed with the Functional Assessment of Chronic Illness Therapy-Abdominal Discomfort (FACIT-AD). Patients with lung and intrathoracic lymph node metastases were assessed with the Prospective Outcomes and Support Initiative (POSI) lung questionnaire. The two one-sided test procedure was used to assess equivalence between the worst QoL score and the baseline score of individual patients. The mean QoL at all time points was used to determine the trajectory of QoL response after SABR. The proportion of patients with 'stable', 'improved' or 'worsened' QoL was determined for all time points based on standard minimal clinically important differences (MCID; BPI worst pain = 2, BPI functional interference score [FIS] = 0.5, FACIT-AD Trial Outcome Index [TOI] = 8, POSI = 3).

RESULTS

All enrolled patients with baseline QoL assessment and at least one follow-up assessment were analysed (n = 133). On equivalence testing, the patients' worst QoL scores were clinically different from baseline scores and met MCID (BPI worst pain mean difference: 1.8, 90% confidence interval 1.19 to 2.42]; BPI FIS mean difference: 1.68, 90% confidence interval 1.15 to 2.21; FACIT-AD TOI mean difference: -8.76, 90% confidence interval -11.29 to -6.24; POSI mean difference: -4.61, 90% confidence interval -6.09 to -3.14). However, the mean FIS transiently worsened at 9, 18 and 21 months but eventually returned to stable levels. The mean FACIT and POSI scores also worsened at 36 months, albeit with a limited number of responses (n = 4 and 8, respectively). Most patients reported stable QoL at all time points (range: BPI worst pain 71-82%, BPI FIS 45-78%, FACIT-AD TOI 50-100%, POSI 25-73%). Clinically significant stability, worsening and improvement were seen in 70%/13%/18% of patients at 3 months, 53%/28%/19% at 18 months and 63%/25%/13% at 36 months.

CONCLUSIONS

Transient decreases in QoL that met MCID were seen between patients' worst QoL scores and baseline scores. However, most patients experienced stable QoL relative to pre-treatment levels on long-term follow-up. Further studies are needed to characterise patients at greatest risk for decreased QoL.

Predictors of Quality of Life Decline in Patients with Oligometastases treated with Stereotactic Ablative Radiotherapy: Analysis of the Population-Based SABR-5 Phase II Trial

AIMS

Most patients experience stable quality of life (QoL) after stereotactic ablative radiotherapy (SABR) treatment for oligometastases. However, a subset of patients experience clinically relevant declines in QoL on post-treatment follow-up. This study aimed to identify risk factors for QoL decline.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases. Prospective QoL was measured using treatment site-specific tools at pre-treatment baseline and 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. The time to persistent QoL decline was calculated as the time from SABR to the first decline in QoL score meeting minimum clinically important difference with no improvement to baseline score on subsequent assessments. Univariable and multivariable logistic regression analyses were carried out to determine factors associated with QoL decline.

RESULTS

One hundred and thirty-three patients were included with a median follow-up of 32 months (interquartile range 25-43). Thirty-five patients (26%) experienced a persistent decline in QoL. The median time until persistent QoL decline was not reached. The cumulative incidence of QoL decline at 2 and 3 years were 22% (95% confidence interval 14.0-29.6) and 40% (95% confidence interval 28.0-51.2), respectively. In multivariable analysis, disease progression (odds ratio 5.23, 95% confidence interval 1.59-17.47, P = 0.007) and adrenal metastases (odds ratio 9.70, 95% confidence interval 1.41-66.93, P = 0.021) were associated with a higher risk of QoL decline. Grade 3 or higher (odds ratio 3.88, 95% confidence interval 0.92-16.31, P = 0.064) and grade 2 or higher SABR-associated toxicity (odds ratio 2.24, 95% confidence interval 0.85-5.91, P = 0.10) were associated with an increased risk of QoL decline but did not reach statistical significance.

CONCLUSIONS

Disease progression and adrenal lesion site were associated with persistent QoL decline following SABR. The development of grade 3 or higher toxicities was also associated with an increased risk, albeit not statistically significant. Further studies are needed, focusing on the QoL impact of metastasis-directed therapies.

Choledocholithiasis: A Review of Management and Outcomes in a Regional Setting

Background Choledocholithiasis is a common surgical presentation with an incidence of 8% to 16% in symptomatic cholelithiasis. Treatment often requires a multi-stage approach via endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC), which can prolong the length of stay (LoS) and expose patients to unnecessary risks. A single-stage procedure, such as LC with common bile duct exploration (CBDE), is a safe and effective option that may decrease LoS. This study compares patient outcomes and management in a regional center and aims to identify factors that predict the presence of confirmed choledocholithiasis. Methods A retrospective cross-sectional analysis was performed on all patients admitted to Toowoomba Hospital for management of diagnosed or suspected choledocholithiasis from January 2021 to March 2023. Patient demographics, ERCP findings, and operative data were collated. Results A total of 195 patients were identified, including 136 patients undergoing multi-stage management, 34 patients who had an ERCP alone, and 25 patients who underwent single-stage management. Single-stage procedures had an 80% success rate with an average LoS of 3.6 days. Multi-stage procedures had an average LoS of 8.1 days and an ERCP success rate of 93%. Complication rates between ERCP (11.7%) and LC with CBDE (9.7%) were comparable. Time to index ERCP and serum bilirubin level were found to be significantly lower in those with positive index ERCP findings compared to those without. Conclusion Single-stage procedures are a safe way to manage choledocholithiasis and are associated with a reduced LoS when compared to multi-stage management, with comparable efficacy and morbidity rates.

Laparoscopic Cholecystectomy in Pregnancy: A Seven-Year Retrospective Study From an Australian Tertiary Center

Background Cholecystectomy is the second most common non-obstetric indication for surgery during pregnancy; however, there is little recent literature specifically exploring perioperative care approaches, and a paucity of Australian data exists. This study investigates the incidence of laparoscopic cholecystectomy (LC) during pregnancy, peri-operative management, and post-operative outcomes in a single Australian tertiary center. Methods A retrospective analysis of LCs performed on pregnant patients between the ages of 16 and 50 years at a tertiary hospital between 2016 and 2023 was completed. Results Twenty-three patients underwent LC. The median gestational age was 17+4 weeks (4+3-30+6). Cases were performed in all three trimesters, with the majority in the second trimester (n=12, 52.2%). Surgery indications were recurrent biliary colic (n=11, 47.8%), acute cholecystitis (n=8, 34.8%), and gallstone pancreatitis (n=4, 17.4%). Obstetrics and Gynecology (O&G) consultations occurred in 56.5% (n=13) of cases. Fetal heart rate (FHR) was recorded perioperatively in 82.6% (n=19) of cases. Preoperative steroids were given to 40% of eligible patients. An intraoperative cholangiogram was performed in 12 (52.2%) cases, of which eight (66.7%) utilized abdominal shielding. There was no perioperative maternal mortality nor fetal loss. Surgical morbidities were pancreatitis (n=1), bile leak (n=1), and intraoperatively recognized bile duct injury (n=1). Two threatened preterm labors and five (26.3%) preterm deliveries occurred. Conclusion Performing LC in pregnancy does carry a risk of major morbidity; however, there was no mortality or fetal loss across all trimesters. The decision to perform abdominal shielding during an intraoperative cholangiogram should be approached sensitively in a case-by-case manner, given recent paradigm shifts in radiology. A multidisciplinary approach with standardized local perioperative care policies regarding procedures such as O&G consultation, perioperative steroid use, and FHR monitoring is strongly recommended.

Rotational thromboelastometry values across age groups in all trauma patients presenting to a level 1 trauma centre: An observational study

OBJECTIVES

To describe rotational thromboelastometry (ROTEM) values (FIBTEM A5, EXTEM A5 and EXTEM CT) across age groups and assess for a statistical trend; and to determine whether any trend in ROTEM values is affected by severity of injury and packed red blood cells (PRBC) requirement.

METHODS

Retrospective observational study at a level 1 trauma centre in Queensland, Australia. A total of 1601 consecutive trauma patients presenting to the ED. ROTEM data described included FIBTEM A5, EXTEM A5 and EXTEM CT. These values are described by age group (≤30 years, 31-45 years, 46-60 years, 61-75 years and >75 years), Injury Severity Score (ISS) category (<12, ≥12, <25 and ≥25) and number of PRBCs transfused in the first 24 h of admission (0 units, 1-4 units, 5-9 units and ≥10 units).

RESULTS

The median age of participants was 37 years (interquartile range [IQR] 25-54 years), with 48.2% of patients had severe trauma (ISS >12) and 13.2% receiving at least one unit of PRBC in the first 24 h of admission. Median (IQR) values for FIBTEM A5, EXTEM A5 and EXTEM CT were 13 mm (10-16 mm), 45 mm (40-49 mm) and 62 s (56-71 s), respectively. A test for trend over progressive age groups showed an increase in FIBTEM A5 (P < 0.001) and EXTEM A5 values (P < 0.001) and a decrease in EXTEM CT values (P < 0.001).

CONCLUSION

The present study demonstrated a pattern of increasing coagulability, as defined by ROTEM, with increasing age group in trauma patients, even among the severely injured. Further investigation is required to determine the clinical impact of these findings on both the ROTEM-guided management and longitudinal outcomes of these patients and whether an age-specific approach is beneficial.

Location of Local Recurrences Post-Prostatectomy Detected by 18F-DCPFyL and Implications for Salvage Radiotherapy Target Volumes

PURPOSE/OBJECTIVE(S)

The use of prostate-specific membrane antigen (PSMA) PET scans have improved detection of recurrent prostate cancer for biochemical failure post-prostatectomy. The primary aim of this study is to assess the location of local recurrences for PSMA PET positive disease post-prostatectomy relative to anatomical landmarks and to inform salvage radiotherapy contouring guidelines.

MATERIALS/METHODS

This is a retrospective study of patients who underwent a staging PSMA PET-CT scan with 18F-DCFPyL tracer. Eligible patients included men with biochemical recurrence (PSA >0.2ng/mL) post-prostatectomy for prostate adenocarcinoma. PSMA positive local disease (GTV) was marked on the CT scan of the PSMA PET/CT, using the PSMA PET scan fused as the secondary dataset. Reference structures were contoured to compare the positional relationship to the GTV local recurrence. Centroids of each GTV position were measured to the closest border of the reference structures and distance measured.

RESULTS

Forty-five patients had a local recurrence on PSMA PET, 28/45 with prostate bed recurrence and 17/45 with seminal vesicle bed recurrence. The median age was 72.7 years, median pre-treatment PSA 0.515 ng/ml (0.2-11.1), pT2 in 37.8% and pT3 in 62.2, ISUP G2-3 was 66.7%, ISUP 4-5 29.6%, 67% ECE, 15.4% SV involvement and 40% positive margin. For prostate bed recurrences, 93.6% of GTVs were within 15mm from the inferior border of pubic symphysis (median 3.3mm [-9.8-15.4]), 83.9% within 10mm from the VUA (median 3.3mm [-17.4-15.9]), and 80.6% were greater than 10mm from the most superior slice of the penile bulb (median 16.4mm [1-29.5]). Laterally, 83.9% of recurrences were within 10mm of midline and 41.9% within 5mm (median 3.3mm [-13.56-11.59]) and all were contained within levator, 35.5% within 5mm (median 7.7 [1-22.6]) of the medial muscle border. 29.0% were within 5mm from the anterior edge of the rectal wall (median -7mm [-32.3-0.5]). Seminal vesicle bed recurrences were within 17.5mm of upper border of pubic symphysis for 88.9% of patients (median -4.69mm[-30.8to18.2]), 100% were more than 7.5mm inferiorly from the vas deferens (median-22.1mm[-32.7to-7.7]). Laterally, 100% recurrences were more than 7.5mm medial from obturator internus (median 5.37mm [-23.1to37.8]), and 88.9% were more than 10mm from midline (median 23.1mm [2.0-36.6]).

CONCLUSION

The 18F-DCFPyL PSMA PET local recurrences can provide detailed localization of prostate bed and seminal vesicle recurrences. Our data can inform contouring guidelines for salvage radiotherapy to the prostate bed, particularly when using anatomical landmarks to define cranio-caudal extent of target volumes. For target volume laterally, the medial wall of levator ani would encompass all prostate bed recurrences, and no seminal vesicles recurrences were seen at the medial border of the obturator internus muscle.

Incidence and management of gallbladder cancer in cholecystectomy specimens: a 5-year tertiary centre experience

BACKGROUND

Gallbladder cancer (GBC) is an uncommon, but highly aggressive cancer. Half of these cases are diagnosed pre-operatively, and the remaining cases are discovered incidentally on post-cholecystectomy specimens. There is a significant geographical variability in GBC incidence, with increasing age, female sex, and prolonged duration of cholelithiasis being risk factors for GBC. The primary aim was to define the overall local incidence of GBC incidental GBC and management of these cases. The secondary aim was to determine any pertinent risk factors in our case population.

METHODS

A retrospective observational study was performed on all the cholecystectomy specimens at the Gold Coast Hospital and Health Service from 1 January 2016 to 2 December 2021. Data was collected via the electronic medical record. The incidence and management of gallbladder cancers was calculated, and association with body mass index (BMI), smoking status, diabetes, inflammatory bowel disease (IBD) was identified.

RESULTS

3904 cholecystectomy specimens were reviewed. GBC was identified in 0.46% of cholecystectomies. 50% of these cases were found incidentally. Abdominal pain was the most common presenting complaint (94.4%). GBC was associated with increased age and BMI and female sex. There was no association between smoking status, diabetes or IBD with an increased incidence of cancer. Tumour staging guided surgical and/or adjuvant chemotherapy.

CONCLUSION

GBC is rare. Patients with symptoms are associated with a poor prognosis. Incidental cancers are common, and negative margin resection based on the T stage of the cancer is the most reliable curative option.

Prehabilitation for general surgery: a systematic review of randomized controlled trials

BACKGROUND

Prehabilitation seeks to optimize patient health before surgery to improve outcomes. Randomized controlled trials (RCTs) have been conducted on prehabilitation, however an updated synthesis of this evidence is required across General Surgery to inform potential Supplementary discipline-level protocols. Accordingly, this systematic review of RCTs aimed to evaluate the use of prehabilitation interventions across the discipline of General Surgery.

METHODS

This study was registered with PROSPERO (CRD42023403289), and adhered to PRISMA 2020 and SWiM guidelines. PubMed/MEDLINE and Ovid Embase were searched to 4 March 2023 for RCTs evaluating prehabilitation interventions within the discipline of General Surgery. After data extraction, risk of bias was assessed using the Cochrane RoB 2 tool. Quantitative and qualitative data were synthesized and analysed. However, meta-analysis was precluded due to heterogeneity across included studies.

RESULTS

From 929 records, 36 RCTs of mostly low risk of bias were included. 17 (47.2%) were from Europe, and 14 (38.9%) North America. 30 (83.3%) investigated cancer populations. 31 (86.1%) investigated physical interventions, finding no significant difference in 16 (51.6%) and significant improvement in 14 (45.2%). Nine (25%) investigated psychological interventions: six (66.7%) found significant improvement, three (33.3%) found no significant difference. Five (13.9%) investigated nutritional interventions, finding no significant difference in three (60%), and significant improvement in two (40%).

CONCLUSIONS

Prehabilitation interventions showed mixed levels of effectiveness, and there is insufficient RCT evidence to suggest system-level delivery across General Surgery within standardized protocols. However, given potential benefits and non-inferiority to standard care, they should be considered on a case-by-case basis.

Time to acute general surgical review: a retrospective study in a tertiary referral centre

BACKGROUND

The Acute Surgical Unit (ASU) is a busy service receiving Emergency Department (ED) referrals for adult and paediatric general surgery care alongside trauma. The ASU model deviates from the traditional on-call model and has been shown to improve efficiency and patient outcomes. The primary aim was to evaluate time to surgical review ED presentation and general surgical referral. Secondary aims were to assess referral numbers, pathology and demographics at our institution.

METHODS

A retrospective observational analysis was conducted on all referral times from the ED to the ASU between 1 April and 30 September 2022. Patient demographics, triage and referral times, and diagnoses were collected from the electronic medical record. Time between referral, review and surgical admission were calculated.

RESULTS

A total of 2044 referrals were collected during the study period, and 1951 (95.45%) were included for analysis. Average time from ED presentation to surgical referral was 4 hours and 54 min with average time to surgical review from referral taking 40 min. On average, total time from ED presentation to surgical admission was 5 h and 34 min. Trauma Responds took 6 min to review. Colorectal pathology was the most commonly referred disease type.

CONCLUSION

The ASU model is efficient and effective within our health service. Overall delays in surgical care may be external to the general surgery unit, or before the patient is made known to the surgical team. Analysis of time to surgical review is a key statistic in the delivery of acute surgical care.

A145 PEDIATRIC PATIENTS’ & PARENTS’ PERSPECTIVES ON TREATMENT PREFERENCE IN EOSINOPHILIC ESOPHAGITIS: A CROSS SECTIONAL, QUALITATIVE RESEARCH STUDY

Background

Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus which impairs quality of life in children and adolescents. Given the wide variety of symptomatic presentations in pediatrics, the varying time to diagnosis, and differing severity (including stricturing phenotype) initial treatments are not standardized. An important part of this individualization, beyond the health care practitioner counseling involves the patients’ and parents’ preferences which incorporates personal beliefs and attitudes.

Purpose

The study aim was to qualitatively describe parental and patient preferences regarding treatment options in EoE.

Method

This was a cross-sectional qualitative research study conducted in the EoE clinic at BC Children’s Hospital, Vancouver. Parents and their children completed semi-structured survey questions regarding treatment preference in EoE. Patients along with their parents who completed their survey questions were included in the study. Incomplete forms were excluded from the study.

Result(s)

The survey was attempted by 15 children, 7-11yrs of age, and 42 children, 12-18yrs of age, along with their parents. Completed response by both parent and their children were seen in 47 patients, 40 were adolescents 12-18yrs of age and 7 were 7-11yrs of age. Parent treatment preferences were diet in 17/47(36.2%), medications in 21/47 (44.7%) and 9/47 (19%) were unsure. 75% of parents who preferred dietary management thought it was less risky than medication. Parents who chose medication thought it would be easier (8/21) and more effective (8/21). Most of the parents’ decisions were influenced by the physician (35/47; 74.5%) and more so by the gastroenterologist (28/47; 59.6%). In 12–18-yr olds, 6/40 (15%) had preference for diet, 25/40 (62.5%) preferred medication and 9/40 (22.5%) were unsure. 3/6 adolescents thought that diet was less risky and 4/6 thought it was more effective than medication. Among the teens who preferred medication, 17/25 (68%) felt it to be easier and 9/25 (36%) thought it would work better than diet. Teenagers found their parents to be helpful for deciding (50%) and doctor (50%) with the gastroenterologist again playing a prominent role. In the 7 to 11yr old age group, 4/7 (57.1%) predominantly had preference for dietary treatment.

Conclusion(s)

The overall preference in the adolescent age group is for medication supported by patients’ and parents’, with ease of use being a primary driver for adolescents, whereas ease of use and effectiveness were drivers for the parents. Parents were more often interested in dietary therapy than the adolescents. With regards to parents of younger children and younger children themselves, dietary management was the preference as they felt it to be less risky. The numbers, though small, represent one of the few studies done on patient preference in EoE. Future studies should include formal qualitative studies and preferences could ultimately be tied to better counseling and tracking adherence to therapy.

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Incidence and management of choledocholithiasis on routine intraoperative cholangiogram: a 5-year tertiary centre experience

BACKGROUND

The incidence of choledocholithiasis on routine intraoperative cholangiogram (IOC) during cholecystectomy is approximately 12%. Cholecystectomy without IOC may lead to undiagnosed choledocholithiasis placing patients at risk of complications such as pancreatitis or cholangitis. This study aims to determine the incidence of choledocholithiasis intraoperatively as well as the associated risk factors and the methods of management.

METHODS

A retrospective observational analysis of all laparoscopic cholecystectomies with IOC at the Gold Coast Hospital and Health Service from 1 January 2016 to 2 December 2021 was carried out. Patient demographics, operative data and cholangiogram findings were collected from electronic medical systems.

RESULTS

A total of 3904 cholecystectomies were carried out over the study period. 3520 (90.1%) had an IOC, and 474 (13.4%) had positive IOC findings. 158 (33.3%) of the cases were managed intraoperatively with hyoscine butylbromide with or without intravenous glucagon followed by biliary tree flushing alone, 183 (38.6%) received transcystic bile duct exploration (TCBDE) with a success rate of 83% and 167 (35.2%) received endoscopic retrograde cholangiopancreatography (ERCP). Choledocholithiasis was incidental in 44 (9.28%) patients.

CONCLUSION

Incidental choledocholithiasis during routine IOC is not uncommon. Management predominantly includes intraoperative TCBDE or postoperatively via an ERCP. This study has not found reliable preoperative factors to predict choledocholithiasis based on preoperative clinical, radiological and biochemical factors. A small proportion of patients received preoperative endoscopic intervention, and the decision-making process requires further investigation.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

Olfactory dysfunction is common in classical infratentorial superficial siderosis of the central nervous system

Background

Established features of classical infratentorial superficial siderosis (iSS) include hearing loss, impaired balance, myelopathy and, less commonly, cognitive compromise. Olfactory function may be affected but dedicated studies are lacking. This study aimed to assess the prevalence of olfactory dysfunction in iSS and correlate it with auditory and cognitive functions.

Methods

Ten participants with iSS completed the University of Pennsylvania Smell Identification Test (UPSIT). The scores were compared with population norms; regression analysis was performed to evaluate associations between the scores and hearing thresholds (3-frequency average, 3FA) or the number of cognitive domains impaired. Imaging was reviewed for haemosiderin distribution and to exclude other causes of olfactory and hearing dysfunction.

Results

Eight of ten participants were male; the mean (standard deviation, SD) age was 52.5 (14.5) years. Olfactory hypofunction was identified in all participants and in six (60%) was moderate or completely absent. The mean UPSIT score of 25.5 (7.8) was significantly worse than population norms (difference in means − 10.0; 95% CI − 15.6 to − 4.4). Linear regression identified an association between UPSIT and hearing thresholds (R = 0.75; p = 0.013). The score decreases by 0.157 units (95% CI − 0.31 to − 0.002; p = 0.048) per unit increase in 3FA, after adjusting for hearing loss risk factors. There was no statistically significant association between UPSIT and cognitive function (R = 0.383; p = 0.397).

Conclusion

We report a high prevalence of olfactory dysfunction in iSS, the severity of which correlated with hearing loss. Olfaction appears to be a core feature of the iSS clinical syndrome that should be assessed routinely.

Spontaneous Cystogastrostomy: A Natural Response

Pancreatic pseudocysts are a common complication of pancreatitis. Conservative management and repeat imaging are appropriate to monitor spontaneous regression. However, in some cases, rupture and haemorrhage of pseudocysts can lead to life-threatening events requiring urgent intervention. We present a male patient in his 30s who was presented to the emergency department with severe pancreatitis in the context of alcohol excess. Past medical history included pancreatitis with a small pseudocyst and splenic vein thrombosis for which he was anticoagulated six weeks previously. Computer tomography of the abdomen and pelvis showed an interval increase in his pseudocyst with haemorrhage secondary to a suspected splenic artery pseudoaneurysm. He was admitted for attempted embolisation and observation. Serial imaging demonstrated progression of the pancreatic pseudocyst and then spontaneous interval decompression via a transgastric fistula, leading to a natural cystogastrostomy confirmed on subsequent endoscopy. We discuss the uncommon sequelae of a complication of pancreatitis, and consider the hypotheses related to this rare occurrence, with suggestions for management and follow-up of these patients.

Uptake of breast reconstruction following mastectomy: a Gold Coast experience

BACKGROUND

The breast reconstruction (BR) rate for women undergoing mastectomy for breast cancer management is 18% in Australia. The Australian Access to Breast Reconstruction Collaborative Group recommends that all women should have access to BR. This study presents BR uptake and outcomes from a breast surgical unit.

METHODS

A retrospective observational study identified women who had curative mastectomy for breast cancer between 1 January 2016 and 31 December 2021. Patient factors and surgical complications were compared between BR and no BR (NBR) patients.

RESULTS

Out of 929 women who had a curative mastectomy, 34% underwent reconstruction. Of this, 89% were immediate, and 11% were delayed. Reconstruction increased from 27% (2016) to 35% (2021). During this time, 588 women had a discussion for BR documented at their initial consultation, 58 after initial surgery and 283 were not documented. The rate of discussion prior to mastectomy increased from 38% to 74%. Women who had BR were more likely to be younger, premenopausal and less likely to be diabetic. Complications requiring return to theatre were higher in reconstructed women (13% vs. 7%). Overall, infected seroma, cellulitis requiring intravenous antibiotics and haematoma requiring drainage were comparable between both groups.

CONCLUSION

Our unit achieved a reconstruction rate of 34%, which is higher than national and international averages. Open discussion of reconstruction is crucial for women to make an informed decision. Further prospective studies exploring barriers to timely reconstruction will improve uptake of BR surgery and allow prioritization of BR services in Australia.

Trends in publication of general surgery research in Australia, 2000-2020

BACKGROUND

The significance of evidence-based surgery has resulted in a shift towards producing high-quality surgical research. The aim of this bibliometric analysis was to evaluate trends in publication of general surgery research in Australia from 2000 to 2020.

METHODS

General surgery publications including clinical trials, randomized controlled trials (RCTs), systematic reviews and meta-analyses by Australian-affiliated authors between 2000 and 2020 were extracted from PubMed. Titles, abstracts, journals and authors were independently screened by two investigators and arbitrated by a third. Publication type and area of focus were manually entered. Quality of articles was measured by trends in impact factor (IF) and SCImago Journal Rank (SJR). Descriptive statistics were used to summarize data and identify trends.

RESULTS

Three hundered and ninety-eight articles met inclusion criteria for this study, with a progressive increase in publications over the study period. RCTs and systematic reviews accounted for 109 and 234 publications, respectively. The median number of authors remained constant (p = 0.060). There was a significant increase in publication of clinical trials and RCTs (p < 0.001) as well as systematic reviews and meta-analyses (p < 0.001). The median IF increased from 1.93 to 3.08, whilst median SJR increased from 1.11 to 1.16, equivalent to organic growth of journal IF and SJR over this period. Female authorship significantly increased over time (p < 0.001).

CONCLUSION

There is a trend towards increased quantity, quality and diversity in Australian general surgery publications, which is indicative of the progression and importance of robust modern surgical research.

Omentoplasty to reduce anastomotic leak in colorectal surgery: a meta-analysis

BACKGROUND

Anastomotic leaks (AL) remain a devastating complication following intestinal anastomoses resulting in increased morbidity and mortality. Wrapping the anastomosis with omentum may be protective although data are conflicting. We performed a meta-analysis to assess the effect of omentoplasty on colorectal anastomoses.

METHODS

PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until August 2021. All randomized controlled trials (RCT) that reported on the use of omentoplasty in colon and rectal surgery were included. The primary outcome was rate of overall AL while secondary outcomes included clinical and radiological AL, overall reoperation and mortality. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed.

RESULTS

Four RCTs were included capturing 1067 patients. The mean (SD) age of the cohort was 61.5 (±14.8) years. On random effects analysis, omentoplasty reduced rate of overall (OR 0.43, 95% CI = 0.21-0.87, p = 0.02) and clinical AL (OR = 0.35, 95% CI = 0.15-0.81, p = 0.01). However, there was no difference in radiological AL (OR = 0.77, 95% CI = 0.40-1.47, p = 0.42), overall reoperations (OR 0.48, 95% CI = 0.18-1.32, p = 0.16) or mortality (OR 0.52, 95% CI = 0.12 to-2.18, p = 0.37). On sensitivity analysis, assessing rectal anastomoses only, the results for overall AL remained similar (OR 0.28, 95% CI = 0.12-0.61, p = 0.002).

CONCLUSION

Although omentoplasty appears to reduce the rate of overall and clinical AL, the heterogeneity in the data prevents definitive recommendations from being made. Further well-designed trials are needed to investigate this technique.

POS0494 AN INVESTIGATION OF JOINT INFLAMMATION DEFINED BY COMPREHENSIVE ULTRASOUND ASSESSMENT AND PAIN SENSITISATION IN PATIENTS WITH ACTIVE RA

Background:

Treat-to-target strategies have improved outcomes in patients with RA. Targets based on clinical assessments of tender (TJC) and swollen joints (SJC) were developed when most patients had active inflammatory disease. It is now recognised some patients have pain sensitisation often termed fibromyalgia (FM), making clinical assessment of inflammatory disease more complex. An indicator of pain sensitisation is the difference between TJC and SJC, an observation we described in a pilot study (1).

Objectives:

To study patients with RA to describe the relationships between enhanced clinical and patient-reported outcome measures (PROMS) and active inflammatory joint disease detected by comprehensive PDUS.

Methods:

158 sequential patients with RA with a DAS28ESR score >¬3.2 were enrolled from GSTT Rheumatology after informed consent. They were assessed by a rheumatologist for 66SJC, 68TJC, fibromyalgia tender points & physician global. Recorded PROMS were: patient global, widespread pain index (WPI), symptom severity score (somatic & fatigue), FACIT fatigue, HAQ, EQ5D QoL, GAD7, PHQ9 and PHQ15. All patients had a 44 joint US scored for PD and grey scale by the EULAR scale blind to all patient data. Data were recorded on MedSciNet and statistical analysis used STATA.

Results:

Patients meeting the ACR 2010 criteria for FM2(n=72) vs those that did not(n=86) had similar demographics. SJC and US doppler scores were higher in the non-FM group, whereas rheumatoid factor, DAS28 and PROMs were higher in the FM group. Analysis of group differences using multinomial logistic regression and subsequent regularised (lasso) logistic regression, showed the FM group related to higher 28TJC, FACIT-F and PHQ15, with the non-FM group related to higher 28SJC, logESR, and lower Differences in 28S/TJC, Physician Global and FACIT-F. Patients were divided into four groups based on presence or absence of at least one PDUS+ joint and FM criteria; -FM-PD, -FM+PD, +FM-PD and +FM+PD, data summarised Table 1. The -FM-PD and -FM+PD groups related to Physician Global and negatively related to FACIT-F, Difference in 28S/TJC, and PHQ15 (-FM-PD). The +FM-PD group related positively to FACIT-F, Difference 28S/TJC, PHQ15, and negatively to Physician Global with +FM+PD related to PHQ9, FACIT-F and DAS28ESR.

TABLE 1.

-FM -PD -FM +PD +FM -PD +FM +PD p-value

Female34 (79%)33 (77%)35 (83%)22 (73%)0.77Total power doppler score0.0 (0.0-1.0)16.0 (10.0-25.0)0.0 (0.0-0.0)9.0 (8.0-20.0)<0.001Total gray scale score40.0(34.0-48.0)57.5(45.0-82.0)34.5(20.0-43.0)60.0(46.0-84.0)<0.001Total Swollen JC3.0 (1.0-5.0)6.0 (3.0-9.0)2.0 (0.0-5.0)5.5 (2.0-10.5)<0.001Total Tender5.5 (3.0-12.0)8.0 (4.0-11.0)13.0 (8.0-20.0)15.0 (8.0-20.0)<0.001Tender-Swollen JC Difference4.0 (0.0-8.0)2.0 (0.0-4.0)8.0 (4.0-18.0)5.5 (2.5-13.5)<0.001ESR mm/hour10.0 (8.0-16.0)14.0 (10.0-30.0)12.0 (7.0-23.0)19.5 (11.5-42.5)0.021Pain VAS50.0 (40.0-65.0)50.0 (30.0-60.0)60.0 (47.5-77.5)67.5 (55.0-80.0)<0.001Patient VAS50.0 (30.0-70.0)40.0 (30.0-70.0)60.0 (40.0-80.0)65.0 (50.0-80.0)0.006Physician VAS30.0 (20.0-50.0)50.0 (40.0-60.0)30.0 (20.0-40.0)50.0 (32.5-70.0)<0.001DAS28 (ESR)4.2 (3.7-4.9)4.7 (4.1-5.2)4.7 (3.9-5.8)5.6 (4.9-6.6)<0.001

Conclusion:

These data using comprehensive US assessment to detect inflammatory joint disease, demonstrate that active inflammation defined as at least 1PDUS+ joint, may account for disease activity in slightly less than half of unselected patients with RA with a DAS28ESR score >3.2. This study shows how frequently pain sensitisation accounts for symptoms and signs in RA. We suggest in addition to central sensitisation, often called FM, another group identified here as -FM-PD, may have pain from joint damage or peripheral pain sensitisation of joints, likely due to different mechanisms than central pain sensitisation.

References:

[1]Mian A et al, BMC Musculoskelet Disord. 2016;17: 404

[2]Wolfe F et al, Arth Care & Res 2010; 62:600

Disclosure of Interests:

Khaldoun Chaabo: None declared, Estee Chan: None declared, Toby Garrood: None declared, Zoe Rutter-Locher: None declared, Alexandra Vincent: None declared, James Galloway Speakers bureau: Dr Galloway has received speaker fees / honoraria from Abbvie, BMS, Celgene, Chugai, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, Sobi and UCB, Sam Norton: None declared, Bruce Kirkham Speakers bureau: Professor Bruce Kirkham has received speaker fees / honoraria from Abbvie, Gilead, Janssen, Lilly, Novartis, Pfizer,and UCB., Grant/research support from: Professor Bruce Kirkham has received research support from Lilly, Novartis and UCB.

Professor Bruce Kirkham has received speaker fees / honoraria from Abbvie, Gilead, Janssen, Lilly, Novartis, Pfizer and UCB.

Sex-based differences in program completion and clinical outcomes in patients following outpatient cardiac rehabilitation

Funding Acknowledgements

Type of funding sources: None.

Background

Females have greater reduction in mortality compared to males, following completion of a cardiac rehabilitation (CR) program, yet they continue to have lower referral rates and program completion. Since 1996, a local rehabilitation program has been the main provider of CR in our health zone. A standardized rapid referral program was implemented in 2008 to improve referral rates of hospitalized patients. Since then, the relationship between sex and CR completion is unknown.

Purpose

To evaluate the relationship between sex and CR completion and to evaluate the association between CR completion and clinical outcomes, stratified by sex.

Methods: We included consecutive patients who were referred to CR and who

1) were hospitalized for an acute coronary syndrome (ACS) or stable angina between 2008 and 2016; 2) had angiographic evidence of at least one-vessel coronary disease; and 3) had revascularization with percutaneous intervention, coronary artery bypass or medical management. The outcomes of interest were CR completion, anxiety and depression categories, exercise capacity, death, and need for revascularization. Logistics regression models were used to determine the association between sex and CR completion. The association between sex, CR completion, and the outcomes of interest were assessed using multivariable cox proportional hazards models.

Results

A total of 726 females and 2645 males were included in this study. The rate of CR completion was lower in females compared to males (64.6% vs 69.98%, p = 0.006). Following adjustment for baseline characteristics, female sex independently predicted lower rates of CR completion, OR 0.81 (95%CI 0.67-0.97).

Both sexes displayed improvements in peak metabolic equivalents (METs) achieved during exercise testing (W: initial 5.99 ± 1.93; 12-week 7.22 ± 1.92; M: initial 7.62 ± 2.04; 12-week 8.81 ± 1.93, p = 0.001). Amongst CR completers, one-year mortality was similar between sex (W: 1.84% vs M: 3.27%, p = 0.118), as was revascularization (W: 14.29% vs M: 11.97%, p = 0.193), however both sexes had higher one-year mortality in CR non-completers.

Conclusion

Despite a standardized CR referral protocol, a sex-difference in CR completion remains. In CR completers, one-year mortality and revascularization was similar in both sexes, however mortality was higher in CR non-completers. Our study suggests that addressing the causes of female CR non-completion following ACS or stable angina may improve outcomes.

Outcomes by CR Completion and Sex All NC (n = 1051) W-NC (n = 257) M-NC (n = 794) p-value All C (n = 2320) W-C (n = 469) M-C (n = 1851) p-value Revascularization-1 year (%) 146 (14.94) 28 (11.72) 118 (15.59) 0.107 267 (12.44) 62 (14.29) 205 (11.97) 0.193 Death-1 year (%) 67 (6.86) 19 (7.95) 48 (6.50) 0.442 64 (2.98) 8 (1.84) 56 (3.27) 0.118 W = Women;M = Men;NC = Non-Completers;C = Completers

A new respiratory scoring system for evaluation of respiratory outcomes in children with spinal muscular atrophy type1 (SMA1) on SMN enhancing drugs

Nusinersen (NUS), the first treatment approved for Spinal Muscular Atrophy type 1 (SMA1), was made available in the UK for SMA1 through the Expanded Access Program (EAP) in 2017. The Great Ormond Street Respiratory (GSR) score was developed as an objective respiratory assessment for children with SMA1 during their treatment. Aims: Track respiratory status of SMA1 children over the course of Nusinersen treatment and compare GSR scores amongst SMA1 sub-types. Single centre study on SMA1 patients using the GSR score at set time points: prior to first NUS dose; 2 weeks post end of loading doses; 2 weeks post-subsequent doses. GSR score ranges 1-28, being 1-9 = Stable minimal support, thorough to 23-28 = Poor reserve with maximum support. 20 SMA1 children underwent NUS treatment between January 2017 - November 2018. Median age of diagnosis was 5.0 months. NUS started at median of 9.57 months. From 5th dose onwards, GSR scores were significantly lower for Type 1C patients compared to Type 1B By month 18, irrespective of subtypes, the whole cohort appears to stabilise GSR Scores. As treatment duration increases, an overall stabilisation of respiratory status across the cohort was observed. Further longitudinal studies are needed to validate the GSR.

Intramuscular abdominal hibernoma: case report of a rare tumour and a review of the literature

Hibernoma is a rare benign tumour that was first described by Merkel in 1906. It arises from remnants of brown fat and has a differential diagnosis of lipoma and liposarcoma. This is a case report of a 31-year-old male with a slow-growing mass in the left flank that produced constant pain radiating to the groin. Computerised tomography localised the mass within the external oblique muscle, which showed some heterogeneity and low attenuation. The mass appeared hypodense to muscle on T1 and hyperdense to muscle on T2 weighted magnetic resonance images. Prominent vascularity of the mass was noted. Finally, the lesion was found to be a ‘typical’ hibernoma on core-needle biopsy. It was surgically resected with a cuff of muscle. He recovered without complication, and there is no clinical evidence of recurrence at 6 months.

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

Targeted cryoprecipitate transfusion in severe traumatic haemorrhage

BACKGROUND

Severe traumatic haemorrhage is the leading cause of death in young adults. Trauma Induced Coagulopathy is a complex and multifactorial phenomenon associated with severe traumatic haemorrhage. Fibrinogen is one of the first coagulation factors to become depleted in TIC and evidence suggests that severely injured trauma patients with hypofibrinogenaemia have poor outcomes. It is postulated that early fibrinogen replacement can improve clinical outcomes. This study investigated cryoprecipitate transfusion in hyopfibrinogeneamic trauma patients.

METHODS

This retrospective, single center, observational study investigated the use of cryoprecipitate in severely injured trauma patients admitted to an Australian Level I Trauma Centre. The primary outcome was time to administration of cryoprecipitate after identification of hypofibrinogenaemia using ROTEM (FIBTEM A5). Data collected included demographics, ISS, laboratory values of coagulation and blood product usage.

RESULTS

71 patients received cryoprecipitate with a median time of 61 minutes [IQR 37-93] from FIBTEM A5 result to initial cryoprecipitate administration. At 24 hours following admission to ED, Clauss Fibrinogen levels increased by 1.30g/L [IQR 0.45-1.85] and FIBTEM A5 assay increased by 8mm [IQR 3.0-11.3]. Changes in both variables were highly significant (p<0.001) and Clauss Fibrinogen versus FIBTEM A5 values showed moderate to strong correlation (R=0.75-0.80).

CONCLUSION

This study demonstrated that early administration of cryoprecipitate was both feasible and efficacious in fibrinogen replacement in severe traumatic haemorrhage. High-level evidence supporting cryoprecipitate or fibrinogen concentrate replacement with regards to efficacy and feasibility is required to guide future clinical practice. This study provided baseline data to inform the design of further clinical trials investigating fibrinogen replacement in traumatic haemorrhage.

A198 EOSINOPHILIC ESOPHAGITIS WITH STRICTURE PRESENTING SHORTING AFTER INITIATION OF ORAL PEANUT IMMUNOTHERAPY

Background

Oral immunotherapy (OIT) is increasingly practiced outside of research settings with reasonable success (Soller 2019).

With OIT, a patient eats their food allergen daily, gradually increasing the dose, with the goal to prevent or reduce the severity of an anaphylactic reaction.

One of the described adverse events of OIT is a risk of developing Eosinophilic Esophagitis (EoE), with cited frequency of 2.7% (Lucendo 2014). In addition, OIT is typically contraindicated in patients with known EoE but patients are not routinely screened for EoE prior to initiation of OIT.

Aims

To present a case of a 12 year old boy with peanut anaphylaxis who developed eosinophilic esophagitis and an esophageal stricture shortly after starting peanut immunotherapy

Methods

Patient chart review was conducted. A literature review was done using the words “eosinophilic esophagitis” and “immunotherapy”.

Results

A12 year old boy with asthma, allergic rhinitis and multiple anaphylactic food allergies, started peanut OIT with an allergist. Prior to OIT, the patient had no symptoms suggestive of EoE such as dysphagia, heartburn, chest pain or washing of food. Approximately 3.5 weeks into treatment, the patient developed daily vomiting. The patient was advised to stop the peanut OIT three days after symptom onset, but the vomiting continued for another 8 days. By the time of endoscopy (16 days after onset of vomiting), the vomiting had completely subsided for the previous five days.

The upper GI endoscopy demonstrated signs of EoE throughout the length of the esophagus. In the mid esophagus there was resistance where the 9.8 mm gastroscope was unable to pass. A smaller gastroscope with a 5.9 mm width was easily able to pass through the stricture. Histology showed marked eosinophilia throughout the esophagus with basal cell hyperplasia, spongiosis, superficial microabscesses and stromal fibrosis consistent with EoE. The patient continued to be ‘asymptomatic’ at the time of endoscopy and after despite the presence of a stricture. After discussion, the patient was started on oral viscous budesonide (OVB) 1mg PO BID.

The patient was re-scoped 4 weeks into OVB therapy with complete resolution of the stricture with neither macroscopic nor histologic findings of EoE. Patient is now off OVB for over a month, remains asymptomatic, and will undergo repeat endoscopy in the upcoming month to ensure normal histology

Conclusions

This is the first case describing EoE with an esophageal stricture shortly after initiation of OIT. Pediatric Gastroenterologists need to be increasingly aware that patients undergoing OIT are at an increasing risk of ‘developing’ or at least ‘unmasking’ EoE. More research is required to evaluate whether EoE screening, by symptom questionnaire or endoscopy is warranted prior to beginning OIT, and whether OIT is truly needed.

Funding Agencies

CAG

Targeted fibrinogen concentrate use in severe traumatic haemorrhage

OBJECTIVE

Fibrinogen is one of the first coagulation factors to be depleted during traumatic haemorrhage, and evidence suggests hypofibrinogenaemia leads to poor outcomes. A number of fibrinogen replacement products are currently available, with no clear consensus on the ideal product to use in severe traumatic haemorrhage. We hypothesised that it will be possible to rapidly administer fibrinogen concentrate (FC) guided by rotational thromboelastometry (ROTEM) FIBTEM A5 in patients presenting with trauma haemorrhage.

METHODS

We examined 36 consecutive patients with trauma admitted to a level 1 trauma centre in Australia who received FC as part of their initial resuscitation. ROTEM analysis was conducted at various time points from emergency department (ED) admission to 48 hours after admission. The primary outcome was time to administration of FC after identification of hypofibrinogenaemia using ROTEM FIBTEM A5. Data were collected on quantity and timing of product transfusion, demographics, Injury Severity Score and laboratory values of coagulation. Spearman rank order correlation was used to determine the correlation between FIBTEM A5 and Clauss fibrinogen (FibC).

RESULTS

Thirty-six patients received FC as their initial form of fibrinogen replacement during the study. Patients were hypofibrinogenaemic by both FIBTEM A5 (6 mm) and FibC (1.7 g/L) on presentation to the ED. It took a median of 22 minutes (IQR, 17-30 minutes) from time of a FIBTEM A5 analysis to FC administration. Both parameters increased significantly (P < 0.05) by 24 hours after admission.

CONCLUSION

This study suggests that administration of FC represents a rapid and feasible method to replace fibrinogen in severe traumatic haemorrhage. However, the optimal method for replacing fibrinogen in traumatic haemorrhage is controversial and large multicentre randomised controlled trials are needed to provide further evidence. This study provided baseline data to inform the design of further clinical trials investigating fibrinogen replacement in traumatic haemorrhage.