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The 52nd Congress of the European
Society for Surgical Research
June 14–17, 2017, Amsterdam, The Netherlands
Guest Editor
Ivo Post, Amsterdam
Abstracts LB01 – LB08
Abstracts O002 – O179
Abstracts V001 – V004
Abstracts P03 – P60
The abstracts are available online, free of charge, under
Basel Freiburg Paris London New York Chennai New Delhi
Bangkok Beijing Shanghai Tokyo Kuala Lumpur Singapore Sydney
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© Copyright 2017 by S. Karger AG,
P.O. Box, CH–4009 Basel (Switzerland)
e-ISBN 978–3–318–05919–9
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S. Karger
Medical and Scientific Publishers
Basel Freiburg Paris London
New York Chennai New Delhi
Bangkok Beijing Shanghai Tokyo
Kuala Lumpur Singapore Sydney
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
© 2017 S. Karger AG, Basel
S. Koljenovic, E. Barroso, T. Bakker Schut, I. Ten Hove,
H. Mast, C. Lanschot, R. Smits, A. Sewnaik, J. Hardillo,
C. Meeuwis, D. Monserez, R. Verdijk, V. Noordhoek Hegt,
P. Caspers, R. Baatenburg de Jong, E. Wolvius, G. Puppels
O. Bugter1, J.A.U. Hardillo1, R.J. Baatenburg de Jong1,
A. Amelink2, D.J. Robinson1
Erasmus MC, Pathology, Rotterdam, Netherlands
Objective: To establish the usefulness of Raman spectroscopy for intraoperative assessment of soft and bone
tissue resection margins during oral cavity squamous cell
carcinoma (OCSCC) surgery. Raman spectroscopy is an nondestructive objective technique that provides (real-time)
information about the molecular composition of tissues. It
can be used ex-vivo and in-vivo without tissue preparation.
Material and Methods: Raman ex-vivo experiments were
performed on freshly resected OCSCC specimens. Results:
The studies have shown that Raman spectroscopy can
discriminate OCSCC from the surrounding healthy soft
tissue, with 99% sensitivity and 92% specificity (170 point
measurements/ 14 patients)1, and can be used to determine
the OCSCC border (25 mapping experiments/ 20 patients)2.
Furthermore, recent study have shown that Raman spectroscopy can detect OCSCC in bone resection surfaces with
high sensitivity (96%) and specificity (83%) (26 mapping
experiments/ 22 patients)3. Conclusions: Our results are
promising and show, for the first time, that an objective
technique like Raman spectroscopy could be applied intraoperatively to evaluate resection margins during OCSCC
surgery including both, soft and bone tissues. This method
could improve the currently reported pure numbers of
adequate resection margins, varying between 2% and
Optical Screening for Laryngeal Cancer Using
Reflectance Spectroscopy of the Buccal
MC Cancer Institute, Otorhinolaryngology and
Head and Neck Surgery, Rotterdam, Netherlands, 2TNO,
Optics, Delft, Netherlands
Background: Head and neck squamous cell carcinoma
(SCC) has an increasing incidence and a 5-year survival rate
of approximately 50%. In order to improve the survival of
these patients it is necessary to develop a screening method
to facilitate early tumor detection. Our aim is to investigate
whether this is possible using a non-invasive optical method
for the detection of field carcinogenesis. Material and
Methods: Patients with primary and untreated laryngeal SCC
and non-oncologic controls were included in this casecontrol study. The optical properties of their buccal mucosa
were measured to assess possible tissue changes caused by
field carcinogenesis. This was done with multidiameter
single-fiber reflectance spectroscopy. We investigated if
differences in optical parameters could be used to differentiate between patients with laryngeal SCC and controls.
Results: Two physiological parameters were significantly
lower in the buccal mucosa of patients with HNSCC than
control patients: blood oxygen saturation (p = 0.030) and
blood volume fraction (p = 0.020). They were combined into
biomarker a, which was lower in the HNSCC patients (0.28
[0.25–0.32]) than the control group (0.30 [0.26–0.35], p =
0.007). Biomarker a could detect the presence of a laryngeal
SCC with a sensitivity of 78% and a specificity of 74%.
Conclusion: We have, for the first time, demonstrated that
the buccal mucosa of patients with laryngeal SCC is altered
by field carcinogenesis. These findings suggest that multidiameter single-fiber reflectance spectroscopy could potentially be used to screen high risk subjects for all head and
neck SCC.
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Intraoperative Assessment of the Resection
Margins by Raman Spectroscopy to Guide
Head and Neck Cancer Surgery
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Validation Study of the Classification of
Intraoperative Complications (CLASSIC) Score
P. Krielen, L. Gawria, M.W.J. Stommel, R.P. ten Broek,
H. van Goor
A Randomized Controlled Trial on the Effect
of a Silver Carboxymethylcellulose Dressing
on Surgical Site Infections after Breast Cancer
Radboudumc, Surgery, Nijmegen, Netherlands
G.M. Struik, W.W. Vrijland, E. Birnie, T.M.A.L. Klem
Background: Surgical outcomes depend on the quality of
Franciscus Gasthuis en Vlietland, Surgery, Rotterdam,
both operative and post-operative care. Validated classification systems for evaluation of intraoperative adverse
events (iAE’s) however, are not available. Recently, the classification of intraoperative complications (CLASSIC) score has
been proposed to evaluate IAE’s. The aim of this study is to
assess the internal validity of the CLASSIC score and its
predictive value for postoperative complications. Methods:
We used the detailed data that was previously prospectively
collected by an independent researcher in the operating
room for the LAPAD study. Two independent teams of investigators scored all registered iAE’s. An interclass correlation
coefficient was calculated to determine the internal validity.
Univariate and multivariate analyses were used to review the
correlation between the CLASSIC score and post operative
complications (Clavien-Dindo). Results: We reviewed a total
of 755 surgeries for iAE’s. In 324 (42.9%) iAE’s were score by
team 1, and 333 (44.1%) by team 2. In 86.9% there was a raw
agreement between both teams. Post-operative complications were scored in 278 (36.8%) of all surgeries. The interrater reliability for CLASSIC score scored was 0.873 (95% CI
0.842–0.904. In multivariate analysis iAE were a significant
and independent risk factor for severe post-operative
complications, with OR 2.19 (95% CI: 1.41–3.41) for minor
iAE’s and OR 3.96 (95% CI: 2.21–7.1) for severe iAE’s. Conclusions: The newly proposed CLASSIC score is a reliable tool
for the classification of iAEs, with good inter-observer correlation. The Classification of iAEs according to CLASSIC correlates with the risk of severe post-operative complications.
Background: The incidence of surgical site infections
(SSIs) after breast cancer surgery is relatively high; ranging
from 3 to 19%. The role of wound dressings in the prevention
of SSI after breast cancer surgery is unclear. This study
compares a silver carboxymethylcellulose dressing
(AQUACEL Ag Surgical (Aquacel)) with standard wound
dressing in SSI rate after breast cancer surgery. Patients and
Methods: A single-centre randomized controlled trial
among women = 18 years, undergoing breast cancer surgery
was conducted. The intervention was the use of Aquacel,
compared with standard gauze dressing. Primary outcome
measure was SSI following CDC criteria. Results: In total 230
patients were analysed: 106 Aquacel and 124 controls. Seven
patients (6.6%) developed SSI in the Aquacel group and 16
patients (12.9%) in the control group (RR 0.51 [95% Confidence Interval (CI): 0.22–1.20]; P = 0.112). In the subgroup of
breast conserving surgery, the risk of SSI was reduced in the
Aquacel group compared with controls: 1/56 (1.8%) vs. 7/65
(10.8%); RR 0.17 [CI: 0.03–0.99], p = 0.047. The Aquacel
group showed better patient satisfaction (median 8 vs. 7 on
a Numerical Rating Scale, p = 0.006), fewer dressing changes
within 48 hours (RR 0.21 [CI: 0.11–0.40], p < 0.001) and lower
wound-related treatment costs (p < 0.001). Conclusion: In
this study among women undergoing breast cancer surgery,
the use of Aquacel did not significantly reduce the occurrence of SSIs, although a trend was found. A significant
reduction of SSIs with a large effect size was found in patients
undergoing breast conserving surgery. Furthermore,
Aquacel resulted in a significantly improved patient satisfaction.
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Spacer Study: A Pilot on the Use of a
Subcutaneous Spacer Injection in the Breast
for Skin Protection during Brachytherapy
G.M. Struik1, A. Ghandi1, I.K.K. Kolkman-Deurloo2,
E. Birnie1, J.P. Pignol2, T.M.A.L. Klem1
Franciscus Gasthuis en Vlietland, Surgery, Rotterdam,
Netherlands, 2Erasmus MC-Cancer Institute, Radiation
Oncology – Physics, Rotterdam, Netherlands
Introduction: Partial breast irradiation is a treatment
option after breast conserving surgery for low risk breast
cancer patients. Main side effect is skin toxicity, with dose to
the skin as main risk factor. In this study, a subcutaneous
spacer injection and its effect on skin dose was investigated.
Methods: A pilot study of an ultrasound guided spacer
injection was performed on mastectomy specimen. Both
hyaluronic acid gel (HA) (‘Barrigel’) and iodined PolyEthyleneGlycol (PEG)(‘TraceIT’) were tested. Success was defined
as creating a spacer thickness of = 5 mm subcutaneously in
a premarked skin area. Usability was measured with the
System Usability Scale (SUS). CT-scans were made pre- and
post-injection. Brachytherapy planning was performed on a
simulated Clinical Target Volume (CTV) and skin isodose was
calculated with and without spacer. Dose to small volumes
(D0.2 cc and D0.05 cc) and percentage of skin isodose = 85%
were calculated as measures for skin toxicity. Results: 22
specimen were included; 11 HA, 11 PEG. Success rate was
100% with and 90.9% with PEG (n.s.). Mean SUS score was
96 for HA and 81 for PEG (p < 0.001). Mean D0.2 cc was 80.8Gy
with and 53.5Gy without spacer (p < 0.001). Mean D0.05 cc was
78.1Gy with and 52.4Gy without spacer (p < 0.001). Skin
(1 cm2) isodose = 85% was present in 13/22 (59.1%) specimen
without spacer and 1/22 (4.5%) specimen with spacer (p <
0.001). Conclusion: A very high success rate of a subcutaneous spacer injection in the breast was shown. A thickness
of = 5 mm can reduce the skin dose dramatically. Clinical
evaluation of the effect on skin toxicity is needed.
Management of Intrathoracic and Cervical
Anastomotic Leakage after Esophagectomy for
Esophageal Cancer: A Systematic Review
M.H.P. Verstegen, S.A. Bouwense, P.D. Siersema, M. Rovers,
C. Rosman
Radboudumc, Surgery, Nijmegen, Netherlands
Background: Anastomotic leakage (0–40%) is a severe
complication after esophagectomy and is associated with
significant mortality rates (30–60%). Factors that may
influence the severity of a leakage are location of anastomosis (intrathoracic or cervical), leakage size and exten-
siveness, time till diagnosis and therapy. Treatment options
ranges from conservative to endoscopic or surgical interventions. The optimal treatment strategy is still under debate
due to absence of high level evidence. Methods: A systematic
literature search was performed in the electronic databases
Medline, Embase and Web of Science up to April 2017 to
identify eligible studies analyzing management of intrathoracic or cervical leakages following esophagectomy for
esophageal or cardiac cancer. Results: Nineteen eligible
articles were found (n = 273). Regarding the intrathoracic
leakages, overall success rates in the conservative, endoscopic drainage and stent group were 86%, 91% and 77%
respectively. The mortality rate was low in the E-VAC study
(0%) and high in the surgery group (50%). Regarding the
cervical leakages, overall success rates in the stent, conservative and endoscopic dilatation group were 71%, 92% and
100% respectively. Conclusion: Duo to small cohorts, heterogeneity between studies and lack of proper description of
the leak, diagnostics and treatment there appears to be no
evidence supporting one treatment only. Based on literature
and our experiences we suggest optimal treatment is a
gradual approach, starting with conservative treatment and
expand necessarily with drainage, surgery or stenting. This
review illustrates opportunities for further research to
achieve a treatment strategy with high level evidence.
Imaging Techniques for Detecting Complete
Response after Neoadjuvant Therapy by
Patients with Esophageal Cancer: A Systematic
Review and Meta-Analysis
D.J.J.M. Gouw, M. Driessen, B.R. Klarenbeek,
M.H.B.C. Stenstra, S.A.W. Bouwense, M.M. Rovers,
R.P.G. Ten Broek, C. Rosman
Radboudumc, Surgery, Nijmegen, Netherlands
Background: In patients treated for esophageal cancer
with curative intent, the percentage of patients with a pathological complete response (pCR) after neoadjuvant chemoradiotherapy is 30%. In these patients, indication for esophagectomy might be reconsidered. However, this requires
accurate non-invasive diagnosis of residual disease after
neoadjuvant therapy, but before resection. There is currently
no widely accepted imaging technique for restaging after
noadjuvant treatment. The aim of this systematic review and
meta-analysis is to assess test characteristics for all imaging
techniques in restaging esophageal carcinoma. Methods:
Eligible studies (Medline, Embase, Cochrane library) were all
diagnostic studies that compared restaging results of imaging
techniques with histopathological results of the specimen
after esophagectomy. A meta-analysis on the use of imaging
techniques in detecting pCR after neoadjuvant therapy was
performed by pooling sensitivities and specificities using a
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Personal Experiences with New Training
Concept in Establishment of Rat Liver
W. Wei1, O. Dirsch2, U. Settmacher1, U. Dahmen1
Jena University Hospital, Department of General,
Visceral and Vascular Surgery, Jena, Germany, 2Klinikum
Chemnitz gGmbH, Institute of Pathology, Chemnitz,
Background: Rat liver Transplantation (LTx) is important
animal model to investigate the mechanisms of liver graft
rejection and liver ischemia/reperfusion injury. It has been
reported that at least 30 procedures was needed to achieve
the first survival. We want to facilitate the learning curve of
Kamada technique for rat LTx using new learning concept
‘video-assisted PDCA (plan-do-check-act) circle’. Methods:
The new concept consists of 3 components: theoretic preparation, stepwise practice and problem analysis. In theoretic
preparation we learned the anatomy and procedures of LTx.
Then microsuture anastomosis, cuff technique anastomosis
and splint technique were practiced stepwise in ‘PDCA circle’
in rat bodies. Each practice was well planned, video-monitored and photodocumented, both of which were in detail
analyzed to identify the problem. The solution was planned
and implemented in the next round practice. The whole
procedures were thereafter trained using ‘PDCA concept’.
Results: After 10 rounds practice, the microsuture anastomosis was handsewed in 10 min with solving the problems
(stomal stenosis, leakage and rupture). After 15 rounds
practice, the cuff anastomosis was finished in 3 min with
solving the problems (vessels rupture, cuff torsion, kinking
and dislocation). After 5 rounds practice, the splint anastomosis was performed in 3 min with solving the problems
(bile duct rupture, bleeding and retraction). At last, after 13
rounds practice, the first 24 hours-survival was achieved
with anhepatic time 25 min. Conclusion: The new learning
concept ‘video-assisted PDCA circle’ can facilitate the
learning curve of rat LTx and to reduce the numbers of
training animal significantly.
Enzymes in Pancreatic Microenvironment and
Their Significance for Disease Progression and
Patient Survival
K.G. Gardian, M.D. Durlik
Mossakowski Research Centre, Department of Surgical
Research and Transplantology, Warsaw, Poland
Background: Pancreatic cancer remains the most
aggressive malignancy of all human cancers. It is characterized by strong desmoplastic reaction. Metalloproteinases
were associated with stroma remodeling and also another
enzyme family: lysyl oxidases. These enzymes catalyze the
cross-linking of collagen in the ECM. Particularly LOXL2 was
associated with progression of disease and occurrence of
lymph node metastasis. It has been shown that LOXL2 is
regulator of MMP2 and MMP9 activity in tumors by the
SNAI1 transcription factor. The aim of this study was to
evaluate expression of LOXL2 and local activity of MMP2
and MMP9 and how they influence patients survival and
disease progression. Material and Methods: Tumor tissue
samples were obtained from 40 patients, who underwent
macroscopically curative resection. The study group
obtained adjuvant treatment with gemcitabine. Tissue specimens were analyzed with immunohistochemistry using
antibody against LOXL2. Activity of MMP2 and MMP9 was
evaluated using gelatin zymography. Results: Pancreatic
cancer cells and stellate cells are the source of LOXL2. We
found high expression of LOXL2 in 18 (45%) cases and low
in 22 (55%). MMP2 was active in all samples and MMP9 in
31 (77.5%). High expression of LOXL2 was associated with
shorter survival. High expression of both LOXL2 and high
activity of MMP9 was strongly associated with lymph node
metastases. Conclusion: Our study confirm the significance
of LOXL2 in invasiveness of pancreatic cancer and also
important role of MMP9 in this process. We think it happens
through epithelial-mesenchymal transition as LOXL2 and
MMP9 were previously associated with this issue.
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bivariate model. Results: In total, 67 articles involving 4434
patients were included in this review. Four image modalities
(PET, CT, EUS, MRI) or combinations thereof had been
examined. The pooled sensitivity (SE) and specificity (SP) for
detecting pCR of the tumor and lymph nodes were SE: 0.61
and SP: 0.80 for PET, SE: 0.20 and SP: 0.93 for CT, SE: 0.05 and
SP: 0.99 for EUS, and SE: 0.80 and SP: 0.83 for MRI. Conclusion:
Restaging of esophageal carcinoma after neoadjuvant therapy
is currently unreliable because of the low sensitivity of CT, PET
and EUS in detecting pCR. MRI has more promising results, but
was only studied in two small pilot studies. More accurate
diagnostic tests are needed.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
© 2017 S. Karger AG, Basel
S.D. Paredes1, L. Rancan1, C. Simón2, S. Ramos3,
F. González-Moraga3, G. Sánchez-Pedrosa3, C. García1,
I. Garutti2, E. Vara1
Y. Yamada, D. Impellizzieri, T. Maeyashiki, K. Bruestle,
L. Dubs, J.H. Jang, U. Karakus, J. Woytschak, I. Inci,
W. Weder, O. Boyman, W. Jungraithmayr
University Hospital Zurich, Division of Thoracic Surgery,
Zurich, Switzerland
Complutense University of Madrid, Physiology, Madrid,
Spain, 2Gregorio Marañón University General HospitalComplutense University of Madrid, Thoracic Surgery
(HGUGM)-Surgery (UCM), Madrid, Spain, 3Gregorio
Marañón University General Hospital, Anesthesiology,
Madrid, Spain
One-lung ventilation (OLV) during thoracic surgery may
induce an inflammatory response that can contribute to the
induction and propagation of frequently occurring postoperative respiratory distress. Activation of beta-adrenergic
receptors increases the expression of pro- and anti-inflammatory mediators and their blockade may attenuate the
systemic inflammatory response. The aim of this study was
to analyze the effect of a continuous perioperative IV
perfusion of esmolol on the modulation of the local
(pulmonary) and systemic inflammatory response in the
perioperative pulmonary resection surgery (LRS) with
periods of OLV. 21 mini-pigs were randomly assigned to 3
groups: CONTROL (C), ESMOLOL (E), and SHAM (S). Group
E received an intravenous esmolol bolus (0.5 mg/kg) and
then an esmolol infusion (0.05 mg/kg/min) throughout the
procedure. The S group had a left thoracotomy without LRS
or OLV. At the end of the LRS the animals were awakened
and after 24 hours they underwent a new general anesthesia
to obtain lung and liver biopsies to analyze the levels and
the expression of inflammatory mediators. Group E showed
a significant lower protein and mRNA expression of TNF-a,
IL-1 and MCP1 with respect to C in both liver (p < 0.05) and
lung (p < 0.01) samples. Esmolol also decreased plasma and
BAL levels of these proinflammatory mediators. Significant
differences were also found in the quantification of
pulmonary edema (p < 0.05) in lung tissue samples. Our
results suggest that esmolol plays an important role in
decreasing the inflammatory response in the intra- and
postoperative periods in animals submitted to LRS.
Induction of Persistent Tolerance to Lung
Transplants by IL-2 Complex-Stimulated
Regulatory T Cells in vivo
Objective: We have previously shown that the immunomodulatory cytokine interleukin-2 (IL-2) in complex (cx) with
a particular neutralizing anti-IL-2 antibody induces potent
expansion of regulatory T (Treg) cells. Here, we evaluated
whether Treg cell-selective IL-2cx could induce allo-Tx
tolerance in a fully MHC-mismatched mouse model of lung
Tx. Methods: Single lung Tx was performed from BALB/c to
C57BL/6 mice. Recipients received intraperitoneal injections
of either PBS (control) or IL-2cx with anti-IL-2 antibody clone
JES6-1 on three consecutive days before Tx. The outcomes
of transplants were analyzed on day 5, 15, 28 and 56 by flow
cytometry, lung functionality (oxygenation and compliance)
and histology. Results: Acute allo-Tx rejection (AR) was
virtually absent macroscopically and histologically in IL-2cxtreated animals on day 5, 15, 28 and even 56 compared to
controls. AR scores, based on ISHLT guidelines, of allo-transplant of IL-2cx-treated mice were significantly lower vs.
control (day 5, p = 0.02; day 14, p < 0.001; day 28, p = 0.007;
day 56, p = 0.04). The population of Foxp3+CD4+CD25+ Treg
cells in IL-2 cx-treated mice was significantly higher within
allotransplants, contralateral nave lungs and spleens on
every time point (p < 0.05, all). IL-2cx-treated allograft on
day 5 had better compliance (5.2 2.2 vs 1.6 0.8 l/cmH2O, p =
0.04) as well as better oxygenation with clamping right nave
lung (253 136 vs 24 4 mm Hg, p = 0.04), compared to the
control. Conclusion: Treatment of recipients using IL-2cx
before lung Tx leads to intragraft Treg expansion, prevents
from acute rejection and maintains a viable engrafted lung
up to 56 days in a fully MHC-mismatched mouse model.
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Esmolol Attenuates Local and Systemic
Inflammatory Response in Lung Resection
Surgery and One-Lung Ventilation
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
The Angiogenic Characterisation of Mesenteric
Adipose Tissue in Crohn’s Disease
M. Eddama, R. Cohen, M. Rodriguez-Justo, L. Clapp,
I. Evans, L. Shen, M. Loizidou
University College London, Surgery and interventional
medicine, London, United Kingdom
Introduction: Crohn’s disease (CD) has a distinct feature
of mesenteric adipose tissue (MAT) expansion, the role of
which is unclear. This study hypothesises that the angiogenic mechanisms in CD MAT are dysregulated. Methods:
Mesenteric, subcutaneous and omental AT were harvested
from 30 patients who underwent ileocolic resection,
including 19 CD and 11 controls. Angiogenic mechanisms
were examined by: histology and immunohistochemistry; RT
PCR gene array; and ELISA. Angiogenic capacity was
measured by matrigel assay. Results: Microvascular density
was significantly (p < 0.01) higher in CD MAT (mean = 29,
SD = 20) than control (mean = 19, SD = 12). Hypoxia
inducible factor-1 staining was higher in CD MAT (n = 22,
67%) than control (n = 18, 22%) (Χ2(2)=11.2, p < 0.01). RT PCR
array confirmed that 47 (56%) of the angiogenic genes evaluated were >2-folds down regulated in CD MAT. Correlation
matrix showed significantly more negative correlations in
CD MAT (n = 711, 20%) than control (n = 109, 3%) (X2(1)=501,
p < 0.0001). The mean z score for negative correlation was
significantly (p < 0.0001) stronger in CD MAT (mean = 0.3,
SD = 0.2) than control (mean = 0.1, SD = 0.1). CD MAT
protein expression of interleukin-6 (mean = 21 pg/mg, SD =
18) and vascular endothelial growth factor (mean = 34 pg/
mg, SD = 19) were significantly (p < 0.05 and p < 0.01) lower
than control (mean = 39 pg/mg, SD = 43) and (mean = 57
pg/mg, SD = 43) respectively. Vascular sprouting was statistically significantly (p < 0.01) lower in CD MAT (mean = 3.2,
SD = 3) than control (mean = 5.2, SD = 4.1). Conclusion: CD
MAT demonstrated dysregulated angiogenesis and significantly lower capacity for vascular sprouting in comparison
to control. The observed dysregulated angiogenesis may
partly explain the role of mesentery in the perpetuation of
CD inflammation.
A Modified ‘One Anastomosis Gastric Bypass’
Technique in Goto-Kakizaki Rats. A Surgical
Model for Type 2 Diabetes Research Without
L. Zubiaga1, R. Abad2, C. Bonner3, GMS García4, F. Auger1,
G. Pasquetti1, J.A. De Gracia2, J. Ruiz Tovar4,
E. De Puelles2, D. Huglo1, J. Kerr-Conte1, F. Pattou1,
T. Hubert1
Université Lille 2. European Genomic Institute for
Diabetes, Lille, France, 2University, Miguel Hernández,
Experimental Animal Service, Alicante, Spain, 3Institute
Pasteur Lille, France, 4University, Rey Juan Carlos,
Histology, Madrid, Spain
Background: The most striking effect of bypass surgery
is the amelioration of glycemia in Type 2 Diabetes (T2D)
independent of weight-loss. However, the underlying mechanisms of action in this surgery remain poorly understood.
Objective: It is desired to know the effect of surgery without
the influence of adipose tissue and weight loss. Using a
diabetic non-obese Goto-Kakizaki rat model we designed a
modified One Anastomosis Bypass Surgery (mOABG):
without restrictive elements, with a low mal-absorptive
component and performing a gastrojejunostomy in omega
loop. Methods: 18 rats were underwent to mOAGB and 18
rats to sham surgery. Each group was subdivided into three
additional groups according to the time of surgery: 12 weeks
of life (12 W); 16 weeks (16 W); and 20 weeks (20 W). In both
group were compared the effects on weight, plasmatic
parameters, histological samples and to high resolution
imaging studies. Results: After surgery, no animal lost
weight. In the OAGB group, a significant improvement in
postprandial glycemic levels in all groups was observed
compared to Sham (p = 0.0001 at 20 W). This effect was
significative even in the older one group, where the damage
in the pancreas tissue, is assumed to be irreversible. But after
surgery, the fibrosis was reduced in mOAGB rats. The MRI
images and the TEP scan studies we were able to confirm the
feasibility of the surgery and the effect in the intestinal
glucose uptake. Conclusion: This technique seems a good
model to study diabetes without obesity. The effects in other
organs, must be deeper studied.
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Hepatic Parenchymal Transection Increases
Liver Volume But Not Function after Portal
Vein Embolization in Rabbits – An ALPPS
P.B. Olthof1, E. Schadde2, K.P. Van Lienden1, M. Heger1,
K. De Bruin1, J. Verheij1, R.J. Bennink1, T.M. Van Gulik1
Academic Medical Center, Surgery, Amsterdam,
Netherlands, 2Rush University Medical Center, Surgery,
Chicago, United States of America
Background: Associating liver partition with portal vein
ligation for staged hepatectomy (ALPPS) induces more
extensive liver hypertrophy than ligation alone. However,
the mechanisms underlying the accelerated liver regrowth
and the functional quality of the hypertrophic liver are presently elusive. This study therefore investigated the effect of
parenchymal transection on liver volume and function
following portal vein embolization (PVE) in a standardized
rabbit model. Methods: Twelve rabbits were subjected to
PVE of the cranial liver lobes and randomized between
parenchymal transection of the left lateral liver lobe versus
no transection (PVE-only). Liver volume of the non-embolized liver lobe was assessed using CT-volumetry and liver
uptake function was determined by 99mTc-mebrofenin hepatobiliary scintigraphy before and 3 and 7 days after PVE.
Results: The increase in non-embolized liver volume 3 days
after PVE was 2.7–fold greater in the transected group
compared to the PVE-only group (56 ± 16% versus 21 ±
12%, respectively, P < 0.01) and 1.7–fold greater 7 days after
PVE (113 ± 34% versus 68 ± 24%, P < 0.01). Liver uptake
function did not differ between groups before PVE (8.4 ±
3.7%/min in the transection group versus 8.9 ± 1.6%/min),
on day 3 (33.2 ± 4.7% after transection versus 30.3 ± 4.6%/
min, respectively) and day 7 after PVE (42.6 ± 8.4% versus
39.1 ± 5.3%/min, respectively). Conclusions: Parenchymal
transection after PVE increases liver growth in terms of
volume but not function. These results indicate that the
rapid volume increase observed after ALPPS does not
coincide with the clinically more relevant functional increase.
Quantitative liver function tests might be essential in ALPPS
to better assess the hypertrophy response and improve
clinical decision-making.
Stress Test of Liver Function Using
99mTc-Mebrofenin Hepatobiliary
Scintigraphy (HBS)
F. Rassam, K.P. Cieslak, P.B. Olthof, T.M. Van Gulik,
R.J. Bennink
Academic Medical Center, Surgery, Amsterdam,
Background: HBS is a quantitative liver function test and
is used to assess total and regional liver function in patients
scheduled for major liver resection. Normally it is performed
after a 4 hours fast which corresponds with the resting liver
function. Knowledge of the stimulated future remnant liver
function could be of interest for optimal patient selection
since the total liver function (TLF) might be underestimated
in fasting patients. We aim to investigate the hepatic functional reserve capacity by assessing the change in TLF after
stimulation with an oral fatty food challenge. Methods:
Healthy volunteers (n = 12) aged 50–60 years underwent
sequential HBS with 100 MBq 99mTc-mebrofenin. The first
scan was performed after an overnight fast, the second scan
after an overnight fast followed by the administration of 250
mL full fat chocolate-milk 30 minutes prior to the scan.
Hepatic 99mTc-mebrofenin uptake rate was calculated as an
increase of 99mTc-mebrofenin uptake over a time period of
150 s. TLF was represented by the 99mTc-mebrofenin uptake
rate as a percentage of the injected dose per minute (%/
min). Results: TLF with and without a food challenge was
21.45 ± 3.01%/min and 25.00 ± 4.26%/min, respectively.
There was a significant increase in the mebrofenin uptake
rate after an oral fatty food challenge; i.e. 3.55 ± 2.51%/min,
95% CI [2.10–5.00], P < 0.0001. Conclusion: TLF increased
after administration of an oral food challenge which may
reflect hepatic functional reserve capacity. Future studies
should determine which factors account for this difference.
Role of the Gut-Liver Axis in Accelerated Liver
D. Tihanyi1, A. Budai1, A. Fülöp1, T. Kovács1,
T.M. Van Gulik2, P.B. Olthof2, A. Szijártó1
University, 1st Department of Surgery,
Budapest, Hungary, 2Academisch Medisch Centrum,
Department of Experimental Surgery, Amsterdam,
Background: Associating liver partition and portal vein
ligation for staged hepatectomy (ALPPS) is a novel method
to induce more rapid liver hypertrophy compared to portal
vein occlusion techniques. Despite the major intest in
induced rapid hypertrophy, the exact mechanisms behind
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Hepatocyte Molecular Transport Changes
Affected by Portal Vein Ligation in Rats
I.K. Illés1, T.K. Kovács1, A.F. Fülöp1, K.J. Jemnitz2,
G.T. Török2, Z.V. Veres2, A.B. Budai1, L.H. Homolya2,
A.S. Szijártó1
Semmelweis University, Hepato-PancreaticoBiliary Surgical Research Center, Budapest, Hungary,
Hungarian Academy of Sciences, Institute of Organic
Chemistry, Budapest, Hungary
Background: Portal vein ligation (PVL) is a suitable
method for preventing hepatic failure after extended liver
resections. Selective ligation of portal branches provokes
ipsilateral atrophy and contralateral hypertrophy of
respective liver lobes. Although morphological alterations
are well-known, relation to certain hepatic functions is
obscure. The aim was to evaluate changes of hepatic organic
anion transport following PVL. Materials and Methods:
Male Wistar rats (n = 48) underwent PVL affecting approximately 80% liver parenchyma. Preoperatively, and
24/48/72/168/336 hours after PVL, via selective bile duct
cannulation, bile- and conjugated bilirubine (BG) excretion,
serum and bile bilirubin levels were measured. Ligated- (LL)
and non-ligated (NLL) liver lobes were weighed and histology
samples were taken (n = 24). Severity of necrosis, Mrp2 and
NTCP expression were assessed with Suzuki-score and
immunofluorescence. Different animals in matching times
underwent collagenase liver perfusion to generate LL and
NLL cell cultures (n = 24). In vitro immunofluorescence
detected transporter (NTCP, BSEP) and cell adhesion protein
(ZO-1) expression. Taurocholate and bilirubine transport
was also assessed. Results: LL underwent necroapoptotic
atrophy and deterioration of bile- and BG production, while
NLL showed hypertrophy (p < 0.01) and an increase in biliary
function. Serum levels, and serum- and biliary bilirubine
fractions were unchanged. The in vitro analysis showed
viable, transporter expressing monolayers from all times and
lobes. Transport analysis confirmed a transitional functional
reduction of both the LL and the NLL and adaptive responses.
Conclusions: PVL-induced liver regeneration resulted in
adaptive changes regarding bile excretion and cellular
transport in both lobes, where cells maintain both their
viability and function.
Efficacy of the Novel Medical Adhesive,
MAR-VIVO-107, in a Chronic Porcine Liver
Resection Model
H. Tanaka, K. Fukushima, F. Gremse,
P. Kadaba Srinivasan, K. Pawlowsky, B. Koegel, R. Tolba
University Hospital RWTH Aachen, Institute for
Laboratory Animal Science and Experimental Surgery,
Aachen, Germany
Background: As insufficient hemostasis after liver surgery
is still a major cause of morbidity and mortality after operation, efficient hemostatic agents are indicated. The purpose
of this study is to confirm the safety and efficacy of a novel
synthetic polyurethane/polyurea wound sealant; MAR-VIVO107, by comparing to a widely used fibrin sealant; Tisseel.
Material and Methods: Twelve Aachener mini pigs were
randomly assigned into two groups. A midline laparotomy
was performed and the left lateral liver lobe was resected,
using a Cavitron Ultrasonic Surgical Aspirator (CUSA) and
vessel ligagions. MAR-VIVO-107 or Tisseel was applied to
the resected lobe. They were observed for 6 months by
computed tomography (CT) scans, blood and urine tests. On
post operative day (POD) 180, they were re-operated and
sacrificed to evaluate the intraperitoneal status. Consecutive
autopsies were performed to confirm the adverse effect of
the wound sealants. Results: There were no major complications in both groups, and haematological and biochemical
analyses also showed no significant differences. The resiual
volume of MAR-VIVO-107 was 11.35 ± 4.09 ml on POD 30,
and gradually decreased (9.26 ± 3.74, 7.72 ± 3.76 and 6.49 ±
3.27 ml on POD 60, 90 and 120, respectively), while Tisseel
was almost eliminated within POD 60. Residual
MAR-VIVO-107 was located at the regenarated liver surface
but induced neither adhesion nor infection. No adverse
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this phenomenon are still unknown. Aim of this study was to
investigate the role of gut-liver axis in portal vein ligation
(PVL) and ALPPS induced liver hypertrophy. Material and
Methods: Male Wistar rats underwent PVL and ALPPS (n =
60). Before the surgery and after 24 h, 48 h, 72 h, 168 h the
portal pressure and the hepatic lobes weight were measured.
We investigated the mRNA expression of FXR (Farnesoid-X
Receptor) and FGFR4 (Fibroblast Growth Factor Receptor 4)
of the regenerated lobe and the ileum. The portal and the
systemic total bile acid concentration were determined.
Results: The regeneration rate and the portal pressure were
significantly higher in the ALPPS group compared to the PVL
group 48 h after operation (217.7 ± 12.9 vs. 155 ± 12.1%; p <
0.001; 21.3 ± 2.4 vs. 17.5 ± 0.6 mm Hg; p = 0.023). The transcription of FXR in the liver was significantly decreased in the
ALPPS group compare to the PVL group (24 h: 0.2 ± 0.1 vs.
0.8 ± 0.2 fold expression; p = 0.0321). The portal and systemic
bile acid concentration were significantly increased in the
ALPPS group (48 h:358.0 ± 18.2 vs. 204.5 ± 37.2 μmol/ml;
p < 0.001, 367.4 ± 82.1 vs. 233.1 ± 67.9 μmol/ml; p < 0.001).
The FGFR4 expression of the liver was also significantly
higher in the ALPPS group (24 h:3.1 ± 0.8 vs. 2.1 ± 0.5 fold
expression; p = 0.032). Conclusion: The alterations of the
gut-liver axis induced by ALPPS may play an important role
in accelerated liver hypertrophy.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
effect was observed from head to toe in both groups.
Conclusion: The safety and biodegradability of MAR-VIVO107, and comparable performance to the gold standard
fibrin have been shown under pre-clinical conditions.
© 2017 S. Karger AG, Basel
Portal Vein Embolization Does Not Result in
Microvascular Flow Differences between the
Embolized and Non-Embolized Liver Lobes
Z Uz, Y Ince, T.H. Mungroop, C Ince, T.M. Van Gulik
Multimethodical Imaging of Hepatic Function
Following Portal Vein Ligation in Rat – ‘Live
from the Liver’
T. Kovács, A. Fülöp, A. Budai, D. Tihanyi, K. Illés,
D.S. Veres, I. Horváth, K. Szigeti, D. Máthé, A. Szijártó
Semmelweis University, 1st Department of Surgery,
Budapest, Hungary
Background: Evasion of posthepatectomy liver failure
during extensive liver resections is clinically frequently
managed by portal vein ligation (PVL), generating the
atrophy- and hypertrophy of liver lobes with ligated and
intact portal inflow, respectively. Morphological alterations
are well-described, while functional alterations remain
vague. Our goal was the multimethodical morpho-functional assessment of post-PVL liver function in rat. Materials
and Methods: PVL affecting ~80% liver parenchyma was
performed on male Wistar rats (Sn = 42). Liver morphology
and global hepatic function were determined preoperatively, as well as 24 h/48 h/72 h/168 h/336 h following PVL
with serial MRI-volumetry, indocyanine-green clearence
(ICG) (PDR, RT15) and 99mTc-mebrofenin hepatobiliary scintigraphy (HBS) (uptake-B1/2, excretion-DSTART) (n = 12).
Regional hepatic function was evaluated by HBS lobar peak
count ratios, as well as confocal laser endomicroscopy (CLE)
(T1/2, Tmax) in matching time points (n = 30). Results: MRIvolumetry confirmed the atrophy of ligated lobes (LL) and
the hypertrophy of non-ligated lobes (NLL) (p < 0.0001).
Global hepatic function, as well as global hepatic uptake
and -excretion were depressed between 24–72 h according
to ICG (p < 0.01) and HBS (p < 0.05). HBS also exhibited
temporary decrease of bilateral regional hepatic function,
followed by NLL functional re-estabilishment ultimately
exceeding preoperative values at 336 h; while LL function
was permanently diminished (p < 0.05). CLE confirmed the
deterioration of NLL-specific uptake- and excretion at 72 h,
followed by normalisation towards 336 h (p < 0.05).
Conclusion: Beyond the atrophy-hypertrophy complex of
the LL and NLL, return of transitionally depressed global
hepatic function may be attributed to a solid functional gain
of the NLL. CLE could be a capable method for selective liver
functional measurement.
Academic Medical Center, Surgery, Amsterdam,
Background: Preoperative portal vein embolization (PVE)
is used to increase future remnant liver volume enabling
extended resections. The microvascular effects occurring
after unilateral portal venous occlusion are however, poorly
understood. The aim of this study is to assess the microvascular changes in the liver lobes after right PVE. Methods:
Videos of the hepatic microcirculation in patients undergoing right hemihepatectomy following PVE were recorded
using a handheld intravital microscope, the CytoCam.
Hepatic microcirculation was measured in the embolized
and the non-embolized lobe after laparotomy. AVA software
v. 3.2 was used to obtain the microcirculatory parameters:
total vessel density (TVD), microcirculatory flow index (MFI),
proportion of perfused vessel (PPV), perfused vessel density
(PVD). Results: Five patients were included after PVE (3
males, 2 females, age 66 ± 5 years). TVD and PVD in the nonembolized lobe were significantly increased compared to
TVD and PVD in the embolized lobe (i.e. 31.47 ± 2.7 19.7 ±
5.9 mm/mm²P:0.0159). PPV and MFI were not significantly
different between the lobes indicating similar microvascular
flow despite the difference in vessel density. Conclusion: The
non-embolized lobe has a significantly higher microvascular
density (TVD and PVD), however without differences in
microvascular flow (PPV and MFI). The overall microvascular
flow is not affected by PVE which casts doubts on the portal
flow differential in inducing the hypertrophy response in the
non-embolized lobes.
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Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Is the Early or Delayed Remote Ischemic
Preconditioning the More Effective from a
Microcirculatory Point of View in Partial Liver
G. Varga1, Z.S. Magyar1, A. Mester1, S. Ghanem2,
G. Nadubinszky1, V. Sogor1, B. Tanczos1, M. Oltean3,
N. Nemeth1
© 2017 S. Karger AG, Basel
IgG4-Associated Cholangitis Mimicking
Perihilar Cholangiocarcinoma; A Persistent
E. Roos, L.M. Hubers, R.J.S. Coelen, J. Verheij,
U.H.W. Beuers, T.M. Van Gulik
Academic Medical Center, Surgery, Amsterdam,
Background: Several methods of ischemic conditioning
(IP) are known, including remote IP (rIPC). The process
means intermitted short-term interruptions of the blood
flow on an organ or extremity prior to another organ’s
manifest ischemia-reperfusion (I/R). However the timing of
the rIPC protocol, i.e. the optimal time before the I/R, has not
been clarified yet. Materials and Methods: On anesthetized
rats a 60-minute partial (~70%) liver ischemia was induced
followed by 120 minutes of reperfusion (Control group, n =
5). In rIPC groups a tourniquet was applied around the left
thigh for 3x10 minutes one hour (rIPC-1, n = 6) or twentyfour hours before the liver I/R (rIPC-24, n = 6). Hemodynamic measurements were performed before and just after
the liver ischemia, and after 30, 60 and 120 minutes of reperfusion (R30, R60, R120). Liver surface temperature (infrared
thermometer) and microcirculatory measurements (laser
Doppler flowmetry) were carried out. Results: In the Control
group one animal died after R60. Blood pressure decreased
in all groups, which was followed by biphasic changes in the
Control group (increase at R60, decrease at R120). In rIPC
groups R120 values almost returned to the normal. Heart
rate increased in the Control and rIPC-1 groups at R120,
while rIPC-24 did not shown important difference. Liver
microvascular perfusion increased by R120, markedly in the
rIPC-24 group (p = 0.016). Conclusions: Considering the
survival, and the results, both rIPC protocols could improve
the condition caused by the partial hepatic I/R. However,
more accurate answer will be given by the histological
Background: Immunoglobulin G4-associated cholangitis
(IAC) is a major manifestation of IgG4-related disease (IgG4RD), a multi-organ inflammatory disorder. Since the disease
presentation closely mimics that of perihilar cholangiocarcinoma (PHC) and other pancreatobiliary malignancies,
misdiagnosis and unnecessary surgery are common. When
not recognized IgG4-RD can remain active for years. Immunosuppression is the correct treatment. IgG4/IgG RNA ratio
is a new diagnostic method to identify IgG4-RD. We aimed
to assess the incidence of IAC in patients resected for
presumed PHC. Methods: All patients that underwent
resection for presumed PHC at our institution between 1984
and 2015 were included. Benign histological specimens
were re-evaluated and scored according to the international
pathological consensus criteria for IgG4-RD. Patients with
benign disease still alive, were re-evaluated to assess IgG4
serum levels and IgG4/IgG RNA ratio to detect activity of
IgG4-RD. Results: Between 1984 and 2015, 321 patients
underwent liver and bile duct resection for presumed PHC.
Of all patients 15% (47/321) were found to have benign
disease on histological examination. 45% (21/47) of patients
with benign disease had evidence of IAC directly after
surgery. The remaining specimens showed unclassified sclerosing inflammation. Out of 15 patients with benign disease
who were re-evaluated recently, 8 had active IgG4-RD.
Conclusion: Benign biliary disorders mimicking PHC have
led to a considerable number of liver and bile duct resections. There was evidence of IAC in 45% of these patients.
When left untreated, IgG4-RD may remain active years after
surgery. Novel accurate diagnostic tests for IAC might
reduce misdiagnosis and unnecessary resection.
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University of Debrecen, Faculty of Medicine, Dept. of
Operative Techniques and Surgical Research, Debrecen,
Hungary, 2University of Debrecen/Faculty of Medicine,
Dept. of Op. Tech. and Surg. Res., Debrecen, Hungary,
Sahlgrenska University Hospital, The Transplantation
Institute, Gothenburg, Sweden
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Comparison of the Effects of Spinal Epidural
and General Anesthesia on Coagulation and
Fibrinolysis in Laparoscopic Cholecystectomy:
A Randomized Controlled Trial
T. Donmez1, S. Demiryas2, E. Hatipoglu2, V.M. Erdem1,
D.U. Erdem1, S. Ferahman2, O. Sunamak3, D. Yildirim4,
A. Hut4
Lutfiye Nuri Burat State Hospital, General Surgery,
Istanbul, Turkey, 2Istanbul Universty Cerrahpasa Medicine
Faculty, General Surgery, Istanbul, Turkey, 3Haydarpasa
Numune Training and Research Hospital, General
Surgery, Istanbul, Turkey, 4Haseki Training and Research
Hospital, General Surgery, Istanbul, Turkey
Backgrounds: Laparoscopic cholecystectomy is usually
performed under general anesthesia. Recently, laparoscopic
cholecystectomy with regional anesthesia has become
popular. This randomized controlled trial aimed to compare
the effect of two different anesthesia techniques in Laparoscopic cholecystectomy on coagulation and fibrinolysis
Methods: This randomized prospective study included 50
low-risk patients for deep vein thrombosis (DVT) who
underwent elective LC without thrombo-emboli prophylaxis.
The patients were randomly divided into two groups according
to the anesthesia technique: the general anesthesia (Group 1
n: 25) and spinal epidural anesthesia (Group 2 n: 25) group.
Low-pressure pneumoperitoneum (10 mm Hg CO2) was used
in both groups. Prothrombin time (PT), thrombin time (TT),
International Normalized Ratio (INR), activated partial thromboplastin time (aPTT) and blood levels of d-dimer and
fibrinogen were measured preoperatively (pre), one hour
(post1) and 24 h (post24) after the surgery. These parameters
were compared between and within the groups. Results: No
clinically or ultrasonograpically evident DVT was observed.
The mean age was 52 ± 12.7 years (range, 19–79 years). Pneumoperiteneum time was similar between group1 (34.6 ± 8.3
min) and group 2 (35.9 ± 11.1). TT levels significantly declined
after the surgery in both of the groups. PT, TT, aPTT, INR,
D-dimer and fibrinogen levels dramatically increased after the
surgery in both of the groups. Conclusions: Despite there
wasn’t any DVT, significant decline TT and dramatic increase
in PT, INR, d-dimer, FDP and fibrinogen were seen followingLC. This may be attributed to the effects of pneumoperitoneum and anesthesia techniques on the portal vein flow.
Comparison of Clinical Outcomes of
Mini Laparoscopic Cholecystectomy and
Conventional Laparoscopic Cholecystectomy
R. Gupta, L. Agarwal, S. Kandpal
Sawai Maan Singh Medical College and Hospital, General
Surgery, Jaipur, India
Background: Scar less surgery is the holy grail of surgery
and the main aim of minimal access surgery was the
reduction of scars and thereby pain and suffering of patients.
The use of laparoscopy has gained widespread popularity in
surgical approaches to abdominal wall hernias and intestinal
and solid organ resection. However, no other operation has
been as profoundly affected by the advent of laparoscopy
as cholecystectomy. In fact, laparoscopic cholecystectomy
(LC) has clearly become the procedure of choice for routine
gall bladder removal. This study will compare the degree of
early post operative incision site pain, and cosmetic results
of laparoscopic cholecystectomy performed using mini
laparoscopic technique (M-LC) and conventional laparoscopic cholecystectomy (C-LC). Materials and Method: The
hospital based comparative observational study was based
on 204 cases of cholelithiasis (102 cases in each group)
undergoing cholecystectomy for symptomatic cholelithiasis.
Simple randomization technique is used for allocation of
cases through chit box method. Post operative pain was
accessed using visual analog scale at 6 and 24 hours after
surgery. Cosmetic outcome evaluation was done using body
image questionnaire and cosmetic score at 28 days following
surgery. Result: In our study, the pain score at 6 and 24 hour,
and cosmesis in M-LC group was significant (p < 0.001)
compared to C-LC. Conclusion: Mini laparoscopy cholecystectomy appears to be a safe, effective and feasible technique and good alternative to conventional laparoscopic
cholecystectomy with potential advantages of reduced early
postoperative incision site pain and better cosmesis.
Evaluation of Staphylococcus Aureus
Eradication Therapy in Vascular Surgery
J.C.M. Langenberg, A.R. Thomas, J. Donker, M. Rijen, van,
J. Kluytmans, L. Laan, van der
Amphia Ziekenhuis, Chirurgie, Breda, Netherlands
Background: Staphylococcus aureus nasal carriage is
associated with increased risk for development of surgical
site infections (SSI) in cardiothoracic, orthopedic and vascular
surgery. It has been shown that the risk for SSI can be reduced
by eradicating S. aureus carriage in cardiothoracic and orthopedic surgery. This reduction has not been investigated for
vascular surgery. This study evaluates S. aureus eradication
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
therapy and SSI in a vascular surgery population. Methods:
A prospective cohort study was performed, including all
patients undergoing vascular surgery between February
2013 and April 2015. Before surgery, patients were screened
for S. aureus nasal carriage and, if tested positive, were treated
with eradication therapy using mupirocin en chlorhexidine. A
control group was used, consisting of a cohort of vascular
surgery patients in 2010, who were screened, but received no
treatment. Results: A total of 444 patients were screened. 104
nasal swabs were positive for S. aureus, these patients were
included in the intervention group. 204 patients were
screened in the 2010 cohort. 51 tested positive and were
included in the control group. The incidence of S. aureus
infection was 5 out of 51 (9.8%) in the control group versus 3
out of 104 in the eradication group (2.2%; 95% confidence
interval 0.02–1.39; P = 0.13). In central reconstructive surgery,
the incidence of S. aureus infection was 3 out of 23 (13.0%) in
the control group versus 0 out of 44 in the intervention group
(P = 0.04). Conclusion: S. aureus eradication therapy results
in a reduction of SSIs caused by S. aureus.
© 2017 S. Karger AG, Basel
(range 3.8 mmol/L–7.2 mmol/L resp. 36420 IU–74360 IU at
t = 36 hr). Perfused flaps showed complete perfusion at the
end of the experiment, whereas control flaps were perfused
incompletely. Flap weight significantly increased in the
perfusion group (range 119%–184%). Biopsies are currently
being analysed, enabling comparison of results within flaps,
between flaps and between different outcomes measures,
but also relating them to the perfusion patterns obtained
with indocyanin-green fluorescence.
Quality of Life after Endovascular, Surgical or
Conservative Treatment of Elderly Patients
Suffering from Critical Limb Ischemia,
Short-Term Results
S.L. Steunenberg1, J. De Vries2, J.W. Raats3, W.J. Thijsse1,
N. Verbogt1, P. Lodder2, G.J. Van Eijck4, E.J. Veen3,
H.G.W. De Groot1, G.H. Ho1, L. Van der Laan1
Amphia Breda, Surgery, Breda, Netherlands, 2University
of Tilburg, Department of Medical and Clinical Ps,
Tilburg, Netherlands, 3Amphia, Surgery, Breda,
Netherlands, 4Bravis, Surgery, Roosendaal, Netherlands
Are Biopsies a Reliable Method for Measuring
Hypoxia-Induced Damage in Extracorporally
Perfused Free Muscle Flaps?
A. Kruit, M.J.M. Schreinemachers, E. Koers, H. Zegers,
D.J.O. Ulrich
Radboud University Medical Centre, Plastic and
Reconstructive Surgery, Nijmegen, Netherlands
Background: Extracorporeal perfusion of free flaps and
extremities has been researched since the early 1980’s,
aiming to prolong the preservation duration of these tissues.
However, due to absent validated outcome measures in the
perfusion setting, a large heterogeneity in outcome measures
exists, making comparison of results difficult or even impossible. This study assessed different methods of outcome
measuring on perfused free muscle flaps, with primary focus
on the reliability of muscle biopsies. Methods: Rectus abdominus muscle flaps were harvested bilaterally in three female
Dutch landpigs (weight 42–67 kg). One flap per pig was
assigned to the control group (100 cc Heparin-solution flush
followed by 4°C storage; N = 3), the other was assigned to
the perfusion group (100 cc Heparin-solution flush followed
by extracorporeal perfusion with 8°C University of Wisconsin
solution; N = 3). The following outcomes were measured at
multiple time points up to 36 hr: preservation fluid samples
(lactate, CK) and muscle biopsies (H&E, electron microscopy,
hypoxia-marker immunofluorescence [HIF-1-alpha], PCR,
micro-array). Three biopsies were taken per time point. Other
outcomes were weight increase and flap perfusion pattern
(indocyanin-green fluorescent imaging) at 36 hr. Results:
Lactate and CK both show on-going increase up to 36 hr
Aims: Treatment for elderly patients suffering from
critical limb ischemia (CLI) could be challenging as most
patients are frail and at advanced age. Outcome measurements traditionally focus on morbidity, mortality and limb
salvage. The goal of this prospective study is to explore the
different treatment modalities in elderly patients suffering
from CLI, with a specific focus on patient’s quality of life
(QoL) and mortality. Methods: Patients suffering from CLI
and = 70 years old were included in two hospitals in the
Netherlands between January 2012 and February 2016.
Patients were divided into three groups (endovascular,
surgical and conservative treatment). Primary outcome
measures were QoL results and mortality. QoL was measured
with the WHOQOL-BREF questionnaire. Follow-up moments
were performed at 1 week, 6 weeks and 6 months after the
initial therapy. Results: A total of 195 included patients were
divided into three groups, according to the received
treatment. Six-month mortality was significantly lower in
surgically treated patients (7%) in contrast to endovascular
treated patients (32%) and conservatively treated patients
(26%). Physical health has significantly increased in all
treatment groups after 6 months follow-up. Psychological,
social relationships and overall QoL have significantly
increased after 6 months in surgically treated patients.
Conclusions: Elderly patients suffering from CLI who seem
to be clinically fit for surgery seem to benefit from surgical
revascularisation the most with lower mortality rates, lower
adverse event rates and significantly gained QoL. Endovascular and conservative treatment are acceptable treatments
to gain QoL in frail elderly with comparable mortality rates.
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Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Robot-Assisted Transthoracic First-Rib
Resection for Venous Thoracic Outlet
F. Hoexum, H.M.E. Coveliers, K.K. Yeung, W. Wisselink
VU Medical Center, Vascular Surgery, Amsterdam,
Background: Venous Thoracic Outlet Syndrome (vTOS) is
in most cases caused by external costo-clavicular
compression of the subclavian vein. Resection of the first rib
is performed in the management of this disorder. We report
our initial results of a minimal invasive transthoracic
approach using the DaVinci surgical robot for resection of
the first rib. Material and Methods: we retrospectively
reviewed the medical records of eight patients who
underwent robot assisted first rib resection in the
management of vTOS. Three 10 mm trocars were used for
transthoracic access of the DaVinci robot for dissection and
resection of the first rib. We analyzed operation time,
hospital stay, and complications. Functional outcomes were
measured using the standardized ‘disability of the arm
shoulder and hand’ questionnaire (DASH). Results: Four
female and four male patients (mean age 39 years, range
28–55 years) underwent robot-assisted transthoracic first rib
resection. Mean operation time was 189 minutes (range
123–320). No mortality or major complications were
reported. Average hospital stay was 5 days (range 4–7).
Mean follow up was 11.4 months (range 6–22). Mean DASH
score was 19.81 points (SD 24.5). Conclusion: Robot-assisted
first-rib resection is a feasible minimal invasive approach for
first-rib resection. This technique has the possibility to
reduce the risks of neurovascular injury because of better
visualization and enables the surgeon to perform a more
extensive venolysis. Future research is necessary to determine
if this technique will result in less complications and an
increased patency of the subclavian vein.
Von Willebrand Profile: Comparison between
HeartMate 3 and HeartMate II
R.Z. Zayat, H.S. Steffen, Ph.D. Goetzenich, A.M. Moza,
M.K. Khattab, S.K. Kalverkamp, L.T. Tewarie,
R.A. Autschbach, J.S. Spillner
RWTH University Hospital, Department of Thoracic and
Cardiovascular Surgery, Aachen, Germany
Background: Acquired von Willebrand Syndrome (AvWS)
has been linked to postoperative bleeding after continuousflow left ventricular assist device (CF-LVAD) implantation.
We thought to compare the von Willebrand factor profile
(vWF) between HeartMate 3 (HM3) and HeartMate II (HMII)
and the incidence of early postoperative bleedings. Methods:
13 HM3 patients were compared with 13 HMII patients.
Serial plasma samples were collected pre-implant and postoperatively on days 1 and 30 to analyze vWF:Antigen
(vWF:Ag) and its activity (vWF:Ac= Ristocetin cofactor
[RiCO]). Loss of high-molecular-weight multimers (HMWMs)
was also compared between groups 2 months after surgery.
Results: Preoperatively, the vWF:ratio did not differ between
groups. In both groups we could detect patients with a
vWF:ratio <0.7 preoperatively. At POD 1 the vWF:ratio was
significantly higher in the HM3 group compared to the HMII
(1.13 ± 0.77 vs. 0.64 ± 0.17, p = 0.047). At 30 POD there was
no significant difference between groups. 2-months postoperatively, 100% of HMII patients had a loss of HMWMs,
compared to only 30.7% of HM3 patients (p = 0.003). 4 pts.
in HMII required redo surgery during the first 30 POD due
to haematothorax, whereas 2 patients in the HM3 required
re-exploration (p = 0.635). Conclusion: We could detect a
subgroup of end-stage heart failure patients, who already
preoperatively had a pathologic vWF:ratio. The fully magnetically levitated HeartMate 3 seems to offer better haemocompatibility than the HMII on short term. Long-term
follow-up is required to investigate the incidence of postoperative bleeding and especially GI-bleeding.
Visualization of Carbon Dioxide Field Flooding
in a Cardiac Surgery Setting
D.I. Iseli, S.V. Vandenberghe, S.D. Demertzis
Cardiocentro Ticino, Cardiac Surgery, Lugano,
Carbon Dioxide (CO2) field flooding is used to prevent air
emboli after open heart surgery. A diffusor in the open
thorax continuously delivers CO2 to purge air and provide a
safe atmosphere that avoids blood-air contact. Uncertainty
surrounds this preventive measure because the CO2 gas is
invisible. In this study we visualized the mixing of CO2 and
air. Three commercially available diffusors and two catheters
were tested in a plastic, transparent thorax model. An optical
technique (Schlieren photography) was used to amplify
refraction and observe the CO2 mixing at three flow rates
(0.85 l/min 1.7 l/min 4.25 l/min). Instantaneous CO2 concentrations were recorded at different intra-thoracic locations.
Imaging shows distinct differences in air purging inside the
thorax. Turbulent intermixing of air affects the CO2 concentration distribution, varying from 94% to 27%, depending on
flow rate, diffusor design and location. The largest diffusor
achieved the best purging and a stable atmosphere within
110 seconds. Each diffusor has an optimal flow rate at which
the CO2 concentration becomes maximum and for small
diffusors this is a low flow rate. High velocity jets from catheters cannot provide effective field flooding. The CO2 atmo-
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
sphere is easily disturbed by moving objects through it or by
air streams caused by moving bodies around the operating
table. We were able to visualize CO2 field flooding and
compare the efficiency of various delivery methods. Diffusors
creating slow gas streams prevent turbulent mixing but
small devices with a low optimal gas flow rate provide insufficient air purging.
© 2017 S. Karger AG, Basel
Evaluation of Collimated Polarized Light
Imaging for Real-Time Intraoperative Selective
Nerve Identification in the Human Hand
K.W.T.K. Chin1, A.F. Engelsman2, P.T.K. Chin3, S.L. Meijer1,
S.D. Strackee1, R.J. Oostra1, T.M. van Gulik1
Suppression of Lung Cancer by Activated
NK Cells and Macrophages via Inhibition of
Dipeptidyl Peptidase-4
J.H. Jang, F. Janker, S. Arni, Y. Yamada, W. Weder,
W. Jungraithmayr
University Hospital Zurich, Division of Thoracic Surgery,
Zurich, Switzerland
Background: Lung cancer is one of the main causes of
death nowadays. DPP4 is an ubiquitously expressed transmembrane glycoprotein bearing enzymatic and costimulatory activity. We previously found the activity of DPP4 of
lung cancer patients to be four times higher compared to
normal lung. Here, we show that DPP4-inhibition suppresses
lung cancer via activation of key immune cells. Methods:
Lung tumors were established by sc. injections of lung
cancer cell lines (LLC:mouse; H460:human) within mouse
strains with or without a DPP4 inhibitor (Vildagliptin). Tumor
growth was evaluated by weight of tumor mass at 2 weeks.
Inflammatory and activation markers were analyzed by IHC,
RT-PCR and FACS. For loss of functions experiments, macrophages were depleted by clodronate-liposome during
Vildagliptin treatment. Likewise, NK cells were depleted by
using IL-15 knockout mouse strain. Results: Vildagliptin
treatment significantly reduced tumor growth of lung
cancer. IHC showed macrophages and NK cells to be significantly increased by Vildagliptin within tumors. Gene
expression levels of the pro-inflammatory cytokines were
significantly elevated. The cytotoxic NK cell markers including
TRAIL were significantly upregulated within the tumor by
Vildagliptin. TRAIL treatment increased γH2AX in vitro.
Clodronate-liposome treated or IL-15 knockout mouse
strain showed significantly reversed tumor size with Vildagliptin. Conclusion: Inhibition of DPP4 decreased lung
cancer growth and increased inflammatory macrophages
and NK cell activity within tumors. Mechanistically, an
increased expression of the cellular stress marker γH2AX by
TRAIL treatment in lung cancer cell lines suggests that NK
cell-derived TRAIL inhibits lung cancer growth.
Background: Intraoperative lesions of peripheral nerve
branches are common complications and difficult to prevent
due to misidentification. Current methods to identify nerves
have significant limitations or could be harmful. The aim of
this study is to validate a novel real-time, non-invasive intraoperative method of nerve identification. Material and
Methods: Dorsoradial peripheral branches of the radial
nerve of a human cadaver hand were identified using the
collimated polarized light imaging (CPLi) system. CPLi was
used to distinguish nerve tissue through the presence or
absence of the anisotropic optical reflection specific for
nerve tissue. The presence of nerve tissue in 13 samples of
the observed cadaver tissue was recorded and independently evaluated by the CPLi operator and confirmed by
histological evaluation. CPLi was also used to detect nerves
at the carpometacarpal joint of one live patient. Results:
Seven samples were examined ex situ, and six samples were
investigated in situ using CPLi. The observations using CPLi
were compared with visual assessment and histologically
verified, which resulted in a 100% correct score for CPLi in
identifying the presence of nerves smaller than 1 millimeter
in width, whilst the surgeon at visual examination had difficulties with detecting nerves in three samples (23%). The
presence or absence of the nerve specific anisotropic optical
reflection could be reproduced during an in vivo observation in a patient. Conclusion: CPLi enables intraoperative,
real-time imaging to reliably identify nerves in situ. This new
imaging method has potential for preservation of small
caliber nerves which are often overlooked during surgery.
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Academic Medical Center, Surgery, Amsterdam,
Netherlands, 2University of Sydney, Surgery, Sydney,
Australia, 3Utrecht University, Condensed Matter and
Interfaces, Utrecht, Netherlands
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Study of Poly (vinyl) Alcohol Scaffolds in
Small and Large Animals for the Treatment of
Abdominal Hernia Repair
D. Feher, K. Juhos, A. Ferencz, Z.G.Y. Szabo, S.D. Csukas,
K. Molnar, A. Jedlovszky-Hajdu, C. Voniatris, M. Zrinyi,
G.Y. Weber
Semmelweis University, Dept. of Surgical Research and
Techniques, Budapest, Hungary
Abdominal hernias are one of the most frequent disorders
treated in a general surgery. Biodegradable poly (vinyl)
alcohol (PVA) mesh being has potential biocompatible
properties, which could prevent such complications like
adhesion, infection, etc. Purpose of the following experiments is to examine in vivo biological adaptation to our PVA
meshes. Two series of experiments were performed. Wistar
rats (n = 60) were randomly sorted into four groups of 15
animals each. Group I PVA scaffolds were placed on the peritoneum and fixed upon the abdominal musculature via four
corner single interrupted sutures. Group II received PVA
mesh (D = 2.5 cm) to repair abdominal wall defects (D =
2 cm) and were fixed with absorbable (5/0) and in group III
with non-absorbable thread respectively. In the control
group only skin incision was made. On swine (n = 2) the scaffolds (D = 8 cm) were implanted laparoscopically and fixed
intraperitoneally without creating a defect upon the right
side anterior abdominal wall. Concurrently polypropylene
meshes were also implanted (left side) serving as a control
measurement. Rats in each group were dissected after 7th,
14th, 28th, 90th and 180th postoperative days and swine
were terminated on the 5th week. Implants were evaluated
macroscopically and histologically. Macroscopical findings
showed significantly more adhesion formation along the
suture line than PVA scaffold itself proving its biocompatibility. Histological examination showed that all of the meshes
were integrated to the host tissue and kept their structure
until the end of the experiments. PVA nanofiber mesh is thus
biocompatible and could be promising biomaterials for the
prevention of incisional hernia formation.
© 2017 S. Karger AG, Basel
and knowledge about the acetabular fracture for inexperienced observers. Method: Seven senior trauma surgeons, 5
junior orthopedic surgeons, 5 senior surgical residents, 5
junior surgical residents and 5 surgical interns were asked to
classify 20 acetabular cases on Xray and 2D CT, 3D-reconstructions, 3D printed models and VR according to the
Judet-Letournel classification. Furthermore, all fellowshiptrained- and senior trauma orthopedic surgeons were asked
to evaluate their surgical approach for every acetabular
fracture. Results: Senior surgeons (? = 0.34), junior surgeons
(? = 0.24), senior surgical residents (? =0.20), junior surgical
residents (? = 0.018) and interns (? = 0.18) showed fair interobserver agreements for X-ray/2D CT. However, 3D printing
showed moderate and substantial inter-observer agreements for senior surgeons (? = 0.60), junior surgeons (? =
0.58), senior surgical residents (? = 0.67) and interns (? =
0.62). VR inter-observer agreements increased especially for
junior surgeons and senior- and junior surgical residents,
respectively ? = 0.50, ? = 0.53 and ? = 0.54. The inter-observer
agreements about the surgical approach remained approximately the same for senior surgeons on all diagnostic
imaging tools. However the inter-observer statistics
increased from fair (? = 0.18) to a moderate agreement (? =
0.40, ? = 0.32) for junior surgeons when comparing X-ray/2D
CT with 3D printed models and VR. Conclusion: We conclude
that 3D printing can be of added value in understanding
acetabular fractures whereas VR is of added value for the
future generation trauma orthopedic surgeons. We
recommend for implementation of 3D printed models and
VR models in the orthopedic surgery training.
Preliminary Results Using a Newly
Developed Projection Method to Visualize
Vascular Anatomy Prior to DIEP Flap Breast
S. Hummelink1, M. Hameeteman1, Y.L. Hoogeveen1,
C.H. Slump2, D.J.O. Ulrich1, L.J. Schultze Kool1
Radboudumc, Plastic Surgery, Nijmegen, Netherlands,
University of Twente, MIRA Institute for Biomedical
Technology, Enschede, Netherlands
The Value of 3D Printed Models and Virtual
Reality in Understanding Acetabular Fractures
L. Brouwers, A.F. Pull ter Gunne, M.A.C. Jongh de,
M. Bemelman, K.W.W. Lansink
Elisabeth-Tweesteden Hospital, Network Emergency Care
Brabant, Tilburg, Netherlands
Introduction: Acetabular fractures are complex and
difficult to understand. We hypothesize that 3D printing and
Virtual Reality (VR) will lead to an increased understanding
In a deep inferior epigastric perforator (DIEP) flap breast
reconstruction, computed tomography angiography (CTA)
is currently considered as the gold standard in preoperative
imaging for this procedure. Unidirectional Doppler ultrasound (US) is frequently used; however, this method does
not distinguish the main axial vessels from perforator arteries
at the height of the fascia, it has a limited penetration depth,
and it cannot assess the branching patterns of the deep
inferior arteries. A new method and system were developed,
which consisted of a video projector preoperatively
displaying the location and intramuscular course of the
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Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Audit of Delays in Discharge for
Non-Reconstructive Breast Surgery at
One District General Hospital
A. Dalrymple, R. Patel, H. Hough, A. Reza, V. Patel,
E. Babu, A. Chakravorty
Hillingdon Hospital London, Breast Surgery, London,
United Kingdom
Background: London Cancer Alliance (LCA) guidelines
state that all medically fit breast surgery patients (excluding
reconstruction cases) should be discharged within 23 hours
of admission. We audited the practice of one London-based
Breast Surgery Unit against these guidelines. Material and
Methods: Data was collected prospectively on 71 consecutive non-reconstructive breast cases between AugustNovember 2016. Data was collected on the type of operation and use of surgical drain. Time to discharge was calculated from time of admission to time of discharge summary
being issued. Reasons behind any delays were recorded.
Results: 71 female patients were included in the audit, mean
age 59.7 years (range 17–84). 74.6% (n = 53) were successfully discharged with in 23 hours of admission. 25.4% of
patients breached the 23 hour target. The average delayed
discharge time was 39.24 hours (range 1–84.5 hours). 83%
of discharges that breached were due to drain-related
issues. One delay was due to surgical complication. Other
reasons included: medical issues, patient choice, prolonged
post-operative recovery, post-operative complications and
timing of procedure. All (n = 14) masectomy patients
breached contributing 78% of the total number of breaches.
Conclusion: Inpatient stay is often extended due to axillary
drains, particularily in the mastectomy subgroup. This is
despite LCA guidelines advocating patients being discharged
with drains in situ. We have implemented a Ward-Based
Drain Management Protocol including: a drain review clinic,
patient information leaflet on drains and targeted breast
care nurse support. We will re-audit to examine if these
simple implementations can improve adherence to guidelines.
Localization of Parathyroid Adenomas Using
11C-methionine-PET after Prior Inconclusive
M.E. Noltes, A.M. Coester, A.N.A. Van der Horst-Schrivers,
B. Dorgelo, L. Jansen, W. Noordzij, C. Lemstra,
A.H. Brouwers, S. Kruijff
Universitair Medisch Centrum Groningen, Surgery,
Groningen, Netherlands
Background: Minimally invasive parathyroidectomy
(MIP) is the recommended treatment in primary hyperparathyroidism (pHPT) for which accurate preoperative localization is essential. The current imaging standard consists of
cervical ultrasonography (cUS) and MIBI-SPECT/(CT).
11C-MET-PET/(CT) has a higher resolution than MIBI-SPECT/
CT. The aim of this study was to determine the diagnostic
performance of 11C-MET-PET/(CT) after initial inconclusive
or negative localization. Material and Methods: We
performed a retrospective single center cohort study of
patients with pHPT undergoing parathyroid surgery after
prior negative imaging and later localization by means of
C-MET-PET/(CT) between 2006 and 2014. Preoperative
localization by 11C-MET-PET/(CT) was compared with later
surgical localization, intraoperative quick PTH (IOPTH),
duration of surgery, histopathology, and follow-up data.
Also differences in duration of surgery between the groups
with and without correct pre-operative localization were
analyzed. Results: In 18/28 included patients a positive
11C-MET-PET/(CT) result corresponded to the surgical
localized adenoma (64%). In 3/28 patients imaging was false
positive and no adenoma was found. In 7/28 patients
imaging was false negative at the side of the surgically identified adenoma. Sensitivity of 11C-MET-PET/(CT) was 72%
(18/25). Duration of surgery of correctly localized patients
was significantly shorter compared to falsely negative
localized patients (p = 0.045). Conclusion: In an intention to
treat 11C-MET-PET/CT correctly localized theparathyroid
adenoma in 18/28 (64%) patients, after previous negative
imaging. A pre-operatively well localized adenoma leads to
a more focused surgical approach (MIP) potentially reducing
duration of surgery and healthcare costs.
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artery perforators and subcutaneous branching on the
patient’s abdomen. All patients (n = 9) underwent a standard
protocol: a preoperative CTA was performed and the DIEPs
were localized using a unidirectional Doppler probe. In
addition, a three-dimensional (3D) reconstruction of the
perforator locations based on CTA was projected on the
abdomen of the patients. All projected perforator locations
were assessed using a unidirectional Doppler probe. The
intraoperative results were collected for comparison. A total
of 88 locations were marked with the use of unidirectional
Doppler and a total of 100 perforators were projected (p =
0.38). In 98 out of 100 projected perforator locations, a
Doppler signal was audible. The intraoperative results
demonstrate that 19 out of 34 transplanted perforators were
correctly identified with unidirectional Doppler (56.9% ±
31.4%), where the projection method properly revealed 29
locations (84.3% ± 25.8%) (p = 0.03). The projection method
identifies more perforators than unidirectional Doppler
probing and is more accurate in pointing out the corresponding perforator found intraoperatively.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Six Months Results of Radiofrequency
Ablation for Benign Solid Thyroid Nodules,
and of Modified Ethanol Ablation for Thyroid
W.J. Bom, F.B.M. Joosten, R.R.J.P. Van Eekeren, E.P. Bom,
Hans De Boer
Rijnstate, Interventional Radiology, Arnhem, Netherlands
Background: Benign thyroid nodules and cysts are
common. Symptomatic solid nodules are usually treated by
surgery, cysts may be aspirated, but if they recur surgery is
usually warranted. Recently, Radio Frequency Ablation
(RFA) has been developed as an alternative to surgery, and
modified Ethanol Ablation (EA) has been introduced to
improve the results of cyst aspiration. In this study we
present the first Dutch case series of RFA, and of modified
EA. Methods: Patiënts with thyroid nodules or cysts greater
than 20 mm but less then 50 mm were included. Cysts had
to be unilocular with benign cytology, solid nodules had to
be benign based on clinical judgement, sonographic characteristics and cytology or histology. Toxic nodules were
not included. Results: Between January 2015 and March
2016 22 patients were referred for EA, and 34 for RFA.
Nineteen were accepted for EA and 15 out of 34 were
included for RFA. EA led to a sustained volume reduction of
87% at six months (p < 0.05). EA failed in 32% of patients.
RFA reduced thyroid nodule volume by a median of 36%
(p < 0.05). Adverse events: one patient treated with EA
developed a painful local inflammatory response. RFA was
without clinically significant adverse events. Conclusion:
RFA and modified EA are promising alternatives to surgery
in well-selected cases.
Groin Pain Characteristics and Recurrences:
Long-Term Results of a Randomized
Controlled Trial Comparing Self-Gripping
Progrip® Mesh and Sutured Polypropylene
Mesh for Open Inguinal Hernia Repair
W.A.R. Zwaans, T. Verhagen, L. Wouters, M.J.A. Loos,
R.M.H. Roumen, M.R.M. Scheltinga
Máxima Medisch Centrum, General Surgery, Veldhoven,
Background: Some patients develop chronic pain
following mesh insertion for an inguinal hernia. A recent trial
comparing a semi-resorbable, self-gripping Progrip® mesh
with a standard sutured polypropylene mesh found that
postoperative pain at three months was attenuated following
the Progrip®. However, it is unknown if long-term pain levels
and hernia recurrence rates are different between the two
techniques. Methods: Patients >18 years undergoing an
open primary hernia repair were randomized to receive a
Progrip® mesh or a standard polypropylene sutured repair
according to Lichtenstein. Pain was measured using a Visual
Analogue Scale (VAS, 0–100) at timed intervals over a three
years period. A hernia recurrence was determined using
physical examination in the outpatient department. Results:
Results of 274 patients were available at the final three year
follow-up point (75% follow up rate). Pain levels were greatly
attenuated over time in both groups (p = 0.05), without
differences between the groups. However, altered groin skin
sensation persisted after three years in both groups.
Moreover, one of five patients receiving a standard mesh
reported a foreign body feeling compared to one of seven
with a Progrip® (p = 0.06). The hernia recurrence rate was
higher in the Progrip® group (11.5% vs. 5%, p = 0.05).
Conclusion: Pain levels three years after insertion of a selfgripping Progrip® mesh or a sutured polypropylene mesh
for an open primary inguinal hernia repair are low, although
altered skin sensation and foreign body feeling is not
unusual. A Progrip® hernia repair is associated with a higher
recurrence rate.
Pulsed Radiofrequency (PRF) or Anterior
Neurectomy for Anterior Cutaneous Nerve
Entrapment Syndrome (ACNES): Initial Results
of a Randomized Controlled Trial
R.C. Maatman1, M.A.H. Steegers2, P.V. Van Eerten1,
T.C. Lim1, J.J. Van den Berg1, S.A.S. Van den Heuvel2,
O.B.A. Boelens3, M.R.M. Scheltinga1, R.M.H. Roumen1
Máxima Medisch Centrum, Algemene Chirurgie,
Veldhoven, Netherlands, 2Radboud Universitair Medisch
Centrum, Department of Anaesthesiology, Nijmegen,
Netherlands, 3Maasziekenhuis Pantein, Department of
Surgery, Boxmeer, Netherlands
Background: Chronic abdominal pain is occasionally due
to entrapped intercostal nerves (anterior cutaneous nerve
entrapment syndrome, ACNES). If abdominal wall infiltration
using an anesthetic agent is unsuccesful, a neurectomy may
be considered. Pulsed Radiofrequency (PRF) applies an electromagnetic field around a nerve possibly leading to pain
relief. Limited retrospective evidence suggests that PRF is
effective in ACNES. Aim was to determine whether PRF may
be used as a minimally invasive alternative treatment in
ACNES. Methods: Patients diagnosed with ACNES who
temporarily respond to abdominal wall injections are
randomized to PRF or neurectomy. Pain was recorded using
a numerical rating scale (NRS, 0 (no pain) to 10 (worst
possible)) prior treatment and 8 weeks after intervention.
Successful treatment was defined as >50% NRS pain
reduction. Secondary outcomes are quality of life, satis-
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
faction and analgesics use. If PRF is unsuccessful, ‘crossover’ to neurectomy is allowed. Results: By October 2016,
data of 42 randomized patients (dropout, n = 3) were
available (21 PRF, 18 neurectomy, 30 women, median age 43
years, range 18–69 years). Median NRS score in the PRF
group dropped from 6.0 (range 2.0–8.0) to 4.5 (range 0–8.0,
p < 0.05) and in the neurectomy group from 6.3 (range
3.3–8.0) to 3.3 (range 0–9.0, p = 0.003). Treatment was
successful in 35% (7/20) of the PRF group and 53% (10/19)
of the neurectomy group. Conclusion: The initial results of
this first randomized trial point towards a potential role of
PRF in ACNES. The trial will be closed (n = 66 patients)
towards the end of 2017.
© 2017 S. Karger AG, Basel
metastasectomy. Identification of positive discordance in
the Her2 receptor is an additional benefit of metastasectomy
and is associated with improved survival.
Improving the Functionality of Intraoperative
Nerve Monitoring (IONM) during Thyroid
Surgery – Is Lidocaine an Option?
R.G. Govindarajan1, A.J. Shah2, R.S. Ravikumar2,
V.S.K.R. Reddy2, C.F. Foster1, A.M. Mukerji2, U.K. Kannan2,
D.L. Livingstone1
The Significance of Hormone Receptor
Discordance between Primary Breast
Tumours and Brain Metastasis
B.P. Hanley, S. Walsh, D.P. O’Leary, C. Power, M. Farrell,
S.P. MacNally, A. Hill
Beaumont Hospital, Breast and Endocrine Surgery,
Dublin, Ireland
Background: Brain metastasectomy rates have increased
in recent years. Targeted therapy in breast cancer metastases is dependent on hormone receptors and human
epidermal growth factor receptor 2 (Her2). Receptor discordance between the primary cancer and metastases may be
used to inform the selection of adjuvant therapies. The aim
of the current study was to measure receptor discordance
and associated clinicopathological variables associated with
breast to brain metastases and analyse their influence on
survival. Materials and Methods: A retrospective review of
49 patients who underwent brain metastasectomy between
2011 and 2015 for histologically proven breast cancer
metastasis was performed. Clinical and pathological parameters, including receptor discordance, were assessed. Interval
until metastatic diagnosis and survival after metastasectomy
were measured. Univariate and multiple regression analysis
were performed to identify potential prognostic indicators
using SPSS v23. Results: Estimated median survival was 19
months. Receptor discordance for the oestrogen, progesterone and Her2 receptors were 19.1% (k = 0.628, p < 0.001),
26.8% (k = 0.358, p = 0.012) and 11.6% (k = 0.768, p < 0.001)
respectively. A significant survival advantage was associated
with Her2 discordance (HR = 3, p = 0.004), absence of additional systemic metastases (HR = 3.2, p = 0.029), complete
tumour resection (p = 0.009) and adjuvant radiotherapy (p =
0.043). Survival was greater for the Her2 patients who were
positively discordant, improving from median 9 months to
median 17 months survival (HR = 3, p = 0.004). Conclusion:
Receptor discordance is a significant feature in breast to
brain metastases and is a further indication to perform a
Background: The successful deployment and data
analysis from the IONM require complete laryngeal relaxation and reflex suppression. We investigated the role of IVLI
to provide such operating conditions. Material and Methods:
After approval from the IRB and registering with, we obtained informed consent from 60 patients.
They were placed in the respective study group (Lidocaine/
placebo) based on the computer-generated coding by the
pharmacy department, who delivered the study medication
(SM) in a prefilled coded syringe to the investigator. All the
patients were anesthetized by narcotic and inhalation based
general anesthesia. The SM was administered by an infusion
pump (1.5 mg/kg/hr., following a bolus of 1 mg/kg). Dragonfly® laryngeal surface electrode and Nerveana® nerve
locator system (NeurovisionTM Medical Products, CA, USA)
were used for IONM during surgery. Results: The number of
hypotensive episodes requiring rescue mediations in ASA 3
patients were significantly higher in the placebo group (p <
0.0361). The stimulating current (STMC) required (0.5 MA)
(p < 0.0001) and the drop in the aggregate impedance levels
(DAIL) by >50% (p < 0.0006) at the end of surgery were
significantly lower in the lidocaine group. Conclusions: The
enhanced laryngeal relaxation and reflex suppression
afforded by the IVLI could have enabled a lower STMC to
elicit a positive signal. The lower STMC promotes less intense
laryngeal alterations, as indicated by the lower DAIL in the
lidocaine group. IVLI can enhance the functionality of the
IONM during prolonged operating time and increased
number of IONM stimulations, while providing a stable
hemodynamic environment.
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Bronx Lebanon Hospital, Bronx, NY/ North American
Partners in Anesthesia, Anesthesia, Bronx, Ny, United
States of America, 2Bronx Lebanon Hospital, Surgery,
Bronx, Ny, United States of America
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Analysis of Factors Which Affect Direction of
Lymphatic Drainage in the Stomach
A.S. Shida, N.M. Mitsumori, M.K. Kawamura, Y.T. Takano,
K.Y. Yanaga
Jikei University School of Medicine, Surgery, Tokyo,
Background and Purpose: We started performing Sentinel
Node Navigation Surgery (SNNS) for patients with Early
Gastric Cancer (EGC) using infrared ray electronic endoscopy
(IREE) with indocyamine green injection from year 2000. The
EGCs usually have complex lymphatic drainage, unidirectional or multidirectional lymphatic drainage. In this study, we
investigated and clarified factors that affect the direction of
lymphatic drainage. Patients and Method: Consecutive 60
patients with EGC who underwent SNNS by IREE from year
2006 to 2014 were enrolled to this study. Patients’ age, gender,
location of tumors, operative method, previous treatment by
endoscopic submucosal dissection, presence of pathological
ulcerative scar and maximum tumor diameter were analyzed.
Result: Bivariate analysis demonstrated that the presence of
pathological ulcerative scar (P = 0.0097), tumor location
[greater curvature (gc) / anterior wall (aw) / posterior wall (pw)
vs. lesser curvature (lc), P = 0.0098], and maxim tumor diameter
(P = 0.0003) were relevant to direction of lymphatic drainage.
Multivariate analysis showed that tumor location (gc / aw / pw
vs. lc, odds ratio 8.2269, P = 0.0110) and the maximum tumor
diameter (odds ratio 1.0565, P = 0.0374) are independent
factors which affect direction of lymphatic drainage. Actually,
78% of tumors which located in lc had unidirectional lymphatic
drainage. In addition, 93% of tumor whose diameter was 40
mm and over had multidirectional lymphatic drainage.
Conclusion: Our investigation showed that the tumor location
and tumor diameter were key factors for the direction of
lymphatic drainage, which helps us to understand the
complexity of lymphatic drainage in the stomach.
Ex vivo Lung Perfusion (EVLP) Decreases
Inflammatory Response in Lungs of
Non-Heart-Beating Donors
R.L. Rancan1, P.A. Puig2, C.J. Casanova2, H.L. Huerta2,
P.S.D. Paredes1, G.I. Garutti2, S.C. Simon2, V.E. Vara1
1Universidad Complutense de Madrid, School of
Medicine, Biochemistry and Molecular Biology III,
Madrid, Spain, 2Gregorio Marañón University General
Hospital, Department of Anesthesiology, Madrid, Spain
The rate of lung utilization for transplantation is low and
mortality among patients on the transplant waiting list is
high. Treatment of injured donor lungs ex vivo lung perfusion
(EVLP) to accelerate organ recovery and ameliorate reperfusion injury could have a major impact in lung transplantation. The aim of this study was to investigate the efficacy
of EVLP improving the function of lungs obtained from asystolic donors (AD). Porcine donor lungs were harvested after
electrical cardiac arrest and a 30-minute period of warm
ischemia, followed by a 3-hour period of cold preservation
of the left lung. Animals were divided into 2 groups (6
animals each): Group 1: Left lung was implanted and reperfusion was maintained for 2 hours. Group 2: Donor lungs
were assessed/reconditioned for 60 minutes in a normothermic EVLP circuit using acellular perfusion solution. Lung
was then recooled, implanted and reperfused for 2 hours.
Lung biopsies were obtained from transplanted lung after
120 minutes of reperfusion and expression of inflammatory
(TNF-α, IL-1β and MCP-1), oxidative stress (HO1), adhesion
molecules (VCAM) and apoptotic (caspase-3, AIF) mediators
in lung tissue were analysed. Non-parametric test were used
to find statistical meaning. Both protein and mRNA
expression of all inflammatory and apoptotic markers were
significantly decreased (p < 0.01) in group 2 (EVLP) in relation
to group 1 (no EVLP). EVLP also decreased HO1 and VCAM
protein expression (p < 0.05). These results suggest that
EVLP allows lung recovery from AD, considered non-viable
lungs, converting them into valid candidates for transplantation.
Impact of Human Leucocyte Antigen
Mismatch on Lung Transplant Outcome
Y. Yamada, T. Langner, I. Inci, C. Benden, M. Schuurmans,
W. Weder, W. Jungraithmayr
University Hospital Zurich, Division of Thoracic Surgery,
Zurich, Switzerland
Objective: Human Leucocyte Antigen (HLA) mismatch
between donor (D) and recipient (R) is likely to impact on the
outcome after transplantation (Tx) of solid organs based on
different immunological risk profiles for allograft dysfunction.
This study evaluated the outcome after lung Tx with D/R
HLA-mismatch. Methods: All patients who underwent lung
Tx were analyzed in this retrospective study between 1994
and 2013 for their matches of HLA (-A, -B, DR) antigens
between D and R, and their association with the incidence of
acute cellular rejection (ACR), chronic lung allograft
dysfunction (CLAD) and overall survival (OS). Results: 385
patients (204 males, 181 females) were included. From these,
189 patients had no HLA match (0/6), 130 had 1/6 match, 54
had 2/6 matches and 12 had 3/6 matches. 128 patients
(33.2%) experienced at least one episode of ACR and 54
(14%) developed CLAD. Univariate analyses did not show a
significant correlation between HLA mismatch and the incidence of ACR, CLAD, or OS. However, a trend was seen
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
towards improved survival in patients having 3/6 matches
compared to others. Also, multivariate analysis revealed that
the number of HLA mismatches (HR 1.48; p = 0.036), the
incidence of ACR (HR 1.81; p = 0.032) and the age of donors
(HR 1.02; p = 0.018) were independent risk factors for CLAD
development. Conclusion: In this single center cohort
analysis, the number of HLA mismatches correlated with the
incidence of CLAD. HLA mismatch should therefore be evaluated as a risk factor for CLAD in larger cohorts and
prospective studies.
© 2017 S. Karger AG, Basel
(HyPACS) protected liver grafts from IRI by suppressing
oxidative damages, in the characteristic manner with its
route of administration.
Efficacy of the Novel Preservation Solution,
Ecosol, in a Rat Liver Transplantation Model
H. Tanaka1, B.M. Doorschodt2, F.K. Fukushima2,
P. Kadaba Srinivasan2, K. Pawlowsky2, K. Hata1, R. Tolba2
Kyoto university, Surgery, Kyoto, Japan, 2University
Hospital RWTH Aachen, Institute for Laboratory Animal
Science, Aachen, Germany
Hydrogen Perfusion after Cold Storage;
A New, Simple, and Non-Invasive
Post-Conditioning for Ameliorating
Hepatic Ischemia/Reperfusion Injury?
I.T. Tamaki, H.K. Hata, Y.O. Okamura, N.Y. Yermek,
H.H. Hirao, T.K. Kubota, O.I. Inamoto, J.K. Kusakabe,
J.Y. Yoshikawa, H.T. Tanaka, S.K. Kageyama, T.T. Tajima,
T.G. Goto, S.U. Uemoto
Kyoto University School of Medicine, Department of
Surgery, Kyoto City, Japan
Background: Cold storage (CS) has long been the gold
standard for liver preservation, though it is unavoidably
accompanied by cold-ischemia/warm-reperfusion injury
(IRI). Hydrogen is ubiquitous gas having anti-oxidative
properties, whereas its application in organ preservation
has not yet been established. Materials and Methods:
Whole liver grafts were retrieved from male Wistar rats.
After 24-hour CS, hydrogen solution (1.0 ppm, 40 ml) was
simply perfused via portal vein (PV), or hepatic artery (HA),
or the both. Functional integrity of the livers was then evaluated by 2-hour oxygenated reperfusion ex vivo at 37°C.
Results: Hydrogen perfusion after cold storage (HyPACS)
significantly lowered transaminase (P < 0.01 in AST, ALT,
and LDH) and HMGB-1 (P < 0.0001) release than in vehicletreated control livers. Hyaluronic-acid clearance was significantly improved by portal HyPACS than in the others (P <
0.01), indicating the efficacy of HyPACS, as well as the superiority of PV route to maintain sinusoidal endothelium. In
contrast, bile production and LDH leakage therein were
both significantly ameliorated by arterial HyPACS (P < 0.01),
reflecting the superiority of arterial route to preserve the
integrity of biliary systems. Consistently, electron microscopy
revealed that sinusoidal ultra-structures were well-maintained by portal HyPACS, while microvilli in bile canaliculi
were well-preserved by arterial HyPACS. The both HyPACS
significantly lowered portal-venous pressure (P < 0.0001).
As the mechanisms underlying these protections, oxidativestress markers (TBARS, 8-OHdG, and Total Glutathione)
were all significantly suppressed by HyPACS (P < 0.01).
Conclusions: Hydrogen perfusion after cold storage
Background: Despite recent advances of orggan transplantation (Tx) techniques and development of various
immune suppressants, there had been no remarkable
progress in graft preservation for over several decades.
Ecosol, an extracellular-type, colloid-based preservation
solution, has recently been developed for washout, cold
storage, and machine perfusion preservation of kidney
grafts. The purpose of this study is to assess the efficacy of
Ecosol compared to the widely used University of Wisconsin
(UW) cold storage solution with rat liver grafts. Material and
Methods: The whole liver grafts were retrieved from
200–250 g of male Lewis rats and transplanted to Lewis
(syngenic) or Brown Norway (allogenic) rats after 8 hours
cold preservation with Ecosol or UW. The recipients were
sacrificed 24 hours or 168 hours after Tx and blood and
tissue samples were collected for biochemical, haematological and histopathological analyses. Result: All the recipients survived in all groups. Although there were no significant differences 168 hours after TX, the liver enzymes 24
hours after Tx were significantly elevated in UW groups. The
portal venous flow after reperfusion was significantly higher
in Ecosol groups (5.24 ± 2.86, 8.16 ± 1.52, 12.31 ± 3.51, and
15.86 ± 0.95 ml/min, in UW-syn, Eco-syn, UW-allo, and
Eco-allo group, respectively). Conclusion: Ecosol improved
the quality of the cold storage graft and maintained the
microcirculation just after Tx also in rat liver model.
Tumor of a Kidney Transplant: Partial
Nephrectomy Preserves the Graft Function
J. Chlupac, J. Fronek
Institute for Clinical and Experimental Medicine,
Department of Transplant Surgery, Prague, Czech
Background: The incidence of urologic tumors is
increased in renal transplant recipients. In case of a kidney
transplant neoplasm, the graft-nephrectomy and hemodi-
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Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Improving Outcomes of Renal Transplantation
from Expanded Criteria Donors by Cold
Ischemia Time Rapid Shortening
Š.M. Malý, L.J. Janoušek, T.M. Marada, O.V. Viklický,
J.F. Fronek
IKEM, KTCH, Prague, Czech Republic
Background: Disproportion between supply and demand
of solid organs for transplantation is forcing us to expand
our indication criteria. In case of expanded criteria donors
(ECD) in renal transplantation, the overall function and graft
survival are decreased. In this prospective study, we propose
a new procedure to shorten the cold ischemia time (CIT) of
the ECD grafts to improve the outcomes. Material and
Methods: The lymph node for cross-match examination was
at first harvested from the groin of a deceased donor. The
actual organ retrieval did not proceed until obtaining results
of negative cross-match and until arrival of the recipients.
Renal transplantation followed immediately after organ
retrieval with no need for additional delays. Thus, the CIT
was shortened dramatically. Between 4/2013 and 3/2016, 15
ECD kidneys were transplanted using this modified retrieval
procedure. The control group included 30 comparable ECD
grafts from the same period. One year follow-up graft
survival and function were analyzed. Results: The immediate
onset of graft function was faster in the primary group than
in the control group: 93.3% versus (vs.) 66.7%, p = 0.026;
Delayed graft function was less frequent: 6.7% vs. 30.0%, p =
0.040; Primary afunction was not observed: 0.0% vs. 3.3%
p = 0.243 N.S. Also, one-year graft survival in the primary
group was higher compared to the control group: 100.0%
vs. 83.3%, p = 0.033. Conclusion: Novel strategy having
recipient prepared for transplant at the time of kidney
retrieval from deceased donor shortens the cold ischemia
time and greatly improves the overall function and survival
of ECD renal grafts.
Urinary Tract Infection after Renal Transplant
J.M. Norris1, E.V. Robinson2, M. Morsy2, A. Wadoodi2,
A. Ghazanfar2, S. Heap2, C. Fraser Taylor2
University College London, UCL Division of Surgery &
Interventional Science, London, United Kingdom, 2St
George’s University Hospitals NHS Foundation Trust,
Renal Transplant Surgery, London, United Kingdom
Background: Urinary tract infection (UTI) is prevalent
after kidney transplantation and can result in transplant
pyelonephritis and graft loss. Here, we have conducted a
retrospective cohort analysis to assess urological risk factors.
Material and Methods: During 2016, 132 adults with endstage kidney disease underwent renal transplant surgery at
our centre. Post-operative UTI was assessed with urine
cultures. Electronic records were mined for: patient age and
sex, causative micro-organism species, presence of duplex
ureter, and timings of urethral catheter and ureteric stent
removal. Results: Post-operative UTI rate was 34.8%.
Recurrent UTI was common and infection rate following
removal of ureteric stents was 18.9%. Females were at significantly greater risk than males (53.1% vs. 26.5%; p = 0.002)
and older patients (over 50-years-old) were at greater risk
than younger patients (64.6% vs. 35.4%; p = 0.08). Duplex
ureter occurred twice and did not increase UTI risk. Mean
interval until catheter removal was 3.9 days (2–11); patients
with catheters for over four days were at an increased risk
(58.3% vs. 41.7%). Median stent removal interval was 32 days
(28–126); patients with stents for over 32 days were at
increased risk (56.5% vs. 43.5%). The commonest bacteria
were: E coli (15.1%), Enterococcus sp (4.5%) and P mirabilis
(3.0%). Conclusion: UTI frequently occurs post-transplantation, with potentially serious repercussions. At our centre,
we have introduced a dedicated transplant urologist to
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alysis reduces the quality of life. Partial nephrectomy may
preserve renal function. We report our experience with 10
patients. Material and Methods: Ten patients with Ten
patients with mean age 61 ± 12 years (37–80 years) and
mean time after kidney transplantation 10 ± 5 years were
diagnosed with allograft neoplasm by routine screening
between 2014–2016. They were treated with partial
nephrectomy. Results: Renal functions before resection:
mean creatinine (Cr) level 141 ± 52 μmol/l and mean estimated glomerular filtration rate (eGFR) 0.82 ± 0.37 ml/min.
All patients suffered from transitory impairment of renal
function postoperatively: Cr = 184 ± 46 μmol/l (increase of
41%, p = 0.05). However, mean Cr level at discharge (12 ±
6 days) decreased to pre-operative level: 142 ± 36 μmol/l
(p = 0.48). Mean follow-up was 565 ± 341 days (103 days-2.8
years). Renal functions at follow-up were non-significantly
reduced: mean Cr = 163 ± 71 μmol/l, (increase of 15%, p =
0.22) and mean eGFR = 0.73 ± 37 ml/min (decrease of 11%,
p = 0.31). Four patients received temporary nephrostomy
peri-operatively. Two patients (20%) suffered from transitory urinary leak treated percutaneously. Three patients
suffered from urinary tract infection (1× sepsis) treated with
antibiotics. Otherwise the recovery was uneventful.
Histology showed renal cell carcinoma 3×, urothelial
carcinoma 5×, collecting duct carcinoma 1× and cortical
cyst 1×. No adjuvant oncologic therapy was needed. All
patients survived tumor-free. Conclusion: Partial
nephrectomy of renal allograft is a feasible approach for
tumor removal with full preservation of graft function. It
should be offered to all patients in whom it is clinically
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
manage urological aspects of transplantation more effectively, including UTI. An interval study will be conducted in
one year to monitor improvement in clinical outcomes.
© 2017 S. Karger AG, Basel
Meta-Analysis of Recurrence after Curative
Surgery of Pancreatic Neuroendocrine Tumors
C.G. Genc1, T.M. Mackay1, S. Van Dieren1, C.H.J. Van Eijck2,
E.J.M. Nieveen van Dijkum1
The Body Surface Area of DBD Donors
Influence the Islet Isolation Yield in Islet
M.C. Chetboun, T.H. Hubert, V.G. Gmyr, R.E. Ezzouaoui,
K.B. Benomar, M.C.V. Vantyghem, F.P. Pattou,
J.K.C. Kerr-Conte
Inserm U1190, University of Lille, France, European
Genomic Institute for Diabetes, Lille, France
Background: Islet allotransplantation requires the
isolation and purification of islets from deceased donor’s
pancreas. The number of islets isolated appears crucial for
clinical outcome but is also highly variable. We studied the
characteristics of pancreas donors and isolation process and
their influence on islet isolation yield. Materials and Methods:
Characteristics of donors, organ harvesting method, and
pancreas isolation technique were investigated retrospectively and compared to islet isolation yield in univariate and
multivariate analysis. Results: Since January 2003, 690
pancreases from brain-dead donors (DBD) were isolated in
Lille. Among them, 224 (32%) were initially sent for research
purpose and 466 (68%) for an initial clinical allograft purpose.
Islet isolations from clinical organs enabled 157 allograft
infusions (34%) with a mean islet yield of 285,871 ± 6,503
IEQ. In univariate analysis, the post purification islet yield
was highly correlated with the weight, the body mass index
and the body surface area (BSA) (respectively: p < 0.0001).
History of Tobacco negatively influenced the islet yield (p <
0.0001). The multi-organ conservation solution during
pancreas procurement (p = 0.002) influenced the isolation
efficiency, but the duration of cold ischemia did not modify
this yield (p = 0.380). In multivariate analysis the clinical
factor with highest impact on isolation success was the BSA
with an odd ratio of 6.3 [2.6–15.3] (p < 0.0001). Conclusion:
Although isolation techniques have been optimized,
procurement of a sufficient islet yield is necessary to perform
islet allograft. Body surface area of the donor is a simple and
consistent predictor of isolation outcome.
Academic Medical Center Amsterdam, Surgery,
Amsterdam, Netherlands, 2Erasmus Medical Center,
Surgery, Rotterdam, Netherlands
Background: Follow-up after curative surgery for
pancreatic neuroendocrine tumors (pNET) is designed to
detect recurrence, however reliable recurrence rates are
difficult to deduct from literature. To develop appropriate
follow-up regimens this knowledge is needed. This metaanalysis aims to gain insight into the prognosis of patients
after curative resection of grade 1 or 2 pNET, by investigating recurrence rate, time to recurrence and predictive
factors for recurrence. Methods: A literature search was
performed on studies reporting recurrence after complete
resection of grade 1 or 2 pNET without distant metastases
or hereditary syndromes. Excluded were studies with less
than 20 patients, patients with R2 resection or (neo)adjuvant
therapy. Results: From a total of 1937 studies, 12 studies
were included. Curative resection was performed in 853
patients between 1982 and 2013, 121 patients had a recurrence. Mean weighted follow-up was 44.1 months. Pooled
recurrence rate was 14%. Sub-analyses showed a pooled
recurrence rate of 5% for non-functional tumors, 17% for
well-differentiated tumors and 7% for R0-resections.
Weighted time to recurrence was 21.7 months. Locoregional
recurrence was seen in 5%, distant metastases in 10%.
Factors associated with worse disease free survival included:
tumor size, tumor grade, lymph node metastases, perineural
invasion and R1 resection. Conclusion: With rates of 14%,
recurrence of pNET is not rare. More research on predictors
is needed to identify patients at risk. With this knowledge
follow-up regimens can be customized and the role of
adjuvant treatment for selected patients can be investigated.
Is Pancreatic Resection Justified for Elderly
Patients with Pancreatic Cancer?
A. Sato, T. Masui, T. Yoh, O.Y. Okuda, N. Sankoda,
T. Anazawa, K. Takaori, Y. Kawaguchi, S. Uemoto
Kyoto University, Department of Surgery, Kyoto, Japan
Background: We experience increasing number of elderly
patients. The aim of the study is to investigate the safety and
long-term outcomes of elderly patients with pancreatic
cancer after pancreatic resection. Materials and Methods: A
total of consecutive 103 patients with pancreatic cancer who
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Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
R1 Incidence in Cephalic
Duodenopancreatectomy Is Influenced by
Standardized Histopathological Protocols
E. Mois, F. Graur, R. Elisei, A. Cote, N. Al Hajjar, C. Puia,
F. Zaharie, A. Bartos, R. Bodea, I. Rusu, I. Cornel
Regional Institute of Gastroenterology and Hepatology,
Prof. O. Fodor, Surgery, Cluj-Napoca, Romania
Background: Obtaining negative microscopically margins
(R0) in cephalic duodenopancreatectomy (CDP) is the gold
standard. Regarding data from literature that a standardized
histopathological examination increases the rate of R1, we
considered necessary to perform a study in our Institute.
Here we present preliminary data. Methods: We analyze 103
cases of cephalic pancreatic ductal adenocarcinoma
operated with curative intentions. We separate these cases
in two grups: first of 60 cases (retrospective) where the
margins were not marked and second of 43 cases
(prospective) for that we used a standardized histopathological examination of the resected margins. While for the
retrospective grup circumferential margin was not detailed,
in the prospective grup we separate this margin in: medial,
anterior, superior and posterior. Results: R1 incidence in
retrospective grup were 38.3%, while in prospective grup
was 55.8%. Circumferential margin was most R1 in retrospective grup (82.6%), and medial (58.3%) and posterior
(33.3%) in the prospective grup. Conclusion: R1 incidence in
cephalic duodenopancreatectomy is influenced by standardized histopathological protocols. The mesopancreas
represents the primary site for positive resection margins.
Our Experience with Pancreaticogastrostomy
as an Alternative to Conventional
V. Vij, R. Bagree, R. Yadav, G. Goel, S. Kalra
SMS Medical College, Jaipur, General Surgery, Jaipur,
Background: Pancreaticoduodenectomy (PD), is a
complex procedure, commonly performed in patients with
traumatic and malignant disease of the pancreas and periampullary region. Pancreaticoenteric anastomosis continues
to be the ‘Achilles heel’ of PD, due to its association with a
measurable risk of leakage or failure of healing, leading to
pancreatic fistula. In our study, we try to establish pancreaticogastostomy (PG) as a safer alternative to conventional
pancreaticojejunostomy (PJ). Material and Methods: In our
centre, from 2012 to 2016, we performed PG in 56 patients
after PD. In our technique, the seromuscular and mucosal
layers of the posterior gastric wall are separated. A duct-tomucosa anastomosis is performed through a small incision
in the mucosal layer. A stent was placed to maintain the
patency of the anastomosis. An inner suture at the seromuscular-mucosal margin incorporating the pancreatic parenchyma and an outer suture on the exterior margin of the
seromuscular layer to wrap the pouch around the pancreas.
Result: In our experience, we did not find any patient developing pancreatic fistula. 10.7% patients developed biliary
leak, which were managed conservatively. Conclusion: PG
has several benefits like it is technically less demanding, the
pancreatic enzymes are inactivated by gastric acid environment. Furthermore the proximity of the pancreas to the
posterior stomach wall allows potentially less tension on the
anastomosis. Two layer duct to mucosa PG is a safer alternative to the conventional PJ.
An Emergent Case Repoert for Prevention
of Pancreatic Fistula (PF)? The Invagination
Method of Pancreas Stump to Stomach
N. Katsura1, Y. Kawai2, T. Gomi2, K. Okumura2, T. Hoashi1,
S. Fukuda1, K. Shimizu1, M. Satoh2
Hospital, Surgery, Yawata, Japan, 2Satoh
Hosoital, Surgery, Hirakata, Japan
Background: Following a prevalence of GIA for treatment
of pancreas stump, more preventive technique for postoperative pancreatic juice leakage has been required. We experienced an emergent case underwent our new technique, to
invaginate pancreatic cut-end to stomach, which could
prevent from occurring P. Material and Method: This time,
we experienced the grade C PF (ISGPF) after the resection of
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underwent curative intent surgery between 2011–2015 were
included from prospective database. They were divided into
two groups: ?75 y/o; elderly (n = 29) and <75 y/o; young
(n = 74). Safety of surgical resection was assessed by postoperative complications, while long-term outcomes were
compared by survival analysis. Results: Between the two
groups, body mass index was significantly lower in elderly
patients (p = 0.046), while other patients baseline characteristics were not differ. There were no significant difference in
occurrence of overall postoperative complications and
grade III-V complications. Overall survival was comparable
between the two groups (1-and 3-year survival rate; 79 and
84%; 7 and 18%, elderly and young, respectively). Further
analysis focused on elderly patients, 2-year survivors showed
lower HbA1c (5.3 and 6.7, p = 0.009) and neutrophil-tolymphocyte ratio (2.2 and 3.2, p = 0.048), indicating patients
with these factors could benefit from pancreatic resection.
Conclusion: Pancreatic resection is justified for elderly
patients. Further strategies feasible for elderly patients may
be a challenge for the future.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Emergency First Presentation of Colorectal
Cancer: A Comparison of Presentation,
Management and Outcomes in Young
Under-50 and Older Over-50 Year Old Patients
P. Singh1, S. Tiwana2, E. Singh2, K. Patel2
University of Cambridge, Addenbrooke’s Hospital,
Plastic & Reconstructive Surgery, Cambridge, United
Kingdom, 2West Suffolk Hospital, Department of General
Surgery, West Suffolk, United Kingdom
Background: Colorectal carcinoma is the fourth
commonest cancer in the UK with an increasing incidence in
young adults. Emergency presentations of colorectal cancer
are associated with unfavourable outcomes. We compare
the incidence, clinical characteristics, management and
outcomes in emergency presentations of colorectal
carcinoma in two cohorts: under-50 and over-50 years old.
Material and Method: Data were collected retrospectively
from all patients with initial emergency presentations of
colorectal carcinoma at West Suffolk Hospital; January 2005
to December 2013. Data was collected from hard copy notes
and electronic databases on demographics, symptoms at
presentation, diagnostic modality, operative management,
oncological staging, histopathological grading, genetic
analysis, tumour location, chemotherapy, and mortality.
Results: 22 patients (under-50), median age 43-years,
male:female ratio 1:1.2 were compared to 300 patients
(over-50), median age 77-years, male:female 1:1, Bowel
obstruction was statistically lower in under-50 (18.3% vs.
40.7%; p = 0.04). Tumour characteristic analysis revealed a
higher incidence of appendiceal (p = 0.001) and mucinous
tumours (p = 0.02), a higher proportion of T1 tumours (p =
0.005) and Duke’s A (p = 0.002) in under-50 s. There was no
significant different in lymph node involvement or grade.
Surgery was performed more often in under-50 s (95.5% vs.
77.0%; p = 0.04) and more on the same day (71.4% vs. 28.1%;
p = 0.01). There was no significant difference in in-hospital
mortality between the under- and over-50 s (4.7% vs. 8.0%;
p = 0.55). Conclusions: The incidence of colorectal cancer is
rising in all age groups, with incidence in under-50 s of 7.3%
presenting as emergencies. Outcomes are comparable in
both age cohort, and despite young patients more likely to
undergo operative intervention, overall mortality was
comparable. We compare emergency presentations
between two age cohorts.
Associating Liver Partition and Portal Vein
Ligation for Staged Hepatectomy (ALPPS):
Failures at the Energetic Level
A. Budai1, A. Fülöp1, T. Kovács1, D. Tihanyi1, L. Tretter1,
G. Horváth1, Zs. Radák2, E. Koltai2, Z Bori2, A. Lukáts1,
A. Szijártó1
Semmelweis University, 1st Department of Surgery,
Budapest, Hungary, 2University of Physical Education,
Institute of Sport Sciences, Budapest, Hungary
Introduction: Recently, ALPPS is the most advanced
2-stage hepatectomy, which induces immense liver regeneration and makes liver resection possible in only 2 weeks.
Unfortunately, many ALPPS patient develops post-hepatectomy liver failure (PHLF) despite the sufficient amount of
liver remnant. Our goal is to examine the cellular energetic
changes behind ALPPS induced liver regeneration. Materials
and method: Male Wistar rats (n = 100) underwent ALPPS or
portal vein ligation (PVL). The animals were sacrificed without
operation (0 h) and 24, 48, 72 and 168 hours after the interventions. The individual liver lobe masses were measured to
calculate regeneration rate and tissue samples were taken
for further investigations. Mitochondrial respiration was
measured with Clark electrode and ATP production using
spectrophotometry. Nuclear respiratory factor 1 -and 2
(NRF1, NRF2) expression was assessed with western blotting.
Mitochondrial morphology was investigated using electronmicroscopy. Results: After 48 h in the ALPPS group the
regeneration ratio of the regenerating liver lobes were
significantly higher, while mitochondrial ATP production
decreased significantly (0.185 ± 0.049 vs. 0.106 ± 0.021
pmol/s/ml, PVL vs. ALPPS, p = 0.0381). The NRF1 concentration was significantly decreased 48 h after in the ALPPS
group compared to the PVL group (1.1 ± 0.1 vs. 0.5 ± 0.2-fold
expression; PVL vs. ALPPS; p ≤ 0.0001), the NRF2 concentration showed no significant differences. Mitochondrial
morphology has changed significantly as the ratio of smaller
than 0.24 μm2 mitochondria elevated significantly in the
ALPPS group compared to the PVL group 48 h after interventions (57.1 ± 10.1 vs. 30.7 ± 8.5%; ALPPS vs. PVL; p =
0.023). Conclusion: According to our results ALPPS causes
major failures in the cellular energy housekeeping of the
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pancreatic tail with the invasion of advanced transverse
colon cancer. In day 1, drain amylase was 85,000 IU/ml.
Immediately we performed our new technique showing
below; after resection of distal pancreas with GIF, without
any additional reinforce, to invaginate the stump to the
gastric posterior wall with single layer anastomosis using 3-0
absorbable suture. The anastomosis is not complicated,
taking about 15 minutes. Result: After this operation, drain
amylase went down to 242 IU/ml. Drain tubes were removed
on 3rd PO day of the 2nd operation. Conclusion: We show
the 2nd report of our new technique following the last ESSR
in Prague. Our technique could be used for the emergent
case with severe PF caused by other abdominal cancer operations.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
The Intraoperative Fistula Risk Score (i-FRS)
in Pancreatoduodenectomy: Development
and Validation in National and International
T.H. Mungroop1, L.B. Van Rijssen1, E.W. Steyerberg2,
C.M. Vollmer3, B. Groot Koerkamp2, M.G. Besselink1
AMC, Surgery, Amsterdam, Netherlands, 2Erasmus MC,
Surgery, Rotterdam, Netherlands, 3University Hospital
of Pennsylvania, Surgery, Pittsburgh, United States of
Background: A postoperative pancreatic fistula (POPF) is
the most threatening complications after pancreatoduodenectomy (PD). Current risk scores predict the risk of POPF
only after surgery, although clinically relevant treatment
decisions are often made intraoperatively e.g., regarding
drain placement and/or the use of somatostatin analogues.
Our aim was therefore to develop an intraoperative fistula
risk score (i-FRS). Methods: We included patients after PD
from three databases: the nationwide Dutch Pancreatic
Cancer Audit (DPCA; 18 centres: 2014–2016), the University
Hospital Southampton NHS (2007–2016) and an independent international database (17 centres: 2001–2016).
POPF was defined as a ISGPF grade B/C pancreatic fistula.
Missing data were imputed with multiple imputation (five
times). A prediction model was developed using multivariable logistic regression modelling. Internal-external validation was performed including model fit-in and cross-validation. Results: 3,955 patients were included with 16%
developing POPF. Three predictors were associated with
POPF: soft pancreatic texture (odds ratio (OR): 3.88), small
pancreatic duct diameter (per mm decrease, OR: 1.30), and
high Body Mass Index (BMI) (per kg/m2 increase, odds ratio
1.05). Discrimination of the model was adequate with a
c-statistic of 0.73 (95% CI: 0.71–0.75). Cross-validation
revealed the following c-statistics: DPCA 0.72, Southampton
0.74, international 0.71. An online calculator is available at Conclusion: The i-FRS
is the first, internationally validated, intraoperative fistula
risk score which predicts risk of POPF based on pancreatic
texture, ductal diameter, and BMI. Future prospective studies
will need to confirm the value of the i-FRS for adequate and
cost-effective use of preventive surgical measures and diagnostics.
Systematic Review of Transarterial
Embolization for Hepatocellular Adenomas
B.V. Van Rosmalen1, C.J.S. Coelen1, M.B. Bieze1,
O.M. Van Delden1, J.V. Joanne1, C.H.C. Dejong2,
T.M. Van Gulik1
AMC, Surgery, Amsterdam, Netherlands, 2University
Hospital of Maastricht, Surgery, Maastricht, Netherlands
Background: Hepatocellular adenoma (HCA) larger than
five centimetres in diameter is considered an indication for
elective surgery, because of the risk of haemorrhage and
malignant transformation. Transarterial embolization (TAE)
is used to manage bleeding HCA and occasionally to reduce
tumour size. TAE might have potential as an elective therapy,
but its current role in this context is uncertain. This systematic
review provides an overview of clinical outcomes after TAE,
in bleeding and non-bleeding HCA. Methods: Two independent reviewers performed a systematic search of literature in PubMed and Embase. Outcomes were change in
tumour size, avoidance of surgery, complications and
malignant transformation, after TAE in bleeding and nonbleeding HCA. The CASP tool for cohort studies was used for
quality assessment of included studies. Results: From 320
potential articles, 20 cohort studies and 20 case reports
including 851 patients met the inclusion criteria. TAE was
performed in 151 of 851 (18%) patients, involving 196
tumours, of which 96 (49%) were non-bleeding. Surgical
treatment was avoided in 73 of 151 (48%) patients. Elective
TAE was performed in 49 patients involving 66 HCAs, with
84% of these patients not requiring surgery. Major complications occurred in 8 of 151 patients (5%) and no mortality
was reported. Among cohort studies, complete tumour
disappearance was observed in 9% of patients, and
regression in 76%. Conclusion: Acute or elective TAE in the
management of HCA is safe. In the elective setting, TAE
provides a potential alternative to surgery.
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Lateral Cutaneous Nerve Entrapment
Syndrome (LACNES): A Previously
Unrecognized Cause of Intractable Flank Pain
R.C. Maatman, N.E. Papen-Botterhuis, M.R.M. Scheltinga,
R.M.H. Roumen
Máxima Medisch Centrum, Algemene Chirurgie,
Veldhoven, Netherlands
Background: Chronic abdominal pain is occasionally due
to entrapped terminal endings of intercostal nerves (ACNES,
abdominal cutaneous nerve entrapment syndrome). Spontaneous neuropathic flank pain is possibly also caused by
involvement of intercostal nerves. Aim is to describe a series
of patients with flank pain due to nerve entrapment and to
increase awareness for an unknown condition coined Lateral
Cutaneous Nerve Entrapment Syndrome (LACNES).
Methods: Patients possibly having LACNES (constant area of
flank tenderness, small point of maximal pain, locoregional
altered skin sensation) presenting between January 2007
and May 2016 received a diagnostic 5–10 mL 1% lidocaine
injection. Pain levels were recorded using a numerical rating
scale (0, no pain to 10, worst possible). A >50% pain reduction
was defined as success. Long term effect of injections and
alternative therapies was determined using a satisfaction
scale (1, very satisfied, no pain – 5, pain worse). Results: 30
patients (21 women, median age 53, range 18–73) were
diagnosed with LACNES. Pain following one injection
dropped from 6.9 ± 1.5 to 2.4 ± 1.9 (mean, n = 22, P < 0.001)
leading to an 81% immediate success rate. Injection therapy
was successful in 16 (pain free n = 7, pain acceptable, n = 9;
median 47 months follow-up). The remaining 14 patients
received (minimally invasive) visceral surgery (n = 5) or other
treatments (medication or manual therapy or PRF, n = 9).
Overall satisfaction with treatment (scale 1 or 2) was attained
in 79%. Conclusion: LACNES should be considered for
chronic flank pain. Injection therapy is long term effective in
more than half of the patients.
Pulsed Radiofrequency (PRF) and
Conventional Radiofrequency (RF) as
Minimally Invasive Treatment Options in
ACNES: A Retrospective Analysis of 45 Patients
R.C. Maatman1, M.A.H. Steegers2, J.W. Kallewaard3,
T. Heeren-Coumans4, M.R.M. Scheltinga1, R.M.H. Roumen1
Máxima Medisch Centrum, Algemene Chirurgie,
Veldhoven, Netherlands, 2Radboud Universitair Medisch
Centrum, Department of Anaesthesiology, Nijmegen,
Netherlands, 3Rijnstate Ziekenhuis, Pijngeneeskunde,
Velp, Netherlands, 4Slingeland Ziekenhuis,
Pijngeneeskunde, Doetinchem, Netherlands
Background: Chronic abdominal pain is occasionally due
to entrapped intercostal nerves (ACNES, abdominal cutaneous nerve entrapment syndrome). Pulsed Radiofrequency
(PRF) and conventional Radiofrequency (RF) are relatively
new treatment options for chronic pain syndromes. Evidence
regarding their effect in ACNES is lacking. Methods: A cohort
of ACNES patients undergoing PRF or RF treatment between
January 2014 and December 2015 was retrospectively evaluated. Pain was recorded using a numerical rating scale
(NRS, 0 (no pain) to 10 (worst possible)) prior treatment and
after 6 weeks. Successful treatment was defined as >50%
NRS pain reduction. Patient satisfaction was scored by
patient global impression of change (PGIC, 1 very much
worse to 7 very much improved). Results: 45 patients were
treated (PRF 27, RF 18, 30 women, median age 46 years,
range 18–69 years). After six weeks, median NRS in the PRF
group decreased from 7.0 (range 6.0–7.5) to 4.0 (range
2.0–6.0, p < 0.001), and in the RF group from 8.0 (range
7.0–9.0) to 4.0 (range 2.0–6.0, p = 0.001). The PGIC score was
4.9 ± 1.8 in PRF group vs. 5.5 ± 1.0 in the RF group. Treatment
was successful in 56% (n = 15) of the PRF group and 50%
(n = 9) of the RF group. Median effect duration was 4 months
(range 2–26) after PRF vs. 5 months (range 2–18) after RF.
Conclusion: Both treatment options may be effective for
ACNES. PRF remains favorable as it offers pain relief without
the nerve tissue destruction associated with RF. A prospective
study is currently conducted to confirm the value of PRF in
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
© 2017 S. Karger AG, Basel
V. Gómez-Gil, G.P. Pascual, M.R. Rodríguez,
C.M.C. Mesa-Ciller, B.P.K. Pérez-Köhler, J.M.B. Bellón
J. Hammerschlag, A. Ferencz, W. Wéber, G. Mohamed,
G. Szabó
University of Alcalá, Surgery, Medical and Social
Sciences, AlcalÁ De Henares, Spain
Semmelweis University, Department of Surgical Research
and Techniques, Budapest, Hungary
Background: Omental adhesions are one of the most
frequently encountered type in clinical practice. This study
examines collagenization over time related to TGF-β1,
TGF-β3 and the type III TGF-β receptor (betaglycan)
expression in omental adhesions. Material and Methods:
Polypropylene meshes (5 x 3.5 cm) were implanted on the
parietal peritoneum of New Zealand White rabbits. Specimens of omental adhesions were obtained 3 (n = 6), 7 (n =
6) and 14 (n = 6) days postimplantation. Native omentum
from unimplanted animals (n = 6) was used as control.
Presence of collagen was assessed by Picro-Sirius Red
staining and immunohistochemical detection of collagen I
and III. TGF-β1, TGF-β3 and betaglycan presence was immunohistochemically evaluated. Results: 3-day adhesions
preserved their adipose composition, though showing
submesothelial thickening and cell migration from milky
spots. The presence of the soluble form of betaglycan in
vessel lumens avoided potential fibrosis due to TGF-β1,
which was expressed in the microvascular network. 7 days
postsurgery, betaglycan mostly appeared as the membranebound form in inflammatory cells, together with an increased
expression of TGF-β1. This produced the deposition of a
collagen matrix giving rise to fibrous zones. At 14 days,
fibrous zones demonstrated presence of soluble betaglycan,
a decrease in TGF-β1 expression and collagen remodelling.
TGF-β3 appeared in zones of adipose regeneration,
concurrent with the presence of the membrane-bound form
of betaglycan. Conclusions: Spatial distribution of soluble
and membrane-bound form of betaglycan, together with
the expression of TGF-β1 and TGF-β3 at each time point, are
key factors to the cytoarchitecture and composition of
omental adhesion tissue. Acknowledgements: SAF201455022-P.
Post-Surgical Adhesion Prevention –
An Experimental Treatment of Diclofenac
on Different Postoperative Days
Background: Adhesion is a common postoperative
complication which causes major morbidity. There is not any
absolute solution which can prevent it completely. Although
the efficiency of different NSAIDs was researched, the examination of the right day of administration has not been
tested. Material and Methods: An intraabdominal adhesion
formation was generated on 47 Wistar rats with a standard
operating procedure. Five groups were treated with
Diclofenac intraperitoneally on different postoperative days
from day 0 to day 4 (named D0-D4). A control group (C)
wasn’t treated at all. On 7th postoperative day all rats were
re-operated and the adhesions were evaluated: adhesion
free animals, total number of adhesions, locations, size and
stabilization. Result: All tested groups showed some
percentage of adhesion free in contrast to control group
where the adhesion formation was 100%. D0 and D1 showed
the highest amount of adhesion free (42.9% and 37.5%).
Group D2 was found to have the lowest adhesion surface
average (0.18 cm2) comparing to C (2.8 cm2). Stable adhesion
formed in D2 only in 40% by 7th day, in C all the adhesion
was stabilized. All the treated groups showed better
outcomes in comparison to the control group. Conclusion:
Diclofenac can reduce the inflammation process in the early
postoperative period that is important in adhesion formation
prevention or reduction. The well determined treatment
time could increase its effectiveness. In our research 1st and
2nd postoperative days were found to have the best
Dynamic Hip Screw (DHS) Failure Rates in
a UK District General Hospital, Comparing
Current Practice for the Management of Neck
of Femur (NOF) Fractures with NICE Guidelines
C.L. Vella, R. King, B. Kapur, A. Lal, P. Bumford, G. Jackson
Arrowe Park University Teaching Hospital, Trauma &
Orthopaedics, Birkenhead, United Kingdom
Aim: To review DHS failure rates and compare current
practice for the management of NOF fractures with NICE
guidance. Method: A retrospective audit based on NICE hip
fracture guidelines. Round 1 audited all NOF fractures
treated with a DHS between April 2013–2014. An inter-
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An Experimental Adhesiogenic Model to
Evaluate Histological Events Over Time in the
Omentum during Adhesion Formation
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Awareness of the Tip-Apex Distance and
Lag Screw Diameter Improves Outcomes
in Dynamic Hip Screw Procedure for
Intertrochanteric Femoral Neck Fractures
I. Byrom, M. Argyropoulos, M. Cartwright-Terry
Southport and Ormskirk Hospital NHS Trust, Southport,
United Kingdom
In the UK up to 75,000 hip fractures occur annually.
Morbidity is high with 10% of patients dying at 1 month and
one third at 1 year. The combined medical and social cost is
estimated at 2 billion pounds. The intertrochanteric fracture
pattern constitutes approximately half of the cases. National
Institute for Clinical Excellence (NICE) guidelines recommends the use of Dynamic Hip Screw (DHS) for the operative
management of the majority of these injuries. A potential
complication of this treatment modality is the cutting out of
the lag screw through the femoral head resulting in significant morbidity and mortality. Consecutive patients receiving
a DHS for intertrochanteric neck of femur fractures were
retrospectively identified using our trauma database at 3
time points. Intraoperative radiographs were assessed, and
patients with incomplete or sub-standard images were
excluded. Patient case files were scrutinised for subsequent
cut-outs. Our intervention between audit cycles included
raising awareness and education of the TAD within the
department. The use of the lag screw diameter as a measuring
tool for intra-operative assessment of the TAD was highlighted. We have shown that through raising awareness of
the TAD amongst surgeons we have been able to improve
operative results. In particular the use of the lag screw
diameter as an intra-operative measuring tool is recom-
mended. Our study adds to the literature supporting the
notion that a TAD under 25 mm reduces the risk of this
complication. Other important factors remain such as
effective fracture reduction and the quality of bone.
The Effects of Tantalum on Cellular
Proliferation and Behaviour: An Analysis of
Its Appropriateness as a Biomaterial for Soft
Tissue Re-Attachment in Orthopaedic Surgery
J.T. Hirst1, E. Gee1, R. Eleotério2, A. Saithna2, J.A. Hunt2
Southport and Ormskirk NHS Hospitals Trust, Trauma
& Orthopaedics, Southport, United Kingdom, 2Institute
or Ageing and Chronic Disease, Clinical Engineering,
Liverpool, United Kingdom
Introduction: Tantalum is able to form large weightbearing structures that osseo-integrate readily. This makes
it an important biomaterial for replacing significant bone
loss. In such cases, function is often poor due to concomitant loss of native tendon insertions. Tendon re-attachment
is therefore an important objective. Clinical results of soft
tissue re-attachment to tantalum are variable. Previous
study has suggested that poor results may be explained by
fibroblast inhibition. The aim of this study was to determine
the effects of tantalum on the cellular behaviour and proliferation of Osteoblasts, Mesenchymal Stem Cells and Fibroblasts to determine whether it is an appropriate biomaterial
for tendon re-attachment. Methods: Cells were cultured
with glass cover slips or ‘commercially-pure’ Tantalumcoated cover slips to compare their behaviour and proliferation during 1, 2, 7, 14 and 28-day culture. The cells were
studied histologically and Cyquant testing was performed.
Results: Osteoblasts grew equally well on both surfaces
forming a dense monolayer and producing bony spicules by
28 days. Mesenchymal stem cells were seen to grow more
convincingly as a monolayer across the tantalum surface
compared to controls. Fibroblast proliferation was similar at
1, 2 and 7 days on both surfaces, however by 14 days the
number of fibroblasts on the Tantalum-coated slips was
double that of the controls. Conclusion: This study demonstrates that tantalum has a significant positive effect on
fibroblast proliferation. This suggests that variable clinical
results of soft tissue re-attachment are not due to fibroblast
inhibition as previously suggested.
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vention to educate and raise awareness of these guidelines
was put in place; practice was then re-audited, April 2015–
2016. X-Rays were reviewed for adequate reduction, subsequent fixation failure and further surgery. Results: 134
patients had DHS fixation in round 2 and 144 in round 1. In
the 2ndcohort there was a reduced failure rate of 2.7% (5/134
patients), compared with 5.6% (8/144). The revision rate
reduced from 4.9% (1stround) to 3%. The 2ndcohort saw the
introduction of trochanteric stabilisation plates (TSP) in 5.2%
of patients. All failures fell into the A3 fracture pattern
category making the cephalomedullary nail a more appropriate implant choice. Conclusion: This study highlights the
importance of improving identification of A3 fractures with
subtrochanteric extension and awareness of NICE hip
fracture guidance regarding their fixation. It raises a question
as to the role of using TSPs with a DHS rather than an cephalomedullary nail. Further research reviewing the outcomes
of TSPs in larger numbers may provide evidence to warrant
inclusion in national guidelines.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
© 2017 S. Karger AG, Basel
B. Van Rosmalen1, I. Alldinger2, K.P. Cieslak1, R. Wennink3,
M. Clarke4, U. Ahmed Ali3, M.G.H. Besselink1
A. Dalrymple, R. Patel, V. Patel, H. Hough, A. Reza,
E. Babu, A. Chakravorty, N.H. Hussain
Hillingdon Hospital London, Breast Surgery, London,
United Kingdom
AMC, Surgery, Amsterdam, Netherlands, 2University
Hospital of Heidelberg, Transplantation Surgery,
Heidelberg, Germany, 3University Medical Centre
Utrecht, Surgery, Utrecht, Netherlands, 4Queen’s
University Belfast, Northern Ireland Network for Trials,
Belfast, Ireland
Background: Publishing protocols of randomized
controlled trials (RCT) facilitates a detailed description of
study rationale, design, and related ethical and safety issues.
Little is known about how the practice of publishing
protocols developed over time. Therefore, this study
describes the worldwide trends in volume and methodological quality of RCT protocols. Methods: PubMed and
EMBASE were searched, identifying 596 protocols published
over a decade. Data were extracted on quality characteristics. Methodological quality was stated as high if adequate
generation of allocation, concealment of allocation and
intention-to-treat analysis were used. A comparison was
made by publication period, geographical region and
medical specialty. Results: The number of published RCT
protocols increased from 69 in the first, to 390 in the third
period (p < 0.0001). Internal medicine and paediatrics were
the most common topics. Whereas most protocols in the
first period originated from North America (n = 30, 44%), in
the second and third this was Europe (respectively, n = 65,
47% and n = 190, 48%) (p = 0.02). Quality of protocols was
higher in Europe compared to North America. Surgical
protocols had the highest quality among the three specialty
topics used in this study (OR = 1.94, CI = 1.09–3.45, p = 0.02).
Conclusion: A five-fold increase in RCT protocol publication
was observed. Although quality of protocols improved, it
varied between geographical regions and across medical
specialties. Improving training in RCT methodology is
therefore important.
Audit of the Standard of Induction for Junior
Doctors into a Breast Surgery Team at a
London District General Hospital
Background: A UK study has highlighted a 6% increase
in mortality for patients admitted on trainee handover day;
this is in line with international evidence showing increased
patient mortality of between 4.3–12.0%. We felt poor
induction is contributing to these statistics. We audited the
standard of Junior Doctor induction at a London-based
Breast Surgery Unit. Materials and Methods: Data was
collected on Junior Doctors working in the Breast Unit in two
cycles using an online 10-question survey. The first cycle was
between August-December 2016. A Junior Doctor Breast
Surgery Handbook was then created and implemented. The
second cycle was then carried out between December 2016–
April 2017. Results: There were 5 responses to both of the
audit cycles, with a response rate of 83%. 40% of the first
cycle disagreed when asked if they had a departmental
induction prior to starting their job in comparison to 20% of
the second cycle. 40% of the first cycle disagreed when
asked if they received information on their duties and
responsibilities, contrastingly 100% agreed when asked the
same question in the second cycle. 60% of the first cycle felt
overall they were underprepared for starting their job, no
Doctors felt underprepared in the second cycle. Conclusion:
Junior Doctor induction was significantly improved following
the creation of a Breast Surgery Handbook. Doctors now feel
more prepared and have a greater knowledge of the job
prior to starting. This will ultimately make the handover
between cohorts of Junior Doctors more efficient and
improve patient safety.
Standardizing the Description of Surgical
Procedures: A Step by Step Framework
T. Nazari1, E.J. Vlieger2, M.E.W. Dankbaar1,
J.J.G. Van Merriënboer3, J.F. Lange1, T. Wiggers2
Medical Center, Surgery, Rotterdam,
Netherlands, 2INCISION Academy, Amsterdam,
Netherlands, 3Maastricht University Medical Center,
School of Health Professions Education, Maastricht,
Background: Learning surgical procedures is traditionally
based on a master-apprentice model. Segmenting procedures into steps is commonly used to achieve an efficient
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Worldwide Trends in Volume and Quality of
Published Protocols of Randomized Controlled
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Effects of Delaying Elective Non-Cancer
Urological Surgery
J.M. Norris1, S. Ravi-Shankar2
University College London, UCL Division of Surgery &
Interventional Science, London, United Kingdom, 2King’s
College Hospital NHS Foundation Trust, Department of
Primary Care, London, United Kingdom
Background: Since 2012, the number of patients waiting
over 18 weeks for elective surgery has risen by 163%. Here,
we have conducted a retrospective multi-centre, multiprocedure cohort study to explore effects of prolonged
waiting lists in elective urological surgery. Materials and
Methods: Across two hospitals, 130 patients were listed for
surgery: percutaneous nephrolithotomy (PCNL; n = 26), or
bladder outflow obstruction surgery (TURP/HoLEP; n = 104),
during one year. Electronic databases were mined for:
complications, A&E attendances and hospital admissions.
Results: Overall, 35 complications occurred, over a mean
waiting time of 132.3 days. In the PCNL cohort, 22 patients
(84.6%) breached the six-week stone target and 11 patients
(42.3%) breached the 18-week NHS target; waiting list
complications included: flank pain (n = 4), haematuria (n =
1) and urosepsis (n = 4); resulting in five stone-related A&E
attendances and four admissions. In the bladder outflow
surgery cohort, waiting list complications included: haematuria (n = 3), epididymo-orchitis (n = 2), catheter-complications (n = 11), urosepsis (n = 5) and patient anxiety (n = 5);
resulting in 15 obstruction-related A&E attendances and six
admissions. Conclusion: In the NHS, ‘low-priority surgery’
and non-cancer work has restricted resource allocation. This
results in delayed elective urological surgery and, as a result,
patients experience increased complication rates and
hospital admissions, across multiple areas of urology.
Radiofrequency Ablation for the Treatment of
Haemorrhoidal Disease: A Novel and Effective
Minimally Invasive Surgical Procedure
M.E. Eddama, M.E. Everson, S.R. Renshaw, C.C. Carvalho,
R.C. Cohen
University College London, Surgery and Interventional
Medicine, London, United Kingdom
Introduction: Haemorrhoidal disease (HD) is a common
colorectal condition that often requires surgical intervention.
Although the treatment choice depends on the size of the
haemorrhoid, less invasive options are more acceptable to
patients. This study aims to report the outcome of a novel
and minimally invasive technique employing a radiofrequency ablation (RF) energy (RafaeloTM procedure) to treat
HD. Methods: A total number of 13 patients who underwent
the RafaeloTM procedure for the treatment of HD were
recruited to this study. The procedure was performed under
deep sedation, in addition to local anaesthesia. A specially
designed RafaeloTM device and associated HPR45i probe
were used to deploy a RF energy of 4 MHz (maximum of
25 Watts) to the haemorrhoidal cushions. Results: The mean
age of the patients was 45 years (SD = 14), 9 (70%) males
and 4 (30%) females. The mean body mass index was 25
(SD = 2). The predominant symptom of all patients was perrectal bleeding. Post-operative pain scores on a scale of 0 to
10 were 0, 2 (SD = 2), 1 (SD = 2), and 0 on immediate, day-1,
day-3 and 2-months follow-up questionnaire. The mean
satisfactory score was 9 (SD = 1.5) out of 10 on 2-months
follow-up. The mean return to work was on postoperative
day 3 (SD = 1). There was no recurrence recorded on a
2-month follow-up for grades 2 and 3 HD, however, 1
patient with grade 4 HD underwent a repeat RafaeloTM
procedure. No serious complications were recorded.
Conclusion: RafaeloTM procedure for the treatment of HD is
safe, and effective with minimal postoperative pain.
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manner of learning. However, the existing methods of
dividing procedures into steps are procedure-specific and
not standardized, hampering their fast application on
multiple procedures of different specialties and thus
worldwide uptake. Aim: The aim of this study is to establish
consensus on the preciseness, novelty, usefulness and applicability of the step by step framework for standardizing the
breakdown of surgical procedures into steps. Within the
framework, definitions are provided for steps and substeps
which are based on the anatomical structures that are
encountered during the procedure. Methods: An international expert panel of 49 experienced surgeons was
approached to establish consensus on the above-mentioned
characteristics of the proposed step by step framework
through a Delphi technique. The applicability was based on
two procedures. The 19 statements were rated on a 5-point
Likert scale. Results: In round one 20 experts participated.
Eighteen of the 19 proposed statements were accepted –
the novelty statement needed further exploration. Based on
the qualitative comments of round one, the emphasis of
round two shifted from novelty to preciseness. Five additional preciseness statements were formulated and all were
accepted by 22 of the 49 experts. Conclusion: The international expert panel supports the preciseness, usefulness and
applicability of the step by step framework. The framework
is a suitable standardized method for the breakdown of
surgical procedures into step by step descriptions and
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
SOFTIE: Soft hOllow Flexible roboT for
Interventional Endoscopy
L.M. Manfredi, C.U. FRSE Cuschieri
University of Dundee, IMSaT, Institute for Medical
Science and Technology, Dundee, United Kingdom
Introduction: A robotic soft colonoscope able to change
its shape to conform to the contours of the individual
patient’s colon, will expedite the painless transit form rectum
to caecum, thereby avoiding need for sedation during
screening colonoscopy (SC). However, the design of such a
mini robotic device is challenging because of the limited
available colonic luminal space (40–90 millimetre) and the
length of the colon (circa 1.5 meter). Methods and Procedures: In contrast to the traditional flexible colonoscope, the
authors propose a novel alternative platform, SOFTIE,
equipped with a high resolution camera at the distal section
and a channel for a biopsy instrument. The design is novel
as it is based on a patented soft and hollow modular pneumatic actuator, made of soft polymer and controlled via an
external simple console. SOFTIE is able to change its form by
controlling each segment without any stress or forces on the
colonic wall, hence ensuring painless SC, thereby increasing
compliance. Results: A preliminary concept of this actuator
has been tested in the lab at IMSaT and has shown high
dexterity with a low pressurised air, an external diameter of
20 mm, and an inner lumen of 5 mm. Conclusions: Preliminary experiments have indicated the potential of the
proposed soft actuator in the development of a new generation of active soft colonoscopes. Different control strategies can be implemented and further improvements in the
design of additional components (e.g. air valves and
embedded electronic system) are needed to reduce size of
the hardware.
A Case Series of Laparoscopic Colorectal
Resections with Natural Orifice Specimen
Extraction (NOSE)
Nasir Ahmad, Ahmed Waqas, Ashu Gumber,
Filippos Sagias, Syed AH Naqvi, Jim Khan, I. Mykoniatis
QAH, Colorectal Surgery, Portsmouth, United Kingdom
Background: The role of laparoscopic colorectal resections with trans-abdominal specimen extraction (TAE) is well
established. Natural orifice specimen extraction (NOSE) is a
novel and relatively uncommon technique and may lead to
similar outcomes. Methods: A total of 35 consecutive NOSE
patients were analysed retrospectively from a prospectively
maintained database. Demographic details, ASA grade,
disease characteristics, intraoperative parameters and post-
operative outcomes were examined. Results: There were 35
patients in this series with median age 59 (29–79) and
average BMI of 25.7. The male to female ratio was 1:2. The
details of type of operation is given in the table. The median
operating time for right sided colectomy was 160 minutes
whereas left sided resections took 270 minutes for
completion. There were no mortality or conversions to open
extraction. Two patients were re operated for stoma related
complications and three other patients had minor complications. Median lymph node harvest was 19. R0 resection was
achieved in 91%. The length of hospital stay was 5 days. No
local metastasis or iatrogenic injuries were seen at the time
of retrieval. Conclusion: Natural Orifice Specimen Extraction
is feasible with short hospital stay and is an attractive option
in pursuit of scar-less surgery. Long-term benefits over TAE
remains to be proven and require a randomised controlled
Laparoscopic Right Hemicolectomy:
A Preferred Approach in Emergency
Cancer Surgery
N. Ahmad, F. Sagias, A. Gumber, A. Waqas, S.A.H. Naqvi,
J. Khan, I. Mykoniatis
QAH, Colorectal Surgery, Portsmouth, United Kingdom
Introduction: Right hemicolectomy is a standard
procedure for cancers involving the right side of the colon.
Advanced cancers may present as surgical emergencies
requiring urgent curative or palliative interventions. The
aim of this study was to assess the feasibility and effectiveness of laparoscopic right hemicolectomy in emergency
situations and to examine its impact on cancer free survival.
Methods: Laparoscopic and open right hemicolectomies
carried out as emergencies in the last ten years were
compared in terms of short term outcomes (post operative
ileus, pain, complications and length of hospital stay),
oncological effectiveness (disease clearance, number of
lymph nodes) and overall survival. Results: There were 120
patients in the open group and 47 patients in the laparoscopic group with a mean age of 72.35 ± 11.66 and 71.35 ±
14.30 years respectively. The median length of hospital stay
was 12 days (standard error of mean: 1.44) and 7 (SEM:1.26)
days respectively. R0 resections were carried out in 93
(77.5%) patients in the open group and 39( 82.97%) patients
in the laparoscopic group. The 30 day mortality in the open
and laparoscopic group was 15 (12.5%) and 6 (12.7%)
respectively. During the study period 90 (75%) cancer
related deaths were recorded in the open group and 22
(46.80%) in the laparoscopic group. Five year survival was
11.66% and 17.02% in the open and laparoscopic group
respectively. Conclusion: The laparoscopic approach to
right hemicolectomy in emergency situations carries a
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Establishment of a Rat Model for Pressurized
Intraperitoneal Aerosol Chemotherapy
L. Van de Sande, W. Willaert, S. Cosyns, W. Ceelen
Ghent University, Surgery, Ghent, Belgium
Background: Peritoneal carcinomatosis is an unmet
medical need. Intraperitoneal chemotherapy has limited
drug distribution and poor peritoneal penetration. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has
shown to improve drug uptake by utilizing the physical
properties of gas and pressure. In this study, a rat model was
developed to further enhance the pharmacologic properties
of PIPAC. Methods: Preliminary pilot studies were performed
to determine the most suitable parameters in our animal
model. Optimal flow rate, injection volume, injection
pressure and pressure of pneumoperitoneum were determined to obtain a homogeneous aerosol. Subsequently, a
rat model for PIPAC was established with these parameters.
To simulate a PIPAC procedure, we used 5 mm balloon
trocars, a nebulizer, a high pressure injector, a laparoscope
and a closed aerosol waste system. Results: It has been
found from the preliminary pilot studies that the most
suitable parameters are the following: nebulization of 8 ml
0.9% NaCl, a flow rate of 0.5 ml/s, an injection pressure of 20
bar and a pneumoperitoneum of 4 mm Hg. Subsequently,
PIPAC was performed in the rat model (n = 3). All rats
survived and there was no leakage observed over the entire
setup. Conclusions: The PIPAC procedure was found to be
feasible and safe in a rat model. In the future, we aim to
study 1) the pharmacological and physical properties of the
aerosol in the rat model and 2) the efficacy of several cytostatics into a SKOV3 xenograft rat model. This way, an
attempt will be made to improve the treatment of peritoneal
Intestinal Anastomoses Made by
Electrothermal Bipolar Vessel Sealing Device.
Preliminary Animal Results
J.P.-Sz. Pap-Szekeres1, L.V. Venczel2, SzI Szabó2,
Cs.D. Csukás3, Cs.G. Cserni2, W.Gy. Wéber3
Country Teaching Hospital Kecskemét, Generál surgery,
KecskemÉT, Hungary, 2County Teaching Hospital,
Department of General Surgery, County T, KecskemÉT,
Hungary, 3Semmelweis University, Faculty of Medicine,,
Department of Surgical Research and Tec, Budapest,
Background: Anastomotic leakage is a serious complication of intestinal resections. Leakage may be associated
with many severe consequences and sometimes life-threatening conditions. Modern electrothermal bipolar vessel
sealing devices (EBVS) are becoming more popular in
surgery. These devices are suitable not only for vessel sealing
but also for tissue fusion. This study aims to develop the
surgical technique of different types of intestinal anastomoses made by EBVS device. Methods: In one porcine three
small intestinal resections were performed by Caiman®
(Aesculap, B-Braun) device. Two of them were side-to-side
fashioned and one was end-to-end, respectively. We
assessed the healing of the anastomoses by our own
“complicated anastomosis healing”(CAS) score, at which 5
different parameters were examined on the tenth postoperative day: 1. signs of peritonitis, 2. intraabdominal adhesions, 3. tissue defect in the anastomotic line, 4. signs of
endoluminal functional exam, 5. histopathology. Each
parameter was given a score of 0 to 2. Results: All three
anastomoses made by EBVS healed well. The CAS score
results of the anastomoses were 1, 2, 0. The end-to-end
anastomosis healing was the best. Conclusions: According
to our preliminary data, all intestinal anastomoses made by
EBVS device proved to be viable and well-healed. With the
help of our CAS scoring system the examination of the
healing of intestinal anastomoses made by EBVS device was
simple and feasible.
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comparable 30 day mortality to open surgery and is associated with better short term outcomes and overall five
year survival.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Primary Hyperparathyroidism Presenting as
Acute Psychosis
P. Singh1, Y. Bauernfreund2, J. Shute2
University of Cambridge, Addenbrooke’s Hospital,
Plastic & Reconstructive Surgery, Cambridge, United
Kingdom, 2North Middlesex Hospital, Department of
Vascular & General Surgery, London, United Kingdom
Background: Hypercalcaemia related psychosis is a rare
phenomenon and hypercalcaemia often presents with
subtle clinical signs of polyuria, polydipsia, abdominal pain
and nausea. This vague clinical picture can delay diagnosis.
Psychosis can further mask the underlying aetiology as
calcium levels are not routinely checked, leading to misdiagnosis as a primary psychotic disorder, resulting in antipsychotic medications with numerous side effects, and
progressive deterioration from their underlying hyperparathyroidism. Correct identification is important and we will
highlight the need to investigate psychotic symptoms for
reversible, organic causes. Case Report: We report the case
of a middle aged Afro-Caribbean patient who was seen by
the hospital psychiatry team following third person auditory
hallucinations. A first set of screening bloods revealed no
obvious abnormality and she was started on antidepressant
and antipsychotic medication. Her condition deteriorated
over the next two weeks with increasing episodes of
psychosis and confusion. She represented and clinical examination revealed a small, palpable neck lump. Bloods revealed
hypercalcaemia (3 mmol/l) and subsequently elevated parathyroid hormone (14 ng/l), low vitamin D (8 nmol/l) and low
serum phosphate (0.6 mmol/l). Ultrasound and radionucleotide imaging with Sestamibi illustrated a parathyroid
adenoma. Following initial medication treatment, and
further curative surgical resection, her psychotic symptoms
completely resolved. Conclusions: The importance of
excluding organic causes for psychotic presentations is
imperative, with misdiagnosis having disastrous consequences. We illustrate primary hyperparathyroidism
presenting as acute psychosis, how we investigated and
managed the patient, and how we followed her and her
family up post-surgery for consideration of MEN 1 and other
genetic predispositions.
Lumbar Subcutaneous Abscess Caused by a
Perforated Appendicular Tumor Herniation:
Anatomic Considerations and Minimally
Invasive Treatment
J.D. Douissard, Z.A. Abassi, L.V. Vouga, P.M. Morel, F.R. Ris
University Hospital of Geneva, Visceral Surgery, Geneva,
Introduction: The triangle of Jean-Louis Petit (TOP) is a
weakness of the lumbar abdominal wall described as a way
for abdominal herniations. Here we describe the case of a
lumbar abscess caused by an appendicular mucinous adenocarcinoma perforation through the TOP and its minimally
invasive management. Case Description: A 73 years old
patient with an abscess of the right lumbar area, fever,
biologic inflammatory syndrome and no abdominal
symptom underwent ultrasound and abdominal CT evaluation wich confirmed abscess in the subcutaneous tissue of
the right lumbar region, extending in the retroperitoneum
from the tip of a dilated appendix, along the psoas muscle
and through the right inferior lumbar triangle so called
"triangle of Jean-Louis Petit" (TOP). Laparoscopic approach
associated with a 3 cm lumbar incision allowed minimally
invasive efficient treatment. No complication was encountered post-operatively and pathology reported a covered
perforation of an appendicular mucinous adenocarcinoma
pT3 Nx G3 Ro. No sign of dissemination was found and after
complete healing of the abdominal wall the treatment was
completed by a laparoscopic right hemicolectomy according
to the multidisciplinary tumor-board decision. One year
follow up showed no mid-term complication. Discussion:
This is the first case described of a perforated appendicular
tumor through the TOP. Lumbar abscess caused by appendicular perforation in general is a very rare condition (6 cases
to date in the literature). The diagnosis is misleading because
of the absence of abdominal signs. The extension of the
abscess in this case follows an anatomic logical, yet unusual
AB0 – Incompatible Split Liver Transplantation
in a Married Couple with Fulminant Hepatic
Failure due to Mushroom Poisoning (Amanita
Phalloides) – A Case Report
T. Pantoflicek, J. Fronek
IKEM, Department of Transplant Surgery, Prague, Czech
Background: The use of split liver graft for emergency
transplantation in two patients is rare, especially the AB0 –
incompatible split liver transplantation. Case Report: We are
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Case Report Describing the Use of Augmented
Reality (AR) to Guide Surgery in Gaza from
M.J. Greenfield1, R.S. Sullivan2
University College London, Medical School, London,
United Kingdom, 2King’s College London, Institute of
Cancer Policy, London, United Kingdom
Introduction: Restrictions on movement of people in
areas of conflict often means that there is a shortage of
medical and surgical expertise in these areas. In this case
report we explore how PROXIMIE, an AR platform enabled
local surgeons in Gaza to be guided by a remote plastic
surgeon acting in Beirut. Case Report: PROXIMIE is an
augmented reality platform that allows a remote surgeon to
virtually scrub in to guide, mentor and support a local
surgeon through a procedure simply by using a tablet or
computer. With augmented reality, the remote surgeon is
able indicate with his hands or annotations, diagrams, and
clinical imaging, the step-by-step approach to a case in real
time. In this case, a young man sustained bomb blast injuries
to his hand which required specialist guidance from a plastic
surgeon at the American University of Beirut Medical Centre.
Using the PROXIMIE platform, the remote surgeon, Dr AbuSitta, was successfully able to guide the surgeons in Gaza
from over 300 kilometres away. Discussion: This is the first
recorded case of AR assisted surgery and as a result of the
success of this case, as well as the growing centralisation of
surgical expertise, we predict AR in surgery becoming more
widely used. There are a number of potential uses from
supporting austere environments and capacity building, to
efficient provision of surgical expertise within and between
hospitals, to medical school and surgical device training.
Unusual Aetiology of Right Leg Neurology
R.R. Goel, V. Muralidharan, M. Goel, S. Al-Islam, D. Gavan,
R. Salaman, H. Al-Khaffaf
Royal Blackburn Hospital, Vascular Surgery, Blackburn,
United Kingdom
Background: Isolated Internal iliac artery aneurysms (IIA)
are rare (0.3%–0.5%). Identified incidentally on radiological
studies or presenting as rupture (33%), with high mortatilty
(33–50%). Materials and Methods: A 42 year old man with
the history of Takayasu’s disease and thoraco-abdominal
aortic aneurysm repair, presented with pain, weakness, and
numbness in the right leg of two weeks duration. His
magnetic resonance scan, suggested right psoas abscess
causing neurological symptoms. Ultrasound guided
drainage was suggested. Ultrasound demonstrated aneurysmal flow. Subsequent computerised tomography angiography revealed a ruptured right internal iliac artery
aneurysm into the right psoas muscle. Patient proceeded to
have an urgent angiogram. A covered stent was placed in
right common iliac artery which occluded the rupture. Usual
clinical presentation of IIA are abdominal pain, back pain,
hydronephrosis, renal failure, haematuria, shock due to free
rupture. IIAAs are more common on the left (61.8% left,
27.3% right, 10.9% bilateral). Treatment options are open,
endovascular or hybrid repair. Results: The post-operative
period was complicated by pancreatitis. His right leg
weakness did not worsen clinically. He is having outpatient
physiotherapy and neurology follow-up. Conclusion: Endovascular means can effectively manage ruptured IIA. Due to
low incidence and only accounting for ten percent of all iliac
aneurysms with varying presentations, knowledge and
management of internal iliac aneurysm is important. With
the advent of novel techniques early means of diagnosis and
management of IIA requires further research.
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reporting about two patients – married couple – with a
fulminant liver failure due to mushroom poisoning (Amanita
Phaloides). They were both placed on the waiting list for liver
transplantation with the highest level of urgency. Male
patient: His acute liver failure was treated with plasmapheresis on day one, followed with artificial liver support
(Prometheus system). The patient received ABO-compatible
full right graft of split liver (Couinaud segments V-VIII).
Smooth and straight forward recovery was observed, with
an episode of acute cellular rejection (ACR) 4-5/9 treated
with corticoids with no major complications. Female patient:
She has been prepared for the transplantation with an
immunoadsorbtion because of AB0 incompatibility (Donor
blood group A, Recipient 0). The patient received a full left
graft of split liver (Couinaud segments I-IV). The immunoadsorbtion was performed in total 6 times. For biliary leak, the
original choledocho-choledocho anastomosis has been
changed to hepatico-jejunostomy. Both patients were
discharged together. Conclusion: Split liver transplantation
for two adult recipients for fulminant liver failure is a safe
technique and should be offered to the acute ill patients
even if there is just an AB0 incompatible donor available.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Acute Cholangitis Caused by Migration of
Metal Clips as a Nidus for the Formation of
Common Bile Duct Stones 13 Years after
Undergoing Laparoscopic Cholecystectomy
H.T. Taketomi
Yamamoto Memorial Hospital, Surgery, Imari, Japan
Choledocholithiasis develops easily in the bile duct and
can develop due to the presence of a foreign substance,
such as artificial silk, inside the bile duct. Laparoscopic cholecystectomy has been widely performed for benign gallbladder lesions, and metal clips are often used to treat the
stump of cystic duct and cystic artery. We report a case of
choledocholithiasis with a migrated surgical metal clip used
to close a cystic duct stump following laparoscopic cholecystectomy as the nucleus.
Nicotine Chewing Gum for the Prevention of
Postoperative Ileus after Colorectal Surgery –
A Multicentre, Double-Blind, Randomised,
Controlled Pilot Study
D.P.V. Lambrichts1, G.S.A. Boersema1, B. Tas1, Z. Wu2,
W.W. Vrijland3, G.J. Kleinrensink1, J.J. Jeekel1, J.F. Lange1,
A.G. Menon4
1Erasmus MC, Surgery, Rotterdam, Netherlands, 2Beijing
University Cancer Hospital & Institute, Surgery, Beijing,
China, 3Sint Franciscus Gasthuis, Surgery, Rotterdam,
Netherlands, 4Havenziekenhuis, Surgery, Rotterdam,
Background: When postoperative ileus is not resolved
after 5 days or recurs after apparent resolution, prolonged
POI (PPOI) is diagnosed. PPOI increases discomfort,
morbidity and hospitalization length and is mainly caused
by an inflammatory response following intestinal manipulation. This can be weakened by targeting the cholinergic
anti-inflammatory pathway, with nicotine as essential regulator. Chewing gum, already known to stimulate gastrointestinal motility itself, combined with nicotine is hypothesized
to improve gastrointestinal recovery and prevent PPOI. This
pilot study is the first to assess effectiveness and safety of
nicotine gum in colorectal surgery. Material and Methods:
Patients undergoing elective oncological colorectal surgery
were enrolled in this double-blind, controlled trial and
randomly assigned to a treatment protocol with normal or
nicotine gum (2 mg). Patient reported outcomes (PROMS),
clinical characteristics and blood samples were collected.
Primary endpoint was defined as time to first passage of
faeces and toleration of solid food for at least 24 h. Results:
Forty patients were enrolled (20 vs. 20). In both groups 30%
of patients developed PPOI. Median time to primary
endpoint (4.50 [3.00–7.25] vs. 3.50 days [3.00–4.25], p =
0.398) and median length of stay (5.50 [4.00–8.50] vs. 4.50
days [4.00–6.00], p = 0.738) did not differ significantly
between normal and nicotine gum. There were no differences in PROMS, inflammatory parameters and postoperative complications. Conclusion: We proved nicotine gum to
be safe but ineffective in improving gastrointestinal recovery
and prevention of PPOI after colorectal surgery. Other
dosages and administration routes of nicotine should be
tested in future research.
Portsmouth Protocol for Triple Assessment
of Colorectal Anastomosis in Robotic Surgery
Reduces Anastomotic Leak & Reoperation
Rates in Rectal Cancer Surgery
Nasir Ahmad, Syed AH Naqvi, Ahmed Waqas,
Ashu Gumber, Filippos Sagias, Jim Khan, I. Mykoniatis
QAH, Colorectal Surgery, Portsmouth, United Kingdom
Introduction: Different techniques to assess the intraoperative integrity of the anastomoses have been described.
The aim of this study was to investigate the impact of triple
intra-operative assessment with Indigocyanine Green (ICG)
with Firefly technology (da Vinci), Flexible Sigmoidoscopy
and underwater-leak test during robotic anterior resections
on post-operative anastomotic leak rate. Methods: Consecutive patients who underwent robotic anterior resection and
intraoperative triple assessment of the anastomoses were
reviewed. Demographic details, comorbidities, tumor stage
and location, operating time, need for defunctioning stoma,
clinical anastomotic leak, radiological leak, reintervention
and other complications were analysed. Results: A total of
89 patients underwent robotic anterior resection with intraoperative triple assessment of anastomoses. The mean age
of the cohort was 68 years (35–88) with 64 males and an
average BMI of 26. There were 13 cancers at the rectosigmoid whereas all others were rectal cancers. Triple
assessment was carried out in all the patients. No defunctioning stoma was given in 22 patients. The average operating time was 250 min (170–456) with an average length of
hospital stay of 8 days (3–43). There were 10 readmissions
including one clinical anastomotic leak which required
surgical intervention (1.12%). Two radiological leaks were
managed conservatively (2.24%). All cases were completed
robotically with R0 resection in 87 cases (98%) and no 30 day
mortality. Conclusion: Portsmouth Protocol for anastomotic
assessment during a robotic anterior resection can be a
useful adjunct and may reduce the re-operation & anastomotic leak rate in colorectal cancer surgery.
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
© 2017 S. Karger AG, Basel
L. Cloe1, C.L. Sparreboom1, J. Van Groningen2, H.F. Hester1,
M.W.J.M. Wouters3, A.G. Menon4, G.J. Kleinrensink1,
J. Jeekel1, J.F. Lange1
S.J. Van Rooijen1, G. Thomas1, F. Carli2, S.O. Dalton3,
C. Johansen4, J. Dieleman1, R.M.H. Roumen1, G.D. Slooter1
Erasmus Medical University Rotterdam, Abdominal
Surgery, Rotterdam, Netherlands, 2Leiden University
Medical Center, Department of Surgery, Leiden,
Netherlands, 3Netherlands Cancer Institute-Antonie
van Leeuwenhoek, Department of Surgical Oncology,
Amsterdam, Netherlands, 4Havenziekenhuis, Department
of Surgery, Rotterdam, Netherlands
Background: Anastomotic leakage (AL) remains a major
complication after surgery for colorectal carcinoma but the
etiology is still unknown. Our hypothesis is that early AL is
mostly related to technical failure of the anastomosis and
late AL to healing deficiencies. Materials and Methods: All
patients undergoing surgical resection for colorectal cancer
in the Netherlands between January 2011 and December
2015 were included. We defined late AL as AL leading to
re-intervention later than 6 days postoperatively. We used
multivariate multinominal regression analyses to test independent associations between patient, tumor and treatment
characteristics and the occurrence of no, early and late AL.
Results: In total 36.929 patients were included, early AL
occurred in 863 (2.3%) patients and late AL occurred in 674
(1.8%) patients. Male gender, lower age, increased BMI,
rectal cancer, laparoscopic surgery, emergency surgery, no
diverting ileostomy were independent risk factors for early
AL. Male gender and rectal cancer were also independent
risk factors for late AL. Charlson Comorbidity Index of = II,
ASA score III-V, preoperative complications, additional
resection because of tumor growth, and preoperative radiotherapy were independent risk factors for late AL but not for
early AL. Conclusions: Most risk factors for early AL were
surgery related factors, representing surgical difficulty,
which might lead to technical failure of the anastomosis.
Most risk factors for late AL were patient related factors,
representing frailty of patients and tissues, which might
imply healing deficiencies.
Preoperative Modifiable Risk Factors in
Colorectal Surgery: An Observational Cohort
Study Identifying the Possible Value of
Maxima Medical Center, Surgery, Veldhoven,
Netherlands, 2The Montreal General Hospital,
Anesthesiology, Montreal, Canada, 3Danish
Cancer Society, Research, Copenhagen, Denmark,
Rigshospitalet, Research, Copenhagen, Denmark
Background: Colorectal cancer (CRC) is the second most
prevalent type of cancer in the world. Surgery is the only way
to cure, however still associated with many complications
(50%) and a reduction in functional capacity (20–40%). The
number and severity of complications is closely related to
patients’ preoperative status. The study aim was to identify
preoperative modifiable risk factors, that could be part of a
prehabilitation program. Materials and Methods: Prospectively collected data of CRC patients undergoing surgery
were analyzed. Modifiable risk factors were correlated to the
Comprehensive Complication Index (CCI) and compared
within two groups: none or mild complications (CCI = 0 or
CCI <20), and severe complications (CCI ≥20). Multivariate
logistic regression analysis was done to explore the
combined effect of individual risk factors. Results: In 139
patients, risk factors related to severe postoperative complications (CCI ≥20) are ASA score III (OR 4.4, 95% CI 1.04–
18.6), and hemoglobin level <7 mmol/L (OR 3.3, 95% CI
1.3–8.2). Number of pack years, malnutrition, alcohol
consumption, neoadjuvant therapy, higher age, and male
sex, were also seen more frequently in the severe complication group. Number of risk factors was predictive for an
increased CCI score ≥20 (OR 5.2, 95% CI 1.8–15). Patients
with CCI ≥20 had a significantly longer hospital stay (16 vs
6 days, p < 0.001). Conclusions: This study revealed that the
risk of getting severe complications increases with the
number of modifiable risk factors present preoperatively.
Multimodal prehabilitation may improve patients’ preoperative status and should be investigated. Therefore, we
initiated a multicenter randomized controlled trial (NTR5947).
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Different Risk Factors for Early and Late
Colorectal Anastomotic Leakage in a
Nation-Wide Audit
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Robotic Complete Mesocolic Excision (CME)
for Transverse Colon or Node Positive Right
Colonic Tumours
N. Ahmad, S.A.H. Naqvi, A. Waqas, A. Gumber, F. Sagias,
J. Khan, I. Mykoniatis
QAH, Colorectal Surgery, Portsmouth, United Kingdom
Introduction: The concept of TME is applicable to
advanced tumors of the right colon with positive lymph
nodes. Laparoscopic complete mesocolic excision with
central vascular ligation (CVL) has been reported. Robotic
surgery has emerged as form of minimal access surgery with
more controlled ergonomics. The aim of this study was
analyse the experience of robotic CME in our institute.
Methods: Consecutive patients with proximal transverse
colon or lymph node positive right colon tumours were
selected for robotic right hemicolectomy with complete
mesecoloic excision. Patient demographics, ASA grade, TNM
stage, operation time, blood loss, length of hospital stay and
the oncological factors such as adequacy of complete mesocoloic excision, specimen length, number of lymph nodes
and CVI were analysed. The robotic technique was analysed
with respect to other techniques reported in the literature.
Results: This case series comprised of 10 patients with an
average age of 73 years. There were four patients with T3
tumor and three patients were lymph node positive on
imaging. All patients were M0. The average total operating
time was 213 min. Hospital stay was 8 days (4–13). The
average number of lymph nodes harvested was 28 (18–38).
R0 resection was achieved in all the cases and there was no
major post-operative complication. Conclusion: Robotic
surgery for complete mesocolic excision is an effective way
of dealing with tumors of the transverse colon or lymph node
positive right colonic tumours. It is envisaged that it would
have its impact on longterm cancer related outcomes.
TEMS: Beyond the Limits
N. Ahmad, A. Waqas, A. Gumber, F. Sagias, S.A.H. Naqvi,
J. Khan, I. Mykoniatis
QAH, Colorectal Surgery, Portsmouth, United Kingdom
Background: Transanal endoscopic microsurgery (TEMS)
is considered suitable for early T1 and some T2 cancers after
down staging the later. The role of TEMS is also limited by
the location, size and percentage of rectal circumference
involved. The aim of this study was to assess the role of
TEMS beyond the usual confines and limits. Methods: All the
patients who underwent TEMS from 2011 to 2016 were
analyzed from a prospectively maintained database. Our
primary endpoint was local and distant recurrence rate and
the treatment offered. The secondary endpoints were intraoperative and postoperative short term outcomes like pain,
hospital stay and return of bowel activity. Results: There
were 46 patients in this cohort with a median age of 74
(42–90) and male:female ratio of 2:1. Neoadjuvant radiotherapy was given to 50% of patients. The details of distance
from anal verge and T stage is given in the table. There were
six local recurrences in the study period (17%). Four of these
required salvage surgical procedures and rest of them were
managed with adjuvant therapy. Conclusion: The local
recurrence rate after TEMS in this series is similar to the
larger published studies. Therefore TEMS procedure may be
offered to carefully selected patients with tumors larger than
three centimeters and sometimes more than 8 cm from the
anal verge.
Survival and Quality of Life after Pelvic
Exenteration for Locally Advanced Colorectal
J. Hida, Y. Yoshioka, H. Ushijima, K. Daito, J. Kawamura,
K. Ueda, T. Tokoro, I. Matsumoto, T. Yasuda, K. Okuno
Kindai University, Surgery, Osaka, Japan
Background: We examined the survival benefit of pelvic
exenteration for locally advanced colorectal cancer with
lymph node metastases, because this issue remains controversial. Methods: Medical records of 56 patients who
underwent curative pelvic exenteration for colorectal cancer
were reviewed retrospectively. Nodal metastases were
examined by the clearing method in 29 patients and by the
conventional manual method in 27 patients. Using a questionnaire, we examined the postoperative conditions (1 to 6
years after surgery; mean, 3 years). Results: Invasion to
contiguous pelvic organs was present in 45 patients (80%)
and absent in 11 patients (20%). Node metastases were
present in 38 patients (68%). Operative morbidity and
mortality rates were 23% (13 patients) and 5% (3 patients),
respectively. Respective five-year survival rates were 60 and
80% in the groups with and without organ invasion (no
significant difference). Five-year survival rates in patients
with nodal metastases was 54.6% but was significantly
higher, 82.4%, in patients without nodal metastases. Fiveyear survival in 32 patients with both organ invasion and
nodal metastases was 53.6%. 35 patients (63%) return to
their normal level of social condition after surgery. However,
the will to live is less (substantive: 18 patients (32%). Conclusions: Long-term survival was afforded by pelvic exenteration for locally advanced colorectal cancer with nodal
metastases. Although most patients return to their normal
level of social condition after surgery, their will to live is less
because of physical discomforts including the presence of
colostomy and urostomy.
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Hematologic Toxicity Associated with
Neoadjuvant Chemoradiotherapy for Patients
with Rectal Cancer – Review
E. Enchev, M.D. Minkov, A. Petrov, M.D. Dimitrov,
M.D. Nikolov, Prof. Yovchev
The Therapeutic Strategy for Esophageal
Bypass Surgery Followed by Definitive
Chemoradiotherapy for Patients with Locally
Advanced Esophageal Carcinoma
University Hospital, General Surgery, Stara Zagora,
Y. Nakajima, K. Kawada, Y. Tokairin, A. Hoshino,
T. Okada, M. Okuda, Y. Kume, Y. Kawamura,
K. Yamaguchi, T. Kawano
Background: Despite the benefits of chemoradiotherapy
Tokyo Medical and Dental University, Department of
Esophageal Surgery, Tokyo, Japan
there is significant toxicity as well as some bias in terms of
the effect on the physical status, intestines, bladder, urinary
and sexual dysfunction. Methods: We’ve searched PubMed
database, critically reviewing the hematologic side effects of
treatment for rectal cancer. Results: The hematologic toxicities: anemia, neutropenia, leukopenia and thrombocytopenia are a cause of morbidity and reduced efficacy of the
antitumor drug treatment due to reduction in the relative
intensity of the dose. Total mortality from febrile neutropenia (t > 38.5 C in absolute neutrophil count <0.5 g/l) in
solid tumors is about 5%. Toxicity profile of the two main
regimes FOLFIRI and FOLFOX differs. The use of FOLFIRI
regime shows a higher incidence of grade 3-4 neutropenia,
and at FOLFOX6 frequency of grade 3-4 neutropenia and
thrombocytopenia are higher. In a retrospective analysis on
FOLFOX4 frequency of grade 3-4 hematologic toxicity was
39%. In patients treated with FOLFIRI, the most common
hematologic toxicity was neutropenia grade 3–18% and
grade 4–13%. Conclusions: Long-course preoperative
chemoradiotherapy (chemo-RT) improves outcomes for
rectal cancer patients, but acute side effects during treatment
may cause considerable patient discomfort and may
compromise treatment compliance. Administration of
G-CSFs reduces the risk of febrile neutropenia of 45% and
early mortality by 40%, increases the relative density of
dosage, but on the other hand increases the incidence of
musculoskeletal pain. The future researches should report
not only acute but also chronic toxicity, and include analyzes
of quality of life.
Background: The prognosis of patients with locally
advanced esophageal carcinoma (laEC) is poor, and the
symptoms caused by a poor oral intake and/or esophagorespiratory fistula (ERF) lead to both poor compliance to
definitive chemoradiotherapy (dCRT) and a poor QOL. We
therefore perform esophageal bypass surgery (EBS) prior to
dCRT in order to allow such patients to eat food while
receiving dCRT. Patients: Seventy-three laEC patients who
received dCRT in our institute after April 2005 were enrolled.
Nineteen had previously undergone EBS (Bypass group).
Results: The reasons for EBS were ERF (n = 11) and esophageal stenosis (n = 8). There were no cases of anastomotic
leakage or severe morbidity. The median duration between
EBS and dCRT was 27.5 (19–64) days. Two patients could not
receive planned dCRT. The response rate of patients who
received dCRT were 64.7% (CR, n = 3; PR, n = 8); the responses
among the 54 patients who received dCRT as the initial
treatment (CRT group) did not differ to a statistically significant extent. The one-year and three-year overall survival
rates in the Bypass group were 49.6% and 34.1%, respectively, and did not differ from the CRT group to a statistically
significant extent. In the Bypass group, 14 patients could not
eat or drink anything and 2 patients ate liquid food preoperatively; however, all patients could eat rice gruel after EBS.
The oral intake of the Bypass group was significantly
improved. Conclusion: EBS followed by dCRT can be an
effective therapeutic option for laEC in terms of the patients’
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
© 2017 S. Karger AG, Basel
M.K. Kawamura1, K.N. Nakada2, K.M. Murakami2,
T.I. Iwasaki2, H.K. Konishi2, T.K. Koyama1, A.S. Shida2,
N.H. Hanyuu2, N.M. Mitsumori2, K.Y. Yanaga2, Y. Takano2
Y.T. Takano, M.N. Mitsumori, S.A. Shida, I.T. Iwasaki,
F.M. Fujisaki, K.M. Kawamura, A.H. Aoki, T.N. Takahashi,
I.Y. Ishibashi, O.N. Omura, Y.K. Yanaga
Jikei University School of Medicine, Surgery, Tokyo,
Kawamura Hospital, Surgery, 356 Fuji Shizuoka, Japan,
The Jikei University School of Medicine, Laboratory
Medicine, Tokyo, Japan
Postgastrectomy syndrome is commonly seen after
gastrectomy. This may be caused by reduced gastric reservoir
capacity and rapid gastric emptying after gastrectomy. In
Japan, laparoscopic distal gastrectomy is often applied to
early gastric cancer to expect early recovery. However, the
implication of the laparoscopic approach on motor physiology of the remnant stomach has not been well described.
Aim: To study the influence of the surgical approach (open
or laparoscopic) in distal gastrectomy on motor function of
the remnant stomach by using 13C-acetate breath test.
Methods: 13C-acetate breath test was performed in 20
healthy volunteers (HV) and 20 patients after distal
gastrectomy with Billroth-I reconstruction either by open
(ODG; n = 12) or laparoscopic (LDG; n = 8) approach. Liquid
meal (200 kcal/200 ml, Racol®, Otsuka Pharm. Co.-Ltd,
Japan) mixed with 100 mg of 13C-acetate was ingested.
Breath samples were collected before and at 5, 10, 15, 20,
30, 40, 50, 60, 75, 90, 105, 120, 135, 150, 165 and 180 minutes
after ingestion of test meal. 13CO2 content was measured by
infrared spectro-photometry. Gastric reservoir and emptying
function were evaluated by the retention rate at 5 minutes
(RR5) and half emptying time (T1/2), which were compared
among the groups. Results: RR5 was 93.7, 66.4*, 33.9*+%,
and T1/2 was 23.3, 7.8*, 4.2*+ minutes (mean), in HV, LDG
and ODG patients, respectively (*p < 0.01 vs. HV, +p < 0.05
vs. LDG). Conclusion: Since laparoscopic approach significantly attenuated impairment of motor function represented by reduced reservoir and rapid emptying as compared
to ODG, which therefore seems useful to reduce postgastrectomy syndrome.
Comparison of Short- and Long-Term Clinical
Outcomes Between Laparoscopic and Open
Gastrectomy for Elderly Patients with Gastric
Background: This study was performed retrospectively to
compare short-and long-term clinical outcomes between
laparoscopic and open gastrectomy for elderly patients with
gastric cancer. Patients and Methods: Gastrectomy with
standard lymph node dissection was performed for consecutive 142 elderly patients (age 75 years or older) with gastric
cancer at Jikei University Hospital from January 2006 to
December 2011, of which 44(31%) were performed laparoscopically; laparoscopic distal gastrectomy (LDG) in 33 and
laparoscopic total gastrectomy (LTG) in 11 cases, respectively, while open distal gastrectomy (ODG) and open total
gastrectomy (OTG) were performed for 49 patients in each.
To evaluate short-term clinical outcomes, postoperative
complications, duration of operation, blood loss and postoperative hospital stay, were retrospectively analyzed. As to
evaluation of long-term clinical outcomes, relapse-free
survival (RFS) after laparoscopic gastrectomy (LG) and open
gastrectomy (OG) were studied. Results: Post-gastrectomy
complications were defined by Clavien-Dindo classification
IIIA or more. Postoperative complications were observed in
12 patients (4 cases after LG vs. 8 cases after OG), which were
comparable between the two groups (P = 0.8542). While
operation time of LG was significantly longer than those of
OG (P = 0.0005), blood loss and postoperative hospital stay
after LG were significantly less than those of OG (P < 0.0001
and P = 0.0338, respectively). As to RFS after gastrectomy,
there was no significant difference between LG and OG (p =
0.0841). Conclusion: LG for elderly patients with gastric
cancer could be performed safely and seems to be acceptable
Risk Factors for Survival after Gastrostomy:
Experienceina Japanese Hospital
K. Nakashima, K. Ogawa, H. Yamamoto, K. Kentaroh,
H. Huaman
Yamamoto Memorial Hospital, Surgery, Imari, Japan
Background: Percutaneous Endoscopic Gastrostomy
(PEG) is a widely used nutritional management method for
patients who are unable to eat. Japanese population is well
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Laparoscopic Approach Maintains Better
Motor function of the Remnant Stomach
after Distal Gastrectomy with Billroth-I
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Sarcopenia Is Associated with Increased
Hospital Expenditure in Patients Undergoing
Cancer Surgery of the Alimentary Tract
J.L.A. Van Vugt, S. Buettner, S. Levolger,
R.R.J. Coebergh van den Braak, M. Suker, M.P. Gaspersz,
R.W.F. De Bruin, C. Verhoef, C.H.C. Van Eijck, N. Bossche,
B. Groot Koerkamp, J.N.M. IJzermans
Erasmus MC University Medical Center, Surgery,
Rotterdam, Netherlands
Background: Sarcopenia is associated with poor postoperative outcomes, and impaired medium- and long-term
survival in cancer patients. Furthermore, it is associated with
increased health-care cost in the USA. We sought to
determine its effect on hospital expenditure in a WesternEuropean healthcare system, with universal access. Patients
and methods: Skeletal muscle mass (assessed on CT), patient
characteristics, and costs were obtained for patients who
underwent major curative-intent surgery for abdominal
cancer between 2005–2015. Patients were classified as
sarcopenic based on established cut-offs. The relationship
between sarcopenia and hospital costs was assessed using
linear regression analysis and Mann-Whitney U-tests.
Results: In total, 501 patients were included with a median
age of 64 (IQR 58–72). Most patients were male (60.5%). The
majority of patients had an ASA-classification of 1–2 (79.2%).
Most patients underwent a resection for colorectal cancer
(36.3%), while 27.3% underwent surgery for colorectal liver
metastases, 25.1% for primary liver tumors, and 11.2% for
pancreatic/periampullary cancer. 227 patients (45.3%) had
sarcopenia. Total hospital costs were higher in patients with
compared with patients without sarcopenia (€17,953 versus
€15,140; P < 0.001). Total costs also increased with lower
sex-specific quartiles of skeletal muscle mass (P = 0.003).
Sarcopenia was associated with higher costs in patients with
a non-complicated postoperative recovery, and in patients
undergoing major surgery. After adjustment for confounders,
sarcopenia was associated with a cost increase of €4,688
(P = 0.004). Conclusion: Sarcopenia was independently
associated with increased hospital costs of almost €5,000
per patient. Strategies to reduce sarcopenia could reduce
costs in an era of incremental health-care expenditure.
Influence on Surgical Stapler Technique on
Mechanical Behavior of Tissue
S. Eschbach, R. Mulligan, M. Miesse
Medtronic, R&D, North Haven, United States of America
Introduction: Surgical stapling involves the compression
of tissue to mechanically appose, seal and cut tissue, while
allowing time for the tissue to properly heal after resection.
Tissue mechanical properties affect the amount of stress
induced during this process. It is known that excessive
mechanical stress can produce certain events such as apoptosis and inflammation. A study was completed on ex vivo
porcine stomach tissue to investigate how tissue stress was
affected by mechanical parameters of the stapler application and to investigate stress levels that induced serosal
tearing. Methods: Previous study has shown a method to
measure tissue stress during stapling. 72 endoscopic stapler
firings were completed in ex vivo porcine stomach at two
tissue thicknesses. In each thickness the stapler was fired at
six speeds (n = 6). Force to fire the stapler and tissue stress
were monitored continuously during firings. Qualitative
assessments were made on the staple line integrity, especially of serosal tearing. Regression analysis was performed
to find a correlation between firing speed and force and
tissue stress. Results: Results are currently being analyzed
and will output a large database of force to fire a stapler,
speed of firing, and stress in the tissue. Incidents of serosal
tearing were recorded in an effort to develop a stress
threshold for the event. Conclusion: Results from this study
will help drive best practices for the use of surgical staplers.
With the development of powered stapling this information
can be used to implement intelligence to optimize the stress
applied to tissue.
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known for its longevity, but most of them need a PEG, which
disrupts their social life arising questions on prolonging
life’s in vain. We herein aimed to ascertain the risk factors for
survival in post-PEG patients, as well as predict the mortality
rates. Material and Methods: One hundred and twenty nine
patients who underwent PEG in our institution between
January 2008 – December 2013 were included in the study.
Data was retrospectively obtained from the hospital medical
records. Age, serum albumin level, CKD, casting glucose
level, observation period and pneumonia were analyzed as
risk factors for survival. Result: The study evaluated 73
women (mean age 84.1) and 56 men (mean age 78.8). One
year post-PEG, the surviva rate was significantly better in
women than in men (57% vs 28% p = 0.003). Regarding
glucose levels, patients with normal levels shouwed a longer
survival time (2200 days) compared to diabetic patients
(1400 days) and those with impaired glucose tolerance (500
days) (?2=7.22229 p < 0.03 df = 2). Conclusion: Gender and
glucose levels may be important risk factors for survival after
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Neutrophil Extracellular Trap-Microparticle
Complexes Trigger Thrombin Generation via
the Intrinsic Pathway of Coagulation
H. Thorlacius, W. Yongzhi, L. Lingtao, Ö.B. Oscar,
W. Johannes, H. Heiko, M. Matthias
Lund University, Surgery, Malmö, Sweden
Background: Abdominal sepsis is associated with
dysfunctional hemostasis. Thrombin generation (TG) is a
rate-limiting step in systemic coagulation. Neutrophils play
a key role in sepsis by expulsion of neutrophil extracellular
traps (NETs) and/or microparticles (MPs) although their role
in pathological coagulation remains elusive. The aim of this
study was to examine the role of NETs and/or MPs from
neutrophils in regulating TG in sepsis. Methods and Results:
Abdominal sepsis was induced by cecal ligation and puncture
(CLP). Sepsis-induced TG in vivo was reflected by a markedly
reduced capacity of plasma from septic animals to generate
thrombin ex vivo. Depletion of neutrophils increased peak
and total TG in plasma from CLP mice. Sepsis was associated
with increased plasma levels of cell-free DNA and DNAhistone complexes, suggesting NET formation in septic
animals. Administration of DNAse not only eliminated NET
formation but also elevated peak and total TG in plasma
from septic animals. Isolated NETs increased TG and co-incubation with DNAse abolished NET-induced formation of
thrombin. Moreover, TG triggered by NETs was abolished in
factor XII-deficient plasma but intact in factor VII-deficient
plasma. Activation of neutrophils simultaneously generated
large amount of neutrophil-derived MPs, which were found
to bind to NETs via histone-phosphatidylserine interactions.
Conclusions: These findings show for the first time that NETs
and MPs physically interact and that NETs might constitute
a functional assembly platform for MPs. We conclude that
NET-MP complexes induce TG via the intrinsic pathway of
coagulation and that neutrophil-derived MPs play a key role
in NET-dependent coagulation.
Identification and Quantification of Activated
Human Microcirculatory Leukocytes: Proof of
Principle and Validation
Z. Uz, T.M. Van Gulik, D.M. Aydemirli, Y. Ince,
D. Van Cuppen, B. Ergin, P. Guerci, B.A.J. De Mol, C. Ince
Academic Medical Center, Surgery, Amsterdam,
Background: Leukocyte recruitment and adhesion to the
endothelium are hallmark features of systemic inflammation
as occurs during sepsis and SIRS. These activated leukocytes
constitute a potential parameter for clinical assessment of
the inflammatory status in critically ill patients. We present
a bedside method to identify and quantify activated leukocytes in the sublingual microcirculation. Material and
Methods: Clips (N = 59) of the sublingual microcirculation
were obtained with the handheld, intravital microscope
(Cytocam). The classical manual counting method and the
new Space-time diagram (STD) method were compared in
34 cardiac surgery patients. To investigate the agreement
between the STD method and the classic manual counting
procedure, weighted Deming regression and Bland-Altman
analyses were used. In addition, intra- and inter-observer (2
observers) coefficients of variation (CVs) were assessed.
Results: Pearson’s correlation coefficient (r) was 0.9779 (P <
0.0001) and the Deming regression coefficient was 1.04
(95% CI: 0.98; 1.10) for the wo methods. There were no
significant differences between the two methods, with an
intercept of the Deming regression of 0.05 (–0.49; 0.59). The
Bland-Altman analysis showed a mean difference (bias) of
0.35 (–2.18; 2.89). The intra- and inter-observer CVs of the
space-time diagram method were 3.0% and 9.8% respectively (when specified to the rolling vs non rolling leukocytes: 3.6% and 2.7% vs 3.1% and 11.1%). Conclusion: The
STD method agrees well with the classical manual counting
procedure. We conclude that the STD is a potential method
for the identification and quantification of activated leukocytes in human microcirculation.
MRI Conspicuity in the Diagnosis of Prostate
J.M. Norris1, A. Freeman2, M. Emberton1
University College London, UCL Division of Surgery
& Interventional Science, London, United Kingdom,
University College London Hospitals NHS Foundation
Trust, Department of Histology, UCLH, London, United
Background: Multiparametric MRI (mpMRI) has multiple
roles in prostate cancer, including: tumour detection, biopsy
guidance and monitoring of disease progression. However,
approximately 7% of prostate cancer is missed by mpMRI.
Here, we have conducted a preliminary investigation into
MRI conspicuity to identify factors that influence a false
negative MRI result. Materials and Methods: 193 men with
suspected prostate cancer underwent mpMRI, followed by
transperineal prostate biopsy. MRI reports were compared
with respective biopsy reports to assess concordance.
Results: 112 men had true positive MRI and 10 men had
false negative MRI. Mean age (65.7-years-old) and PSA (6.4
ng/mL) did not differ significantly between groups (p =
0.196). Univariate analysis of prostate-specific factors
demonstrated the importance of prostatic architecture
disruption. Patients with false negative MRI had significantly
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Time Related Enteric Mucosa Oxidative Stress
in Experimental Obstructive Jaundice
E. Angelis1, C. Georgiou2, C. Lilimpakis3, A. Tsepelaki4,
D. Zisimopoulos2, E. Kalaitzopoulou2, C. Vagianos1
Laiko General Hospital, General Surgery, Athens, Greece,
University of Patras, Department of Biology, Patra,
Greece, 3Hull Royal Infirmary, Depart. of Neurosurgery
Hull Royal Infir, Hull, United Kingdom, 4Newham
University Hospital, Department of General Surgery,
London, United Kingdom
Background: The purpose of this study was to investigate the time related cellular and biochemical changes of
enteric mucosa in obstructive jaundice, resulting in increased
oxidative stress damage. Materials and Methods: 54 male
rats were used. Obstructive jaundice was induced by dividing
CBD and animals were sacrificed in 12 and 48 hours, 7 and
14 days. Sham and control animals were added accordingly.
At sacrifice blood samples were collected in order to verify
obstructive jaundice. Mucosal samples were also collected
from a standardised section of the small intestine, near the
ileocecal valve. The total protein of the sample was isolated,
delipidated and analyzed for oxidative stress biomarkers,
which were protein carbonyls and protein malondialdehyde
(PrMDA). Results: All animals survived the experiment and
seemed to be in good health at sacrifice. Comparable
obstructive jaundice was found in all. Mucosal sample
collection was always successful. A statistically significant
peak-increase in samples (over control and sham) was
observed for PrMDA at 2–7 days and for protein carbonyls
at 14 days after operation. Conclusion: Obstructive jaundice
induced in experimental rats, causes significant oxidative
damage to small intestine proteins via formation (a) of
carbonyls (generated by oxygen free radicals), and (b) of
PrMDA (i.e., product of their reaction with MDA; biomarker
of lipid peroxidation). The changes were differing according
to the time period examined! The clinical interest of these
findings may include efforts towards reversal of oxidative
stress induced damage in the above mentioned time
Reperfusion Injury to the Retina May Be
Reduced by Pharmacological Pretreatment
in a Rat Model
I. Garcia-Alonso1, J. San Cristobal2, B. Herero de la Parte1,
A. Gonzalez-Bada1
University of The Basque Country, Dpt. of Surgery,
Leioa, Spain, 2University Hospital Basurto, Oftalmology,
Bilbao, Spain
Background: Though there are treatments which can
restore blood flow to the retina when the central retinal artery
is blocked, reperfusion may yet cause severe damage to the
organ. After developing a murine model of retinal ischemiareperfusion, we have tried to reduce the reperfusion damage
by administering drugs just prior blood flow restoration.
Methods: Eight groups of 8 WAG/RijHsd male rats (300 g)
were used. Under diazepam (15 mg/kg) plus Ketamine (80
mg/kg) anaesthesia, saline was infused into one eye,
increasing intraocular pressure to 150 mm Hg provoking
retinal ischaemia. Five minutes before restoring ocular
pressure to normal values (starting reperfusion of the retina)
drugs were administered intraperitoneally: folinic acid (2.5
mg/kg), allopurinol (50 mg/kg), pravastatin (4 mg/kg), trifluoperazine (10 mg/kg), calmidazolium (2.4 mg/kg), 7-nitroindazole (10 mg/kg). After 60’ of reperfusion, the animals were
sacrificed, the eyes removed and the retinas (normal and
ischemic) were embedded in paraffin. Results: Cytoplasmic
Oedema Index (COI) in non-treated rats was significantly
higher than in any of the treated animals (102.5 ± 35; p <
0.001). This index was dramatically reduced by 7-nitroindazole (19.9 ± 16.3) and folinic acid (31.7 ± 14.7). The other
drugs also reduced COI but to a lesser extent (around 50%, if
compared to non-treated animals): allopurinol (48.9 ± 23.3),
pravastatin (56.1 ± 46.5), trifluoperazine (49.1 ± 47.4), calmidazolium (40.6 ± 29.7). Conclusions: In our murine model,
reperfusion injury in the retina has been significantly reduced
by administering different drugs just prior to restoring blood
flow to the ischemic organ.
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higher rates of bladder outflow surgery than those with true
positive MRI (20% vs. 4.5%, p = 0.043). Rates of prostatitis
and BPH were also higher in the false negative MRI group
compared with the true positive MRI group (20% vs. 6.3%,
and 30% vs. 23.2%). Additionally, patients with false negative
MRI had smaller prostates (32.8 cc vs. 38.7 cc) and tumours
(3.85 mm vs. 5.55 mm; CCL) (p = 0.06) compared to those
with true positive MRI. Conclusion: By assessing false
negative mpMRI in a consecutive cohort of men with
suspected prostate cancer, we have identified prescient
features that may influence a negative report. This research
provides a basis from which further studies can be conducted,
with the aim of reducing false negative investigation in the
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
The Use of the Portable AirdriveTM Machine
Perfusion System in Graft Preservation during
Kidney Transplantation: Pilot Study in Kidney
Transplantation of Grafts from Post-Mortem
J.H.E. Houtzager, S.D. Hemelrijk, I.C.J.H. Post, M.M. Idu,
F.J. Bemelman, T.M. Gulik van
Academic Medical Center Amsterdam, Surgical
laboratory, Amsterdam, Netherlands
Background: Kidney donor graft shortage led to the use
of marginal donors such as non-heart beating donor (NHBD)
kidneys. Preservation of the graft by hypothermic machine
perfusion (HMP) provides a viable solution to reduce the
warm ischemic (WI) damage-induced graft loss. In preclinical
animal studies, the Airdrive HMP system has shown to be
safe, and to improve renal function and graft structural
integrity after induced WI damage. The aim of the present
study is to introduce the Airdrive system in clinical kidney
transplantation and assess the feasibility and patient safety.
Methods: Seven kidney grafts will be preserved using the
Airdrive HMP system between arrival at the AMC and
implantation in the recipient. The main study endpoint is the
absence of adverse effects due to the use of Airdrive HMP.
Every unexpected event possibly related to the use of the
Airdrive that occurs during the transplantation procedure or
within 1-month follow-up, will be evaluated. Results:
Currently three kidney grafts were included in the study.
During the preservation period of this three kidney grafts in
the Airdrive HMP, no technical problems occurred. Mean
perfusion parameters were; duration 12 hr., pressure: 25 mm
Hg, flow: 61 ml/min, resistance: 0.68 and temperature:
10.0°C. During transplantation and within one month followup, no side effects occurred in the three recipient patients.
Conclusions: This preliminary results show the feasibility of
the use of the AirdriveTM HMP system in clinical kidney
transplantation. The four remaining inclusions have to be
performed before patient safety and feasibility can be
Development of Paclitaxel-Loaded Gelatin
Microspheres for the Treatment of Peritoneal
Carcinomatosis from Ovarian Origin
K. De Clercq1, E. De Thaye1, W. Ceelen2, O. De Wever1,
J. Van Bocxlaer1, C. Vervaet1
Ghent University, Pharmaceutics, Ghent, Belgium,
Ghent University Hospital, Gastrointestinal Surgery,
Ghent, Belgium
Background: The majority of patients with ovarian cancer
present advanced peritoneal metastasis with a high
percentage of relapse. Intraperitoneal (IP) chemotherapy
increases drug concentration at tumour sites in the peritoneal cavity. Paclitaxel (PTX) with a high peritoneal/plasma
concentration ratio is a promising molecule for IP treatment.
Genipin-crosslinked gelatin microspheres (GP-MS) as a
novel IP sustained-release PTX delivery system are evaluated
in vitro. Material and Methods: GP-MS were loaded with
PTX by immersion in an ethanolic PTX solution or aqueous
PTX-nanosuspension. Incorporation efficiency was determined by UPLC-UV-MS/MS. In vitro release of several types
of PTX-GP-MS was evaluated at 37°C and pH 7.4 over 21
days via dialysis method. Influence of PTX-GP-MS (0.005–
0.25 mg/ml) on viability of SKOV-3 cells was analysed after
14 days by MTT assay. Results: Using a PTX-nanosuspension
instead of ethanolic PTX-solution improved PTX loading
from 3.4 μg to 39.2 μg PTX per mg MS. PTX-release from
GP-MS was sustained over 21 days, obtaining higher concentrations for GP-MS loaded with PTX-nanosuspension. Blank
GP-MS had no influence on cell viability (viability 96.66 ±
0.41%) after 14 days. In contrast, 0.005 mg/ml PTX-GP-MS
reduced viability to 8.67 ± 2.78%, other PTX-GP-MS concentrations completely inhibited cell survival. Conclusion: PTX
was more efficiently loaded into GP-MS if PTX is formulated
as nanosuspension. PTX-release from GP-MS was sustained
over several weeks. Cell experiments indicated that sustained
release of PTX is potent to inhibit cell survival. PTX-GP-MS
can be a promising delivery system for IP administration,
their effect for treatment of peritoneal carcinomatosis in a
mouse model will be investigated.
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Distinct Role of the Alimentary, Biliary,
and Common Limbs: The Abc of Glucose
Metabolism after Roux-en-Y or One
Anastomosis Gastric Bypass
C. Marciniak, G. Baud, M. Daoudi, A. Quenon, V. Raverdy,
V. Gmyr, T. Hubert, R. Caiazzo, F. Pattou
Lille Univ Hospital, EGID, Lille, France
Background: Roux-en-Y gastric bypass (RYGB) improves
postprandial glucose metabolism beyond weigth loss.
However, the direct contribution of each intestinal segment
of RYGB (alimentary limb/AL, biliary limb/BL, and common
limb/CL) to this metabolic benefit is unknown. We aim to
decipher the effect of each intestinal limb of gastric bypass
on postprandial glucose response (PGR). Material and
Methods: Adult healthy minipigs (n = 28, 49 ± 5 kgs) were
submitted to a sham operation or one of 4 bypass variants:
RYGB (short BL, long CL, short AL), distal RYGB (short CL,
short BL, long AL), one anastomosis gastric bypass (OAGB)
(short BL, long CL, no AL), or distal OAGB (long BL, short CL,
no AL). mixed-meal test was performed post operatively to
measure PGR and intestinal sodium dependent glucose
transport, as well as postprandial GLP-1. Results: Body
weight decreased after bypass and postprandial GLP-1
increased. PGR decreased with shortening of CL, as well as
with increasing of BL. The decrease of PGR was related to
reduced xylose AUC. Xylose AUC was not modified by the
absence of AL; increased when sodium (5 g of NaCl) was
added to the meal after distal OAGB; and decreased when
Phlorizin (an inhibitor of sodium dependent glucose
transport) was added to the meal in RYGB. Conclusion: PGR
decreases after bypass in relation with intestinal sodium
dependent glucose transport. PGR is reduced with longer BL
(more reabsorption of endogenous sodium contained in
bile) and/or shorter CL (limited contact of endogenous
sodium with ingested glucose).
Mouse Models of Primary Lung Cancer
J.H. Jang, F. Janker, W. Weder, W. Jungraithmayr
University Hospital Zurich, Division of Thoracic Surgery,
Zurich, Switzerland
Background: Lung cancer is the most prominent cancer.
Several models of primary lung cancer research are in use,
however, no systematic evaluations of the models are
available. Here, we assess and reappraise the most robust
models of primary lung cancer for their suitability of cancer
evolution and target-ability for new therapeutics. Method:
Three models of primary lung cancer were evaluated: (I)
Urethane was injected to develope a lung cancer model. LLC
cell line was injected (II) intravenously (i.v.) or (III) subcutaneously (s.c.) to establish lung cancer models. Tumor nodule
was counted macroscopically and microscopically. IHC of
immune cells were performed for characterization of the
tumor. The intra-pulmonary lymphatic tissue formation was
assessed. Results: Urethane injection induced 100% lung
cancer in mice. We found the urethane i.p. develops intrapulmonary lymphatic tissue. While i.v. injection of LLC cell
line developed diffuse lung tumor, s.c. injection also stably
developed single tumor nodule. IHC revealed that all tumors
were consistently positive for Ki-67 and immune cells are
positive for F4/80, CD4, CD8, and NKp46. Conclusion: The
urethane-induced primary lung cancer is reliable and reproducible method, but need relatively longer time period for
the development. The i.v. and s.c. tumor models are established within short period. The tumors developed by s.c.
enable for the analysis of the tumor only. The involvement
and characteristics of immune cells found within tumors
were comparable across all models. Injections of i.v. or s.c.
of cell line can be considered as convenient model to
develop various types of lung cancers.
Pancrelipase with Branched-Chain Amino
Acids for Preventing Nonalcoholic Fatty Liver
Disease after Pancreaticoduodenectomy
Y. Shintaro, Y. Nao, M. Yusuke, T. Higaki, T. Takayama
Nihon University School of Medicine, Department of
Digestive Surgery, Tokyo, Japan
Aim: To investigate the efficacy of the early administration of pancreatic enzymes combined with elemental diet
of branched chain amino acids (BCAA) for nonalcoholic fatty
liver disease (NAFLD) after pancreaticoduodenectomy (PD).
Methods: Data were obtained for 122 consecutive patients
who underwent PD. High-titer pancrelipase and BCAA-rich
solution was administered via a feeding tube from POD4 (PB
group: n = 31). Ninety-one patients who underwent PD prior
to this treatment were included as a control group (n = 91).
The radiological changes in the liver and pancreatic parenchyma related to NAFLD before and after PD were assessed
on CT, and trends in the liver function and nutritional status
were evaluated over the 180-day period after PD. Results:
The patient background factors, histopathology and operation-related variables did not differ significantly between
the two groups. Liver attenuation [56 HU (–13–73) vs. 61
(26–69), p = 0.015] and the liver to spleen attenuation ratio
[1.12 (–0.38–1.48) vs. 1.24 (0.89–1.49), p = 0.018] were significantly decreased and the pancreatic parenchyma was
significantly thinner [17.9 mm (8.6–25.3) vs. 13.9 mm (2.5–
23.2), p = 0.02] in the control group at three months after
the operation. The alanine aminotransferase levels were also
higher in the control group (p < 0.05, at POD 14, 30, 60 and
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
90), while the serum albumin (p < 0.05, at POD 30, 60 and
180) and total protein (p < 0.05, at POD 30, 60, 90 and 180)
levels were significantly better in the PB group. Conclusions:
Early supplementation of high-titer pancrelipase combined
with a BCAA-rich elemental diet decreases the risk of NAFLD
after PD.
© 2017 S. Karger AG, Basel
Function Assessment of Individual Hepatic
Lobe by Indocyanine Green-Fluorescent
Technique in Mouse Model of Portal Vein
R.K. Kiuchi, T.S. Sakaguchi, L.T. Le Minh, S.F. Furuhashi,
T.M. Takeda, T.H. Hiraide, Y.S. Shibasaki, Y.M. Morita,
H.K. Konno
The Morphometric Analysis of the
Decellularized Bovine-Derived Peritoneum
in the Nephropexy at the Early Stages of the
A.N. Abatova
Karaganda State Medical University, Department
of Pathological Anatomy and Forensic Medicine,
Karaganda, Kazakhstan
Background: In the available literature review we haven’t
found data of the employment of the decellularized bovinederived peritoneum in the nephropexy. The purpose of our
research was study morphometric value of the decellularized bovine-derived peritoneum with the tissue of the
kidney in early stages. Material and Methods: The decellularized bovine-derived peritoneum of 1.0 x 1.0 cm segment
have been utilized for the nephropexy for 32 rats. In our
research was used the morphometric method. Autopsy had
been by 7th day, 14th day, 21st and 30th days. Histological
evaluation was performed on hematoxylin and eosin. Quantitative assessment of cellular infiltrate was conducted in 300
cells and angiogenesis activity calculation at 400 x magnification. Results: The seventh day of the exhibition was characterized by the predominance of granulocytic white blood
cells and macrophages. The result has indicated on significant reduction in the number of granulocytic cells, macrophages, and the predominance of lymphocytic cells for the
7 days of the experiment. Significant differences in the
average number of plasma cells and the number of vessels
on different days hasn’t been noted. On the 14th day was a
significant predominance of stromal cells of lymphocytic
cells. The study has demonstrated phasic formation of
connective tissue for 21 days. Application of decellularized
bovine-derived peritoneum was characterized by the least
amount of cells infiltration by 30 day. Conclusion: The decellularized bovine-derived peritoneum has deserved scientific
interest since the results demonstrated early formation of
mature, wealthy exposure to kidney tissue, forming a minimally tissue inflammatory reactions.
Hamamatsu University School of Medicine, Second
Department of Surgery, Shizuoka, Japan
Introduction: Indocyanine green (ICG) test is commonly
used to evaluate liver function. However, it cannot examine
the segmental liver function separately. We present the
usefulness of ICG-fluorescent technique (ICG-F test) to individually evaluate the hepatic lobule funcition in mouse
model of portal vein ligation (PVL). Materials and Methods:
In anestehtized C57BL/6J male mice, the left portal vein
branch was microscopically ligated. As ICG-F test, the fluorescent intensity (FI) of the liver was continuously measured
until 15 minutes after ICG injection with the fluorescent
imaging system. The test was performed before and 7 days
after PVL. Average FI 15 minutes after ICG injection was
converted into the concentration of ICG with external
standard. Results: The weight of non-PVL liver (nPVLL)
significantly increased 7 days after PVL (37.2% to 64.8% of
the whole liver, P < 0.001). Without (before) PVL, FIs of both
lobes equally increased gradually and reache a peak around
15 minutes after ICG injection. Seven days after PVL, in
contrast, peak FI was significantly higher in nPVLL than in
PVL liver lobe (PVLL) (166.5 vs 120.2, P = 0.001). The calculated concentration of ICG in nPVLL was similarly higher than
in PVLL (2.97 μg/mL vs 1.79 μg/mL, P = 0.001). Assuming
that the value calculated by multiplying the ICG concentration by liver weight is proportional to the functional liver
volume (FLV), nPVLL’s FLV significantly increased 7 days
after PVL (40.6% to 75.3% of the whole liver, P < 0.001).
Conclusion: ICG-F test would be useful to evaluate the
hepatic lobule function.
Barcelona – Classification (BCLC) Through
Surgeon’s Eyes
P.D. Pekli1, B.K. Keczer1, T.T. Takács2, A.F. Fülöp1,
P.Ó. Ónody1, A.K. Kiss1, L.H. Harsányi1, A.S.Z. Szijártó1
University, 1st Department of Surgery,
Budapest, Hungary, 2Honvéd Hostpita, Surgical
Department, Budapest, Hungary
Background: Hepatocellular carcinoma (HCC) is the most
frequent type of malignant liver tumor. Currently, liver
resection is the first line curative treatment for single HCC
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Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Long Term Outcome of Hepatocellular
Carcinoma after Liver Resection: Significance
of Radical Resection and Subsequent Surgical
Treatments for Recurrences
T.Y. Yoh1, S.S. Seo1, E.H. Hatano2, S.O. Satoshi1, A.S. Sato1,
Y.O. Okuda1, K.T. Taura1, T.K. Kaido1, S.U. Uemoto1
Kyoto University, Surgery, Kyoto, Japan, 2Hyogo College
of Medicine, Surgery, Nishinomiya, Japan
Backgrounds: The role of re-surgery for recurrent HCC is
not clearly understood. We aim to appraise whether our
aggressive surgical management provides recurrent hepatocelluar carcinoma (HCC) survival benefit. Methods:
Consecutive 1109 patients who underwent hepatectomy
from 1995 to 2015 were retrospectively reviewed. During
follow-up period, 783 patients (70.6%) developed recurrence. Of these, 173 patients underwent surgeries for recurrence, whereas the remaining 610 did not undergo surgeries.
Clinicopathological factors and long-term survival were
studied. Survival analysis were performed in subgroups
according to the three recurrence pattern; intrahepatic (n =
119 vs. 384, with surgery vs. without surgery), extrahepatic
(n = 17 vs. 47) and intra with extra-hepatic recurrence (n =
37 vs. 179). Results: Compared with patients without surgery,
patients with surgery showed higher serum AFP levels (P =
0.008), better liver function at first resection (determined by
ALBI-grade and Child-pugh grade; both P < 0.001) and their
time to recurrence was longer (15.9 vs 10.4 months, P <
0.001). 5-year survival after recurrence [SAR] rate was significantly longer in patients with surgery (53.0 vs. 25.7%, P <
0.001). Moreover, patients with surgery showed better
survival than those without surgery in any recurrence
patterns (5-year SAR rate, intrahepatic; 62.4 vs. 35.5%, extrahepatic; 30.0 vs. 2.9%, intra with extrahepatic recurrence;
34.1 vs. 10.6%, all P < 0.001, respectively). Conclusions:
Aggressive surgical management of recurrent HCC is
important to provide long-term survival. Recurrent HCC
patients with lower serum AFP levels and well-preserved
liver function at first resection may be the candidates.
Resection of Recurrent Tumors after Initial
Surgery for Intrahepatic Cholangiocarcinoma
J. Arita, H. Hiroko, A. Nobuhisa, K. Junichi, S. Yoshihiro,
K. Kiyoshi, K. Norhiro
University of Tokyo, Hepato-Biliary and Pancreatic
Surgery Division, Tokyo, Japan
Introduction: Resection of recurrent tumor after initial
hepatectomy in patients with intrahepatic cholangiocarcinoma (ICC) is controversial. Effects of re-resection for
recurrent tumors were assessed. Methods: Retrospective
analysis was performed using the records of the patients
undergoing initial resection for ICC between 1994 and
2016. Results: A total of 133 patients underwent radical
initial resection of ICC tumors; including 73 men and 60
women; 66 (33–88) years old at median; maximal tumor size
4.5 (1.2–12) cm at median; 44 patients had invasion to
hepatic hilum. The 5-year OS and DFS rates after initial
resection for the 133 patients were 41% and 29%, respectively. Ninty-four patients experienced tumor recurrence
and 18 of them underwent re-resection; the median OS
after diagnosis of tumor recurrence was 34.7 months, and
the 3 and 5 year-survival rates were 48% and 21%, respectively. Whereas, for the remaining 76 patients without
resection, the median OS after diagnosis of tumor recurrence was 12.6 months, and 3 and 5 year-OS-rates were
13% and 5%, respectively. The survival curve of patients
undergoing re-resection was significantly better than those
without re-resection (P = 0.002). On the other hand, the
median DFS after re-resection (n = 18) was 11.4 months
with 36% of 1-year DFS. Conclusion: Re-resection of
recurrent tumor may be useful for selected patients, in
particular for localized tumors, regardless of extrahepatic or
not, and long disease free interval after initial surgery.
However, more aggressive adjuvant chemotherapy would
be needed because two thirds of patients experienced
tumor recurrence again within 1 year after re-resection.
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with compensated cirrhosis. The therapeutic management
for HCC is still very challenging and complex, due to different
score- and classification systems. The Barcelona Clinic Liver
Cancer (BCLC) Staging System remains the most widely used
for HCC management guidelines, based on tumor burden,
severity of liver disease, and the patient’s performance
status. Liver resection is recommended just in ‘very early’
and ‘early-stage’ HCC (BCLC 0 or BCLC A). Based on these, a
large proportion of patients would’t get curative treatment.
Material and Methods: From 2000 to 2015 there were 172
patients with HCC who underwent liver resection at
Semmelweis University 1st. Department of Surgery. Demographic details, etiological factors, BCLC stage, operation
type, and survival were analyzed retrospectively. Results:
The mean age of the patients was 69.2 year, 77.9% male,
22.1% female, HBV infection in 0.58%, HCV in 16.8% and
alcohol abuse in 11.6% were verifiable. Major hepatectomy
was performed in 60%. Based on our data the patients were
in the following BCLC stages (1.8%–0; 64.5%-A; 28.1%-B;
5.4%-C). Overall 1-, 2-, 3- and 5-year survival rates were
77.6%, 64.5% 56.4%, and 41.9% respectively. Patients in
BCLC B stage had 1-, 2- and 3-year survival rates at 67.7%,
51.6% and 41.9%. Conclusion: We found, that liver resection
can achieve better or at least comparable survival outcomes
of selected intermediate (BCLC-B) HCC patients compared
with palliative therapy (TACE).
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Low Skeletal Muscle Mass Is Associated with
Increased Hospital Costs in Patients with
Cirrhosis Listed for Liver Transplantation
J.L.A. Van Vugt, S. Buettner, L.J.M. Alferink, N. Bossche,
R.W.F. De Bruin, S. Darwish Murad, W.P. Polak,
H.J. Metselaar, J.N.M. IJzermans
Erasmus MC University Medical Center, Surgery,
Rotterdam, Netherlands
Background: Sarcopenia is associated with increased
morbidity and mortality in liver transplant (LT) candidates.
Our aim was to investigate the association between sarcopenia and hospital costs in patients listed for liver transplantation. Methods: Consecutive patients with cirrhosis listed for
LT between 2007–2014 in a Eurotransplant centre were identified. Patients listed with high urgency, for acute liver failure,
re-transplantation, and multivisceral transplantation were
excluded. Skeletal muscle mass was measured on computed
tomography (skeletal muscle index [SMI], cm2/m2) performed
within 90 days from waiting list placement. Sex-specific quartiles were created. The lowest quartile represented patients
with sarcopenia. Results: In total, 363 patients were listed
during the study period, of which 225 were included. Median
waiting list time was 169 (IQR;46–306) days and medium
MELD-score was 16 (IQR;11–20). The total hospital costs in
patients with sarcopenia were €11,294 (IQR;3,570–46,469)
compared with €6,878 (IQR;1,305–20,683) in patients without
sarcopenia (p = 0.008). An incremental skeletal muscle mass
was significantly associated with a decrease in total costs
(€458 per incremental SMI, 95% CI 14–902, p = 0.043), independent of the total waiting list time. Although costs during
admission for transplantation did not significantly differ
between patients with and without sarcopenia, a significant
difference was found when these costs were added to the
waiting list costs (€98,703 versus €81,982, p = 0.037).
Conclusion: Sarcopenia is independently associated with
higher costs during waiting list placement of LT candidates,
as well as with higher total hospital costs in patients undergoing LT. Optimizing patients’ skeletal muscle mass may
therefore lead to a decrease in hospital expenditure.
Does Etiology of Hepatic Steatosis Influence
Surgical Outcome – A Systematic Review
A.S. Schenderlein, U.D. Dahmen
University Jena, Clinic for General, Visceral, Vascular and
Transplantation Surgery, Jena, Germany
Background: The aim of this systematic review is to
evaluate the impact of the underlying etiology of hepatic
steatosis on surgical outcome and liver regeneration. We
decided to focus on animal studies. In contrast to clinical
studies, animal studies are based on standardized and well
characterized steatosis induction protocols. Methods: Using
the PRISMA guidelines, we searched PubMed and Google
Scholar for articles related to hepatic steatosis, hepatectomy
and liver regeneration in rats and mice. Reference lists from
original articles were further assessed to retrieve all relevant
studies. All publications were analysed according to species,
strain, etiology, steatosis type, survival rate and kinetics and
intensity of liver regeneration. Results: We identified 18
studies dealing with the effect of hepatic steatosis in hepatic
regeneration after liver resection. Dietary models were most
frequently used with Methionine and choline deficiency diet
(MCD, 8/13) and High Fat Diet (HFD, 4/13) being the most
prevalent. The majority of studies (17/18) reported an
impairment and/or delay of hepatic regeneration after PhX.
In contrast the only study using western diet (WD 1/13)
stated that regeneration was enhanced. Genetic models
were the second largest entity with db/db (3/7) and ob/ob
(2/7) mice and Sugar rats (2/7). Hepatic regeneration was
impaired in all genetic models. Conclusion: The impact of
hepatic steatosis on liver regeneration seems to be determined by the underlying etiology. This finding calls for a
confirmatory experimental study aiming for a detailed investigation of the mechanism underlying the impairment of
regeneration in animals with steatosis of different etiology.
Progression in Splenic Fibrosis in Patients with
Portal Hypertension
Y. Iimuro1, A. Yada2, T. Okada2, J. Fujimoto2
Nirasaki Municial Hospital, Surgery, Nirasaki, Japan,
Hyogo College of Medicine, Surgery, Nishinomiya,
Background: Splenectomy often improves liver function
in patients with advanced portal hypertension (PH). Spleen
stiffness evaluated by ultrasonography well predicts the risk
of esophageal variceal bleeding, while whether the stiffness
reflects only blood congestion or even fibrosis is unclear. We
hypothesized that splenic fibrosis gradually progresses with
PH advancement, and that this fibrosis results in a vicious
circle of PH. The aims of the present study were to investigate histological changes in human spleen in PH, and speculate the significance of splenectomy. Methods: Forty-two
HCV-positive patients with liver fibrosis underwent laparoscopic splenectomy and liver biopsy. Histological changes in
liver and spleen, and blood test were retrospectively
compared. Results: After splenectomy, significant leukocytosis was observed in addition to thrombocytosis. Moreover,
the improvement of S-Alb and prothrombin activity was
detected. In the spleen with mild or moderate PH, dilated
splenic sinus and narrowed splenic cord were detected in
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Portal Vein Embolization Prior to Resection of
Colorectal Liver Metastases Does Not Impact
Oncological Outcomes
J. Huiskens1, P.B. Olthof1, E.P. Van der Stok2, T. Bais1,
K.P. Lienden1, J. Krumreich3, R. Roumen3, D.J. Grünhagen2,
C.J.A. Punt1, M. Van Amerongen4, J.H.W. De Wilt4,
C. Verhoef2, T.M. Van Gulik1
AMC, Medical Oncology & Surgery, Amsterdam,
Netherlands, 2Erasmus MC, Surgical Oncology,
Rotterdam, Netherlands, 3Maxima MC, Surgical
Oncology, Veldhoven, Netherlands, 4Radboud UMC,
Radiology, Nijmegen, Netherlands
Introduction: This study aimed to compare survival
outcomes of patient subjected to major liver resection for
colorectal liver metastases (CRLM) with or without PVE. To
reduce selection bias, propensity score matching was
performed for PVE and non-PVE patients with overall and
disease-free survival as primary endpoints. Methods: All
consecutive patients who underwent major liver resection
for CRLM at three academic medical centers and one large
community liver center between January 2000 and December
2015 were included. For a propensity matched comparison,
all patients who underwent PVE followed by a major liver
resection were selected. Major liver resection was defined as
a resection of at least three Couinaud liver segments.
Patients were matched to patients who had undergone
major liver resection without PVE. Results: Of 745 patients
undergoing major liver resection for CRLM, 53 patients (7%)
underwent portal vein embolization before liver resection.
These patients had similar complications compared to
patients without PVE, 90-day mortality was higher. Patients
who had undergone PVE had worse disease-free survival
and a trend towards lower overall survival. A total of 46
patients who underwent PVE had sufficient data and were
matched. Both disease-free and overall survival were comparable between the two groups after matching. Conclusions:
Comparable disease free survival and overall survival were
found in patients who were resected after portal vein embolization before major liver resection compared to matched
controls treated with major surgery alone. PVE does not
affect long term oncological outcomes in patients proceeding
with liver resection.
Assessment of Colorectal Liver Metastasis:
First Results of the Dutch Colorectal Cancer
Group (DCCG) Liver Metastases Expert Panel
of the CAIRO5 Study
J. Huiskens1, P.B. Olthof1, A. Keijser2, K.P. Lienden1,
M.R.W. Engelbrecht1, J.J. Hermans3, I.Q. Molenaar4,
C. Verhoef5, K.P. De Jong6, G. Kazemier7, T.M. Ruers8,
J.H.W. De Wilt3, A.M. Rijken9, M.F. Gerhards10,
M.S.L. Liem11, J.M. Klaase11, G.A. Patijnn12, M.G. Oijen1,
C.J.A. Punt1, T.M. Van Gulik1
AMC, Medical Oncology & Surgery, Amsterdam,
Netherlands, 2Comprehensive Cancer Centre, Data
Management, Utrecht, Netherlands, 3Radboud UMC,
Radiology, Nijmegen, Netherlands, 4UMCU, Surgery,
Utrecht, Netherlands, 5Erasmus MC, Surgical Oncology,
Rotterdam, Netherlands, 6UMCG, Surgery, Groningen,
Netherlands, 7VUmc, Surgery, Amsterdam, Netherlands,
AvL-NKI, Surgery, Amsterdam, Netherlands, 9Amphia
Hospital, Surgery, Breda, Netherlands, 10OLVG, Surgery,
Amsterdam, Netherlands, 11MST, Surgery, Enschede,
Netherlands, 12Isala Klinieken, Surgery, Zwolle,
Background: Data on secondary resections of colorectal
liver-only metastases (CRLM) are di cult to interpret due to
lack of consensus on resectability criteria. The ongoing fase
3 trial CAIRO5 of the DCCG investigates the optimal systemic
induction regimen in patients with unresectable CRLM, with
prospective evaluation at baseline and during follow-up by
a national expert panel of liver surgeons and radiologists
according to uniform criteria. Methods: CRLM are scored as
resectable, potentially resectable or permanently unresectable. Evaluation is performed independently by 3
randomly assigned liver surgeons. In the absence of
consensus, 2 additional surgeons are invited for a majority
consensus. Results: 282 CT-scans (143 baseline, 139 followup) were evaluated. Results were available at a median of 8
days (IQR 4–12). Consensus by 3 surgeons was achieved in
146 evaluations (52%). Nineteen (7%) evaluations consisted
of completely opposing views (resectable vs. permanently
unresectable). 115/143 patients were assessed after downsizing systemic therapy. 63/115 (55%) were assessed as
resectable during follow-up, of which 41 underwent
resection. Conclusion: Prospective evaluation of CRLM
patients by a expert panel according to uniform criteria with
feedback of surgical outcomes is a unique aspect of CAIRO5.
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the red pulp. In the spleen with advanced PH, many aSMApositive cells and significant amount of fibrillar collagen
were observed in the splenic cord. The aSMA-positive area
and the amount of fibrillar collagen were well correlated
with the preoperative splenic volume, degree of liver fibrosis
(positively), and platelet counts (negatively), suggesting the
gradual development of splenic fibrosis. Conclusion: Splenic
congestion could be reversible after viral eradication or liver
transplantation, while advanced splenic fibrosis observed in
this study seemed irreversible. In patients with advanced
splenic fibrosis, splenectomy may possibly be useful therapeutic modality even if liver transplantation or viral eradication is available.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Challenge to Ultimate Minimally Invasive
Hepatic Surgery
J.F. Fukuda
Yamamoto Memorial Hospital, Surgery, Imari, Japan
Introduction: It is reported that epidural anesthesia (EA)
has fewer complications than general anesthesia (GA). We
have reported the safety of laparoscopic cholecystectomy
under EA without endotracheal anesthesia since 1992. We
have started open hepatectomy under EA without endotracheal anesthesia since 2010. And then, we completed laparoscopic hepatectomy under EA without endotracheal anesthesia. This time, we report the availability of laparoscopic
hepatectomy under epidural anesthesia without endotracheal anesthesia. Methods: An epidural catheter was inserted
via the seventh thoracic vertebral interspace. 7 mL of 2%
mepivacaine hydrochloride was injected every 40 minutes.
Abdominal cavity was insufflated with carbon dioxide gas at
less than 8 mm Hg and 4 trocars were placed. The hepatic
parenchyma was transected with a bipolar energy device.
The Glissonian sheaths and the left hepatic vein were divided
with a surgical stapler. Results: We have completed laparoscopic cholecystectomy for over 300 cases. We have
completed open hepatectomy for over 20 cases. We have
completed laparoscopic hepatectomy for one case. In the
case of laparoscopic hepatectomy, the surgical procedure
was completed in 3 hours and 6 minutes with 110 mL of
blood loss. Conclusions: Laparoscopic hepatectomy under
epidural anesthesia solely without endotracheal anesthesia
has possible advantages in accelerating postoperative
recovery and may extend opportunities for elderly patients
or those with respiratory diseases, allowing them to receive
radical treatment of hepatic malignancies.
Patient Outcome from Emergency Laparotomy
Improved with Increasing ‘Number of
Consultant Surgeons On-Call’ in a University
Hospital: Audit Loop Completion
F. Mahmood, A. Hussain, S. Azhar, A. Tsiamis
Royal Stoke University Hospital, Colorectal/General
Surgery, Stoke-On-Trent, United Kingdom
Aim: The National Emergency Laparotomy Network
(NELA) published an average mortality rate of 11.1% and a
median length of 16.3 days in patients undergoing emergency laparotomy. The aim of this study was to evaluate the
outcomes of emergency surgery in after addition of one
more consultant in the daily on-call rota. Methods: This
retrospective study involved adult patients undergoing
emergency laparotomy under general surgical domain
between March to May 2013 (first audit) and June to August
2015 (second audit). Appendicectomy, cholecystectomy and
simple inguinal hernia patients were excluded. Data was
collected on patient demographics, ASA, morbidity, 30-day
mortality and length of hospital stay. Results: During the
second 3-month period, 123 patients underwent laparotomy vs 84 in the first audit. 67(54.4%) patients were males
and 56(45.6%) females. Median age was 65(23–93) years.
56.01% were ASA III or above vs to 41.9%. 23.40% required
ITU admission. 38% had bowel anastomosis vs 35.7%. 4.2%
of bowel anastomoses leaked compared to 16.6%. 30-day
mortality was 10.50% vs 21% and median length-of-hospitalstay was 11 vs 16 days. Lower ASA grade significantly
increased likelihood of being alive, as was being female,
younger age and not requiring ITU admission post-op.
Crucially a second on-call consultant was 2.2 times more
likely to increase the chances of patients not dying (p =
0.031). Conclusion: Our audit-loop suggests adding a
second consultant to the daily on-call rota significantly
reduces postoperative mortality and morbidity. We suggest
this change to applied to other high volume centres across
the country to improve outcomes after emergency laparotomy.
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We demonstrate this process is feasible and complex, since
consensus was obtained in only 52% of the evaluations.
Correlative studies between panel decisions and outcome
are being planned after su cient follow-up.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Anesthetic Management for
Parathyroidectomy in a patient with
Myasthenia Gravis (MG) – Is Intravenous
Lidocaine Infusion (IVLI) an Option?
R.G. Govindarajan1, A.J. Shah2, C.F. Foster1,
R.S. Ravikumar2, J.P. Park1, A.A. Amini-Hadjibashi2,
P.T. Prava2, D.L. Livingstone1
© 2017 S. Karger AG, Basel
Predictive Factors for Positive Microscopic
Resection Margin in Curative Surgical
Management of Colorectal Liver Metastases
F.G. Graur, A.M.C. Cosma, R.E. Elisei, E.M. Mois,
N.A.H. Al Hajjar
University of Medicine and Pharmacy "Iuliu Hatieganu"
Cluj-Napoca, Surgery, Cluj-Napoca, Romania
Background: MG is an autoimmune disease characterized by the antibodies against acetylcholine receptors
compromising neuromuscular transmission leading to focal
or generalized muscle weakness. Multi organ involvement
and agents used to treat MG may complicate their perioperative management. We report the use of IVLI in the anesthetic management of one such patient. Material and
Methods: 81-year old female, 102 kg, with h/o MG, DM,
HTN, HLD, CKD, CVA, primary hyperparathyroidism and
COPD was scheduled for left inferior parathyroidectomy.
Her medications included Prednisone 10–1 and
Pyridostigmine 180–1. IV lidocaine bolus (1 mg/kg)
followed by IVLI infusion (1 mg/kg/hr.) were administered
30 minutes prior to induction and continued through the
procedure. After preoxygenation with 100% oxygen the
patient was induced with 2 mg Midazolam, 100 mcg,
Fentanyl and titrated doses of Propofol (200 mg) and intubated without using a muscle relaxant. Anesthesia was
maintained with fentanyl (75 mcg) and Sevoflurane (1–1.5%).
Recurrent Laryngeal Nerve monitoring (RLNM) was done
during the surgery. Approximately 30 minutes prior to the
conclusion of the surgery Neostigmine infusion was started
(2 mg/hr.) The patient was extubated after documenting T4/
T1 of 0.9, completely awake, breathing spontaneously and
responding with a firm handgrip. The Neostigmine infusion
was continued for two hours postoperatively when she
could accept oral Pyridostigmine. Her postoperative ICU
stay was uneventful. Results: By providing complete
laryngeal relaxation and reflex suppression IVLI has enabled
smoother intubation, effective RLNM, stable intraoperative
course and prompt extubation in our patient. Conclusions:
In well optimized patients with MG, IVLI can be a useful
alternative to TIVA during GA without muscle relaxants.
A challenge for the surgeons represents the microscopic
positive resection margin, which is thought to be correlated
with worse overall survival (OS). Demographic results
showed a number of 75 patients, a male: female ratio of 1.27,
with 63 years age at the moment of intervention. There was
a number of 9 cases (12%) of synchronous metastases and
66 cases (88%) metachronous metastases, diagnosed at a
mean of 31 months from the intervention for the primary
tumor. The mean follow-up was 29 months. 59 (21, 4%)
minor interventions were performed, with a number of one
or two segments resected, and 16 (78.6%) major interventions, with the resection of minimum 3 segments. The
resection margin was positive (R1) in 27 cases (36%) and
negative (R0-margin at more than 1 mm. from the metastasis) in 48. Overall Survival at 2 and 5 years for the R1 group
is 43%, respective 29%, versus R0 group, with 58.5% and
49%, but was not statistically significant (p = 0.781).
Synchronous metastases presented a worse prognostic, with
a survival of 33% at 5 years versus metachronous metastases
with 48%, but this difference was not significantly statistic
either, with a p value of 0.34. Factors predicting R1 margins
will be identified after univariate and multivariate statistically analysis. Our results proved that the less differentiated
the tumor is, the worse is the prognosis on survival. Also, the
type of microscopic resection margin didn’t show a statistic
significant influence on the survival, findings mentioned in
other studies.
Robots in Surgery – Past, Present and Future
F. Graur1, R. Elisei1, E. Mois1, C. Vaida2, D. Pisla2,
N. Al Hajjar1
of Medicine and Pharmacy "Iuliu Hatieganu"
Cluj-Napoca, Surgery, Cluj-Napoca, Romania, 2Technical
University of Cluj-Napoca, CESTER, Cluj-Napoca,
Robotic surgery is a real pioneer field in which research
occupies the most important role. This surgical field is in
continuous development proving to be a better therapeutic
option in certain procedures. Science-fiction represents the
beginning of robotics, followed by the development of the
industrial robots and later on the medical robots used
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Bronx Lebanon Hospital, Bronx, NY/ North American
Partners in Anesthesia, Anesthesia, Bronx, Ny, United
States of America, 2Bronx Lebanon Hospital, Surgery,
Bronx, Ny, United States of America
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Pyoderma Gangrenosum Following
Autologous Breast Reconstruction
P. Singh1, S. Tuffaha2, S. Robbins2, S. Bonawitz2
University of Cambridge, Addenbrooke’s Hospital,
Plastic & Reconstructive Surgery, Cambridge, United
Kingdom, 2Johns Hopkins University, Department of
Plastic Surgery, Baltimore, United States of America
Background: Pyoderma gangrenosum is an uncommon
disorder characterized by the development of painful cutaneous ulceration, commonly precipitated by dermal injury at
surgical sites. It is a diagnostic challenge as it manifests as
necrotizing wounds which are commonly misdiagnosed as
postoperative wound infection or ischaemia. We aim to
discuss the clinical features and histopathological findings
that allow for rapid identification of pyoderma gangrenosum
following autologous breast reconstruction, and suggest an
algorithm to aid diagnosis. Case Report: We report the case
of a 48-year-old female who presented for immediate breast
reconstruction with deep inferior epigastric perforator
(DIEP) flaps following bilateral mastectomies for invasive
breast carcinoma. We chronologically follow her recovery,
involving the development of ecchymotic lesions at the
donor and recipient sites. We recap the pathophysiology
behind the theory of ‘pathergy’ and the investigative mindset
that allowed us to accurately and effectively recognize and
manage this potentially devastating post-operative complication. Conclusion: Pyoderma gangrenosum is a condition
that mimics postoperative wound infection or ischemic
necrosis, but must be managed very differently. Further
surgical intervention can, in fact, exacerbate the problem
through further dermal injury. We present the algorithm
now utilized at our institutions for recognizing and managing
this condition.
Ischaemia-Reperfusion Injury Is Reduced by an
Anti-Ischaemic Agent in Skin Flaps
L. Petrovics, F. Németh, Z. Trojnár, T. Nagy, P. Hardi,
G. Pavlovics, I. Takács, G. Jancsó
University of Pécs, Surgical Research and Techniques,
PÉCs, Hungary
Background: Ischaemia-reperfusion injury is one of the
major detrimental factor during the free flap surgery. This
study aimed to investigate the effect of trimetazidine (TMZ),
a potent anti-ischaemic agent, on oxidative stress, inflammation and histopathological changes, using the epigastric
skin flap model in rats. Materials and Methods: 40 Wistar
rats were divided into four groups. I. group: Nonischaemic
control group II. group: Ischaemic control group. III group:
Rats received TMZ on the operation day, 30 minutes before
the ischaemia. IV. group: TMZ was given after the ischaemic
period, at the onset of the reperfusion. Oxidative stress was
assessed by measuring the level of malondialdehyde (MDA)
and reduced gluthatione (GSH) from the blood. The inflammatory response was evaluated using an ELISA kit for TNF-a
from the flap tissue. Histopathological examination was
also performed from skin samples. Results: GSH levels were
significantly higher in the TMZ treated groups, compared to
the ischaemic control group. MDA concentrations were
reduced considerably, only in the III. group, compared to
the ischaemic control group. TNF-a levels were significantly
decreased also only in the III. group. According to the histopathological findings, TMZ treatment was also successful.
Conclusion: Based on our results trimetazidine can reduce
the degree of the ischaemia-reperfusion injury and inflammation, so it has the possibility, to be a potential drug
during free flap surgeries or even during replantations, but
to explore the mechanism and the details of its usage,
further investigations are required.
New Reconstruction Method of
Tracheomalacia – Using 3D Technique,
Animal Model
T.I. Takács
University of Pécs, Department of Surgical Research and
Techniques, PÉCs, Hungary
Background: Tracheomalacia is a chronic state with
airway collapse caused by the absence of tracheal cartilages.
Congenital and iatrogenic forms are known. The aim of our
investigations was to create a chronic animal model with
different tracheomalacia state in order to evaluate the physiological effects and subsequent reconstructive procedures
of it. Material and Methods: There are many animal models
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nowadays. The first surgical robots was modified industrial
robots, but from that point they has their own development.
In the beginning this article is a short history of surgical
robotics, followed by the presentation of some surgical
robots used nowadays. In the second part of the article there
are discussed the characteristics of the future surgical robots
and a proposal of a minimally invasive SILS robot.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Impact of Peritoneal Adhesions on Incision to
Delivery Interval in Caesarean Section
J. Metzemaekers1, dr. R.P.G Ten Broek2, dr. E.A. Bakkum1
OLVG, Gynaecology, Amsterdam, Netherlands,
Radboud, Surgery, Nijmegen, Netherlands
Background: Adhesions are commonly presumed to
cause increase in incision-to-delivery interval (IDI), and antiadhesion barriers have been marketed to reduce adhesion
formation following caesarean section. However, there is no
evidence that such barriers reduce IDI. Moreover, it remains
unsure if the increase in IDI can be contributed to intra-peritoneal adhesions. Objective: Aim of this study was to
compare IDI in primary and repeat caesarean section, and
evaluate the impact of peritoneal adhesions on IDI. Study
Design: We performed an observational prospective consecutive study in a teaching hospital with 82 women undergoing a caesarean. Primary outcome measures were incisionto-delivery interval IDI, time from incision to opening of
visceral peritoneum (pre peritoneal time; PPT) and time from
opening of visceral peritoneum to delivery interval (intra
peritoneal time; IPT). Results: The mean IDI for primary
caesarean was 6.38 minutes ± 2.52. versus 10.45 minutes±4.07
in repeat caesarean sections. The difference was significant
p < 0.01. The PPT was 4.02± (5.00–3.04) in primary caesarean
vs 6:38± (8.12–5.05) P = 0.03 CI 95% [–04.17; –0.55]. IPT
however, was comparable between groups with 2.32 ± 2.51–
2.13 in primary vs 2.56 ± 3.33–2.19 in repeat caesarean P =
0.244 [–01.04; 00.17] Conclusion: Our analysis shows that
the increase in IDI in repeat caesarean sections primarily
originates from extra-peritoneal layers. Intra-peritoneal
adhesions are often present in repeat sections, but seldom
require adhesiolysis and do not seem to cause an increase
in IDI. Because, anti-adhesion barriers only reduce intraperitoneal adhesions these agents are not expected to reduce
IDI in repeat caesarean section.
Treatment for Overactive Bladder: Is Posterior
Tibial Nerve Stimulation the Best Option?
J.M. Norris1, S.M.B. Momin1, J. Choi1, B.G.T. Coumbe1,
S. Ravi-Shankar2
University College London, UCL Division of Surgery &
Interventional Science, London, United Kingdom, 2King’s
College Hospital NHS Foundation Trust, Department of
Primary Care, London, United Kingdom,
Background: A review in urological surgery was
conducted to answer the question: In patients with overactive bladder (OAB), does posterior tibial nerve stimulation
(PTNS), compared to other therapies, improve clinical
outcomes? Materials and Methods: Using a defined protocol,
a total of 230 papers were identified, of which three were
suitable for inclusion. Two studies compared PTNS with
parasacral nerve stimulation (PNS), and one study compared
PTNS with electrical stimulation plus pelvic floor training.
Results: The first study compared PTNS and PNS in children
with OAB, and demonstrated that PNS was significantly
more effective than PTNS in completely relieving symptoms,
however both techniques were equally effective in reducing
dysfunctional voiding. The second study compared PTNS
and PNS in women with OAB, and demonstrated that both
techniques improved quality of life. The third study compared
PTNS with electrical stimulation plus pelvic floor training,
and demonstrated significant improvements in daily micturition, nocturia and urge incontinence in both groups.
Conclusion: Therefore, the clinical bottom line is that both
PTNS and PNS improve quality of life in OAB. Furthermore,
PNS appears to have greater efficacy in children, whilst PTNS
may have a greater effect in women. Further appropriately
powered level 1 studies are necessary to clarifying this
important issue.
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to find in the literature (rabbit, dog) where tracheomalacia
were created and treated in different ways. In our study 2
porcine (weighing: 25 kgs) were operated. During the procedures trachea cartilages were partially removed to investigate physiological effect of the trachea wall leakage.
Further studies were carried out on healthy piglets, to visualise the upper airway of the porcine. Traditional CT-scan,
micro-CT-scan and MRI was carried out to reconstruct the
larynx and trachea of the porcine. Results: The model is
suitable for chronic investigations of the different tracheomalacia states, depending on the number of removed cartilages. The lethal amount of missing cartilages of the trachea
is also defined, and we could endoscopically demonstrate
the changes inside the airways. A 3D model of a porcine
trachea is created by using the mentioned imaging.
Conclusion: A chronic tracheomalacia porcine model was
successfully created, which is easy and quick to reproduce.
A 3D porcine trachea-model was printed which will be used
to investigate further the trachea cartilages, and the reconstructional options of it. Further aim of ours to 3D print an
extra luminal usable stent for the tracheomalacia patients.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Basilic Vein Transposition for Unsuitable
Upper Arm Cephalic Vein Haemodialysis
Access May Attenuate Concurrent Hand
M.W.M. Gerrickens1, B. Govaert1, J.A.W. Teijink2,
M.R. Scheltinga1
Máxima Medisch Centrum, Surgery, Veldhoven,
Netherlands, 2Catharina Ziekenhuis, Surgery, Eindhoven,
Background: Some haemodialysis (HD) patients with a
brachial arteriovenous fistula (AVF) have an unsuitable
upper arm cephalic vein necessitating basilic vein transposition (BVT). It was incidentally observed that patients
reported a warmer and less painful HD-hand after BVT. This
study aimed to assess whether signs and symptoms of
haemodialysis access-induced distal ischaemia (HAIDI) are
attenuated following BVT for an inadequate needle access
segment. Methods: Patients with brachial arteriovenous AVF
scheduled for BVT and suffering from concurrent hand ischaemia were followed between 2005 and 2016. Hand ischaemia was graded as proposed in a 2016 consensus meeting.
Hand ischaemic questionnaire (HIQ) scores (0 points, no
ischaemia – 500 points, maximal ischaemia), digital brachial
index (DBI, normal >0.6) and access flow (mL/min) were
compared before and after BVT. The cephalic vein and all
side branches of the basilic vein were ligated during the
operation. Results: Ten patients were studied (8 males, 61
[54–75] years). BVT was performed 8 [4–10] months following
initial AVF construction. Preoperative DBI and HIQ were
inversely correlated (R2=61%, P=.023). After surgery, HIQ
dropped from 119 [0–290] to 9 [0–78] (P=.043) whereas DBI
increased from 0.51 [0.39–0.67] to 0.85 [0.68–0.97] (P=.012).
Access flows decreased from 1818 ± 560 mL/min to 1248 ±
265 mL/min (P=.043). Surgery-associated complications
were not observed and dialysis was continued uninterruptedly. Eight patients reported total recovery from HAIDI
6 weeks postoperatively. Conclusion: Transposition of the
basilic vein for an unsuitable upper arm cephalic vein access
attenuates signs and symptoms of hand ischaemia in most
patients with concurrent HAIDI.
A Novel Surgical Model as a Foundation for
Further Living Organ Engineering in vivo
A. Wang, P. Felgendreff, C. Hua,, W.W. Wei, C. Schindler,
C. Kan, U. Dahmen
Experimentelle Transplantationschirurgie, Klinik
für Allgemein-, Viszeral- und Gefäβchirurgie
Universitätsklinikum Jena, Jena, Germany
Background: Partial organ decellularization in-vivo, also
called chemical resection, was first described by Pan
(IntJBiochem&CellBiol 2016) as a potential treatment option
instead of surgical resection. They achieved selective
perfusion of the right inferior liver lobe in rats at the expense
of completely blocking portal vein and inferior cava.
Objective: Our study aims for establishing a novel method
for partial liver perfusion in-vivo with preservation of physiological blood flow to the remaining liver. In the long run,
we aim to conduct organ engineering in-vivo and to explore
repopulation and functional recovery of the decellularized
liver lobes. Materials and Methods: Using male Lewis Rats
(n = 6), we created a by-pass circulation within left median
(LM) lobe and left lateral (LL) lobe. The stem of LM- and
LL-portal vein was blocked and cannulated distally, whereas
the confluence of LM- and LL-hepatic vein was cannulated
(22 g basket cannula) and blocked distally using 6-0prolene.
Results: Using heparinized saline, the targeted liver lobes
were indeed perfused selectively from the inlet and drained
via the outlet we designed. Physiological perfusion of the
other liver lobes was maintained as well as blood flow
through the vena cava. We encountered transient minor
problems such as leakage of perfusate and bleeding. Conclusions: Selective perfusion of the targeted liver lobes while
preserving the blood flow of vena cava and the remaining
partial liver is technically feasible in rats. Our novel method
of partial liver perfusion may provide the foundation for
further exploring liver engineering and the process of liver
functional recovery in-vivo.
Lateral Pelvic Lymph Node Dissection in Rectal
A. Navarro-Sánchez, J. López-Fernández,
J.R. Hernández Hernández
Hospital Universitario Insular De Gran Canaria, Colorectal
And General Surgery, Las Palmas De Gran Canaria, Spain
Background: Rectal tumours below the peritoneal
reflection have the potential to metastasize to lateral pelvic
lymph nodes (LPLN). This has been reported up to 27%.
Neoadjuvant chemoradiotherapy followed by low anterior
resection with total mesorectal excision (LAR-TME), which is
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
ALPPS Treatment for Synchronous Bilobar
Multiple Colorectal Liver Metastases
H. Yoshidome, K. Shinmura, H. Shibasaki, D. Nobumoto,
M. Yoshino, A. Oki, J. Nakamura, K. Kato
Japanese Red Cross Saitama Hospital, Surgery, Saitama,
Background: Aggressive surgical resection for colorectal
liver metastases (CRM) may prolong survival. Staged hepatic
resection such as ALPPS and two-stage hepatectomy has
been of use to treat patients with multiple bilobar CRMs.
Herein, we show the video to perform associating liver
partition with portal vein ligation for staged hepatectomy
(ALPPS). Video: A 45-year-old man has an ascending colon
cancer and synchronous bilobar multiple CRMS. The serum
CEA levels were 54.8 ng/ml. Liver mets were more than 20
nodules. Because of lack of functional liver remnant and
progressive disease, simultaneous resection for liver and
primary tumor was unable to be performed. The only
possible procedure was ALPPS. At the first stage, partial liver
resection of S4a, S4b, and S3 to remove the mets and liver
partition was performed, combined with vascular taping of
the right portal vein, right hepatic artery, and right hepatic
vein. Simultaneously, right hemicolectomy with lymph node
dissection was performed. After the 7 days of the first
surgery, 86% of remnant liver parenchyma was increased. At
the 9th postoperative day, the second surgery was performed.
The postoperative complication was surgical site infection
and bile leakage, but without liver failure. The pathological
findings showed pT3N2H2. He received adjuvant chemotherapy with XELOX + Bmab. He is alive without recurrence
for 7 months after surgery. Conclusion: ALPPS procedure is
safe and beneficial for treatment of synchronous bilobar
CRMs in selected patients.
Utility of Postoperative Serum C-Reactive
Protein Value as a Prognostic Factor for
Patients with Open Radical Gastrectomy for
Advanced Gastric Cancer
Y.H. Hojo, Y.K. Kanokogi, M.H. Hirata, A.S. Sugimoto,
Y.F. Fujita, Y.K. Kawasaki, T.S. Sakamoto, J.Y. Yoshikawa,
H.I. Iwama, S.U. Usuki, M.T. Tada, Y.S. Shirakata,
J.T. Tamura, A.M. Maki
Hyogo Prefectural Amagasaki General Medical Center,
Surgery, Amagasaki, Hyogo, Japan
Background: Prognosis of operated gastric cancer
patients has been reported to be associated with postoperative complications with severe inflammation such as
anastomotic leakage and pancreatic fistula. Serum C-reactive
protein (CRP) value is one of the common parameters of
these inflammatory events. Previous study suggested that
postoperative serum CRP value was a reliable indicator of
survival after gastrectomy for gastric cancer. We investigated the utility of postoperative serum CRP value as a
prognostic factor for patients with open radical gastrectomy
for advanced gastric cancer. Material and Methods: 237
patients with pStage ? or ? gastric cancer underwent open
radical gastrectomy from January 2007 to December 2014 at
Hyogo prefectural Amagasaki Hospital in Japan. We selected
185 patients according to our criteria and conducted a retrospective analysis regarding the association between postoperative maximum serum CRP value during hospitalization
and prognosis. We compared the relapse free survival rate
and overall survival rate between two groups divided by
postoperative maximum serum CRP value, cut off 12 mg/dl.
Result: Recurrence occurred in 63 patients (34.05%). 3 year
relapse free survival rate of low CRP group (69.08%) was
significantly higher than high CRP group (54.52%) (p =
0.0304). 3 year overall survival rate of low CRP group (79.05%)
was also significantly higher than high CRP group (64.16%)
(p = 0.0357). Conclusion: Postoperative serum CRP value
can be an excellent indicator of the prognosis after open
radical gastrectomy for advanced gastric cancer.
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commonly performed in western countries, are not enough
to eradicate LPLN. In contrast, Lateral pelvic lymph node
dissection (LPLND) has become the standard management
in Japan. We present a video showing a laparoscopic right
LPLND in a patient with rectal cancer. Material and Methods:
A 70 years-old female was referred to our unit for rectal
tumour 8 cm from the anal verge. Staging computed tomography (CT) showed no distant metastasis and magnetic resonance imaging (MRI) revealed a T2N2b rectal cancer. After
neoadjuvant chemoradiotherapy MRI demonstrated a
T2N2a tumour with right LPLN involvement. Results: Laparoscopic LAR-TME with loop ileostomy and right LPLND
were performed. Postoperative recovery was uneventful and
she was discharged 5 days postprocedure. Histopathology
showed a pT2N1a rectal cancer. Six non-metastatic lymph
nodes were harvested in the LPLND. She is currently on
adjuvant chemotherapy. No recurrence has been demonstrated to date. Conclusions: Japanese guidelines
recommend LPLND in rectal tumours with lower border
located below the peritoneal reflection with radiological
positive LPLN with the aim to reduce pelvic recurrence and
improve 5-year survival rate; although it carries risk of sexual
and urinary dysfunction. This management is not well stablished in western countries. Laparoscopic LPLND has the
advantages of minimally invasive surgery so it is the recommended approach in experienced hands.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Adipose-Derived Mesenchymal Stem Cells
Slow Disease Progression of Acute-On-Chronic
Liver Failure
M.I. Prieto
J. Fuentes1, A. Blázquez-Martínez1, S. Argudo3,
C. Marcano1, J.P. Pérez-Robledo1, J.L. Marijuan1,
J. Díaz-Domínguez1
LA PAZ, Surgery, Madrid, Spain, 2Hospital Universitario
del Sureste, 1, Department of General and Digestive
Surg, Madrid, Spain, 3Universidad Complutense, School
of Medicine, Madrid, Spain
Background and Aims: A serious complication of chronic
hepatic insufficiency is acute on chronic liver failure, a recognized syndrome characterized by acute decompensationof
cirrhosis and organ/system failure. We investigated the use
of adipose derivedmesenchymal stem cells (AD-MSCs) in an
experimental model of acute on chronicliver failure,
developed by microsurgical extrahepatic cholestasis in the
rat. Methods: Rats undergoing microsurgical extrahepatic
cholestasis were treated byintraparenchymal liver injection
of human or rat AD-MSCs, undifferentiated orpreviously
differentiated in vitro toward the hepatocyte lineage.
Results: The groups treated with rat AD-MSCs showed less
ascites, lower hepato- andsplenomegaly, less testicular
atrophy and an improvement in serum biochemical hepaticparameters. There was also an improvement in histological
liver changes, in which thearea of fibrosis and bile duct
proliferation were significantly decreased in the grouptreated with predifferentiated rat AD-MSCs. Conclusions: An
isograft of hepatocyte predifferentiated AD-MSCs injectedintraparenchymally 2 weeks after microsurgery in extrahepatic cholestatic rats prevents secondary complications of
acute on chronic hepatic failure. These data support the
potential use of autologous AD-MSCs in the treatment of
human cholestasis, andpecifically of newborn biliary atresia,
which could be beneficial for patients awaiting transplant.
SATB1 Expression of Colorectal Carcinomas
Versus Colorectal Adenomatous Polyps
G.S. Yalcin1, M. Gonultas2, R. Pekcici2, E. Kumcu3,
M. Yasaran2, S. Hucumenoglu2
Kecioren Research and Training Hospital, Pathology
Department, Ankara, Turkey, 2Ankara Research and
Training Hospital, Pathology Department, Ankara,
Turkey, 3Bingol Government Hospital, Pathology
Department, Bingol, Turkey
Background: “Special AT-rich sequence-binding
protein-1”(SATB1) is a global genome organizer and is
found to be effects on carcinogenesis and progression of
various malignancies including colorectal carcinoma (CRC).
In this study we aimed to investigate the expression of
SATB1 in CRC and colorectal adenomatous polyps (CAP).
Material and Methods: We examine 227 CRCs and 129
CAPs. SATB1 protein expression is evaluated by immunohistochemistry in cancerous tissue and unchanged mucosa of
CRC patients; and in adenomatous epithelium and
unchanged mucosa of CAP patients. Results: We found
significantly higher expression in cancerous tissue than
normal mucosa, and in adenomatous epithelium than
normal mucosa. SATB1 expression of adenomatous
epithelium was significantly higher than cancerous tissue
(55.0% vs 42.7%, respectively). Furthermore, SATB1
expression of left colon tumors were significantly higher
than right colon tumors (46.3% vs 28.6%, respectively) and
conventional adenocarcinomas than mucinous carcinomas
(45.5% vs 6.3%, respectively). SATB1 expression was significantly higher in CAPs bearing high grade dysplasia than
polyps with low grade dysplasia (77.8% vs 51.4%, respectively). Multivariate analysis revealed that SATB1 expression
did not correlate with patients’ overall survival, but this
analysis was limited by a relatively short period of follow-up
(median follow-up time 27,00 months). Conclusion: The
higher expression of SATB1 in CAP patients than CRC
patients suggesting that SATB1 may have a role in the early
stages of carsinogenesis of CRCs. This was the first study
showing SATB1 expression in CAPs. Our results, with
supporting new studies, can provide SATB1 as a prognostic
parameter in CRC and CAP patients.
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Colonoscopic Tattooing of Colorectal Lesions –
How are We Actually Doing?
M. Nnaji1, H. Nageswaran2, C. Vickery2, L. Hunt2
University Hospitals Birmingham NHS Foundation
Trust, Colorectal Surgery, Birmingham, United Kingdom,
Taunton and Somerset NHS Foundation Trust,
Colorectal Surgery, Taunton, United Kingdom
Background: As a result of difficulties visualising colonic
lesions intraoperatively particularly in laparoscopic surgery,
in addition to localisation of lesions for future surveillance,
it is imperative to identify the precise location of such lesions
by colonoscopic tattooing. The aim of this audit was to
ascertain if quality assurance guidelines for colonoscopic
tattooing of colonic lesions were adhered to in our trust.
Materials and Methods: A total of 119 patients with
suspected colorectal cancer that underwent colonoscopy
between Jan 2009 and Nov 2011 were identified from our
bowel cancer screening programme (BCSP) database. We
reviewed their endoscopic reports to investigate if the
lesions identified during colonoscopy were tattooed
according to St Mark’s colonoscopic tattooing protocol.
Results: Of the 119 patients identified, 84 had an endoscopic report available. Mean age was 67 years and male to
female ratio was 1.5:1. 41 patients (49%) who had their
lesions tattooed were recorded. 13 patients (15%) had
lesions in the caecum and lower rectum which didn’t need
tattooing (according to guidelines). 30 patients (36%) had
no documentation regarding tattooing of lesions identified.
Incomplete documentation accounted for the majority of
cases of non-compliance. Conclusion: Correct localisation
of colonic lesions is extremely important for adequate
surveillance and for surgical resection of colonic tumours.
Education is key in addressing the challenge of poor documentation to ensure colonoscopic tattooing guidelines are
Emergency Presentations of Colorectal Cancer:
Can GPs Reduce the Occurrence?
R. Mahapatra, M. Grainger, M. Nevin
Countess of Chester Hospital NHS Foundation Trust,
General Surgery, Chester, United Kingdom
Background: A large number of patients with Colorectal
Cancer (CRC) still presenting as an emergency. Patients
presenting to primary care with symptoms are referred
urgently. The aim of this study was to evaluate those patients
with an emergency presentation had symptoms which could
have led to earlier referral. Methods: A retrospective analysis
of emergency presentation with CRC between in 2013 and
2015 from two hospitals UK was performed. Patients were
questioned regarding their CRC symptoms and consultation
prior to admission. Results: 34 patients presenting with CRC
as an emergency. 76% of patients had abdominal pain; 29%
vomiting; 35% change in bowel habit; 8% rectal bleeding
and 8% bowel obstruction. 88% patients had symptoms
present prior to admission; median time of 3 months. 62%
of patients had symptoms for longer than 2 weeks. 70%
patients with prior symptoms presented to Primary Care on
at least one occasion. The median number of visits was 3.
Eighteen of these 21 patients had ‘practitioner delay’.
Fourteen of these 21 patients had change in bowel habit or
iron deficiency anaemia. Conclusions: Patients who present
with CRC as an emergency experience patient and practitioner delay prior to their diagnosis, with 70% consulting
Primary Care with their symptoms prior to admission. 53%
of patients had suffered ‘practitioner delay’ whereby they
presented to their GP with symptoms which meet the NICE
criteria for referral to Hospital. GPs should be reminded of
the NICE guidelines for referral of patients with suspected
CRC in order to decrease practitioner delay.
A Prospective Study to Investigate CRP as a
Single Predictor for a Difficult Laparoscopic
Cholecystectomy or Its Conversion. Results
from the First 118 Patients
A.D. Gerrard, E. Norris, V. Shetty, P. Turner, K. Pursnani,
J.B. Ward, C.B. Ball, R.S. Date
Royal Preston Hospital, Upper GI Surgery, Preston,
United Kingdom
A high CRP has been shown to be a good independent
predictor for conversion during laparoscopic cholecystectomy in a retrospective study. We predict that the risk of
conversion (ROC) is higher with a raised CRP, and is
dependent on indication of surgery, rather than patient
factors: high BMI or previous surgery. We aim to prospectively validate CRP as a single factor for predicting conversion,
or difficult laparoscopic cholecystectomy (LC). Emergency
admissions with gallstone disease from July to Dec 2016
were included in the study. The patients were grouped
according to their indication: Group 1 – Gallbladder disease
(Biliary colic or Cholecystitis), Group 2 – Common Bile Duct
(CBD) stones and Group 3 – Gallstone pancreatitis. The peak
CRP during admission was correlated with conversion during
LC or a difficult procedure defined as a Nassar score of 4. In
group 1, the rate of conversion when CRP >200 was 46.4%
(13/28) compared to 13.5% (7/52) when CRP was less than
200 (P = 0.0013). In groups 2 (0/5, 0/14) and 3 (0/10, 0/9) no
patient required conversion to an open procedure. In group
1 when CRP >200, 60.7% (17/28) operations were graded
Nassar 4 and 15.4% when CRP <200. Conversion rate in
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
groups 2 & 3 is low. In Group 1, a high CRP is strongly related
to an increasingly difficult procedure and increased ROC.
Predicting conversion based on indication and degree of
inflammation of the gallbladder, related to CRP, may be the
way forward when planning operations to make them safer.
© 2017 S. Karger AG, Basel
Appendicitis Due to a Serrated Adenoma. Does
It Increase the Risk of Colorectal Cancer?
A. Navarro-Sánchez, J. López-Fernández, J.R. Hernández
Hospital Universitario Insular de Gran Canaria, Colorectal
and General Surgery, Las Palmas de Gran Canaria, Spain
Stoma Related Complications after Covering
Ileostomy Construction
S. Haneda, K. Takahashi, F. Saijo, N. Matsumura,
R. Nomura, M. Muto, A. Yasumoto, K. Sawada,
H. Chitose, K. Sato, T. Toshima, M. Shibahara,
Y. Katayose, H. Tokumura
Tohoku Rosai Hospital, Surgery, Sendai, Japan
Background: In colorectal surgery with low level anastomosis, covering ileostomy is often recommended. Stoma
related complications occasionally occur after ileostomy
construction and it affect straightly to the QOL of the
patients. However, there are few reports reviewed for the
stoma related complications after covering ileostomy. The
aim of this study was to investigate the incidence of stoma
related complications. Method: A prospective study was
carried out on 43 patients who underwent surgery with
covering ileostomy construction in Tohoku Rosai Hospital
between January 2015 and December 2016. The rate of the
stoma related complications was investigated. Results: In
total, 43 patients (32 men, 11 women) were included. Median
age, and the follow up period were 58 (22–85), and 174
(53–495) days. Primary diseases were rectal cancer in 24
(55.8%) patients, ulcerative colitis in 15 (34.9%), and others
in 4 (9.3%). Performed procedures were ileo-anal (canal)
anastomosis in 15 (34.9%), low anterior resection in 14
(32.6%), intersphincteric resection in 10 (23.2%), and others
in 4 (9.3%). Early stoma related complications (within 30
post-operative days) occurred in 3 (7.0%); mucocutaneous
dehiscence in 1, retraction in 1, and fistula in 1. Late stoma
related complications occurred in 4 (9.3%); parastomal
hernia in 2, infection in 1, and prolapse in 1. No surgical
therapy was necessary for the stoma related complications.
Conclusions: The rate of the stoma related complications
was low and no severe complications occurred. Our surgical
therapy for covering ileostomy construction were considered
Background: Serrated adenomas are heterogeneous
group of lesions which are characterized by a histological
appearance as ‘sawteeth’. It is recognized their potential
malignant transformation to colorectal cancer by the
serrated pathway of carcinogenesis. Material and Methods:
A 36-year-old female presented to our unit with right iliac
fossa pain and fever. Her past medical history included
psoriasis since childhood and eutocic delivery 3 weeks
before complicated with dilated cardiomyopathy. Blood test
revealed leuckocytosis. Computed tomography demonstrated acute appendicitis. Results: Diagnostic laparoscopy
was performed showing acute appendicitis. The tip of the
appendix was perforated with an adjacent abscess. The
abscess was drained and the appendix removed laparoscopically. The postoperative recovery was uneventful and the
patient was discharged three days after the procedure.
Histopathology shown acute appendicitis and a serrated
adenoma of the appendix. The patient is under rheumatology review and currently awaiting colonoscopy. Conclusions: Several studies have determined the relation between
serrated adenomas and colorectal cancer through the
serrated pathway of carcinogenesis. This could represent up
to 20–30% of all colorectal neoplasms. Risk factors of developing cancer are: size over 10 mm, multiplicity, sessile
serrated adenoma, presence dysplasia and proximal location.
Current guidelines recommended removal of all polyps and
endoscopic surveillance.
Laparoscopic Adjustable Gastric Banding in
P. Rimmer
Obstetrics & Gynaecology, Warwick, United Kingdom
Background: The prevalence of obesity in pregnancy is
rising and associated with numerous health outcomes. Many
patients are unable to achieve long-term weight loss and as
such the incidence of bariatric surgery to achieve this weight
loss is on the rise, notably laparoscopic adjustable gastric
banding (LAGB). New questions have arisen with regards to
the effectiveness of LAGB and its impact on gestational
weight gain and caesarian section rates. Methods: We
searched the literature to review pregnancy outcomes in
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Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Microcirculatory, Micro-Rheological and
Histological Alterations during and after Renal
Ischemia and Reperfusion in a Rat Model
K. Petö1, N. Nemeth1, Z.S. Magyar1, A. Mester1, V. Sogor1,
A. Deak1, S. Ghanem2, B. Tanczos1, L. Bidiga1, B. Nemes1
University of Debrecen, Faculty of Medicine, Dept. of
Operative Techniques and Surgical Research, Debrecen,
Hungary 2University of Debrecen / Faculty of Medicine,
Dept. of Op. Techn. and Surg. Research, Debrecen,
Background: Renal ischemia-reperfusion (I/R) is associated with several functional and morphological deviations.
However, micro-rheological and microcirculatory relations
have not yet been elucidated completely. Materials and
Methods: In anaesthetized rats were the left femoral artery
was cannulated, median laparotomy was performed and
both kidneys were exposed. In Control group (n = 6) no
other intervention happened. In I/R group (n = 10) the right
kidneys’ vessels were ligated and after a 60-minute ischemia
the organ was removed. The left renal vessels were clamped
for 60 minutes followed by 120-minute reperfusion. LaserDoppler (LD) flowmetry was performed on small intestine
and liver before/after the ischemia, and in the left kidney
during the reperfusion (R30, R60, R120). In parallel, blood
samples were taken for erythrocyte deformability, aggregation, acid-base and hematological parameters. Biopsies
were taken from the kidneys. Results: During reperfusion
renal blood flux unit showed a mild increase, intestinal
values increased continuously, while hepatic values
decreased by R120. Lactate level significantly increased by
the end of the reperfusion accompanied with decreased
blood pH. Enhanced erythrocyte aggregation and impaired
deformability were observed from the 30th minute of reperfusion. A slight hemoconcentration and increased leukocyte
count occurred. In ischemic kidneys anisometric vacuolization in proximal tubuli, cytoplasmatic hyaline granules,
eosinophilia were observed, and additional inchoate neutrophils in the reperfused kidneys. Conclusions: Micro-rheological parameters impair during renal I/R, that may
contribute to microcirculatory deterioration. Besides histological signs of tissue damage, LD-flowmetry indicated
microcirculatory failure in the reperfused kidney, liver and
intestine, too. The model can be suitable for studying various
agents against I/R injury.
Assessment of the Gingival Microcirculation
at Teeth and Dental Implants; A Preclinical
in-vivo Pilot Study
A. Deák1, Z.S. Fülöp2, B. Tánczos1, V. Sógor1, K. Sári2,
I. Varga2, N. Németh1, A. Stavropoulos3, C.S. Hegedus2
University of Debrecen, Faculty of Medicine,
Department of Operative Techniques and Surgical
Research, Debrecen, Hungary 2University of Debrecen,
Faculty of Dentistry, Department of Biomaterials and
Prostheti, Debrecen, Hungary, 3Faculty of Odontology,
University of Malmo, Department of Periodontology,
Malmo, Sweden
Background: Good blood microcirculation is an
important feature of healthy gingiva. Periodontal diseases
are associated with various microcirculatory impairments,
either as the reason and/or the consequence of disease.
Little is known about the microcirculation around dental
implants. The aim of the study was to non-invasively
examine the microcirculation of peri-implant area. Materials and Methods: In 7 beagle dogs, 4 dental implants
were installed in each side of the previously edentualated
(4-4 premolars each side) and completely healed mandible.
About 8 months after implant installation, the gingival
temperature was measured with an infrared thermometer
and the gingival microcirculation with a laser Doppler
flowmeter, around the 1st molar and the submerged and/
or exposed implants, respectively. Results: No significant
differences were observed in the measured temperature of
the gingiva next to the teeth (30.62 ± 1.17°C) and implants
(29.92 ± 1.45°C, p = 0.172), respectively. Similarly, no
significant differences in microcirculation were observed
(BFU values: 70.01 ± 13.67 and 70.09 ± 27.52), respectively.
However, in cases where implants (n = 7) were unintentionally exposed during healing and presented with
mucosal recession/inflammation, BFU values were significantly lower (28.78 ± 15.62) comparing to the gingiva
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patients who had undergone LAGB. Results: Gestational
weight gain – five studies were identified which examined
pregnancy and LAGB. The weight gain varied from –28 kg to
+32 kg. Women who had undergone LAGB gained significantly less weight than controls. Caesarian section – eleven
studies were identified which examined the rate of caesarian
section and LAGB. One study concluded C/S was lower but
not significantly. Two concluded the rate of C/S was raised
in LAGB and one study concluded there was no statistically
significant difference. Six found a statistical significant lower
incidence of C/S in LAGB patients. Discussion: Poorly
controlled weight gain in pregnancy can result in complications such as gestational diabetes, large for gestational age
infants, shoulder dystocia and emergency caesarian section.
Our review identified several studies examining LAGB
surgery and pregnancy outcomes. We identified LAGB
patients had a reduced incidence of gestational weight gain
and caesarian section. This demonstrates the benefit of
bariatric surgery in controlling gestational weight gain and
its potential to reducing the incidence of caesarian section.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
around the teeth and nearby the complication-free
implants (p < 0.001). Conclusions: No significant differences were observed in the temperature and the microcirculation of healthy gingiva near teeth and submerged
implants, respectively. However, significantly lower microcirculation values were observed around implants with
© 2017 S. Karger AG, Basel
Technical Aspects of the Microsurgically
Created Carotid-jugular Fistulas in Rats.
A Pilot Study
S. Ghanem1, Z.S. Magyar2, A. Mester2, N. Nemeth2
University of Debrecen / Faculty of Medicine,
Department of Operative Techniques and Surgical
Research, Debrecen, Hungary, 2University of Debrecen,
Dept. of Op. Tech. and Surg. Res., Debrecen, Hungary
Z.S. Magyar1, A. Mester1, S. Ghanem2, G. Nadubinszky1,
G. Varga1, V. Sogor1, B. Tanczos1, M. Oltean3, N. Nemeth1
University of Debrecen, Faculty of Medicine, Dept. of
Operative Techniques and Surgical Research, Debrecen,
Hungary, 2University of Debrecen / Faculty of Medicine,
Dept. of Op. Tech. and Surg. Res., Debrecen, Hungary,
Sahlgrenska University Hospital, The Transplantation
Institute, Gothenburg, Sweden
Background: Before the ischemia-reperfusion (I/R) short
cycles of remote organ ischemia (preconditioning) can be
protective against the damage. However, there is no
consensus on the optimal amount of tissue, the number and
duration of ischemia, and the timing of the preconditioning.
The hemorheological background of the process is also
unknown, nevertheless, the micro-rheological parameters
have important role in the determination of the microcirculation. Materials and Methods: In anesthetized rats ~70%
partial liver ischemia was induced for 60 minutes; reperfusion 120-minute reperfusion was observed (Control, n =
5). In the preconditioned groups a tourniquet was applied
on the left thigh for 3x10 minutes with 10-minute reperfusion periods 1 h (rIPC-1, n = 6) or 24 h (rIPC-24, n = 6)
before the liver ischemia. Blood samples were taken before
the procedure and 30, 60 and 120 minutes after liver reperfusion. Acid-base parameters, hematological parameters,
red blood cell (RBC) aggregation and deformability were
tested. Results: Lactate concentration significantly increased
in all groups by the end of the reperfusion, but the blood pH
remained compensated. The liver I/R caused hemoconcentration in the Control group. The RBC aggregation parameters were increased for R60, especially in the rIPC-24 group,
but no significant difference was observed between the
groups. The deterioration of the RBC deformability parameters were pronounced in the Control and the rIPC-24
groups. Conclusions: Remote ischemic preconditioning alleviated several hemorheological changes caused by the liver
I/R. However, the optimal time (i.e. early or delayed) of the
remote preconditioning cannot be decided based on these
Background: Numerous microsurgical shunt models,
including carotid-jugular fistula, are known in the literature.
Each of them has various advantages and disadvantages
regarding the hemodynamic and microcirculatory effects, as
well as microsurgical technique. This study is a small scale
preliminary work conducted in order to evaluate feasibility
of common carotid artery – external jugular vein fistula in
rats. Materials and Methods: In anaesthetized rats the right
external jugular vein (EJV) and right common carotid artery
(CCA) were isolated through a horizontal incision across the
lower neck. The CCA was ligated below the bifurcation and
the proximal cut end was spatulated laterally. The EJV was
ligated, and the proximal cut end was spatulated medially.
End-to-end anastomosis was performed using running
sutures on the posterior and anterior wall of the anastomosis, between corner stitches, with 10-0 monofilament
nylon suture. After recovery the animals returned to their
cage with postoperative analgesia and daily observation.
Results: The shunt geometry could be set without marked
stretching of the vessels and the anastomosis line. Extensive
dissection of the vein adventitia makes the anastomosis
difficult. Unilateral carotid ligation and the presence of the
shunt did not result in obvious neurological/behavioral
symptoms, however, bleeding/hematoma may cause
complications in the early postoperative days. Six weeks
later examination didn’t show neurological symptoms.
Conclusion: After the necessary technical learning curve, this
unilateral carotid-jugular fistula in rats is a feasible model for
further microsurgical arterio-venous shunt studies, using
hemodynamic, microcirculatory, micro-rheological, and
histomorphological investigative methods.
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The Beneficial Effects of Remote Ischemic
Preconditioning on Micro-Rheological
Parameters in the Rat
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Assessment of Right Ventricular Systolic
Function and Venous Return after
Non-Cardiac Thoracic Surgery
R.Z. Zayat, H.S. Steffen, S.K. Kalverkamp, R.A. Autschbach,
P.D. Goetzenich, N.H. Hatam, J.S. Spillner
RWTH University Hospital, Department of Thoracic and
Cardiovascular Surgery, Aachen, Germany
© 2017 S. Karger AG, Basel
Long Term Biological and Mechanical Behavior
of New Cyanoacrylate Adhesives Used to Fix
Polypropylene Mesh in an Extraperitoneal
Hernia-Repair Model
V. Gómez-Gil1,3, G. Pascual1,3, M.R. dríguez1,3,
C. Mesa-Ciller1,3, B. Pérez-Köhler1,3,
M. Fernández-Gutiérrez2,3, J. San Román2,3, J.M. Bellón1,3
of venous return and right ventricular systolic function after
cardiac surgery. We hypothesized that non-cardiac thoracic
surgery without pericardial opening might also alter both
venous return and right ventricular systolic function.
Methods: In a prospective observational investigation, 14
patients (7 female) planned for lobectomy (6 pts had right
side lobectomy, 9 pts underwent open thoracotomy, 5 pts
had Video Assisted Thoracoscopic Surgery, VATS) without
prior cardiac or thoracic surgery were included. Conventional and speckle tracking echocardiography were used to
assess venous return and right ventricular systolic function
before and shortly after lung surgery. Besides standard
echocardiographic parameters, the following parameters
were derived from the apical four chamber view: tricuspid
annular plane systolic excursion (TAPSE, mm), right
ventricular fractional area change (RV-FAC, %), tricuspid
annular systolic peak (TASV, cm/s), global longitudinal peak
systolic strain (LSG, –%) and strain rate (LSRG, –1/s) including
the free wall and the septum, average longitudinal peak
systolic strain (LSFW, -%) and strain rate (LSRFW, –1/s) of the
free wall and spectral Doppler of the hepatic veins deriving
S/D ratio. Results: All patients underwent uneventful surgery.
Parameters measured are summarized in table 1. Pre- and
postoperative values correlated well, but no significant
alterations of venous return and right ventricular systolic
function were found. Conclusion: Our study indicates that
opening of the thoracic wall and pleural cavity does not
result in significant changes in both venous return and right
ventricular systolic function. Larger, multicenter studies are
necessary for further evidence.
University of Alcalá, Surgery, Medical and Social
Sciences, AlcalÁ De Henares, Spain, 2Polymer Science
and Technology Institute-CSIC (ICTP-CSIC), Polymer
Biomaterials Group, Madrid, Spain, 3Networking
Biomedical Research Centre on Bioengineering,
Biomaterials and Nanomedicine (CIBER-BBN)
Background: As an alternative to sutures, meshes used
for hernia repair can be fixed using cyanoacrylate-based
adhesives. Their main problem, toxicity, is being solved
increasing the length of their alkyl chain. This preclinical
study compares the long term behavior of cyanoacrylates of
different chain length, already used in hernia repair and new
ones for this application. Materials and Methods: Partial
abdominal wall defects were repaired using a Surgipro mesh
in 18 New Zealand white rabbits, and groups established
according to the mesh fixation method: sutures (control),
Glubran2(n-butyl), Ifabond(n-hexyl), and the new cyanoacrylates: SafetySeal(n-butyl), Evobond(n-octyl). Six months
after surgery, the recovered implants were examined to
assess TA degradation, host tissue reaction and biomechanical strength. Results: All the cyanoacrylates groups
showed good host tissue incorporation in the meshes.
Macrophage response of Glubran/Ifabond was quantitatively greater compared to sutures. Cell damage caused by
the adhesives was similar and only Glubran induced significantly more damage than the sutures. Significantly lower
collagen 1/3 mRNA expression was induced by Ifabond than
the remaining fixation materials. No differences were
observed in collagen levels except for slightly reduced
collagen I deposition in Glubran/Ifabond groups, and of
collagen III in the suture group. No differences in mechanical
strength emerged between the suture and cyanoacrylates
groups. Conclusions: All the cyanoacrylates showed good
long term behavior and tolerance irrespective of their long
or intermediate chain length. Cyanoacrylate residues
persisted at six months indicating their incomplete degradation. Biomechanical strengths were similar across the TA
groups and neither were differences with the sutures.
Acknowledgements: SAF2014-55022-P.
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Purpose: Previous studies have shown regular alteration
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Gender and Age-Related Differences of
Micro-Rheological Parameters during
Intestinal Ischemia-Reperfusion in Rats
A. Mester, Z.S. Magyar, V. Sogor, B. Tanczos, N. Nemeth
University of Debrecen, Department of Operative
Techniques and Surgical Research, Debrecen, Hungary
Numerous studies suggest that gender and age have a
great influence on hemorheological parameters. It is known
that during ischemia-reperfusion (I/R) the micro-rheological parameters of the blood (red blood cell aggregation
and deformability) worsen, and it may contribute to microcirculatory deterioration. We aimed to investigate the
gender and age-related micro-rheological alterations
during intestinal I/R. Under general anesthesia after the
cannulation of the left femoral artery median laparotomy
was performed on CD outbred rats. In the young control
animals there were no other interventions (female n = 7;
male n = 7). In the young and old I/R groups (female and
male, n = 6–7/group) the superior mesenteric artery was
clipped for 30 minutes, and a 120-minute reperfusion
period was observed afterwards. Blood samples were taken
before and at the 30-minute ischemia (Base, I30), in the
30th, 60th and 120th minutes of the reperfusion (R30, R60,
R120). Hematological parameters (Sysmex F800), erythrocyte deformability (LoRRca MaxSis Osmoscan) and aggregation (Myrenne MA-1) were determined. Leukocyte count
increase in the old female I/R group was more expressed
than in the young females, this difference was not specific
in the male groups. Platelet count elevated in the old female
I/R group, while in the male I/R groups young animals
showed higher values. Aggregation index values increased
in all groups being the lowest in the old male group. Erythrocyte deformability worsened, mainly in the old I/R male
group. Micro-rheological parameters show gender and
age-related differences during intestinal I/R. These observations have importance in the planning and evaluation of
experimental data.
Influence of Experimental Intra-Abdominal
Hypertension on the Serum sCD14
Y.M. Turgunov, D.N. Matyushko, Zh.M. Koishibayev,
M.M. Mugazov
Karaganda State Medical University, Surgery #2,
Karaganda, Kazakhstan
Background: One of the most frequent and heavy
complications associated with intra-abdominal hypertension (IAH) is development of the septic state. The sCD14
is considered as the earliest marker of bacterial and fungal
infections: increasing of its level means disturbance of
barrier function of intestine and the beginning of bacterial
flora circulation in blood flow. Objective: To evaluate the
influence of IAH on the sCD14 in serum. Material and
Methods: The experimental research: male rats of the same
age, weight, diet (n = 100). Among them: a control group
(n = 10) – animals without affecting; comparison group
(n = 90) – animals, which was artificially created by IAH of
different degrees (15, 25, 35 mm Hg) and different exposure
times (3, 12, 24 hours). In all animals we investigated the
serum sCD14. Results: The sCD14 concentration in serum
linearly increases to rising of the abdominal pressure. At
the same time, there is statistically significant difference in
groups with IAH and control group. The insignificant
increasing of sCD14 concentration is noted only in group
15 mm Hg + 3 hours. IAH 25 and 35 mm Hg causes almost
double rising of sCD14 concentration even in 3 hours, and
further at IAH duration till 12–24 o’clock there is a sharp
jump of sCD14 at 7–10 times. There are very insignificant
differences between the 12-hour and 24-hour sCD14
concentration in all groups. Conclusions: sCD14 protein
can be considered as the early biomarker of the preseptic
state at the intra-abdominal hypertension demonstrating
enterogenous translocation of microorganisms to the
blood flow.
Characteristics of Lymphocyte-Infiltrating
Papillary Thyroid Cancer
J.J.L. Lee, T.P.L. Liu, P.S.Y. Yang, S.P.C. Cheng
MacKay Memorial Hospital, Department of Surgery,
Taipei, Taiwan
Background: The tumor-promoting or tumorsuppressing role of tumor-associated lymphocytes remains
a subject of debate. We examined the thyroid cancer data of
The Cancer Genome Atlas and attempted to define the relationship between lymphocyte infiltrates and clinical and
molecular presentations. Methods: Patient characteristics
and transcriptome profiling were compared between groups
dichotomized by the percentage of tumor-infiltrating
lymphocytes of the primary tumor. Differentially expressed
genes were subjected to functional enrichment analyses.
Results: In 52% of the tumors, there was no lymphocyte
infiltration. Papillary thyroid cancer with infiltrating lymphocytes was associated with classical histologic features, multifocality, and lymph node metastasis. Patients with
lymphocyte-infiltrating cancer had a longer overall survival
(log-rank P = 0.018). A total of 3151 differentially expressed
genes were identified. Pathways related to immune response
were upregulated, where the expression of several thyroidrelated genes was downregulated. Conclusion: Papillary
thyroid cancer with tumor-infiltrating lymphocytes is asso-
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Hypercoagulation as Result of Intraabdominal
D.M. Matyushko, T.Y. Turgunov, M.M. Mugazov,
K.Z. Koishibayev
Karaganda State Medical University, Of Surgery # 2,
Karaganda, Kazakhstan
Background: Most of the complications of intraabdominal hypertension (IAH) (phlebothrombosis and etc.) is
related to the changes in blood coagulation. Objective: To
evaluate the influence of IAH on blood coagulation. Material
and Methods: The experimental research: a control group
(n = 10) – intact animals; comparison group (n = 90) –
animals with IAH 15, 25, 35 mm Hg and different times (3,
12, 24 hours). We investigated the main coagulation
parametres. Results and Conclusions: Intraabdominal
pressure 15 mm Hg for 3 hours (corresponds to the
magnitude and duration of pneumoperitoneum during
laparoscopic operations) causes minor changes coagulation
parameters (within tolerance), which proves the safety of
pneumoperitoneum. Intraabdominal pressure 25 and 35
mm Hg for 3 hours cause laboratory signs of hypercoagulation, however, statistically significant differences are not in
all the coagulation indicators. Intraabdominal pressure of
15, 25 and 35 mm Hg for 12 hours caused undoubtedly,
statistically significant signs of hypercoagulation. Changes
in the coagulation parameters of intraabdominal pressure
groups 15, 25 and 35 mm Hg for 24 hours can be considered
in two ways: as an adaptation to stress and return to normal
coagulation parameters or the initial signs of the next phase
– hypocoagulation. There is no possibility to make clear
conclusion in this experiment.
Decellularized Bovine-Derived Peritoneum:
Impact of a Biological Graft on Long-Term
Incorporation in Rats
N.T. Abatov
Karaganda State Medical University, Surgical diseases #2,
Karaganda, Kazakhstan
Background: Decellularized bovine-derived peritoneum
is a new biological implant, for the first time using for
abdominal wall reconstruction in an experiment. The aim
was to assess the structural changes of the abdominal wall
upon contact with bovine-derived peritoneum implant in
the long-term period after implantation. Material and
Methods: Bovine-derived peritoneum grafting was observed
after inlay implantation in a standardized rodent animal
model (n = 16). After 90, 180 days of implantation, morphological analysis of the inflammatory response was performed:
macroscopically – infection existence in implantation area,
adhesion and seroma formation; microscopically – inflammatory tissue reaction, fibrosis and granuloma formation
were investigated. The tissue was stain with H&E, Van
Gieson’s with pikro-fuchin. Results: Macroscopically, in all
cases no seroma formation or infection was observed.
Adhesion formation at the margins of implants and suture
sites were registered in 31% cases. By the 90th day, microscopically, there was a significant overrepresentation of
stromal cells – fibroblasts/fibrocytes in cellular profile (more
than 87%). On the 180th day it has been seen a mature cicatricial tissue without a chronic inflammatory process around
implantation area. Conclusion: Decellularized bovinederived peritoneum implant in the long-term period of the
experiment showed adequate wound healing process with
cicatrization, without chronic post-implantation inflammation. Given data is allowed to continue using this
biological graft for abdominal wall hernia repair in clinical
study perspectively.
Decellularized Bovine-Derived Peritoneum:
Morphometric Analysis of Implantation Area
Between the Graft and Abdominal Wall in Rat
R.M. Badyrov
Karaganda State Medical University, Surgical Diseases
#2, Karaganda, Kazakhstan
Background: This is the first experimental study of decellularized bovine-derived peritoneum as a new biological
implant for repairing abdominal wall defects. The aim was to
assess the infiltrating cells profile of an implantation area in
early stages of the experiment. Material and Methods: Open
abdominal wall defect repair was performed in 24 white
non-linear rats, weight 180–225 g. Bovine-derived peritoneum implants were 1.5*1.5 cm per one animal. Observation periods were 5, 21, 30 days (n = 8 in each group).
Morphometric study of a representative section of the
implantation area was conducted in 300 cells, 400χ, out of a
suture line. Infiltrating cells were presented by granulocytes,
lymphocytes, plasmacytes, macrophagocytes, fibroblasts/
fibrocytes. The tissue was stain with H&E, Van Gieson’s with
pikro-fuchin. Statistical analysis was performed using
Kruskal-Wallis test, P value <0.05. Results: By the 5th day
cellular infiltration predominance of granulocytes (42.50 ±
3.94) of other cells (lymphocytes = 28.92 ± 2.76; plasma-
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ciated with an upregulation of immune response and
cytokine production, with a trend for an overall survival
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
The Antiseptic Effect of Chlorine-Dioxide
(ClO2) on Rat Model
J.K. Juhos1, N.Z. Noszticzius2, F.A. Ferencz1, S.z.G.y. Szabó1,
F.D. Fehér1, C.s.D. Csukás1, W.G.y. Wéber1
Semmelweis Egyetem, Department of Surgical Research
and Techniques, Budapest, Hungary, 2Budapest
University of Technology and Economics Faculty of
Natural Sciences, Institute of Physics, Department of Phy,
Budapest, Hungary
Background: Nowadays, antibiotics resistance is one of
the most serious health problem, hence there is a growing
need for a new, effective, and not harmful antiseptic agent
without any resistance. Fluoroquinolones are widely used in
urinary tract infections, however in many countries these
antibiotics are not effective in more than half of patients. The
‘no resistance’ effect of chlorine-dioxide (ClO2) has recently
been recognised, therefore we analyzed the local effect of
ClO2 on rat bladder. Material and Methods: The bladder of
5 female Wistar rat were filled with ClO2 solution for 5
consecutive days. The suitable ClO2 solution is prepared
every morning in dark, sealed bottle and injected into the
rat’s bladder through a polyethylene tube as a catheter. All
of rats were euthanized 5 days later after the last lavage and
the bladders were sent for histological analysis. Results: In
the five-day experiment a rat died on the second day, the
bladder, the pelvic organs, intestines and the abdominal wall
were totally damaged. The catheterization of rest of the
animals was easily done, although at the end, each has
become more difficult to catheterize. Except the died rat –
possibly died due to technical reasons – the lavage of ClO2
solution did not cause any damage neither macroscopically
nor microscopically. Macroscopically, the abdominal cavity
and the bladder are intact, edema-, irritation- or damage of
mucosa was not identified. Conclusion: According to our
result, the ClO2 solution didn’t damage the bladder mucosa,
its’ efficacy is going to be verified by microbiological testing.
Adipose Derived-Stem Cell Xenograft
Decreases Lymphangiopathy in Rats with
Decompensated Biliary Fibrosis: A Possible
Mechanism to Ameliorate Acute-on-Chronic
Liver Failure
T.F.D. Funes1, M.I. Prieto Nieto1, L. Tresierra1, S. Argudo2,
M.A. Aller3, A. Blázquez Martínez4, M. De Miguel4,
C. Marcano1, J. Arias3, L. Santamaria5, J.L. Marijuan1,
J. Díaz-Domínguez1
LA PAZ, Surgery, Madrid, Spain, 2Hospital Arganda del
Rey, Surgery, Madrid, Spain 3Universidad Complutense,
Surgery, Madrid, Spain, 4IDiPAZ, Cell Engineering
Laboratory, Madrid, Spain 5Universidad Autónoma,
Anatomy, Histology and Neuroscience, Madrid, Spain
The splanchnic inflammatory response related to chronic
liver failure produces a hypertensive portal intestinal vasculopathy. Our study is about the lymphatic microcirculation
in the small intestinal, and its response to xenogenic intrahepatic transplant of predifferentiated hepatocytes from
human adipose derived stem cells was performed using a
biliary fibrosis model produced by microsurgical obstructive
cholestasis in rats. Hepatic portal enteropathy produced in
cholestatic rats occurs with greater lymphatic microvessels
in the mucosa and submucosa layers than in muscle layer.
Thus, the lymphatic microvessel volume fraction was
superior (p < 0.001) in the mucosa (0.16 ± 0.01) and
submucosa (0.16 ± 0.01), in regards to the muscle layer
0.015 ± 0.01. The lymphatic microvessel length density was
also higher in the mucosa (76.89 ± 2.86 mm–2; p < 0.001) and
submucosa (14.87 ± 2.86 mm–2; p < 0.01), in relationship to
the muscle layer (5.04 ± 2.92 mm–2). These alterations
predominate in the duodenum (volume fraction: 0.10 ± 0.01
and length density: 33.55 ± 5.98 mm–2) and ileum (volume
fraction: 0.16 ± 0.01 and length density: 38.62 ± 6.07 mm–2).
After xenotransplantation of the predifferentiated hepatocytes obtained from human adipose-derived stem cells, liver
function improved. Furthermore, there were significantly
fewer lymphatic impairments, including a decrease (p <
0.01) in the lymphatic microvessel volume fraction in both
mucosa (0.10 ± 0.01) and submucosa (0.13 ± 0.01). In
conclusion, the xenotrasplant of human stem cells predifferentiated to hepatocytes in rats with biliary fibrosis reduces
the degree of liver failure, as well as the splanchnic inflammatory response, which causes intestinal lymphangiopathy
and ascites.
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cytes = 7.33 ± 1.36, macrophagocytes = 7.04 ± 1.36; fibroblasts/fibrocytes = 14.21 ± 2.96) was observed. That characterizes the exudative phase of tissue reaction in response to
the implantation, surgical trauma. By the 21st day cellular
infiltration occurs statistically significant (p < 0.05) decrease
of inflammatory cells (granulocytes = 4.46 ± 1.18; lymphocytes = 19.4 ± 6.19; plasmacytes = 0.96 ± 0.84), with significant overrepresentation of stromal cells – fibroblasts/fibrocytes = 65.54 ± 7.25. By the 30th day there was a predominance of mature connective tissue in correlation with the
number of fibroblasts/fibrocytes (72.13 ± 3.72) in the cellular
infiltrate. Conclusion: Results demonstrate an adequate
wound healing process in the postoperative period, without
causing severe post-implantation inflammation, with cicatrization in the implantation area. These data show possible
clinical usefulness of this biological graft for abdominal wall
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Stromal Podoplanin Expression and
Clinicopathological Role in Breast Carcinoma
E. Kumcu1, H. Unverdi2, R. Pekcici3, G.S. Yalcin4,
M. Yasaran3, S. Hucumenoglu3
Bingol Government Hospital, Pathology, Bingol, Turkey,
Gaziantep Ersin Arslan Hospital, Pathology, Gaziantep,
Turkey, 3Ankara Research and Training Hospital, Surgery,
Ankara, Turkey, 4Kecioren Research and Training
Hospital, Pathology, Ankara, Turkey
Background: While cancer research has been focused
on tumor cells primarily, recent studies shown that tumor
stroma contribute to carcinogenesis as well as tumor cells.
This stroma characterizes with so called cancer associated
fibroblasts (CAFs), which have different molecular features
from stromal fibroblasts, affects patient prognosis and
treatment. The mucin-type sialoglycoprotein podoplanin,
due to its expression on lymphatic endothelium, is widely
used as a immunohistochemical marker for the discrimination between lymphatic and blood vessels. However,
recently podoplanin was also reported to be expressed in
various cancer cells, dendritic cells, and CAFs. The aim of this
study is to evaluate the relationship between the stromal
expression of podoplanin in invasive breast carcinoma and
clinicopathologic parameters. Material and Methods:
Podoplanin expression was evaluated immunohistochemically in 153 breast cancers. Tumors with ≥10% distinct cytoplasmic podoplanin staining in CAFs were considered as
positive. Results: In 65.3% of analysed tumors, podoplanin
expression was found positive in CAFs. According to our
results, podoplanin positive CAFs correlated significantly
with tumor size (p = 0.012), tumor grade (p = 0.032) and
cerbB2 score (p = 0.032). Conclusions: Our results suggest
that podoplanin expression by CAFs could be a poor prognostic marker for breast carcinoma. CAFs may be a specific
therapeutic target against human mammary cancer.
Improved Compliance to Trauma Alert Criteria
May Optimize Patient Safety with Sustained
Low Undertriage
F.L. Linder, K.M. Mani, C.J. Juhlin, H.E. Eklof, M.B. Björck,
L.H. Holmberg
Akademiska Sjukhuset, Section of Acute Care surgery
and Trauma, Uppsala, Sweden
Objectives: To evaluate trauma alert criteria regarding
compliance, under-and overtriage and identify riskfactors
for misstriage. Methods: In a retrospective cohort study, all
consecutive surgical trauma patients at a university hospital
in 2012 were included. Patients were stratified into three
groups based on trauma team activation (full trauma team,
limited trauma team and no trauma team). Case records
were reviewed for mechanism of injury, vital signs and
injuries. Compliance to alert criteria was evaluated and injury
severity score (ISS) combined with the Matrix method was
used for over- and undertriage. Results: A total of 1461
patients were identified and 37 excluded due to various
reasons. Of patients included, 73 (5.1%) activated a full
trauma team, 732 (51.4%) a limited trauma team and 619
(43.5%) did not activate any trauma team. Undertriage was
3.5% (95% CI 2.6–4.6%) and overtriage 32.9% (95% CI 22.3–
44.9%) in the complete cohort. Compliance to alert criteria
was measured by comparing initiated alert with the authors
re-triage based on prehospital case records. Compliance to
full trauma team criteria was 80% (68–88%), for limited
trauma team 54% (51–58%) and for no trauma team 79%
(76–82%). After re-triage, the Matrix method resulted in an
undertriage of 2.9% (95% CI 2.1–4.0%) and an overtriage of
39.4% (95% CI 29.4–50.0%). Conclusions: Over-and undertriage in this study of <35% and <5% respectively is in line
with the American College of Surgeons Committee On
Trauma recommendations. Increased compliance to trauma
alert criteria would result in fewer trauma team activations
without affecting patient safety.
Adhesion Prevention Post-Caesarian Section
M. Rimmer, J. Lancaster
Obstetrics & Gynaecology, Warwick, United Kingdom
Background: Caesarian section accounts for approximately 25 % of deliveries in Europe and is following an everrising trend. Multiple caesarians present a challenge to the
obstetrician with the development of adhesions making
subsequent caesarian a technically more challenging
procedure. This has wide ranging implications notably an
increased risk of damage to adjacent organs and delay in
extraction of the fetus in emergency caesarian section. We
sough to identify the possible methods in which adhesions
could be reduced following caesarian section. Methods:
The literature was searched for studies examining the
prevention of adhesions post-caesarian section and a
comparison of the techniques was undertaken. Results:
Several methods of adhesion reduction were proposed
including; peritoneal closure; anti-adhesion absorbable
membranes; absorbable gels and non-absorbable barriers.
Discussion: Despite several studies looking at peritoneal
closure, only a few have looked at the long-term outcome
of formation; all concluded that there was no statistically
significant difference in the formation of adhesions. Antiadhesion absorbable membranes & gels were also examined
however there were no large-scale randomized studies
looking at their use. However two small nonrandomized
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Current Insights in Extracorporeal Perfusion
of Free Tissue Flaps and Extremities –
A Systematic Review and Data Synthesis
A. Kruit, H. Winters, M.J.M. Schreinemachers, D.J.O. Ulrich
Radboud University Medical Centre, Plastic and
Reconstructive Surgery, Nijmegen, Netherlands
Introduction: Despite of on-going experimental trials in
animals, many uncertainties still exist on extracorporeal
perfusion of free flaps and extremities. The aim of this review
is to systematically appraise the available evidence
comparing extracorporeal perfusion of free flaps and
extremities with the current gold standard of cool storage.
Methods: An electronic systematic search was performed to
identify original articles evaluating the effects of extracorporeal perfusion of free flaps or extremities. Preservation
with a single flush of solution fell beyond the scope of this
review. Primary outcomes were histology, serum markers
and tissue function. Oedema was the secondary outcome.
Results: A total of 3485 articles were identified, of which 21
were included into the review. The perfusion period varied
from 1 hour to 10 days, 8 articles also described replantation. Risk of bias scores were generally low. Three articles
were excluded due to a missing control group or unclear
study groups. Primary outcomes showed overall better
results in the perfused groups. However, the development
of oedema was broadly described, irrespective of the type
of perfusion fluid. A meta-analysis could not be performed
due to large heterogeneity in methodological setup,
perfusion fluids and outcomes. A data synthesis was
performed for histology and oedema. Conclusions: Although
the overall trend seems positive in favour of extracorporeal
perfusion, this is hard to objectify due to poor quality of the
available evidence and large heterogeneity. There is a need
for well-conducted experiments, focusing on validating
outcome measures, oedema prevention and maximum safe
perfusion time.
Laparoscopic Treatment for Urachal Remnants:
Our Technique and Outcome
T.S. Shikano
Yokkaichi Municipal Hospital, Surgery, Yokkaichi, Japan
Introduction: The urachus is a remnant of the allantois,
which usually becomes obliterated shortly after birth.
Urachal remnants are relatively rare but may potentially
cause symptom requiring intervention and an increased risk
for developing adenocarcinoma. Although traditionally they
are treated by open complete surgical excision of the urachal
tract from the umbilicus to the bladder, recently there have
been several reports of the laparoscopic excision of urachal
remnants. Here we report our experience with a laparoscopic approach to managing symptomatic urachal remnant.
Method: Eight patients (from 14 year-old woman to 34
year-old man) had a laparoscopic excision of a complicated
urachal remnant for 4 years. Three ports were routinely used,
one 12 mm camera port and two 5 mm additional working
ports on the right abdomen. After the introduction of a
5 mm flexible scope, we performed through three 5 mm
port. The urachal remnant was dissected from the umbilicus
to the bladder dome and then removed intact with the intraabdominal ligation and suturing reconstruction of the peritoneum. Results: All operations had no complications and
minimal blood loss (5 ml and 10 ml) with short duration of
operation time (mean 85 min) and short post operative
hospital stay (mean 2.4 days). Conclusions: The laparoscopic approach appears to be a safe and effective alternative to open surgery for this condition. The reduced
morbidity of this procedure and better cosmetic result
would appear advantageous.
New Therapeutic Perceptions in a Patient with
Severe Complications after HSV-1 Keratitis
D. Kalogeropoulos1, A. Geka2, E. Katsanevakis1, G. Kitsos1,
C. Kalogeropoulos1
Hospital of Ioannina, Ophthalmology,
Ioannina, Greece 2Private Practice, Ophthalmologist,
Private Practice, Patra, Greece
Background: Keratitis caused by Herpes Simplex (HSV)
can have detrimental effects on the cornea leading to loss
of vision. Modern therapies can contribute in the prevention
of anatomical and functional damage. Material and Methods:
An 80-year-old gentleman with HSV-1 keratitis of the left
eye (confirmed diagnosis after microbiological investigation) presented 3 months after the anti-viral treatment
with corneal blurring, severe epitheliopathy, thinning of the
stroma and neovascularization. When he was referred visual
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studies reported a reduced time form incision to delivery in
subsequent caesarian section when absorbable barriers
were used. Non-absorbable barriers were an option in the
prevention of small bowel obstruction however their used in
caesarian section has not ben examined. Despite the small
evidence base the use of anti-adhesions membranes in
repeat caesarian section could be of benefit in patients
wishing to undergo further pregnancies with positive
benefits to both mother and baby.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Management of a Wound Caused by an
Unexploded RPG Missile Lodged in Anterior
Thoracic Wall: Report of a Case
S.K. Kaymak1, A. Ünlü2, O. Hançerliogullari2, H. Sinan2,
T. Özer2, N. Zeybek2
Gulhane Education and Research Hospital, General
Surgery, Ankara, Turkey 2Gulhane Training and Research
Hospital, General Surgery, Ankara, Turkey
Introduction: Global increase in terrorist attacks using
modern military weapons have changed the trauma patterns
and increased the challenges faced by modern trauma
surgeons. We hereby present a casualty wounded by an
unexploded RPG missile. Case Report: The field paramedics
intubated an unconscious 26-year old male wounded by an
unexploded RPG missile to the right anterior chest wall.
While the casualty was being resuscitated and monitored in
the field, simultaneously the EOD (Explosive Ordinance
Disposal) specialists removed the RPG from the thoracic
wound under necessary security precautions. The casualty
was transported to a nearby Role 2 hospital. The 40 cm x 8
cm diagonal wound extended between the supraclavicular
to subxyphoid area. The tissue damage involved the pectoral
and intercostal muscles. There was alsoflail chest due to
fractures of ribs 4–8, second and third degree burns on the
right thoracic wall, hemopneumothorax, and right pulmonary
contusion. A chest tube was inserted. There was no visible
full thickness defect on the chest wall. The diagonal wound
was debrided, rib fractures fixated surgically and VAC
(Vacuum Assisted Closure) system was applied. The vac
dressings were changed 10 times within 30 days and the
wound defect was successfully treated with advancement
flaps. The casualty was discharged 45 days after the incident.
Discussion: VAC system is extremely useful in the
management of difficult and complicated combat wounds.
Within the last 5 years, we have accumulated a large experience in treating these wounds and VAC is an indispensible
part of it.
Recurrent Sarcoma of the Liver with
Infiltration of Inferior Vena Cava and
Its Replacement with Aortic Allograft –
A Case Report
V. Lovasova, J. Chlupac, M. Kollar, J. Fronek
Institute for Clinical and Experimental Medicine,
Department of Transplant Surgery, Prague, Czech
Background: Soft tissue sarcomas are a heterogeneous
group of malignant tumours derived from mesenchymal
cells. Primary hepatic sarcomas of the liver are extremely
rare in adults. Prediction of biological behaviour is difficult.
Treatment of choice seems to be surgical resection. Surgical
radicality of the procedure is crucial for patient’s survival.
Case Report: We present a case of a successful R0 resection
of recurrent liver sarcoma and replacement of inferior vena
cava with aortic homograft. Male patient aged 31 was diagnosed by 25 cm histologically primitive neuroectodermal
tumour (PNET) of the right kidney. He underwent right
nephrectomy and adrenalectomy followed by chemotherapy. One year later, resection of two liver metastases –
PNET, was performed. Then the patient was referred to our
unit for second opinion with recurrent liver mass for possible
resection. Right hemihepatectomy with resection of segment
I, diaphragm resection, resection of the inferior vena cava
and replacement with allogenic aortic patch, were performed.
The patient was discharged from the hospital 23 days after
surgery. This time, 9 months after surgery, the patient is
without any signs of recurrence, with no need of adjuvant
therapy. Conclusion: Liver sarcomas are rare malignant
tumours. Radicality of surgery is crucial for patients survival,
due resistance of sarcomas to chemotherapy. Unfortunately,
the prognosis is poor in most cases. If there is a need to
replace VCI, there are more possibilities. One of them is the
substitution with aortic allograft.
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acuity of the left eye was very low, as he could only count
fingers at 1 foot. He was initially started on oral acyclovir
(800 mg OD) and topical sulfate poly-carboxymethyl
glucose. Afterwards he undergone an amniotic membrane
(AM) transplantation and localized treatment with anti-VEGF
factors. 1 month after the AM transplantation there was an
obvious improvement of the corneal surface. Ophthalmic
suspension of cyclosporine-A 1% was also added on his
treatment. After 3 months a transplantation of stem cells
(deriving from the sclerocorneal junction of the right eye)
was carried out at the sclerocorneal junction, as the corneal
damage and neovascularization was more severe at this
anatomical area. Results: 4 months after the last surgery
visual acuity was 1/10 (note a Hx of old vascular episode)
and the cornea was sufficiently clear with no signs of epitheliopathy and almost complete subsidence of the neovascularization. Conclusions: Transplantation of AM and stem
cells in combination with anti-VEGF factors and topical
administration of sulfate poly-carboxymethyl glucose (a
regenerative factor of corneal matrix) contribute substantially in the management of herpetic keratitis complications.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Appendicular Neuroendocrine Tumor, Rare
Pathology That Can Be Overlooked
A. Chirca
University Emergency Hospital Bucharest, General
Surgery, Bucharest, Romania
Appendicular tumors are very rare, with the appendiceal
carcinoid tumor being the most frequent type arising from
the appendix. In the majority of cases they are asymptomatic and usually discovered during appendectomy
where their macroscopic appearance may raise suspicion
on this condition. Diagnosis confirmation relies on pathological examination of the resected appendix and the
surgical attitude differs depending on tumor size, from
simple appendectomy to right hemicolectomy. The aim of
this case-presentation is bring to your attention a challenging case of a young patient suffering from this rare
condition. We present the case of a 22-year old female
patient with no prior medical and surgical history who
presented at the emergency department with 12 hours of
right lower quadrant pain and nausea. Ultrasound and
laboratory findings were normal. Due to these symptoms
suggestive for an acute pathology surgery was proposed.
During open appendectomy an approximately 2 cm tumor
at the tip of the appendix raised suspicion of a neuroendocrine tumor (NET). In this case simple appendectomy was
performed. Confirmation regarding the tumor type was
made by the pathological exam that stated thatthe tumor
was awell-differentiated NET, with clear-cell carcinoid
subtype. The patient was discharged free of symptoms and
routine follow-ups were scheduled. We choose to present
this case to raise awareness on this potentially curable and
rare condition that can be overlooked, to highlight the
importance of the pathological exam in confirming the
diagnosis and aiding in the decision regarding the right
Primary Mature Cystic Teratoma Mimicking
as Left Suprarenal Mass in an Adult Female
G. Goel, R. Mandia, R. Yadav, A. Vyas
Swai Man Singh Medical College and Hospital, General
Surgery, Jaipur, India
Background: Primary Retroperitoneal teratomas are very
rare in adults. Teratomas are tumors that are derived from
embryonal tissue and composed of somatic cell types from
two or more germ layers. Most teratomas in this region
(retroperitoneal) are secondary to germ cell tumors of the
testes or ovaries. We report a case of unilateral primary
mature cystic teratoma of the retroperitoneum mimicking as
left suprarenal mass in an adult female patient. Material and
Methods: A 26-year-old female patient developed dull
aching left upper quadrant and left flank pain. She was
admitted to the hospital where, on ultrasound, EUS and CT
scan, she was found to have an 87*108*93 mm cystic mass
in the left suprarenal area. Results: After series of investigations, patient was operated in elective settings through a left
subcostal incision and found to have approx. 8*9 cm cystic
mass in left suprarenal area, free from spleen, pancreas,
adrenal and kidney. Mass was excised uneventfully and sent
for histopathological examination. Biopsy report confirmed
mass as primary mature cystic teratoma. Conclusions:
Primary retroperitoneal teratoma is a rare entity in adults.
Although usually asymptomatic, large neoplasms can cause
abdominal and flank pain. Preoperatively, the diagnosis can
be established by its characteristic appearance on CT. It is
important to note that the masses placed at suprarenal
region are likely to be confused with adrenal masses as in
our case.
‘Pneumatosis Sistoides Intestinalis’ Occurring
after Endoscopic Balloon Dilatation: A Rare
Case Report
S.K. Kaymak1, O. Hançerliogullari2, R. Senocak2,
M. Fa Can2
Gulhane Education and Research Hospital, General
Surgery, Ankara, Turkey, 2Gulhane Training and Research
Hospital, General Surgery, Ankara, Turkey
Introduction: Pneumatosis cystoides intestinalis (PSI) is a
rare disease, characterized by subserosal and submucosal
cysts filled with air in the gastrointestinal tract. Many gastrointestinal system diseases, such as pyloric stenosis, may be
associated with PSI. We aimed to present a case of PSI
detected incidentally during surgery in a patient with pyloric
stenosis undergoing endoscopic balloon dilatation. Case: A
62-year old male patient was admitted to the emergency
department with a complaint of hematemesis one year ago.
Esophagogastroduedonoscope revelaed two ulcerous
lesions settled in a hyperemic area of about 4 cm in the pylor
and pyloric stenosis. Biopsy results were reported as benign.
Afterwards, the patient underwent endoscopic balloon dilatation 3 times in total. Although he could tolerate liquid diet,
the patient underwent surgery because of swallowing difficulty, bloating and 10 kilograms of weight loss over the past
year. At exploration; a cystic formation limited with serosa in
about 120 cm of a small intestine and extensively dilated
stomach were observed. When small bowel serosal biopsy
specimens were evaluated intraoperatively, there was no
malignant finding and morphological findings were
compatible with pneumatosis cystoides intestinalis (PSI).
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© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
Rupture of Inferior Vena Cava Caused by a
Blunt Trauma from a Tractor
J. Kristek1, P. Hromadka2, M. Konarik1, J. Fronek1
Institute for Clinical and Experimental Medicine,
Department of Transplant Surgery, Prague, Czech
Republic, 2District Hospital Liberec, Department of
Surgery, Liberec, Czech Republic
Background: Juxtahepatic inferior vena cava traumatic
rupture and high grade liver injuries are still life-threatening
injuries. About 50% of the patients die within 24 hours after
injury. Case Report: We present a case report of a successful
treatment of a 34-year old patient with polytrauma
comprising a rupture of the juxtahepatic inferior vena cava
caused by a blunt injury from a tractor. The treatment
consisted of two stages. The first part of the treatment
consisted of damage control laparotomy at the level I trauma
center. After necessary stabilization, the patient was airtransported to receive the definitive treatment at the tertiary
care facility experienced in hepatopancreatobiliary surgery.
As the level of injury was not clear prior to the second stage
surgery, cardiac team also assisted the operation. To repair
the vena cava rupture it was necessary to advocate the total
hepatic vascular exclusion. The treatment was successful.
Conclusions: Two-stage approach with transport to
specialized unit is beneficial in infrequent and demanding
situations of ruptures of the inferior vena cava.
Lower GI Haemorrhage Resulting from a
Dieulafoy Lesion of the Ascending Colon
G. Cameron, S. Mahapatra, N. Eardley
Countess of Chester, General Surgery, Chester, United
Case Report: We report the case of an 88 year old female
who presented with massive lower gastrointestinal haemorrhage. CT-angiography showed an active bleed from the
hepatic flexure, and she was stabilised and transferred to
another hospital for emergency embolization. However the
subsequent angiogram could not identify an active bleed.
After a further haemorrhage she underwent an emergency
laparotomy & subtotal colectomy with end-ileostomy. She
was transferred to Intensive Care post-operatively but made
a good recovery. Histological analysis revealed an abnormal
focus within the distal ascending colon with an area of
mucosal ulceration with overlying fibrin and blood clot
beneath which was thick-walled large tortuous ulcerated
vessel, extending from the subserosa, through the muscularis propria & submucosa into the lamina propria. These
appearances are consistent with a Dieulafoy’s lesion.
Discussion: Dieulafoy disease is a rare cause of gastrointestinal bleeding, thought to account for only 5% gastrointestinal bleeds. 75% Dieulafoy lesions are found in the stomach,
and Extra-gastric lesions are much rarer, with only 5% found
in the colon. They are often difficult to diagnose due to
intermittent bleeding and often require multiple endoscopies plus/minus angiography to confirm a diagnosis. The
literature surrounding management of upper gastrointestinal Dieulafoy lesions is well established and suggests that
bleeding Dieulafoy lesions can be managed endoscopically
in 90% of cases, with angiography & embolization reserved
for refractory bleeding. However the literature surrounding
rarer colonic lesions is less well established where it would
appear therapeutic endoscopy is less effective and more
often surgery is required.
Late Diagnosis of Ileo-Colic Intussusception as
a Cause of Abdominal Pain in Adults: A Case
E.K. Katsanevakis1, D. Kalogeropoulos2, E.M. Eleftheria3,
E.T. Eudokia3, N.T. Tsiminikakis3, K.O. Oikonomou3,
C.A. Antoniou3, S.M. Moschonas3
Scarborough General Hospital, Obs and Gynae,
Scarborough, United Kingdom, 2University Hospital of
Ioannina, Medical School, Ioannina, Greece, 3General
Hospital of Chania, B Surgical Department, Chania,
Introduction: Intussusception in adults is rare, as it represents 5% of all cases of intussusception and accounts for
1%–5% of bowel obstructions in adults. Clinical presentation
and imaging features often vary, thus making the diagnosis
of bowel intussusception challenging and difficult. CT scan
and ultrasonografy are considered the most useful imaging
techniques. Treatment usually requires resection of the
involved bowel segment. Case Presentation: A 62 year old
Greek male presented to the emergency department with
acute exacerbation of abdominal pain and vomiting.
2-month history of abdominal pain that was coming and
going, which was treated with cholecystectomy, was also
referred by the patient. At physical examination, flatulence
and rebound pain were observed. Bowel sounds were
tinkling. Plain abdominal film revealed signs of small bowel
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Finally, uncut gastrojejunostomy (made at 50 cm far away
from ligament of Treitz) + truncal vagotomy + sigmoid
colon repair were performed. Conclusion: In the presence of
free air radiologically in the abdomen, PSI should also be
kept in differential diagnosis in addition to intestinal perforation or bacterial infections.
© 2017 S. Karger AG, Basel
Eur Surg Res 2017;58(suppl 2):1–69
DOI: 10.1159/000479831
Published online: September 21, 2017
obstruction. A contrast-enhanced abdominal computed
tomography scan demonstrated a soft tissue mass at the
anatomical region of the ileo-colic valve. Colonoscopy
revealed the presence of a telescoping bowel segment in the
ascending colon while identification of the ileo-colic valve
was not possible. No leading point was observed. The
patient undergone a right colectomy, concerning the risk of
possible malignancy. Histopathology diagnosed intussusception accompanied with inflammation of the visceral peritoneum and the bowel wall. Conclusion: Adult bowel intussusception is considered a rare condition, in addition to
children. Percentage of preoperative mis-diagnosis is high,
because of nonspecific symptoms. Abdominal CT is the most
sensitive imaging method for the diagnosis. Surgical intervention with resection of the involved bowel segment is
necessary, because adult intussusception is often associated
with malignancy.
Nontraumatic Splenic Rupture as the Initial
Manifestation of Acute Myeloid Leukemia in
Emergency Department
S.K. Kaymak1, A. Attil Aydin2, R. Senocak2, S. Bilge2,
O. Hançerliogullari2, Z. Kilbas2
Education and Research Hospital, General
surgery, Ankara, Turkey, 2Gulhane training and research
hospital, Emergency department, Ankara, Turkey
© 2017 S. Karger AG, Basel
leukemia is extremely rare, and only a few cases have been
reported thus far. Here, we present a case of a spontaneous
splenic rupture in a patient with no history of prior trauma
but who presented with abdominal pain and in advanced
tests had a definitive diagnosis of acute myeloid leukemia.
Case: A 49-year-old male patient presented to the emergency department with fever, weakness, and nausea continuously for the previous 3 days. An Extended Focused
Assessment with Sonography for Trauma examination
conducted to detect the etiology of hypotension revealed
diffuse freefluid and splenomegaly. The patient was admitted
to the surgical intensive care unit with a diagnosis of spontaneous splenic rupture secondary to infection. Later, it was
decided to perform splenectomy. Results of the histological
evaluation of the spleen were unexpectedly reported to be
acute myeloid leukemia. Discussion: Physicians working in
emergency department should keep in mind abdominal
pathologies in cases presenting with hypovolemic shock
without trauma history. Therefore, imaging methods
directed to this probability should be considered. A Focused
Assessment with Sonography for Trauma imaging modality
may be indicated as a screening test in the emergency
department. Spontaneous splenic rupture should always be
considered in a differential diagnosis in cases with unknown
hematological malignancy that present to the emergency
services with abdominal pain and/or with a clinical picture
of hypovolemic shock.
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Introduction: Splenic rupture is a life-threatening
condition and the most frequently seen cause of trauma. A
splenic rupture as the initial manifestation of acute myeloid
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