Abstract Volume WCS 2015

Abstracts
1
Organization 46th World Congress of Surgery WCS 2015
Bangkok, Thailand, 23 – 27 August 2015
held by the
INTERNATIONAL SOCIETY OF SURGERY ISS/SIC
and its Integrated and Participating Societies
Jointly organized with the
ROYAL COLLEGE OF SURGEONS OF THAILAND RCST
Congress President
Nopadol Wora-Urai, Thailand
Congress Vice Presidents
Vajarabhongsa Bhudhisawasdi, Thailand (RCST)
Robert Parkyn, Australia (IAES)
Selman Uranüs, Austria (IATSIC)
Olle Ljungqvist, Sweden (IASMEN)
Polly S.-Y. Cheung, Hong Kong SAR (BSI)
Masaki Kitajima, Japan (ISDS)
K.A. Kelly McQueen, USA (ASAP)
SCIENTIFIC PROGRAM COMMITTEES
a) International Society of Surgery / Société Internationale de Chirurgie (ISS/SIC)
President ISS/SIC & Congress President
President elect ISS/SIC
Immediate Past President ISS/SIC
Secretary General ISS/SIC
General Treasurer ISS/SIC
Editor in Chief WJS
Councilor
Councilor
Councilor
Councilor
Councilor
IAES Representative
IATSIC Representative
IASMEN Representative
BSI Representative
ISDS Representative
ASAP Representative
Nopadol Wora-Urai, Bangkok, Thailand
Marco G. Patti, Chicago, IL, USA
Göran Akerström, Uppsala, Sweden
Jean-Claude Givel, Lausanne, Switzerland
Sats S. Pillay, Port Elizabeth, South Africa
John G. Hunter, Portland, USA
Adam J. Dziki, Lodz, Poland
Alberto R. Ferreres, Buenos Aires, Argentina
Doris Henne-Bruns, Ulm, Germany
Andrew G. Hill, Auckland, New Zealand
Yuko Kitagawa, Tokyo, Japan
Chen-Hsen Lee, Taipei, Taiwan
Charles N. Mock, Seattle, WA, USA
José E. Aguilar-Nascimento, Cuiaba, Brazil
Sarkis H. Meterissian, Montreal, QC, Canada
Tonia Young-Fadok, Phoenix, AZ, USA
K.A. Kelly McQueen, Nashville, TN, USA
b) Integrated Societies of ISS/SIC
and their Representatives
IAES
The International Association of Endocrine Surgeons
Chen-Hsen Lee, Taiwan – Geoffrey B. Thompson, USA
www.iaes-endocrine-surgeons.com
IATSIC
The International Association for Trauma Surgery and Intensive Care
Charles N. Mock, USA – Christine Gaarder, Norway
www.iatsic.org
IASMEN
The International Association for Surgical Metabolism and Nutrition
José E. Aguilar-Nascimento, Brazil – Dileep Lobo, UK
www.iasmen.org
BSI
Breast Surgery International
Sarkis H. Meterissian, Canada – Omar Z. Youssef, Egypt – Shawna C. Willey, USA
www.bsisurgery.org
ISDS
International Society for Digestive Surgery
Tonia M. Young-Fadok, USA – Alessandro Fichera, USA
www.cicd-isds.org
ASAP
Alliance for Surgery and Anesthesia Presence
Kelly McQueen, USA – Kathleen M. Casey, USA
www.asaptoday.org
2
c) Participating Societies (International Societies)
and their Representatives in the Program Committee of WCS 2015
AAS
Association for Academic Surgery
Melina R. Kibbe, USA – Justin B. Dimick, USA
www.aasurg.org
AAST
American Association for the Surgery of Trauma
Thomas Scalea, USA
www.aast.org
APIMSF
The Ambroise Paré International Military Surgery Forum
Mark W. Bowyer, USA – Zvonimir Lovric, Croatia – Norman M. Rich, USA
www.apimsf.org
AWS
Association of Women Surgeons
Danielle Walsh, USA
www.womensurgeons.org
EAES
European Association for Endoscopic Surgery
Mario Morino, Italy
www.eaes-eur.org
FELAC
Federación Latinoamericana de Cirugía
Italo Braghetto, Chile - Samuel Shuchleib, Mexico
www.felacred.org
ISBI
International Society for Burn Injuries
Basil A. Pruitt, Jr., USA – Richard L. Gamelli, USA
www.worldburn.org
SLS
Society of Laparoendoscopic Surgeons
Richard M. Satava, USA
www.sls.org
WOFAPS
World Federation of Associations of Pediatric Surgeons
Jay L. Grosfeld, USA
www.wofaps.org
d) National Societies of Thailand
and their Representatives in the Program Committee of WCS 2015
RCST
Royal College of Surgeons of Thailand
Vitoon Chinswangwatanakul, Bangkok
APST
Association of Pediatric Surgeons of Thailand
Paisarn Vejchapipat, Bangkok
3
Local Organizing Committee WCS 2015
Chair, Advisory Board:
Arun Pausawasdi
Advisory Board:
Thongueb Uttaravichien
Chomchark Chuntrasakul
Prinya Sakiyalak
Thongdee Shaipanich
Naronk Rodwarna
Nopadol Wora-Urai
Honorary Presidents:
Soottiporn Chittmittrapap
Vajarabhongsa Bhudhisawasdi
President:
Supakorn Rojananin
Vice-Presidents:
Pornthep Pramyothin
Apirag Chuangsuwanich
Parinya Thavichaigarn
Wuttichai Thanapongsathorn
Members:
Darin Lohsiriwat
Tanaphon Maipang
Sukit Panpimanmas
Thanyadej Nimmanwudipong
Sudhachit Linananda
Chanchai Nimitrvanich
Veera Buranakitjarpoen
Sriprasit Boonvisut
Nopadol Penkitti
Chaiwit Thanapaisal
Paisit Siriwittayakorn
Kriangsak Prasopsanti
Thavat Prasatritha
Preecha Siritongtaworn
Thiravud Khuhaprema
Pramook Mutirangura
Vichao Kojaranjit
Sathien Tumtavitikul
Arun Rojanasakul
Secretary General:
Wichai Vassanasiri
Deputy Secretary General:
Vitoon Chinswangwatanakul
Yaovanuch Kongdarn
Rattaplee Pak-art
Thawatchai Akaraviputh
Suebwong Juthapisit
Sukchai Satthaporn
Thun Ingkakul
Scientific Secretariat and Congress Secretariat
Scientific Secretariat WCS 2015
Mr. Chris Storz
c/o ISS/SIC
Seltisbergerstrasse 16
4419 Lupsingen
Switzerland
Tel:
Fax:
e-mail:
URL:
+41 61 815 96 67
+41 61 811 47 75
[email protected]
www.iss-sic.com
Tel:
Fax:
e-mail:
URL:
+66 2965 89 09
+66 2965 89 19
[email protected]
www.cdmthailand.com
Professional Congress Organizer (PCO)
Congress Secretariat WCS 2015
Mrs. Chariya Sudasna, Mr. Sumate Sudasna
c/o CDM
68/877 Rattanathibet Soi 28,
Bangkrasor, Muang,
Nonthaburi 11000
Thailand
4
Abstract Volume WCS 2015
World Congress of Surgery WCS 2015, Bangkok, Thailand
23 – 27 August 2015
The Works in this volume represent the submitted Abstracts accepted for presentation at WCS 2015. The Abstracts
are printed as submitted by the author and represent their opinion. The Congress and its Organizers may not be held
responsible for any unauthorized text given. Abstracts presented within the Scientific Sessions of the Royal College of
Surgeons of Thailand (RCST) are not published in this volume.
The Authors’ Index lists all authors as per the author listing of the submitted Abstracts and indicates the Session
Numbers where the presentation is given (e.g. 18.17 refers to Session Number 18, Presentation Number 17). PE…
refers to abstracts included in the Poster Exhibition of the Congress but not presented within a regular Session. The
Congress Handbook WCS 2015 lists all presentations by the session numbers which serve as a reference to the
Abstract. Poster Exhibition presentations are listed at the end of the volume.
Authors’ Index
Al Qurashi Turki
18.28,PE141
Al Sabah Salman
PE082,PE083,PE084
Al Subaie Saud
PE084
Alenezi Khaled
PE082
Alesina Pier
147.03
Algan Meltem
PE054
Aliyeva Gunay
178.04
Almquist Martin
219.05
Al-Mulla Ahmed
PE082
AlNumairy Ahmed
18.19,PE138
AlNumairy Mohammed
18.19,PE138
Al-Oweis Jalal
54.05
Al-Riyees Lolwah
78.06
Alsharqawi Nourah
PE082,PE083,PE084
AlSubaie Soud
PE082
Alyami Hussain
46.01
Aman Sami
176.04
Ambrus Rikard
PE181
Amemiya Ryusuke
80.03
Anand Akshay
151.02,198.04
Anbalakan Kamalesh
34.05,PE124
Ando Masahiko
PE006
Andretta Michela
PE068
Angelos Peter
64.06
Aniss Adam
PE038
Aniss Ahmad
41.01
Ansaloni Luca
113.05
Anuwong Angkoon
112.01
18.39,178.06
Anvarov Khikmat
Apffelstaedt Justus
149.06,149.07
Applewhite Megan
64.06
Arigami Takaaki 4.03,4.06,PE090,PE126,PE127,PE128
Arima Kota
PE192
Arita Seiji
139.05
Ariyaratnam Roshan
222.04
Aro Ellinoora
224.03
Arya Shipra
178.09
Asaga Sota
78.01,PE073
asai yasuyuki
PE010,PE105
Asano Yuka
114.04,PE025
Aschebrook-Kilfoy Briseis
64.06
194.04
Aschoff Anna
Asomah Francis
PE008
Atashili Julius
222.01
Atasoy Deniz
PE099
Ayandipo Omobolaji
PE092
AAA
Annu Babu
18.17
Aarabi Shahram
113.06
Abatov Nurkasi
PE002
Abdujapparov Sulaiman
PE094
Abdujapparov Sulaymon
PE132
Abdullaev Yakubbay
PE196
Abdumanap Alhasov
82.02
Abe Yuko
PE063
Abe Yuta
80.03,80.07
Aboutanous Michel
18.49
Abraham Deepak
PE042
Abraham Ned
111.01
Abu Fara Marwan
PE141
Abu-Zidan Fikri
18.01,18.38,18.41,176.02,176.04
Acar Turan
170.04
Acharya Shamasunder
PE032
Achiam Michael
PE181,PE183
Acker Shannon
PE209
Acosta Stefan
224.05
Agarwal Akshay
114.13,151.03
Agarwal Amit
135.03,147.01,219.04,PE020,
PE021,PE031,PE043
78.04,135.03,147.01,149.03,219.04,
Agarwal Gaurav
PE020,PE021,PE031,PE043,PE056
Aggarwal Vivek
PE056
Aghayeva Afag
PE099
Aguilar-Nascimento José Eduardo
151.04
78.05
Aguirre Jose
Ahmed Saleem
PE153
Aho John
18.31
Aida Masatsugu
PE039
Ajioka Yoichi
111.07
Akagi Ichiro
PE170
Akagi Tomonori
111.05
Akamaru Yusuke
PE118
Akaraborworn Osaree
18.04
Akiba Tadashi
39.09,PE162
AKIMOTO SHUNSUKE
4.02,PE179
Akiyama Hirotoshi
PE006
Akmal M
PE077
PE078
Akmal Muhammad
Akranurakkul Prinya
PE165
Akutsu Yasunori
PE180,PE182
Akyildiz Mahir
PE022
Al Mulla Ahmed
PE083,PE084
5
Aytac Erman
Ayyash Imad
Azuma Kazunari
Boonyagard Narong
Boufraqech Myriem
Bozbiyik Osman
Bracco David
Braghetto Italo
Bratushka Volodymyr
Bresnahan Erin
Brewster Luke
Bronson Nathan
Bruny Jennifer
Brusov Pavel
Bryan Timothy
Bucki Krzysztof
Budde Cristina
Buta Marko
PE099
176.04
18.07
BBB
Baatjes Karin
149.07
Baba Hideo
170.03,PE001,PE192
Baba Kenji
18.27
Babiera Gildy
78.05
Baca Bilgi
PE099
Baghdadi Yaser
18.11, 54.02
Bai Jigang
PE137
Bajec Andrej
217.01
39.02,PE194
Bakens Maikel
Bakens MJAM
217.03
Baking Saleshe Tracy Anne
117.10
Balasubramaniam Sunder
18.09
Balentine Courtney
64.03
Ballı Ömür
170.04
BALTA Ahmet
134.06
Bamba Takeo
4.08,PE172
Bandara Withana Arachchillage Kumarasiri
18.37
Bando Etsuro
PE123
Bansal Naval
46.03,PE043
Barajas Fregoso Elpidio
112.07
194.03,219.03
Barczynski Marcin
Barut Pinar
PE054
Bass, MD Kathryn
18.23
Bataev Khassan
82.01,82.02,117.02,PE178
Bayraktar Onur
PE099
Behbudov Vugar
178.04
Belfontali Valentina
64.05
Bellantone Rocco
194.02,231.01
Belmouhand Mohamed
PE183
Benali Abdelali
198.07
Benassi Renata
134.02
Benders M.
82.03
Bendinelli Cino
PE032
Bendjaballah Ali
PE108
Beneduzzi Juliana
134.02
Bensard Denis
PE209
Beppu Toru
170.03,PE192
Bergenfelz Anders
219.05
Bergquist John
39.08
Berns Kathleen
18.21
Berquist William
82.04
Bertozzi Serena
PE068,PE071
Besselink MGH
39.02
Bestard Oriol
135.01
Bhalla Shalini
PE076
Bharghav PRK
46.03
Bhatia Eesh
147.01
Bhattacharya Neeta
PE076
Bhoo Pathy Nirmala
114.18
Bicudo-Salomao Alberto
151.04
Bingener Juliane
235.05
Bissett Ian
39.04
Bjärnevik Caroline
PE102
Blokhuis Taco
18.10,18.36
Blum, MD Craig
18.23
Boddie David
117.08
Boeck Marissa
113.01
78.02,114.03
Boland Michael
Boltz Melissa
PE029
Bongers M
39.02,217.03,PE194
Boonpipattanapong Teeranut
34.03,177.01
Boonsinsukh Thana
170.01
39.03,178.05
41.05
PE022
54.05
PE140
178.07
112.03
178.09
PE187
PE209
PE206
18.23
PE200
139.06
135.06
CCC
Cabrera Vargas Marcela
113.01
Çakır Volkan
170.04
Calderwood Santos
PE205
Calland James
77.03
Cancio Leopoldo
103.04
Cantaberta Mario
PE186
Capocelli Kelley
PE209
Carty Sally
PE045
231.02,PE044
Castagnet Marion
Cedolini Carla
PE068,PE071
Cengiz Fevzi
170.04
Cha Seong Jae
PE049
Chabot John
112.02
Chagpar Anees
78.05
Chagpar Ryaz
PE034
Chainiramol Prattana
18.04
Chaiyapan Welawee
34.03
CHAKRAVARTHY SIDDHARTHA
114.09
Chan Albert
39.05,PE142
Chan Amy
149.02
Chan Diane Toi-yin
194.06
Chan Kwong Man
PE064
Chan Michelle WY
114.08
Chan Patrick
114.11
Chan See Ching
39.05,PE142
Chan Sharon
149.02,149.04
Chan Yiong Huak
PE124
Chand Gyan
135.03,PE021,PE043
Chang David
77.01
Chang Hang-Seok 147.02,219.02,PE047,PE048,PE053
Chang Hojin
147.02,219.02,PE047,PE048,PE053
Chang Wei Wen
PE062
Chanswangphuvana Pakkavuth
39.03,178.05
Chao Stephanie
82.04,82.05
Chapman William
PE208
Chen Herb
64.03
Chen Herbert
PE036
Chen Jui Yu
PE058
Chen Yi-Ju
PE052
Chen Yiyi
139.06
Cheng Jolene Yu Xuan
18.09
CHERIAN ANEESH
114.09
Cherian Anish
PE042
Chernyshev Sergey
103.03
Cheung Catherine
149.02
PE064
Cheung Kwok Fai
Cheung Polly
149.02
Cheung T.T.
PE139
Cheung Tan To
39.05,PE142
Cheung TT
39.06
6
Chi Chin-Wen
PE058
PE153
Chia Clement
Chia Clement
PE155
Chiba Takehiro
PE117
Chichom-Mefire Alain
18.22,18.35,222.01,PE203
Chikamoto Akira
170.03,PE192
Chin Koei
198.02
Chitra Subramaniam
PE005
Chiu Philip
100.01,134.04
Cho Akihiro
PE122
Cho Donghui
PE069
Cho Jin Seong
PE046
Cho Jiyoung
PE050
18.33
Choadrachata-Anun Jirat
Choi Ji Woo
PE051
Choi June Young
PE027
Chok Kenneth
39.05,PE142
Chooklin Serge
PE143,PE144
Choudhry Asad
54.02
Chow Khuan Kew
112.05
Chow Tam
149.04
Christopher Lee Kheng Siang
PE085
Chu Cheuk Man
100.01
Chua Darren
34.05,PE124
Chua Felicia Hui Zhuang
18.09
112.08,PE057
Chung Ki-wook
Cima Robert
177.05
Clark Orlo
PE052
Clifton-Bligh Rory
41.01
Coccolini Federico
113.05
Cohen Eli
113.04
Cohen Mark
PE026
Cotton Michael
46.02
Courvoisier Thomas
PE044
Cox Jacob
18.44
Coyne Christopher
PE045
Cruzado José
135.01
Csukas Domokos
178.08
Curti Gaudenz
111.03
DDD
Daiko Hiroyuki
Daisuke Hashimoto
Dartigues Peggy
Das Srijit
Daskalakis Kosmas
Day Kristopher
De Calan Loic
De Crea Carmela
de Hingh IHJT
de Jongh Mariska
Decharun Katawaetee
Dejong CHC
Del Rivero Jaydira
Delbridge Leigh
Demelinne J
DEMIR Pervin
DEMIRBAS Sezai
Denariyakoon Sikrit
Deo S V
Deo SVS
Devkota Sagar
Dhar Anita
Dicker Rochelle
Djuraev Mirjalol
Djuranovic Srdjan
Djurisic Igor
PE176
170.03
198.07
PE085
135.04
64.04
PE044
194.02,231.01
39.02,217.03,PE194
18.48
PE207
39.02
PE024
41.01,PE038
217.03
134.06
134.06
151.07
28.08,114.10,114.12
114.05
54.05
224.02
18.44
PE132,PE197
217.01
135.06
Dodson Thomas
Doihara Hiroyoshi
Doki Yuichiro
Dolan James
Dominguez Carlos
Donatini Gianluca
Dong Dinghui
Doreen Lee L P
Dorman Robert
Drike Inese
Duda Rosemary
Duh Quan-Yang
Duren Mete
Dutka Yaromyr
Dutta Sanjeev
Duvalko Olexandr
Duwayri Yazan
Duzhiy Igor
Dzodic Radan
178.09
PE063
PE118
217.06
PE140
231.02,PE044
224.07
149.05,PE074,PE075
18.23
PE088
PE205
PE052
PE054
PE143,PE144
82.05
PE188,PE189
178.09
178.07
135.06
EEE
Ebina Aya
Egamberdiev Dilshod
ehsan aisha
Eid Hani
Eken Torsten
Ekrouf Shehab
Elder Elisabeth
Elfenbein Dawn
Ellam Sten
Ellis Ryan
Ellul Joseph
Elsayed Mohammad
Emery Richard
Endo Hirofumi
Endo Itaru
Endo Yuichi
Enlund Hannes
Erguner Ilknur
Erol Varlik
Ertas Burak
Etoh Tsuyoshi
Etoundi Mballa Georges
Evoy Denis
5.02
PE132,PE197
PE080
18.38,18.41
54.01
PE082,PE083,PE084
114.16,PE060
64.03,PE036
117.05
41.05
235.01
64.04
54.06
18.14,18.26
134.01,217.05
170.05
PE191
PE099
PE022
PE054
PE109
18.44,77.02
78.02,114.03
FFF
Fabricius Rasmus
Fahy Aodhnait
Faraj Shadi
Farley David
Farra Josefina
Fenwick John
Ferencz Andrea
Fernández Alsina Enrique
Fernandez Ranvier Gustavo
Ferree Steven
Ferreira Alice
Ferri Lorenzo
Ferris Robert
Fleischer Norman
Flynn William
Folek Jessica
Fon Alain
Fong Yiew Fah
Fottner Christian
Franckevica Ivanda
Francos José
7
217.02
18.11,18.24,177.02
113.02
100.03
112.06,PE035
PE008
178.08
135.01
112.03
54.04
198.01
77.05
PE045
PE024
18.23
135.05,194.05
18.35
224.01,224.06
5.01
PE195
135.01
Fraser Sheila
French James
Friese Randall S.
Fueldner Frank
Fujii Shoichi
Fujikawa Takahisa
Fujishiro Ken
Fujita Takashi
Fujita Takeo
Fujiwara Naoto
Fujiwara Yuki
Fukata Shinji
Fuks David
Fukuchi Minoru
Fukuda Kazumasa
Fukunari Nobuhiro
Fukuoka Osamu
Fukuoka Toshio
Fukushima Mitsuhiro
Furukawa Kenei
Furukawa Toshiharu
Fushida Sachio
Futagawa Yasuro
Fyrsten Ellen
Gupta Rajni
Gupta Shivam
Gupta Shyam
Gupta Sushil
Guzhñay Blasco
Gvozdenovic Miomir
Gvozdenovic Miomir
41.01,PE038
114.16,PE060
113.03
170.09
111.05
4.07,80.06,PE190
PE006
18.20,18.43,54.03,77.04
PE176
PE177
170.06,PE160
PE006
198.07
28.07,PE086,PE087,PE110
34.07
PE039
5.02
18.46
135.02, PE041
170.06,PE160
235.03
PE114
PE162
41.06
GGG
Gaarder Christine
Galeev Shamil
Gallardo José Luis
Gallucci Pierpaolo
Gambhir Sanjay
Gara Sudheer
Garbus Sam
García-Barrasa Arantxa
Gardovskis Janis
Garg Pankaj
Garg vaibhav
Gayet Brice
Geraghty James
Ghasoup Asem
Gie Hooi Tan
Gilbert Erin
Gill Anthony
Giray Serdar
Gloor Beat
Gocho Takeshi
Gogia Ajay
Gohrbandt Antje
Gonzáles Javier Ricardo Simons
Gosnell Jessica
Goto Michitoshi
Govednik Cara
Goyal Puneet
Graf Michael
Graham Susannah
Gray Andrew
Greenhalgh David
Grieder Felix
Grivna Michal
Grogan Raymon
Grönroos Juha
Gruen Russell
Gruener Beate
Guan Zheng
Guigard Sébastien
Gullo Giuseppe
gupta amit
235.04
18.42
PE076
219.04,PE020,PE031
222.03
18.47
217.01
HHH
Habermann Elizabeth
18.11,18.13,177.05,235.05
Hacıyanlı Mehmet
170.04
Haidegger Tamas
178.08
Haider Adil
18.49
224.03,224.04
Hakala Tapio
Hakamada Kenichi
PE106
Halloul Zuhir
PE018,PE019
Halonen Jari
117.05
Hamaguchi Mitsuhide
18.06,18.16
Hameed Morad
77.01
Hamel Christian
111.03
Hamuo Ahmad
PE081
Hamy Antoine
PE044
Hamzaoglu Ismail
PE099
Han Tang
134.05
Haniu Kento
PE023
117.07
Hanpresertpong Jitti
Hanyu Takaaki
4.08,PE172
Happonen Pertti
PE191
Harada Yurina
PE095
Haraguchi Naotsugu
111.06,PE095
Hardcastle Timothy
18.36
harlak ali
PE135
Harrison Jeff
39.04
Hartikainen Juha
117.05
Haruki Koichiro
170.06,170.07,PE160,PE162
Hasegawa Hirotoshi
34.01
Hasegawa Suguru
PE098
Hashimoto Daisuke
PE192
Hashimoto Isaya
PE129
Hassan Tiara
PE066
Hasselmann Julien
224.05
Hasuo Kimiatsu
PE065
Hatori Shinsuke
PE111
Hatta Kouhei
PE093
Hatthachote Pananda
176.03
Haugen De Anna
54.06
Hayasaka Ken
4.04,PE059,PE171,PE173
Hayashi Eiji
PE007
Hayashi Hiromitsu
170.03,PE192
Hayashi Hironori
41.04
Hayman Amanda
39.08
Hayoz Stefanie
111.03
Hayruddinov Rafik
PE174
Heeres Marjolein
18.02,18.10
Helenowski Irene
113.01
Hellman Per
41.06,135.04
Henne-Bruns Doris
80.04
Henning Marcus
46.01
Henry Jaymie
46.02
Herbella Fernando
4.01,134.02,198.01
Hernandez Matthew
18.34
Hernesniemi Jussi
224.04
112.07
Herrera González Antonio
Herrera Hernández Miguel
112.07
Herrera-Escobar Juan
18.49
Hesselink Lillian
18.02
Hessman Ola
41.06
54.01
PE196
113.01
231.01
78.04
41.05
217.06
135.01
PE088,PE195
114.12
PE161
198.07
78.02,114.03
18.28,PE141
114.18
139.06,217.06,PE187
41.01
PE054
111.03
PE162
114.05,114.12
194.04
113.01
PE052
PE097
135.05
PE020
111.03
PE038
PE032
18.12
111.03
18.38
64.06
139.02
222.04
80.04
PE137
64.05
114.03
18.17
8
Hibi Taizo
80.03,80.07
PE098
Hida Koya
Hidaka Wataru
PE107
Hietbrink Falco
18.02,18.08,54.04
Higashijima Jun
28.02,80.01,PE119
Higashijima Junn
PE151
Higashiyama Takuya
PE041
Hill Andrew
39.04
Hill Andrew
46.01
Hill Andrew
217.08,PE100
Hillenbrand Andreas
80.04
Hillingsøe Jens
217.02
Hirai Kenjiro
PE121
198.08
Hirakata Atsushi
Hirakawa Kosei 4.05,28.04,114.02,114.04,PE025,PE166
Hiraki Masatsugu
PE150
Hiramitsu Takahisa
41.03,219.01,PE028,PE030
Hirano Atsushi
PE136
Hirano Katsuhisa
28.05,PE004,PE089
Hirao Motohiro
111.06,PE095
Hirashima Kotaro
4.08,PE172
Hirata Tooru
PE175
Hiratsuka Takahiro
PE109
Hiremath Bharati
117.06
Hirose Hajime
PE113
80.02,139.03,139.04,198.03,198.05,
Hirose Yuki
198.06,217.04,PE133,PE146,PE147,
PE148,PE156,PE158
Hiroshima Yukihiko
PE136
Hisamori Shigeo
PE098
Ho Leung Sing
PE064
Hojo Seishi
39.09
Hojo Takashi
78.01,PE073
Holloway Claire
78.06
Honda Shinsaku
PE123
Hong Qian Tai
224.01
Hong Qiantai
224.06
Hong Suck Joon
112.08,PE057
Hoosain Fatima
18.36
Horiuchi Kiyomi
PE023
Horiuchi Takashi
170.06,170.07,PE160
Hosoda Kei
PE115,PE168
Hotokezaka Masayuki
PE096
Houwert R
54.04
Howley Isaac
18.42
Hsu Jeremy
113.02,114.16
Hu Jesse
112.05
Huang Shih-Ming
64.01,112.09,PE037
Huey Cheong Wei
PE155
Huey Terence
PE153
Hughes Tyler
78.05
Hulmi Tanja
134.07
Hung Chien-Ling
PE037
Hung Chung-Jye
PE037
Hunt Kelly
78.05
Hunter John
217.06
Husain Nuzhat
114.13,151.02,198.04
Hussain Zahir
5.03,5.04,100.02
Hutter Matthew
77.01
Hwang Ghee
222.02
Hyder Adnan
18.42,18.44
Hyder Adnan
77.02
III
Ichikawa Ryosuke
Ichikawa Yasushi
Ichimanda Michihiro
Ide Takao
Igari Kimihiro
Ikeda Atsushi
Ikeda Masataka
Ikemoto Tetsuya
Ilves Imre
Imai Tsuneo
Imamura Yu
Imola Daniela
Imura Satoru
Inabnet III William
Inamoto Susumu
Inari Hitoshi
Inomata Masafumi
Inoue Yoshinori
Iqbal A
Irie Shouichi
Ishibashi Keiichiro
Ishibe Atsushi
Ishibe Takuya
Ishida Hideyuki
Ishida Hijime
Ishigami Sumiya
Ishigure Kiyoshi
Ishiguro Toru
Ishihara, Toru
Ishikawa Hideki
Ishikawa Takashi
Ishimaru Kei
Ishimaru Naoki
Ishitani Michael
Ishitani Michael
Isobe Yo
Isom Chelsea
Issa Nabil
Itano Osamu
Itatani Yoshiro
Ito Yasuhiro
Iwagami Shiro
Iwamoto Takayuki
Iwasaki Hiroyuki
Iwase Ryota
Iwashita Yukio
JJJ
Jagust Marcy
Jain Vinod
Jakhetiya Ashish
Jamaris Suniza
James Benjamin
Jaroensuk Jittima
Jayasuriya Kamal
Jee Keem Low
Jendresen Marianne
Jenkins Donald
Jenkins Donald
Jenkins Donald
Jimbo Kenjiro
Jin Aizhen
Jin Judy
Jørgensen Jørgen
Jørgensen Jørgen Joakim
Joseph Bellal
Joshipura Manjul
Jovanovic Dusan
Juillard Catherine
PE097
134.01
PE109
9
170.02,PE150
PE016,PE017
PE122
111.06,PE095
80.01,PE151
134.07
41.04
PE001
PE186
80.01,PE151
112.03
PE003
PE055,PE065
111.05,170.05,PE109
PE016,PE017
PE077
PE175
28.07,PE086,PE087,PE110
134.01
18.16
28.07,PE086,PE087,PE110
PE173
4.03,4.06,18.27,PE090,
PE126,PE127,PE128
PE010,PE105
28.07,PE086,PE087
18.45
18.20,18.45,77.04
4.08,PE172
PE198
18.14,18.26
18.24,177.02
177.05
PE131
64.02
113.01
80.03,80.07
PE003
135.02,PE041
PE001
PE063
PE055,PE065,PE111
170.07,PE160
170.05
PE024
117.09
114.05,114.10
114.18
64.06
PE061
18.40
PE153
PE181
18.21,18.24,177.02
18.13
54.02,54.06
78.01,PE073
112.05
PE029
54.01
54.01
113.03
54.05
217.01
18.44,77.02
Juma Talib
Junnarkar Sameer
Junnarkar Sameer
JunSeong Lee
Jyrkkä Johanna
Kawazu Ayako
PE169
PE054
Kaya Hakan
Kebebew Electron
41.05,194.01,219.06
Keilmann Annerose
194.04
Kela Bahirath
54.05
Kessler Katharina
18.19,PE081,PE138
Kesu Balani Levin
PE085
Keyser Zamira
149.07
Khadjibaev Abdukhakim
18.39
Khalid Muhammad
PE127
Khalil Mazhar
113.03
Khan Khizar
PE077,PE078,PE080
Khan Zahra
PE035
112.06
Khan, BA Zahra
Khanenko Vasil
PE188,PE189
Kharchenko Sergiy
178.07
khasawneh mohammad
18.21
Khasawneh Mohammad
18.11
Kheruka Subhash
78.04
Khomiak Andrii
PE188,PE189
Khomiak Igor
PE188,PE189
Khudoyarov Sanjarbek
PE197
Kiernan Colleen
64.02
Kihara Minoru
135.02,PE041
Kijima Takashi
4.06,PE126,PE128
PE090
Kijima Takashii
Kikuchi Hiroko
18.14,18.26
Kikuchi Hiroto
PE131
Kikuchi Shiro
PE115
Kikumori Toyone
41.04
Kim Brian
18.31
Kim Bup-woo
147.02,219.02,PE047,PE048,PE053
Kim Hyeung Kyoo 147.02,219.02,PE047,PE048,PE053
Kim Jung Hee
PE027
Kim Kweon Cheon
112.04
Kim Seok-Mo
147.02,219.02,PE047,PE048,PE053
Kim Su-jin
231.04,PE027
Kim Yoo Seok
112.04
Kim Youngmin
PE050
Kimura Masami
PE014,PE154
Kimura Ryosuke
PE173
Kimura Toshiro
PE106
King Booker
103.04
Kinoshita Jun
PE114
Kinoshita Takayuki
78.01,PE073
KIRIAKOPOULOS ANDREAS
PE040
Kishimoto Takuma
PE007
Kita Yoshiaki
18.27
Kitagawa Yuichi
PE006
Kitagawa Yuko
34.01,34.06,34.07,80.03,
80.07,235.03,PE184
Kitago MInoru
80.03,80.07
Kitahara Kenji
170.02
Kitamura Eiji
PE096
Kitamura Maki
18.20,18.43,54.03,77.04
Kitano Mitsuhide
18.32
Kitano Seigo
111.05
Kiviniemi Vesa
PE191
Klemenova Irina
103.03
Kobayashi Kaoru
135.02,PE041
Kobayashi Takashi
80.02,111.04,114.01,139.03,
139.04,149.01,198.03,198.05,198.06,
217.04,PE133,PE146,PE147,PE148,
PE156,PE158,PE175
PE136
Koda Keiji
Koeda Keisuke
PE117
Koefod Steen
PE181
PE082,PE083,PE084
PE153
PE155
PE069
PE191
KKK
Kabir Tousif
PE125
Kader Shakeel
PE079
Kaewsaengrueang Khanitta
18.04
Kaga Shinichiro
18.25
Kahn Delawir
77.01
Kaida Takayoshi
170.03
18.46
Kaihara Toshie
Kainuma Osamu
PE122
Kakesu Takanori
PE169
Kamei Keiko
PE193
Kamer Erdinç
170.04
Kameyama Hitoshi
111.04,111.07,198.03
Kamiya Mariko
PE111
Kamiya Satoaki
PE107
Kanamori Jun
PE176
Kanazawa Shinsaku
PE067
Kanda Tomohiro
PE157
Kaneko Hironori
PE067
PE096
Kanemaru Mikio
Kang Hyein
PE027
Kang Kyung Ho
PE049
Kang Sun Hee
PE050
Kanngern Samornmas
34.03
Kano Yosuke
4.08,PE172
Kaplan Edwin
64.06
Kaplan Sharone
64.06
KAPOOR HARIT
4.02,PE179
Karahasanoglu Tayfun
PE099
Karakas Elias
147.03
Karakatsanis Andreas
135.04
Karenovics Wolfram
64.05
Karimata Hiroyuki
4.04,PE059,PE171
Karnjanawanichkul Watid
117.07
Karyakin Nikolay
103.03
Kasahara Akio
PE111
Kasetsermwiriya Wisit
178.02,178.03,235.02,PE163
Kashihara Hideya
28.02,PE119
Kashiwagi Shinichiro
114.02,114.04,PE025
Kashuk Jeffry
113.04
Kastarinen Helena
PE191
Katada Natsuya
PE115,PE168
Katada Tomohiro
139.03,139.04,198.05,198.06,
PE147,PE148,PE156
Kato Yoshiyasu
PE010
Kaur Navneet
114.14
Kaur Taranjeet
PE187
Kavalukas Sandra
64.02
Kawabata Kazuyoshi
5.02
Kawabata Yasuji
PE006
Kawada Kenji
PE003,PE098
Kawada Kenro
PE110,PE177
Kawahara Hidejiro
39.09
Kawai Kentaro
18.07
Kawai Satoru
PE107
Kawajiri Hidemi
114.02,114.04
34.06,34.07,PE184
Kawakubo Hirofumi
Kawamorita Keisuke
PE185
Kawamura Taiichi
PE123
Kawano Tatsuyuki
28.07,PE177
Kawasaki Takashi
111.04
10
Koenderman Leo
Kofoed Steen
Koga Hiroki
Koga Yasuo
Koide Yoshikazu
Koike Naoto
Koishibayev Zhandos
Kojima Yoh
Kojima Yutaka
Kondo Takayuki
Kong Wai Chung
Konishi Fumio
Kono Tsuguaki
Konturek Aleksander
Kopchak Kostyantin
Kopchak Volodimir
Kormos Katalin
Korvenoja Pekka
Kosai Nik Ritza
Kosenko Pavel
Kössi Jyrki
Kosugi Chihiro
Kosugi Shinichi
Kotake Rina
Kotewall Nicholas
Kotze Maritha
Kozuki Akihito
Kraimps Jean
Krishna Sanjeev
krishnani narendra
Kubo Naoshi
Kubota Akio
Kubota HItoshi
Kudo Toshifumi
Kühme Tobias
Kuiper, MD Jeremy
Kulvatunyou Naroung
Kumagai Youichi
Kumamoto Takafumi
Kumar Awanish
Kumar Chitresh
Kumar Rakesh
kumar subodh
kumar suresh
Kumari Neeraj
Kumari Niraj
Kuo Jennifer
Kuoppala Jaana
Kurata Kento
kurimoto keisuke
Kuriyama Akira
Kuroiwa Koujirou
Kurtulmus Neslihan
Kushwaha Jitendra
Kuwabara Akifumi
Kvasivka Olexandr
Kwok Carol
Kwon Hyungju
Kwon Oh Kyung
Kwong Ava
Laird Amanda
PE024
194.05
Lairmore Terry
Lairmore Terry
135.05
Lake Douglas
77.03
Lakshmi J
18.42
Lal Punita
78.04,149.03
Lam Candice
100.01
Lam Rosana
149.04
Lam Shi
194.06
Lam Yvonne
149.04
Lang Brain Hung-Hin
PE027
Lang Brian Hung-hin
194.06,231.03
Lang Hauke
5.01,194.04
18.48
Lansink Koen
Lanzarini Enrique
PE140
Laohapensang Mongkol
177.03
Laopeamthong Issaree
178.02,178.03,235.02,PE163
Latifi Rifat
113.03
Lau Tommy
149.04
Lausevic Mirjana
18.47,217.01
Lausevic Zeljko
18.47,217.01
Lavryk Olga
PE033
Law Siu
149.04
Learoyd Diana
41.01
Lee Chen-Hsen
PE058
100.03
Lee Grace
Lee James
112.02
Lee Jeonghun
PE051
Lee Kyu Eun
231.03,231.04,PE027
Lee Yong Sang
147.02,219.02,PE047,PE048,PE053
Lee Yu-Mi
112.08,PE057
Leelachai Prompong
178.02
Leenen Luke
18.02,18.08,18.10,18.36
Leenen Luke
54.04
Lemanu Daniel
39.04,217.08
Lemmens VEPP
39.02,217.03,PE194
Lemmers P.M.A.
82.03
Leonard Jennifer
54.02
Leong Mario
114.16
Leppäniemi Ari
111.02,217.07
Lerdsirisopon Sopon
178.02,178.03,235.02,PE163
Lett Ronald
222.02
Leung K.C.
PE134
Levy Miroslav
PE104
Lew John
112.06
Lew John
PE035
Li Jason Yu-Yin
194.06,231.03
Li Jianhui
39.01,224.07
Li Jianpeng
80.05,134.03,170.08
Libutti Steven
PE024
Lim Ming
46.05
LINOS DIMITRIOS
PE040
Lipska Ludmila
PE104
Liu Huimin
224.01,224.06
Liu Peng
170.08
Liu Shirley
100.01,134.04
Liu Tse Jia
PE062
LIU WENYAN
134.03
Lo Chung Mau
39.05,PE139,PE142
Lok Hon Ting
134.04
Lombardi Celestino
194.02,231.01
Londero Ambrogio P
PE068,PE071
PE071
Londero Viviana
Long Kristin
PE026
Lou Irene
PE036
Low Jee Keem
PE155
LU JIANWEN
39.01,80.05,134.03
18.08,18.10
PE183
170.02
28.01
PE093
139.05
PE002
PE198
PE097
34.01
PE064
111.05
PE180
194.03,219.03
PE188,PE189
PE188,PE189
178.08
117.05
PE085
PE112
134.07
PE136
4.08,111.04,PE172
117.10
194.06
149.06
151.01
231.02,PE044
46.01
78.04,219.04,PE031
4.05,PE166
177.06
PE007
PE016,PE017
224.05
18.23
113.03
28.07,PE086,PE087,PE110
134.01,217.05
151.03,235.04,PE009
135.03
114.12
18.17
18.03
PE031
219.04
112.02
PE191
PE025
PE010,PE105
18.46
PE006
PE054
114.13,151.02,151.03,
198.04,235.04,PE009
PE120
PE188
PE064
231.04
28.06
114.08,PE072
LLL
Labow Daniel
Lagoo Sandhya
Laguna Saavedra Juan Mauricio Pavel
Lai Paul
112.03
PE205
113.01
134.04
11
Lu Jian-Wen
Lukic Silvana
Lusan Alexandr
Lv Yi
Lyndon Mataroria
MMM
Ma Feng
Ma Jia
MA KW
Ma Kwok Kuen
Macalino Joel
MacCormick Andrew
MacEachren Campbell
Madani Amin
Madiba Thandikosi
Madiba Thandinkosi
Madiyorov Bakhtiyor
Maeda Kiyoshi
Maeda Kotarou
Maehara Yoshihiko
Mafune kenichi
Magata Hisato
Magema Jean-Philippe
Magnone Stefano
Magoshi Shunsuke
Mahanama Thamaranath
Mahmood S
Mahmood Shahid
Makay Ozer
Makino Hiroshi
Makuuchi Rie
Mali Juha
Maneechay Wanwisa
Manfredi Roberto
Mans Stefan
Marcadis Andrea
Markovic Ivan
Marti Walter
Maruyama Hiroshi
Maruyama Tomohiro
Maskelis Romualdas
Mast Richard
Masuda Munetaka
Masuoka Hiroo
Mathis Kellie
Mathur Sandeep
Mathur Sandeep
Matniyazova Shakar
Matsubara Hisahiro
matsuda kiyoshi
Matsuda Mutsuhito
Matsuda Satoru
Matsui Koshi
Matsumoto Akio
Matsumoto Ippei
Matsumoto Shokei
Matsumoto Yasunori
Matsunaga Hiroyuki
Matsuo Kenichi
Matsuoka Shinji
Matsushima Tomohide
Matsushita Daisuke
Matsushita Hidenobu
Matsuyama Ryusei
Matsuzaki Yasutaka
PE107
PE086,PE087
Matsuzawa Takeaki
Matusda Kiyoshi
18.14
Matyja Andrzej
PE200
Matyushko Dmitriy
PE002
Mayanagi Shuhei
PE176
Mayilvaganan kanarathinam
PE005
Mayilvaganan Sabaretnam
46.03
Mbome Victor
222.01
McCoy Kelly
PE045
McDermott Enda
78.02,114.03
McGrath Shaun
PE032
McKenzie Travis
100.03
114.18
Mee Hoong See
Mehrotra Prateek
PE076
Meizoso Jonathan
112.06
Mentes Oner
PE135
Mentula Panu
111.02,217.07
Merriman Lisa
139.06
Metwally Tarik
PE138
Meybodi Farid
PE060
Meyer Frank
170.09,PE018,PE019,PE164
Michitsuka Yukio
PE067
Michiura Toshiya
PE113
Miederer Matthias
5.01
PE115,PE168
Mieno Hiroaki
Mikaere Hinetamatea
PE100
Mikata Shoki
PE118
Miller Christopher
113.01
Miller Joy
114.13
Millo Corina
41.05
Minamiguchi Sachiko
PE003
Minamimura Keisuke
PE175
Miralliè Eric
PE044
Misawa Takeyuki
39.09,170.06,PE162
Mishima Shiro
18.07
mishra anand
117.09,117.09
Mishra Anjali
135.03,147.01,PE020,PE021,
PE031,PE043
46.03
Mishra Saroj
Mishra Saroj
PE021
Mishra Saroj
PE043
Mishra Saroj
135.03,147.01,PE020
MISHRA SK
219.04
misra samir
117.09,117.09
Mitani Yasuyuki
177.06
Mitchell Barbara
PE204
Mitsugu Sekimoto
111.06
Mittal Balraj
149.03
Mittal Sanchit
198.04
Mittal Sumeet
4.02,PE179
Miura Kohei
80.02,217.04,PE156,PE158
Miura Takuya
PE106
Miya Akihiro
135.02,PE041
Miyake Masakazu
111.06,PE095
Miyamoto Atsushi
111.06
Miyashita Masao
PE170
Miyashita Tomoharu
PE114
Miyauchi Akira
135.02,PE041
Miyauchi Hideaki
PE091
Miyawaki Yutaka
PE177
Miyazaki Michihiko
111.06,PE095
PE113
Miyazaki Satoru
Miyazaki Yasuaki
PE113
Miyoshi Atsushi
170.02
Mizobata Yasumitsu
18.25
Mizuguchi Yoshiaki
198.08,PE157
151.06
135.06
103.03
39.01,80.05,134.03,151.06,
170.08,224.07,PE137
46.01
39.01,80.05,134.03,170.08,
224.07,PE137
39.01,224.07
39.06
114.08
18.05
217.08
18.30
77.05
PE079
34.02
117.01,PE174
28.04
PE093
PE001
PE175
PE096
34.08
113.05
PE067
18.40
PE077
PE078
PE022
PE170
PE123
111.02
34.03
113.05
18.48
112.06,PE035
135.06
111.03
PE170
PE133
PE201
135.01
39.07,PE055,PE065,PE116
135.02
39.08
114.05
114.12
PE094
PE091,PE180,PE182
18.26
34.01
PE185
PE159,PE167
PE146
PE193
18.32
PE180
PE107
PE136
PE093
18.06,18.16
4.03,4.06,PE090,PE128
PE010
134.01,217.05
12
Mizumoto Motoko
PE121
28.07,PE086,PE087,PE110
Mochiki Erito
mochizuki toru
18.26
Mohamed Awadelkarim
PE081
Mohammad Taher Mustaffa
PE085
Mohanapriya Gajarajan
5.03,5.04,100.02
Mohd Noor Nor Alia
PE124,PE155
Mohd Taib Nur Aishah
114.07
Mohmmed Saif elddin
18.28
Moir Christopher
18.24,177.02
Moir Christopher
177.05
Monchik Jack
64.04
Monono Martin
18.44,77.02
34.02
Moolla Zaheer
Moon Tong
PE069
Moorman J.
77.03
Moreno Pablo
135.01
Mori Koichi
217.05
Mori Mikito
PE136
Mori Motomi
198.02
Mori Ryutarou
217.05
Mori Shinichiro
18.27
Morimura Naoto
18.45
Morine Yuji
80.01,PE151
Morisaki Tamami
114.02,114.04
80.08,PE145
Morise Zenichi
Moriya Hiromitsu
PE115,PE168
Moriyama Makoto
PE167
Moro Kazuki
114.01,149.01
Morohashi Hajime
PE106
Morris David
18.31
Moss Travis
77.03
Motoki Takayuki
PE063
muduly Dillip
114.05,114.10
Mugabi Patrick
222.02
Mugazov Miras
PE002
Muguruma Kazuya
4.05,28.04,PE166
Muhammad Shoaib
54.05
Mulder David
77.05
Mullan Brian
100.03
Mungnirandr Akkrapol
177.04
Murakami Katsuhiro
PE098
Murakami Kentaro
PE180,PE182
Murao Yoshinori
18.06,18.16
Musha Nobuyuki
PE120
Musholt Thomas
194.04
Musholt Thomas
5.01
Musleh Maher
PE140
Muslumov Gurbankhan
178.04
Muthukumar Sankaran
5.03,5.04,100.02
Muto Yorihiko
PE091
Nagayama Minoru
Naidu Sanjeev
Nait slimane Naima
Nakagawa Shigeki
Nakai Takuya
Nakajima Yasuaki
Nakamori Shoji
Nakamura Eriko
Nakamura Kenichi
Nakamura Masanori
Nakamura Rieko
Nakanishi Kenichi
Nakano Masahide
Nakano Masato
Nakao Takami
Nakao Toshihiro
Nakata Yasuyuki
Nakatsutsumi Keita
Nakayama Gakuryu
Nanda Gitika
Narain Tushar
Narayanan Sriram
Narushima Kazuo
Nascimento Priscilla
Natarajan Suresh Khanna
Natsugoe Shoji
NNN
Nabeya Yoshihiro
PE122,PE169
Nadlonek Nicole
PE209
Næss Pål
54.01
Naga Vikram
PE125
Nagahara Hisashi
28.04
Nagahashi Masayuki80.02,114.01,139.03,139.04,149.01,
198.03,198.05,198.06,217.04,PE133,
PE146,PE147,PE148,PE156,PE158
Nagai Erin
PE023
PE113
Nagaoka Makio
Nagata Junnichi
PE007
Nagata Matsuo
PE169
Nagata Takuya
28.05,PE070,PE089,PE129,
PE159,PE167
13
PE012
PE008
PE108
170.03
PE193
PE177
111.06,PE095
34.06
PE001
PE010,PE025
34.07,PE184
41.04
PE039
111.07
18.16
28.02,PE119
PE193
18.18
217.05
PE056
224.02
224.01,224.06
PE091
134.02
34.05
4.03,4.06,18.27,PE090,
PE126,PE127
Natsugoe Syoji
PE128
Nätterlund Kristina
PE102
Navsaria Pradeep
77.01,77.01
Nematov Odiljon
117.03,117.04
Neri Silvia
PE068,PE071
Ng Enders
100.01,134.04
Ng Kwok Wai
PE134
Ng Wai Kin
PE064
Ngamby Marquise
18.44,77.02
Ngerncham Monawat
177.03,177.04
Ngiam Kee Yuan
112.05
Ngowe ngowe Marcelin
18.22,18.35,PE203
Ni Cearbhaill Roisin
78.02
Nickerson Terry
18.31
Nicol Andrew
77.01,77.01
Niihara Masahiro
PE185
NIK MAHMOOD NIK RITZA KOSAI
178.01
Nikiforov Yuri
PE045
Nilubol Naris
41.05,194.01,219.06
Nishi Masaaki
28.02,PE119
Nishida Toshiro
PE118
Nishikawa Gen
PE098
Nishikawa Kazuhiro
PE118
Nishikawa Toru
PE039
Nishimaki Tadashi
4.04,PE059,PE171,PE173
Nishimori Takanori
PE091
Nishiwaki Hitoshi
18.06
Nishizawa Masato
PE017
Nita Gabriela
113.05
Nitta Hidetoshi
170.03,PE192
Niyas Seyed Mohamed Mohamed
18.37
Noda Hironobu
PE117
Noda Masahiro
18.27
Noda Satoru
114.02,114.04,PE025
Nogami Hitoshi
111.07
PE063
Nogami Tomohiro
Noguchi Tsuyoshi
PE109
Nomura Akinari
28.01
Nontasuti Bunthoon
PE015
Nordback Isto
139.02
Nordenström Erik
Nordin, MD Andrew
Norlen Olov
Noshiro Hirokazu
Nowak Wojciech
Pan Hong
PE134
113.03
Pandit Viraj
Panichkul Suthee
176.03
Pantoja Millán Juan
112.07
Pape Hans Christoph
18.10
Parameswaran Rajeev
112.05
Parent Brodie
113.06
parihar anit
18.03
Park Cheong Soo 147.02,219.02,PE047,PE048,PE053
Park Ki Cheong
147.02
Park Min Ho
PE046
Park Myung
54.06
Park Sung Jun
PE049
PE049
Park Yong Keum
Parker Maile
18.11,18.21
Parodi Pier Camillo
PE068
Partrick David
PE209
Parvez Elena
222.02
Pasternak Artur
PE200
Pasternak Jesse
PE052
Pastora Javier
PE205
Patel Dhaval
41.05
Patel Dhaval
PE130
Patti Marco
4.01,134.02,198.01
Paul Mazhuvanchary
PE042
114.09
PAUL MJ
Paul Thomas
PE042
Pecorelli Nicolo
77.05
Perera Asanga
18.40
Pererva Liudmyla
PE188,PE189
Perrier Nancy
PE026
Peşkersoy Mustafa
170.04
Peters Mary
64.02
Pfeifer Roman
18.10
Phan Dinh
PE018
Piazzalunga Dario
113.05
Pienaar Rika
149.06
Pierangelo Angelo
198.07
Pillay Shannon
34.02
Pillay Shunmoogam
PE008
Pino Luis
18.49
Pitkänen Otto
117.05
Pliss Mikhail
28.03
Pliss Mikhail
28.03,PE101,PE196
Polites Stephanie
18.24,177.02
Polites Stephanie
18.13
Polites Stephanie
54.06,177.05
Pollock Terina
217.08
Poon Ronnie
39.05,PE142
Pradelle Irene
PE071
Pradhan P
PE021
pradhan Roma
219.04,PE031
Preechayudh Suppareuk
18.33
Preiss Joshua
178.09
Premathilake Tharanga Lasantha
18.37
Price Matthew
222.03
Price Raymond
222.03
Prichard Ruth
78.02,114.03
Prieditis Peteris
PE195
Pripatnanont Choosak
117.07
Pruitt, Jr. Basil
103.04
Puchkov Dmitriy
139.01
139.01
Puchkov Konstantin
Pulkkinen Jukka
139.02,PE191
Punamiya Sundeep
PE155
219.05
18.23
135.04
28.01,170.02,PE150
194.03,219.03
OOO
O’Keefe Grant
113.06
O’Keeffe Terence
113.03
Obadiel Yasser
18.15
Ochi Tomohiro
78.01,PE073
Oda Hitomi
135.02,PE041
Oda Jun
18.07
PE106
Odagiri Tadashi
O'Doherty Ann
78.02,114.03
Ogata Hideaki
PE067
Ogawa Hirofumi
PE185
Ogura Takuya
78.01,PE073
Ogwang Martin
222.02
Ohashi Taku
198.03,217.04
Ohashi Toya
170.07
Ohira Gaku
PE091
Ohira Masaichi
4.05,PE166
Ohira Shusaku
PE007
Ohshima Yuji
139.05
170.05
Ohta Masayuki
Ohta Tetsuo
PE114
Ohtani Hiroshi
28.04
Oishi Takashi
PE131
Okabayashi Koji
34.01
Okabayashi Takehiro
151.01
Okabe Hirohisa
PE192
Okada Manabu
41.03,219.01,PE028,PE030
Okada Naoya
PE176
Okada Yoshito
PE007
Okamoto Hiroshi
18.46
Okamoto Takahiro
PE023
Okamura Takuma
111.07
Okello Tom
222.02
Oki Eiji
PE001
Okubo Keishi
4.06,PE090,PE126,PE128
Okumura Hiroshi
4.03,18.27
Okumura Tomoyuki 28.05,PE089,PE129,PE159,PE167
Omi Yoko
PE023
Omori Takeshi
PE118
Onoda Naoyoshi
114.02,114.04,PE025
Oragano Luigi
231.01
Ordonez Carlos
18.49
Oruci Merima
135.06
Osada Ryusuke
PE167
Osaku Tadatoshi
PE067
Oshima Takashi
39.07,PE116
Osumi Koji
PE131
Ota Masayuki
PE109
Ota Mitsuyoshi
134.01
Ota Takumi
PE180
Othman Deran
231.02
Otomo Yasuhiro
18.18
Oyama Katsunobu
PE114
Ozdemir Murat
PE022
OZER Mustafa
134.06
OZTURK Bulent
134.06
PPP
Paajanen Hannu
Pak-art Rattaplee
Palmieri Tina
134.07,139.02,PE191
18.29
18.12
QQQ
14
Qiang Zhang
Quadrelli Lisandro
Quinn Cecily
Sagar Sushma
18.17
PE054
Saglican Yesim
Saida Fumitaka
18.32
Saikawa Yoshiro
34.06,PE184
Saisaka Yuichi
151.01
Saito Fumi
PE067
Saito Hiroshige
PE169
Saito Katsumasa
PE177
Saito Keita
PE146
Saito Ryota
PE162
Saito Shuji
111.05
Saito Yoshiyuki
34.07
Saito Yu
80.01,PE151
PE133
Sakai Takeshi
Sakai Yasuo
PE120
Sakai Yoshiharu
PE003,PE098,PE121
Sakamoto Akiko
PE023
Sakamoto Kazuhiro
PE097
Sakamoto Tetsuya
18.20,18.43,18.45,54.03,77.04
Sakamoto Yoshiyuki
PE106
Sakata Ikuhiro
18.06
Sakata Jun
80.02,114.01,139.03,139.04,
149.01,198.03,198.05,198.06,217.04,
PE133,PE146,PE147,PE148,PE156,PE158
Sakurai Katsunobu
4.05,PE166
PE170
Sakurazawa Nobuyuki
Sallinen Ville
111.02
Salman Mohammed
PE081
Salomão Rosana
151.04
SAMA Akanyun
18.22
Sammalkorpi Henna
217.07
Samphao Srila
114.17
Sandor Md Jozsef
178.08
Sangkhathat Surasak
34.03,117.07,177.01
Sangthong Burapat
18.04,177.01
Sano Koichiro
PE096
Santrac Nada
135.06
Sargin Asuman
PE022
Sarpel Umut
112.03
Sarwar Hasan
PE204
Sasaki Akira
PE117
Saskin Refik
78.06
Sato Ayano
18.07
Sato Harunobu
PE093
Sato Koichi
PE198
Sato Takuji
PE176
Sato Yu
4.08,PE172
Satoi Shunpei
PE193
Sawada Yu
217.05
SAYDAM Mehmet
134.06
Schad Arno
5.01
Schiller Henry
18.31
Schlegel Cameron
64.02
Schneider David
64.03
Schneider David
PE036
Scholtz Veronika
PE019
Schuetz Steven
113.01
Schwartz Myron
112.03
Scrybin Oleg
PE196
Secchi Mario
PE186
Sedaghat Negin
PE060
Seek Win
46.05
147.03
Seeliger Barbara
Seki Shiko
PE131
SEKIMOTO MITSUGU
PE095
Sekine Shinichi
28.05,PE089,PE129,PE159
Sen Soman
18.12
41.02
PE186
78.02,114.03
RRR
Rabhi Hassan
PE108
Rachkov Victor
82.01,82.02,117.02,PE178
Raffaelli Marco
194.02,231.01
Raftery Daniel
113.06
Rai Anurag
18.03
Raj Dheeraj
PE161
Rajan Reynu
178.01,PE085
Rajan Sendhil
78.04,147.01,PE056
178.09
Rajani Ravi
Rajatapiti Prapapan
PE207
Ramachandran Anu
18.49
RAMAKANT POOJA
114.09,PE042
Ramanathan Palaniappan
28.08
ranjan piyush
18.17
Ranjit Anju
18.49
Rao Mohan
18.42
Rasulov Abdugaffar
PE174
Rasulov Abdugaffor
117.01
Ratanalert Worapon
117.07
Rathi Sudheer
PE161
139.02
Räty Sari
Ravikumar Krishnan
5.03,5.04,100.02
Raviv Gabe
113.04
Rayawa Rawira
178.10
Razek Tarek
54.05,77.05
Razumovskiy Alexander
82.01,82.02,117.02,PE178
Reichel Andreas
PE164
Reinders Folmer Eline
18.48
Ren Fenggang
170.08,PE137
Renzhu Pang
41.02
Reukviboonsri Somboon
PE207
Rhee Peter
113.03
Richards Melanie
100.03
Rickard Jennifer
46.04
Riemen Anna Helene Katrin
18.30,117.08
Rino Yasushi
39.07,PE055,PE065,PE116
Risaliti Andrea
PE068
Risum Øyvind
54.01
Rodas Edgar
222.03
Rodas Edgar
222.03
Rodriguez Michael
PE035
Rodsakan Tanakorn
178.03
Rönkä Kirsi
134.07
Roodt Liana
77.01
Rookkachart Thammanij
170.01
Rossi Leonardo
PE186
Rowly Rafiqul
PE204
Ruangtrakool Ravit
177.04
Rubtsov Mikhail
PE196
Ruderman Lucy W.
113.01
Rudolf Erin
64.03
Rudolph Navin
231.02
Rui Lim
PE125
Ryo Song
PE010
Ryotokuji Tairo
PE177
Ryu Young Jae
PE046
SSS
Sa'at Hamizah
Sabaretnam Mayilvaganan
Sadacharan Dhalapathy
Sadieh Omar
PE066
PE043
5.03,5.04,100.02,PE056
18.28
15
Senanayaka Kithsiri
Senanayake Kithsirii
Seneviratne Thilanka
Seow Jonathan
Sessa Luca
Shafii Susan
Shah Mihir
Shah Parth
Shalabi Haadi
Shalabi Saggah
Shapiro Michael B.
Shapiro Milda
Sharipov Azamat
Sharma Atul
Sharma Dayanand
Sharma DN
She Wong Hoi
SHELAT VISHAL
Shelat Vishal G
Shelat Vishalkumar
Shen Wen
Sheppard Brett
Shetter Elinor
SHI AIHUA
Shiba Hiroaki
Shibata Masahiro
Shibutani Masatsune
Shibuya Kazuto
Shien Tadahiko
Shiino Sho
Shima Yasuo
Shimada Atsushi
Shimada Mitsuo
Shimada Takehiro
Shimada Yoshifumi
Shimada Yutaka
Shimizu Tetsuya
Shimoji Hideaki
Shinoda Masahiro
Shinyama Naoki
Shiota Tetsuya
Shirai Junya
Shirai Yoshihiro
Shiraishi Atsushi
Shiraishi Norio
Shiroshita Hidefumi
Shivanna Paramesh
Shoji Yoshiaki
Shouhed Daniel
Shuai Yang
Shubert Christopher
Shukla Nootan
Shukla Nootan
shukla pooja
Shuto Kiyohiko
Sidhu Stan
Siemssen Mette
Sierra Salazar Mauricio
Siguan Stephen
Sillesen Martin
Silva Luciana
Simizu Tetsuya
Simsa Jaromir
Simtniece Zane
Sin Ka Yan
SINAN Huseyin
Singh Kul
Singh Kul Ranjan
Singh Kulranjan
Singh Primal
Singh Suyash
Singh Usha
singhal maneesh
Siperstein Allan
Siperstein Allan
Sippel Becky
Sippel Rebecca
Sirichindakul Boonchu
Sirivong Prayuth
Sitoh Nadya
Sitoh Yih
Siu Alvin
Smeeing Diederik
Smirnov Dmitry
Snyder Samuel
Snyder Samuel
So Wing Yee
Sobajima Jun
Sobnach Sanju
Soda Hiroaki
Soeda Hiroshi
Sohlberg Ericka
Sohn Hee Ju
Solis Carolina
Solorzano Carmen
Somaratne Kosala
somasekar soumya
Songtish Dolrudee
Sonkar Abhinav
176.01
18.37
176.01
PE125
194.02
178.09
54.05
PE179
222.03
222.03
113.01
217.06
117.03,117.04
28.08
114.12
114.05
39.05,PE142
34.05,PE153
PE155
PE124
PE052
139.06,PE187
77.02
80.05
170.06,170.07,PE160
41.04
28.04
PE159
PE063
78.01,PE073
151.01
PE131
28.02,80.01,PE119,PE151
34.01
111.04,111.07
PE004,PE089,PE167
198.08
4.04,PE059,PE171
80.03,80.07
18.25
PE121
PE111
170.06,170.07,PE160
18.18
PE109
PE109
28.08
PE184
112.03
41.02
39.08
28.08,114.05
114.10,114.12
219.04,PE031
PE136
41.01,PE038
PE181
112.07
117.10
217.02
4.01
PE157
PE104
PE195
PE064
134.06
151.02,198.04,PE056
114.13,PE021
235.04,PE009
39.04
151.02
114.14
18.17
PE029,PE034
PE033
64.03
PE036
PE152
PE103
114.15
114.15
PE139
54.04
151.05
194.05
135.05
100.01
28.07,PE086,PE087,PE110
77.01
PE122
18.07
217.06
PE049
PE205
64.02
176.01
114.14
PE165
114.13,151.02,151.03,
198.04,235.04,PE009
Soop Mattias
39.04
Souza Rodrigo
198.01
Spence Richard
77.01
Sperga Maris
PE195
Spicer Jonathan
77.05
Spijkerman Roy
18.36
Sreenivas Vishnu
114.05
Srimotayamas Satit
178.02,178.03,235.02,PE163
Srivastav P
198.04
Srivastava Anurag
224.02
Stålberg Peter
41.06,135.04
Stang Michael
PE045
Stepanenko Nikita
82.01,82.02,117.02,PE178
Stevens Kent
18.44,77.02
Stevens Kent
18.42
Stojimirovic Biljana
18.47
Stolwijk Lisanne
82.03
Stopa Malgorzata
194.03
Stopa Małgorzata
219.03
Strandby Rune
PE181
Stratakis Constantine
41.05
Strumfa Ilze
PE088,PE195
stubbs james
18.21
Stubbs James
54.06
Su'a Bruce
46.01,217.08,PE100
Subramaniam Narayana
117.06
Sudo Natsuru
139.03,139.04,198.05,198.06,
PE147,PE148,PE158
Suehiro Taketoshi
PE013
PE072
Suen Dacita
Sueta Hideto
PE096
Sugano Nobuhiro
PE111
Suganuma Nobuyasu
PE055,PE065
Sugimoto Kiichi
PE097
16
Sugitani Iwao
Suh Insoo
Suito Hiroshi
Suksamanapun Nutnicha
Sumiyoshi Tatsuaki
Sundhagen Jon
Sung Tae-Yon
Suradi Hassan
Suresh RV
Suss Joachim
Sutthatarn Pattamon
Sutton Paul
Suwannarat Daryth
Suzuki Kazuhumi
Suzuki Shinsuke
Svendsen Lars
Svendsen Lars Bo
Svenningsen Peter
Swaroop Mamta
Sywak Mark
Szabo Gyorgyi
Szura Mirosław
Tan Ern Yu
114.11
114.07
Tan Gie Hooi
Tan Ming Yuan
224.01,224.06
Tan Mona
114.06,114.15
Tan Wee Boon
112.05
Tanaanantarak Pattama
114.17
Tanaka Akira
4.07,80.06,PE190
Tanaka Eiji
PE121
Tanaka Hiroaki
4.05,28.04,PE166
Tanaka Kuniya
PE136
Tandon Anupama
114.14
Taneja Ashish
PE100
Tang Andrew
113.03
114.11
Tang Serene
Tangjatuporn Warakarn
114.17
Taniai Nobuhiko
198.08,PE011,PE157
Tanizawa Yutaka
PE123
Tanompetsanga Rapheephat
39.03,178.05
Tansawet Amarit
178.02,178.03,235.02,PE163
Tantemsapya Niramol
177.03
Tanthanuch Monthira
117.07
Tarique Abdhullah
PE204
Tarpley John
PE202
Tarpley Margaret
PE202
Tatsubayashi Taichi
PE123
114.01,149.01
Tatsuda Kumiko
Taura Naohiro
PE014,PE154
Taylor Liezel
18.36
Taylor Sandra
18.12
Techapongsatorn Suphakarn
178.02,178.03,235.02,
PE163
PE094
Ten Yakov
Teo Li Tserng
18.09
Teo Soo Hwang
PE066
Teo Soo-Hwang
114.07
Teo Ying Xin
18.09
Terabe Yasuhito
PE006
Terada Takafumi
18.25
Teraoku Hiroki
PE151
Terashima Masanori
PE123
Tetali Shailaja
18.42
Teuben Michel
18.10,18.36
Thaiwatcharamas Kanokrat
PE207
Thielman Nathan
PE205
Thiels Cornelius
18.21,18.24,177.02
Thiels Cornelius
39.08
Thiels Cornelius
18.11,18.31,54.02
Thiengthiantham Rangsima
PE103
Thier Mark
219.05
Thompson Geoffrey
100.03
Thong Meow Keong
PE066
Thongkhao Komet
18.04
Thulkar Sanjay
28.08,114.12
Tillyashaykhov Mirzagaleb
117.03,117.04
tiwari sandip
117.09,117.09
Toda Kazuhisa
5.02
Tohma Takayuki
PE091
Tokairin Yutaka
PE177
Tokumaru Teppei
151.01
Tokumitsu Hiroki
PE023
Tokunaga Masanori
PE123
Tokunaga Ryuma
PE001
28.02
Tokunaga Takuya
Tokuyama Jo
PE131
Tomida Akihiro
PE107
Tomiki Yuichi
PE097
Tominaga Yoshihiro
41.03,219.01,PE028,PE030
5.02
PE052
PE180
177.03,177.04
151.01
54.01
112.08,PE057
PE032
5.03,5.04,100.02
103.01,103.02
34.04
PE085
177.01
PE091
134.01
PE183
217.02,PE181
217.02
113.01
41.01,PE038
178.08
PE200
TTT
Tada Seiichiro
4.07,80.06,PE190
PE120
Tadashi Tanabe
Taewprasert Piya
178.02,178.03,235.02,PE163
Tahan Chandler
198.01
Taher Mustafa
178.01
Taib Nur Aishah
114.18,PE066
Taieb Mustapha
PE108
Taira Naruto
PE063
Tajima Hidehiro
PE114
Tajima Yosuke
111.07
Takabe Kazuaki
114.01,149.01
Takada Satoshi
PE114
Takagi Kenji
PE107
Takahashi Kunihiko
54.03
Takahashi Makoto
PE097
Takahashi Naoki
PE169
Takahashi Ryo
PE098
Takahashi Tsunehiro
34.06,34.07,PE184
Takahashi Tsuyoshi
PE118
Takashima Tsutomu
114.02,114.04,PE025
Takasu Chie
28.02,80.01,PE119,PE151
Takata Atsusi
PE119
Takata Hideyuhi
PE011
Takata Hideyuki
198.08,PE157
Takaya Tsuyoshi
PE096
Takayama Hiroomi
170.05
Takebayashi Katsushi
PE185
Takeda Kazuhisa
134.01,217.05
Takei Hiroyuki
78.03
Taketo Makoto
PE003
Takeuchi Dai
41.04
Takeuchi Hiroya
34.06,34.07,PE184
Takeuchi Toshiaki
139.05
Takeyama Yoshifumi
PE193
Takiguchi Nobuhiro
PE122,PE169
Takii Yasumasa
111.04
Takizawa Kazuyasu
80.02,139.03,139.04,198.03,
198.05,198.06,217.04,PE133,PE146,
PE147,PE148,PE156,PE158
PE110
Takubo Kaiyo
Takuya Nagata
PE004
Tamura Nobuichiro
18.46
Tan Edward
18.10
17
Tomoda Mitsuhiro
Tomonaga Ayumi
Tomoyuki Okumura
Tonooka Toru
Toquero Lawrence
Torregrosa Vicens
Toyama Kunihiro
Toyofuku Takahiro
Toyokawa Takahiro
Trapencieris Peteris
Tripathi Navneet
Triponez Frédéric
Tsang Julian
Tsang Simon
Tseng Ling-Ming
Tsikitis Vasilliki
Tsubono Toshihiro
Tsubosa Yasuhiro
Tsuburaya Akira
Tsuchida Junko
Tsukada Kazuhiro
39.09
18.43
PE004
PE122
235.01
135.01
PE093
PE016,PE017
4.05,28.04,PE166
PE195
PE020
64.05
194.06
PE139
PE058
198.02
PE120
PE185
PE116
114.01,149.01
28.05,PE004,PE070,PE089,
PE129,PE159,PE167
Tsukada Tomoya
PE114
Tsukamoto Ryouichi
PE097
Tsunoda Shigeru
PE121
18.20,18.43,54.03,77.04
Tsunoyama Taichiro
Tsuruma Tetsuhiro
PE012
Tsuruta Masashi
34.01
Tsushima Takahiro
PE185
Tullavardhana Thawatchai
PE165
Tulsyan Sonam
149.03
Turgunov Yermek
PE002
Turtiainen Johanna
224.03,224.04
Tytgat S.
82.03
UUU
Ubl Daniel
Uchida Eiji
Uchida Eiigi
Uchida Hiroki
Uchida Kenichiro
Uchida Kotaro
Uchida Yasuyuki
Uchikado Yasuto
Uchino Hayaki
Uchiyama Shuichiro
Udara Piyal
Udelnow Andrej
Udomsawaengsup Suthep
Ueda Junji
Ueda Jyunji
Uejima Toshufumi
Uenosono Yoshikazu
Uesato Masaya
Ulmasov Firdavs
Ulukaya Sezgin
Ungkitphaiboon Withoon
Uno Masanori
Urakami Hidejiro
Ushiku Hideki
Usmanov Bekzod
Usmanov Bekzod
Uwagawa Tadashi
Uy Christian
Uzzau Alessandro
VVV
Validire Pierre
198.07
Valtola Antti
117.05
van der Werff D.
82.03
van der Zee D.C.
82.03
van Gestel YRBM
39.02,PE194
van Herwaarden M.
82.03
van Laarhoven Jacqueline
54.04
Vanags Andrejs
PE088,PE195
Vanella Serafino
231.01
Vänni Ville
224.04
Varma Ashok
PE021
Vasko Ervins
PE088
PE061
Vassanarisi Wichai
Vavrinchuk Sergey
PE112
Veeraswamy Ravi
178.09
Vejchapipat Paisarn
PE207
Velázquez Fernández David
112.07
Verasmith Pimprapa
235.02
Vercruysse Gary
113.03
Verla Vincent
18.35
Verma Ashok
135.03,147.01,PE020,PE043
Vichajarn Pondech
39.03,178.05
Vicuña Anita
222.03
Vidal Fortuny Jordi
64.05
46.05,134.05
Vijayan Appasamy
Vilanueva Maria Elena
PE140
Viriyaroj Vichit
170.01
Vironen Jaana
134.07
Vishalkumar G Shelat
PE125
Visokai Vladimir
PE104
Vorasittha Athaya
PE015
Vukojevic Vladimir
217.01
WWW
Wada Norihito
34.06,34.07,235.03,PE184
Wadhwaniya Shirin
18.42
Wagie Amy
18.13
Wagie Amy
177.05
WAHIDY AZRIN AHMAD
178.01
Wakabayashi Hideyuki
PE170
Wakai Toshifumi
4.08,80.02,111.04,111.07,114.01,
139.03,139.04,149.01,198.03,198.05,
198.06,217.04,PE133,PE146,PE147,
PE148,PE156,PE158
Wakai Tosifumi
PE172
Wall James
82.04,82.05
Walsh Danielle
PE208
Walz Martin
147.03
Wang Haohua
39.01,224.07,PE137
Wangpatravanich Alisara
18.29
Waqas A
PE077
Waqas Ahmed
PE078
Warren Bryan
18.36
Watanabe Kazuhiro
39.09
Watanabe Kiminori
170.05
Watanabe Masahiko
111.05,PE115,PE168
Watanabe Takashi
177.06
Watanabe Toru
28.05,PE004,PE089
Watanabe Yuji
PE198
Watters David
222.04
Watzka Felix
5.01
178.08
Weber Gyorgy
Weber Matthias
5.01
Weerasekara Deepaka
18.40
Weijie Marc
134.05
Wessem Karlijn
18.02,18.08
235.05
PE157,PE170
PE011
170.05
18.25
18.07
18.20,18.43,54.03,77.04
4.03
18.46
PE096
18.40
PE018,PE019
39.03,178.05
198.08,PE011,PE157
PE150
18.16
4.03,4.06,PE090,PE126,
PE127,PE128
PE180
PE132,PE197
PE022
PE165
PE107
PE131
PE115
117.01
PE174
170.07
18.05
PE068,PE071
18
White Monique
PE024
18.40
Widanapathirana Saman
Widenly Mohammed
PE141
Wieghard Nicole
198.02
Wijasika Wararak
PE152
Wijesundara Wijesundarage Nandima Thilina
18.37
Will Uwe
170.09,PE164
Wingo Matthew
112.02
Wong Fidelia
114.08
Wong Kai Pun
194.06,231.03
Wong Kwai
149.04
Wong Melissa
198.02
Wong Po Yan
PE064
100.01
Wong Simon
Wongkhan Supang
176.03
Woo Jung- Woo
231.03
Woo Yin Ling
114.07,PE066
Woon Winston
PE153
Woon Winston
PE155
Worhunsky David
82.05
Wright Robert
82.04
XXX
Xianying Meng
XU XIANGHUA
Xue Fei
Yashiro Masakazu
Yasui Hirofumi
Yi Jinwook
Yigsakmongkol Narongchai
Yip Cheng Har
Yip Linway
Yodying Hariruk
Yokoyama Keiichi
Yoneyama Katsuya
Yoo Jenny
Yoon Jong Ho
Yoon Jung Han
Yoon Sook Yee
Yoshida Akira
Yoshida Eri
Yoshida Hiroshi
Yoshida Masayuki
Yoshida Motohira
Yoshida Naoya
Yoshida Yusaku
Yoshikawa Kozo
Yoshikawa Takaki
Yoshikawa Yusuke
Yoshimoto Yasunori
Yoshioka Isaku
Yoshioka Masato
Youn Yeo-Kyu
Yu Hyeong Won
Yu Tzu-Chieh (Wendy)
Yu Wansik
Yukawa Norio
Yukioka Tetsuo
Yuksel Esra
Yura Masahiro
Yusif-zade Kenan
Yuza Kizuki
41.02
80.05,134.03,224.07
80.05,170.08
YYY
Yada Kazuhiro
170.05
yadav santosh
117.09
Yadav Vivek
PE161
Yadev Shilpi
113.02
Yagi Hiroshi
80.03,80.07
Yagi Ryoma
111.04
Yamabe Kazuo
PE113
Yamada Keiko
5.02
Yamada Shinichiro
80.01
Yamada Takaharu
PE198
Yamada Takanobu
39.07,PE116
Yamaguchi Tetsuji
28.05,PE004,PE089
Yamamoto Hiroshi
PE122,PE169
Yamamoto Naoto
39.07,PE116
Yamamoto Seiichiro
111.05
Yamamoto Takamasa
PE003
Yamamoto Takayuki
41.03,219.01,PE028,PE030
Yamamoto Yuji
PE111,PE198
Yamamura Eigi
18.26
Yamamura Eiji
18.14
Yamamura Hitoshi
18.25
yamamura kazuo
PE010,PE105
Yamamura Noriyuki
PE118
Yamanaka Ayumi
PE055,PE065
Yamasaki Yoichi
PE126
Yamashita Keishi
PE115,PE168
Yamashita Koji
78.03
Yamaue Hiroki
177.06
Yan Xiaopeng
39.01,170.08,224.07,PE137
Yanaga Katsuhiko
39.09,170.06,170.07,PE160,PE162
Yanagita Shigehiro
4.03,4.06,PE126,PE127,PE128
Yang An-Hang
PE058
YANG HUAN
134.03
ZZZ
Zaidi Ghazala
Zamorano marcelo
Zangbar Bardiya
Zargaran Eiman
Zarroug Abdalla
Zayyat Imad
Zeynalov Natig
Zhang Da
Zhang Ning
Zhang Xu-Feng
Zhao Carrie
Zheng Xinglong
Zhu Hongfa
Zielinski Martin
Zielinski Martin
Zielinski Martin
Zietlow Scott
Zietlow Scott
Zlotnik Alexander
Zogg Cheryl
Zoucas Evita
Zuber Markus
Zuiani Chiara
19
4.05,PE166
PE185
231.04
170.01
114.07,PE066
PE045
170.01
18.16
PE111
PE045
112.08,PE057
PE046
114.07,PE066
PE055
PE106
198.08,PE011,PE170
78.01
PE198
PE001
PE023
28.02,PE119
PE116
34.01
80.06,PE190
PE129,PE159
198.08,PE157
231.03,231.04,PE027
PE027
46.01
28.06
39.07,PE116
18.07
PE022
34.06
PE149,PE199
80.02
147.01
PE140
113.03
77.01,77.01
177.05
176.02
178.04
PE137
PE029
151.06
PE029
39.01
112.03
18.21,18.24,177.02
18.13
18.11,54.02,54.06
18.21,177.02
18.11,54.02
PE002
18.49
PE102
111.03
PE071
4.01
THE EFFECT OF ORAL SUCRALFATE ON THE POSTPRANDIAL PROXIMAL GASTRIC ACID POCKET
L. C. Silva1, F. Herbella1,*, M. G. Patti2
1
2
Department of Surgery, Federal University of São Paulo, São Paulo, Brazil, Department of Surgery, University of
Chicago, Chicago, United States
Introduction: An unbuffered layer of acidity that escapes neutralization by food has been demonstrated in volunteers
and gastroesophageal reflux disease patients, corresponding to the postprandial proximal gastric acid pocket
(PPGAP). It is elusive if this layer of acidity is best conceptualized as a “film” or as a “pocket”. Previous studies
showed that an alginate-antacid formulation, that forms a raft above the gastric contents, eliminates or displaces the
PPGAP. However, there are no studies on the effect of mucosal coating drugs. This study aims to analyze the effect
of oral sucralfate on PPGAP in GERD patients.
Materials & Methods: A total of 20 patients (age 53 (41 – 60), 13 females) were studied.All patients underwent upper
endoscopy to analyze the presence of hiatal hernia, esophagitis or Barrett’s esophagus. Patients underwent a highresolution manometry for localization of the lower border of the lower esophageal sphincter (LBLES). A station pullthrough pH monitoring was performed from 5cm below the LBLES to the LBLES in increments of 1cm in a fasting
state and 10min after a standardized fatty meal and also 10 min after oral administration of 2g sucralfate. Postprandial
proximal gastric acid pocket was defined by the presence of acid reading (pH<4) in a segment of the proximal
stomach between non-acid segments distally (food) and proximally (LBLES). The PPGAP extent and position were
compared before and after sucralfate. Standard 24h pH monitoring was performed for objective characterization of
GERD.
Results: After meal, PPGAP was not found in four patients and these were excluded from the analysis. After
sucralfate, PPGAP extent increased in 7 (43,7%) and diminished in 4 patients (25%). In 2 patients (12,5%) PPGAP
disappeared, in 2 (12,5%) kept the initial length and position and in one (6,26%) moved upwards. Two patients
(12,5%) had intraesphincteric PPGAP before sucralfate; in 1 (6,25%) the PPGAP moved down and in the other it
disappeared after sucralfate. In 11 individuals (68,7%) PPGAG remained below the LBLES in both measurements and
in one (6,25%) it became intrasphincteric after sucralfate.
Conclusion: Sucralfate did not show a neutralization effect on the PPGAP, supporting the theory of acid pocket, not
film.
Disclosure of Interest: None declared
20
4.02
INDICATIONS, TECHNIQUES AND PERIOPERATIVE OUTCOMES FOR PATIENTS UNDERGOING
ESOPHAGECTOMY FOR BENIGN DISEASE
S. Mittal1, H. KAPOOR1,*, S. AKIMOTO1
1
SURGERY, CREIGHTON UNIVERSITY, OMAHA, United States
Introduction: A subset of patients with benign disease may require esophageal resection. In some this may be after
previous anti-reflux surgical interventions. We describe the indications and outcomes of benign esophageal resections
done at our institution.
Materials & Methods: All patients undergoing esophagectomy were entered in a prospectively maintained database.
After Institutional Review Board approval, the database was reviewed to identify patients with benign indications
between 2003-2014. Data variables analyzed included demographics, pre-operative work-up, primary pre-operative
symptoms, intraoperative and postoperative complications and mortality. Chi square test and t-tests were used to
compare the various variables among the groups.
Results: A total of 293 patients underwent esophageal resection during the study period of which 45 (15.7%) patients
(27 females) had benign disease. Most common diagnosis were achalasia (including other dysmotility disorders) (20),
previous anti-reflux surgery (12) including mesh related issues (8) and perforations (7). Others included undilatable
stricture (3), giant GIST (2) and aorto-esophageal fistula (1). Mean age was 60.8 (+ 14.7) yrs, 10 (22.2%) cases were
emergent and 12 (26.7%) patients had a Charlson comorbidity score of >2. Dysphagia (80%) and recurrent aspiration
(20%) were the most common indications. Nearly 2/3rds of patients had previous foregut surgeries (10 with one, 15
with two and 4 with three). Most patients (36/45- 80%) required open surgery while minimally invasive surgery was
feasible in 20%. There were trans-abdominal (4), trans-hiatal (20) and trans-thoracic (21) procedures. Stomach was
the most common conduit used (75.6% vs 15.6% colon and 8.9% Jejunum). Six patients were staged with spit fistula
followed by interval re-construction. Median ICU and hospital stay was 4 and 14 days respectively. There was one
(2.2%) 30-day mortality, which occurred after discharge. 23 (51%) patients had a significant postoperative morbidity
(Clavian Dindo grade>3) including 7 (15%) anastomotic leaks. Nine patients have required re-operative intervention
after hospital discharge most commonly a distal gastrectomy for patients with colon interposition. Three patients
continued to require enteral supplementation via tube feeds more than 3 months after surgery.
Conclusion: Esophageal resection is a viable albeit morbid option for patients with benign disease. Enteral nutrition
can be restored in majority of these patients.
Disclosure of Interest: None declared
21
4.03
IS SENTINEL NODE NAVIGATION SURGERY USEFUL FOR EARLY STAGE ESOPHAGEAL CANCER?
S. Natsugoe1,*, Y. Uenosono1, T. Arigami1, D. Matsushita1, S. Yanagita1, Y. Uchikado1, H. Okumura1, S. Ishigami1
1
Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical and Dental
Sciences, Kagoshima, Japan
Introduction: If the sentinel node (SN) concept is established for esophageal cancer, it will be possible to safely
reduce the extent of lymphadenectomy. Our objective was to perform SN mapping in esophageal cancer to assess
distribution of lymph node metastases with the goal to reduce the need for extensive lymphadenectomy.
Materials & Methods: A total of 114 patients who underwent esophagectomy with sentinel node mapping were
enrolled in this study. Eighty-one patients had clinical(c) T1N0 and 33 patients had cT2N0. And another 24 cases
were enrolled to EMR/ESD with SN dissection. To detect the SN, radio-guided method was used. Technetium-99m tin
colloid was injected into submucosal layer around the primary tumor the day before resection. Lympho-scintigraphy
was usually obtained 2 hours after injection. Intraoperative SN detection was performed using gamma probe. All
dissected lymph nodes were diagnosed by conventional pathological diagnosis using HE staining. In order to detect
micrometastasis, immunohistochemistry(IHC) staining and reverse transcriptase polymerase chain resection(RT-PCR)
were also performed.
Results: Detection rate of SN was 93.8% (76/81) in cT1N0 and 100% (33/33) in cT2N0. The mean number of SN per
case was 2.9 in cT1N0 and 3.4 in cT2N0. Lymph node metastasis were found in ten (17.6%) of cT1 cases and sixteen
(48.5%) in cT2 cases by HE staining. Micrometastasis was detected five and three cases in cT1 and cT2 with IHC
staining and furthermore, micrometastasis was detected in three cases with RT-PCR in cT1. Diagnostic sensitivity and
accuracy based on SN status was 94.4% and 98.4% in cT1, and 68.4% and 81.8% in cT2. In EMR/ESD cases, SN
was detected in all cases. The mean number of SN per case was 2.3. Overt metastasis was found in one patients and
by HE, and micrometastasis was found in another one case by IHC.
Conclusion: SN concept is acceptable in cT1N0 cases. SN concept might enable to perform less invasive surgery
with reduction of lymphadenectomy.
Disclosure of Interest: None declared
22
4.04
OUTCOME OF INDUCTION TRIPLET CHEMOTHERAPY OR CHEMORADIOTHERAPY FOLLOWED BY
ESOPHAGECTOMY FOR MARGINALLY UNRESECTABLE T4 ESOPHAGEAL CANCER
T. Nishimaki1,*, H. Shimoji1, K. Hayasaka1, H. Karimata1
1
Digestive and General Surgery, University of the Ryukyus, Nishihara, Okinawa, Japan
Introduction: In a prospective cohort study evaluating the efficacy of multimodal therapy consisting of induction triplet
chemotherapy or chemoradiotherapy (CRT) and subsequent esophagectomy for marginally unresectable T4
esophageal cancer, 57 patients with the disease underwent 2 courses of 5FU/doxorubicin/nedaplatin (FAN)
chemotherapy, 3 courses of docetaxel/cisplatin/S1 (DCS) chemotherapy, or 40-66 Gy CRT as the induction therapy.
The aim of the study was to evaluate the outcome of the 3 types of multimodal therapy in these patients, and to
determine the adequate induction therapy for T4 esophageal cancer.
Materials & Methods: Of the 57 patients, 17, 29, and 11 underwent FAN chemotherapy (2002 – 2006), CRT (2006 –
2013), and DCS chemotherapy (2013 - ), respectively. The short- and long-term results were compared among these
patients. In all patients, suspicious T4 site was the trachea, bronchus, or aorta with or without other additional
structures.
Results: Major response of tumor to the induction therapy was observed in 35%, 69%, and 91% of patients who
underwent FAN chemotherapy, CRT, and DCS chemotherapy, respectively (p = 0.013). Although manageable in all
cases, the toxicity grade 3 or higher occurred in 73% of patients undergoing DCS chemotherapy, whereas that was 49
% and 59% in patients undergoing FAN chemotherapy and CRT, respectively. R0 resection rate (64%) after DCS
chemotherapy was comparable to that (69%) after CRT, whereas that was 47% in patients undergoing FAN therapy.
Mortality/morbidity rates after esophagectomy were 20%/50%, 4.5%/77%, and 0%/75% in patients undergoing FAN
chemotherapy, CRT, and DCS chemotherapy, respectively. The 5-year survival rate after R0 esophagectomy was
38% and 62% in patients who underwent FAN chemotherapy and CRT, respectively.
Conclusion: CRT seems to be superior over FAN chemotherapy as the induction therapy for marginally unresectable
T4 esophageal cancer in terms of response rate, R0 resection rate, and long-term survival. DCS chemotherapy has
strong power to reduce the tumor volume (response rate: 91%) even in cases of T4 esophageal cancer. Therefore,
DCS chemotherapy is considered to be a promising induction therapy for marginally unresectable T4 esophageal
cancer.
Disclosure of Interest: None declared
23
4.05
OUTCOMES OF GASTRECTOMY IN PATIENTS OLDER THAN 80 YEARS.
A SINGLE INSTITUTION REVIEW
K. Sakurai1,*, K. Muguruma1, T. Toyokawa1, N. Kubo1, H. Tanaka1, M. Yashiro1, M. Ohira1, K. Hirakawa1
1
Department of Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan
Introduction: In Japan, aging progresses and opportunities of medical care for elderly patients older than 80 years
are increasing with the extension of life expectancy. The aim of this study was to clarify the operative morbidity and
long-term survival of gastrectomy for elderly patients with gastric cancer.
Materials & Methods: The clinicopathologic and survival data of primary gastric cancer patients older than 80 years
(elderly group) who underwent gastrectomy at Osaka City University Hospital from January 2003 to December 2010
were retrospectively analyzed. For comparison of clinicopathologic findings and postoperative outcome, the data for
366 patients (60-69 year-old: control group) who underwent gastrectomy during the same periods were collected.
Results: The review of our database identified 95 patients older than 80 years who had underwent gastrectomy for
gastric cancer. In the preoperative clinicopathological data, The proportion of male patients were significantly less in
the elderly group than in the control group (57.9% vs 76.5%, p<0.01). More elderly group than control had multiple
comorbidities (p<0.01). Pathological staging results for the elderly group were not significantly different from them for
the control group. The proportion of D2 dissection was significantly less in the elderly group than the control group
(37.9% vs 50.3%, p=0.03). In the short term outcome analysis, the elderly group showed no significant difference in
morbidity and mortality in comparison with the control group (morbidity; 23.2% vs 23.2%, mortality; 1.1% vs 0.5%). In
the long term outcome analysis, the 5-year overall survival (OS) of stage I patients was worse than the 5-year disease
specific survival (DSS) (5-year OS/DSS; 76.2%/100%, p=0.02). The elderly stage II and III patients had significantly
poorer prognosis than the control patients (stage II elderly/control; 17.0%/76.2%, p<0.01, stage III elderly /control;
27.7%/59.0%, p<0.05). In the subset analysis of the elderly stage II and III patients, D2 dissection and adjuvant
chemotherapy showed no significant results on survival.
Conclusion: The operative complication rate of elderly patients was comparable to the control group. Follow-up with
attention to accompanying illness and other malignant disease of stage I elderly patients is needed. For stage II, III
disease patients, a novel drug which is acceptable for the elderly is needed.
Disclosure of Interest: None declared
24
4.06
CLEAN-NET WITH SENTINEL NODE DISSECTION FOR EARLY GASTRIC CANCER
Y. Uenosono1,*, T. Arigami1, S. Yanagita1, K. Okubo1, T. Kijima1, D. Matsushita1, S. Ishigami1, S. Natsugoe1
1
Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medicine, Kagoshima,
Japan
Introduction: If the Sentinel Node (SN) concept is applicable to patients with early gastric cancer, it would prove
useful to identify the rational extent of lymph node dissection during surgery. A prospective multicenter trial was
reported from Japanese Society for SN navigation surgery in 2013. The results of detection rate and accuracy of this
study are 97.5% and 99%, respectively. On the other hands, Combination of Laparoscopic and Endoscopic
Approaches to Neoplasia with Non Exposure Technique (CLEAN-NET) was reported for gastrointestinal tumor. The
purpose of this study is to confirm the safety of CLEAN-NET with SN dissection in early gastric cancer.
Materials & Methods: Sixteen patients with cT1N0 gastric cancer diagnosed by preoperative examinations were
enrolled in this study. One day prior to surgery, 99mTechnetium-tin colloid was endoscopically injected around the
tumor. SNs dissection was performed before CLEAN-NET. All SNs were assessed by intraoperative rapid diagnosis
using HE staining and RT-PCR. CLEAN-NET was started during the examination of SNs. If the SNs were found
metastasis or micrometastasis, operation method was converted to standard gastrectomy and lymph node dissection.
Results: SNs were identified in all patients and the average number of SNs was 5.2. CLEAN-NET with SN dissection
was completed in 14 patients. One patient was performed laparoscopic assisted distal gastrectomy, because
metastasis was found in SN. Another one patient was performed segmental gastrectomy, because rest stomach after
CLEAN-NET was become misshapen. In all patients with CLEAN-NET, lymph node metastasis was not found by HE
staining and RT-PCR. All patients did not have a complication after surgery. Final pathological findings demonstrated
free from the tumor in horizontal margins.
Conclusion: CLEAN-NET with SN biopsy could be safely performed as a less invasive surgery. This procedure is
very useful for early gastric cancer.
Disclosure of Interest: None declared
25
4.07
IS CURATIVE-INTENT SURGERY FOR GASTRIC CANCER FEASIBLE IN PATIENTS RECEIVING
ANTITHROMBOTIC THERAPY? – ASSESSING PERIOPERATIVE AND LONG-TERM OUTCOMES OF GASTRIC
CANCER PATIENTS WITH ANTITHROMBOTICS.
S. Tada1,*, T. Fujikawa1, A. Tanaka1
1
Surgery, Kokura Memorial Hospital, FUKUOKA, Japan
Introduction: In patients receiving antithrombotic therapy(ATT), including antiplatelet therapy(APT) and
anticoagulation therapy(ACT), for prevention of cardiovascular and/or cerebrovascular complications, feasibility and
long-term outcome of curative-intent resection of gastric cancer still remain unknown.
Materials & Methods: 323 consecutive patients with gastric cancer undergoing curative-intent operation between
2006 and 2012 in our institution were reviewed. Among this cohort, 124 patients(38.4%) regularly received ATT.
Perioperative management of patients with high thromboembolic risks included bridging heparin therapy for ACT and
continuation of aspirin monotherapy for APT. Perioperative and long-term outcomes including disease-free
survival(DFS) and overall survival(OS) in patients with ATT(ATT group) were compared with those of patients without
ATT(non-ATT group).
Results: There were no significant differences in postoperative bleeding and thromboembolic complications between
ATT and non-ATT groups (3.2% vs 1.0% and 2.4% vs 1.5%, respectively). Significant differences were observed in
five-year DFS(70%vs81%,p=0.026) and OS(67.7%vs82.4%,p=0.007), although multivariate analysis showed only
lymph node metastases (hazard ratio(HR)=12.9,p<0.001) and microvessel invasion(HR=2.51,p=0.005), but not ACT
or APT, were significant prognostic factors regarding DFS. Multivariate analysis also showed lymph node metastases
(HR=2.949,p=0.004), microvessel invasion(HR=2.21 p=0.018), high ASA score(>=3, HR=2.08,p=0.025), poor
performance status(>=3,HR=4.70,p=0.01), and residual gastric cancer(HR=4.21,p=0.012) were independent factors
for OS, but neither ACT nor APT affected OS.
Conclusion: Curative resection of gastric cancer can be carried out safely and successfully even in patients with ATT,
without any impairment of both short-term and long-term outcomes.
Disclosure of Interest: None declared
26
4.08
PROGNOSTIC SIGNIFICANCE OF PERITONEAL LAVAGE CYTOLOGY AT THREE CAVITIES IN PATIENTS
WITH GASTRIC CANCER
Y. Kano1,*, S. Kosugi1, T. Ishikawa1, Y. Sato1, T. Hanyu1, K. Hirashima1, T. Bamba1, T. Wakai1
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
Niigata, Japan
Introduction: Positive peritoneal lavage cytology (CY1) is an adverse prognostic factor in patients with gastric cancer
and those are classified as Stage IV according to the Japanese Classification of Gastric Carcinoma and Cancer
Staging Manual of the American Joint Committee on Cancer. It is recommended that peritoneal lavage cytology (CY)
be performed in Douglas’s pouch; however, the rationale for performing CY at one abdominal cavity is unclear. We
sought to determine the prognostic significance of intraoperative CY at three different cavities and to establish the
optimal treatment for CY1 patients.
Materials & Methods: A total of 1,039 patients with primary gastric adenocarcinoma who underwent CY at three
cavities (Douglas’ pouch, left subphrenic cavity, and right subhepatic cavity) were enrolled; 116 (11%) patients had at
least one positive cavity. We retrospectively analyzed the clinicopathological characteristics and survival of these 116
CY1 patients. The median follow-up period was 14 months. The survival rates were calculated using the Kaplan-Meier
method, and differences between survival curves were assessed using the log-rank test. We performed a multivariate
analysis by Cox’s proportional hazards model to identify independent prognostic factors of significance.
Results: There were 13 patients (11%) with serosa-negative tumors and 89 patients (77%) with the macroscopic
infiltrative type, including type 3 and type 4. R1 resection due to CY1 was performed in 56 patients, including 10
patients with minimal peritoneal metastasis that was completely resected simultaneously. Seventeen (15%) of the
patients had negative cytology at Douglas’ pouch but positive cytology at one or both of the other cavities. The 116
patients’ overall 2- and 5-year survival rates were 22.9% and 6.2%, with the median survival time (MST) of 11 months.
The overall 2-year survival rates for the patients with positive cytology at 1, 2, and 3 cavities were 41.9%, 35.8%, and
15%, with MSTs of 17, 18, and 9 months, respectively (P<0.01). The multivariate analysis revealed that macroscopic
type 4 tumor (P=0.02), R2 resection (P<0.01), and lymph node metastasis (P=0.03) were independent prognostic
factors. Among the CY1 patients with type 4 tumors, there was no significant difference in survival between the
patients who underwent R1 versus R2 resection.
Conclusion: CY at three cavities is a useful method to decrease the false-negative rate. Palliative gastrectomy has
no prognostic significance in the CY1 patients with type 4 tumors.
Disclosure of Interest: None declared
27
5.01
SURGICAL TREATMENT OF NEUROENDOCRINE NEOPLASM OF THE SMALL INTESTINE: A
RETROSPECTIVE ANALYSIS
F. M. Watzka1,*, A. Schad2, C. Fottner3, M. Miederer4, M. Weber3, H. Lang1, T. J. Musholt1
1
2
3
Clinic of General, Visceral- and Transplantation Surgery, Institute of Pathology, Endocrinology and Metabolic
4
Diseases, Clinic of Nuclear Medicine, University Medical Center University Mainz, Mainz, Germany
Introduction: Neuroendocrine Neoplasms of the small intestine are noticed more frequently over the past 35 years.
They constitute 25% of all NENs and 29% of all tumors of the small intestine. Surgical treatment of these tumors
improves patient’s survival and supports symptom palliation.
Materials & Methods: In a retrospective study data about 83 surgically treated patients with neuroendocrine
neoplasms of the small intestine (48 males and 35 females) with a median age of 62 years (range 25-86 years) were
analyzed.
Results: Most common clinical features were abdominal pain (69.1%), bowel obstruction (16.2%), bowel perforation
and peritonitis (3.0%), gastrointestinal bleeding (10.3%), weight loss (13.2%), and carcinoid syndrome (30.9%). 65
patients (78.3%) had lymphatic metastasis and in 57 patients (68.7%) distant metastasis were present. Segmental
bowel resection (44) was the most common surgical procedure, followed by right hemi-colectomy (32) and explorative
laparotomy (7). In most patients (74.7%) a lymphadenectomy (systematic/selective) was performed. The 5-year
survival of patients who underwent a systematic- or a selective lymphadenectomy differed significantly (82.2% vs.
40.0%). The overall 1-, 3- and 5-year survival rates were 96.1%, 88.2%, and 74.5%, respectively.
Conclusion: Mesenteric lymph-node metastases are almost invariably present and have significant impact on
patients’ prognosis. Systematic lymphadenectomy prevents complications and improves the survival.
Disclosure of Interest: None declared
28
5.02
NATURAL HISTORY OF ASYMPTOMATIC PAPILLARY THYROID MICROCARCINOMA: TIME-DEPENDENT
CHANGES IN CALCIFICATION AND BLOOD FLOW DURING ACTIVE SURVEILLANCE
O. Fukuoka1,*, I. Sugitani2, A. Ebina1, K. Toda1, K. Kawabata1, K. Yamada3
1
2
Division of Head and Neck, The Cancer Institute Hospital of JFCR, Department of Endocrine Surgery, Nippon
3
Medical School Graduate School of Medicine, Department of Ultrasonography, The Cancer Institute Hospital of
JFCR, Tokyo, Japan
Introduction: Prospective trials of nonsurgical observation have shown progression rates of only 5-10% in patients
with asymptomatic papillary microcarcinoma (PMC). Older patients are reportedly more stable than younger patients
under observation. The recent American Thyroid Association guidelines adapted active surveillance for very low-risk
PMC as an alternative to immediate surgery. This study investigated time-dependent changes in calcification and
blood supply on ultrasonography to clarify the natural course of PMC.
Materials & Methods: We have been conducting a prospective trial of nonsurgical observation for asymptomatic
PMC since 1995. We examined calcification patterns and blood supply for 480 lesions in 384 patients (53 men, 331
women; mean age, 54.0 years; mean observation period, 6.8 years; range, 1-23 years). Calcification pattern was
classified as: A) none; B) micro; C) macro; or D) rim. Blood supply was classified as: E) poor; or F) rich.
Results: Of the 480 lesions, progression of disease was seen in 32 (6.7%), including 28 with ≥3 mm enlargement and
4 with clinically apparent lymph node metastasis. Cumulative progression rate was 4.9% at 5 years and 8.5% at 10
years. No significant difference in progression rate was evident between age groups. Mean age for initial calcification
pattern was 52.1 years for A (n=135), 54.2 years for B (n=235), 56.3 years for C (n=96) and 60.1 years for D (n=14),
and progression rates were 9.6%, 6.0 %, 5.5%, and 0%, respectively. Consolidation of calcification was seen during
observation in 161 lesions (33.5%). The cumulative rate of consolidation was 54% at 7 years, but lesions that
developed rim calcification never showed progression. Blood supply was poor in 410 lesions and rich in 70 lesions at
initial presentation. Progression rates differed significantly by blood supply (poor, 22 lesions [5.4%]; rich, 10 lesions
[14.3%]). Eleven lesions changed from poor to rich blood supply during observation, 2 of which (18.2%) progressed.
Conversely, only 3 of 43 lesions (7.0%) that changed from rich to poor blood supply progressed.
Conclusion: PMCs in older patients tended to show stronger calcification patterns and PMCs with stronger
calcification patterns tended to show lower progression rates. The majority of PMCs observed for >7 years showed
consolidation of calcification. PMCs with rich blood supply showed a higher progression rate.
Disclosure of Interest: None declared
29
5.03
EBSLN AND FACTORS INFLUENCING ITS IDENTIFICATION AND ITS SAFETY IN PATIENTS UNDERGOING
TOTAL THYROIDECTOMY- A STUDY OF 456 CASES
K. Ravikumar1,*, S. Muthukumar1, D. Sadacharan1, G. Mohanapriya1, Z. Hussain1, R. Suresh1
1
Endocrine Surgery, Madras Medical College, Chennai, India
Introduction: The external branch of the superior laryngeal nerve (EBSLN) is at surgical risk during superior thyroid
pole ligation during thyroidectomy. Majority of studies have addressed the identification of these nerves and its
reported incidence. Type IIa and IIb are particularly at risk of injury during thyroidectomy. Very few studies have
addressed the relationship of these nerves with the volume of the thyroid gland.
Materials & Methods: A retrospective evaluation of 456 patients who underwent total thyroidectomy were analysed
from the prospectively maintained database in a dedicated Endocrine Surgery centre between June 2012 and Dec
2014. The EBSLN was diligently identified and preserved before individual ligation of the superior thyroid pedicle. The
nerve was graded as per the Cernea classification (type I, IIa and IIb). The volume of the individual lobes was
calculated using the standard WHO correction (length x breadth x depth x 0.479) in the thyroidectomy specimen ex
vivo. Based on the volume, goiters are sub classified as large (>50 cc) & small (≤50 cc) and toxic & non toxic based
on hyperthyroidism. The grading of EBSLN was correlated with hyperthyroidism and volume of each lobe.
Results: In 456 patients (912 nerves), EBSLN was identified in 849/912(93.09%) and not seen in 63/912(6.91%). The
EBSLN grading based on Cernea classification: type I- 156/912 (17.1%), type IIa – 522/912 (57.23%) and type IIb in
171/912 (18.75%).The mean volume of 912 lobes were 33.25 cc, 25.56cc in non toxic (n=540) and 44.4 cc in toxic
lobes (n=372). The prevalence of large goiters was 180/912(19.73%), 32/180(17.8%) in non toxic and 148/180(82.2%)
in toxic lobes.
Type IIb nerve was predominantly seen in 161/180(89.4%) of large goiters: 20/32(62.5%) nontoxic and
141/148(95.27%) toxic lobes respectively (p<0.001).The proportion of type IIb nerves were predominant in toxic
141/372(37.9%) compared to non toxic lobes 25/540(5.46%)p<0.001
EBSLN
Non Toxic lobes
Toxic lobes
Total
(n=540 nerves)
(n=372 nerves)
(n=912)
Volume
Volume
Volume
Volume
n (%)
≤ 50 cc
> 50 cc
≤ 50 cc
>50 cc
n (%)
n (%)
n (%)
n (%)
Type I
129(14.1%)
27(2.96%)
156(17.1%)
Type IIa 328(35.9%) 7(0.76%) 183(20.06%)
4(0.43%)
522(57.23%)
Type IIb
5(0.54%)
20(2.19%)
5(0.54%)
141(15.46%) 171(18.75%)
Not seen
46(5.04%)
5(0.54%)
9(0.98%)
3(0.32%)
63(6.91%)
Conclusion: Large goiters are not uncommon in toxic cases. The EBSLN is at highest risk of injury in this subgroup of
patients and surgical expertise is essential to identify this entity of EBSLN to perform a safe thyroidectomy
References: 1. Cernea CR, Ferraz,AR, Furlani J et al. Identification of the external branch of the superior laryngeal
nerve during thyroidectomy, Am journal of surgery, December 1992 Volume 164, Issue 6, Pages 634–639
2. Cernea CR , Nishio S, Hojaij FC et al. Identification of the external branch of the superior laryngeal nerve (EBSLN)
in large goiters.Am J Otolaryngol. 1995 SepOct ;16(5) :30711.
3.Lu WT , Sun SQ, Huang J, Zhong Y et al.An applied anatomical study on the external laryngeal nerve loop and the
superior thyroid artery in the neck surgical region Anat Sci Int . 2014 Jul 2.[Epub ahead of print ]
4. Furl an JC et a.l, Surgical Anatomy of the Extra laryngeal Aspect of the Superior Laryngeal Nerve, Arch Otol
aryngol Head Neck Surg. 2003;129 (1):7982.
5. Hwang SB , Lee HY, Kim WY et al.The anatomy of the external branch of the superior laryngeal nerve in Koreans.
Asian J Surg. 2013 Jan;36(1) :139.
Disclosure of Interest: None declared
30
5.04
A PROSPECTIVE STUDY ON CARDIOVASCULAR DYSFUNCTION IN PATIENTS WITH HYPERTHYROIDISM
AND ITS REVERSAL AFTER SURGICAL CURE
S. Muthukumar1,*, K. Ravikumar1, D. Sadacharan1, G. Mohanapriya1, Z. Hussain1, R. Suresh1
1
Endocrine Surgery, Madras Medical College, Chennai, India
Introduction: Cardiovascular dysfunction (CVD) is a major cause of mortality and morbidity in hyperthyroidism.CVD
and its reversibility after total thyroidectomy (TT) has not been adequately addressed. This prospective case control
study evaluates the effect of hyperthyroidism on myocardium & its reversibility after TT.
Materials & Methods: Surgical candidates of new onset hyperthyroidism, Group A (n=41, age< 60 years) were
evaluated with 2D Echocardiography, serum N terminal Pro Brain Natriuretic Peptide (NT pro BNP) at the time of
diagnosis (Point A), after achieving euthyroidism (Point B) with antithyroid drugs and 3 months after TT (Point C).20
patients with non toxic benign thyroid nodules undergoing TT served as controls (GroupB).
Results:
Both groups were age and sex matched. Group A(n=41) comprised Graves disease(n=22) & Toxic Multinodular
goiter(n=19).At point A, CVD was evident in 26/41(63.4%), Pulmonary hypertension(PHT) in 24/41(58.5%) –mild in
17/41(41.4%) & moderate in 7/41(17%),dilated cardiomyoapthy(DCM) in 8/41(19.5%), heart failure in 4/41(9.7%), NT
pro BNP elevated in 28/41(68.3%). At point B, recovery was observed in PHT 19/26 (73.1%), DCM 4/8 (50%), heart
failure 4/4(100%), NT proBNP in 3/28(10.7%). At Point C, further improvement occurred in PHT 23/24 (95.8%), DCM
7/8 (87.5%), heart failure 4/4(100%), NT pro BNP in 24/28(85.7%).
Variables
Point A
Point B
Point C
p
value
LV End diastolic dimension(mm)
46.56±6.25
43.46±5.45
41.17±4.33
<.01
LV End systolic dimension (mm)
31.73±5.59
29.04±5.35
2.56±3.97
.004
LV End diastolic volume (ml)
95.26±25.9
80.99±20.76
72.24±13.54
<.01
LV End systolic volume (ml)
4.48±16.79
38.90±14.90
34.48±9.42
.009
LV ejection fraction
59.34±6.48
59.76±5
62.95±4.16
<.01
Early/late mitral inflow filling velocity
1.06±.33
1.23±.29
1.42±.21
.015
Pulmonary hypertension(mm/Hg)
35.34±8.11
27.68±5.19
24.98±3.45
<.01
NT pro BNP (pg/ml)
420.14±337.99
198.67±167.1
106.54±37.45
.001
mean± S.D, LV-left ventricle
Conclusion: Pulmonary hypertension, the most common cardiac event in Hyperthyroidism is completely reversible at
3 months after TT. Various parameters of cardiovascular dysfunction improved consistently after surgical cure. NT pro
BNP levels correlated well with the severity and duration of cardiovascular dysfunction and hence can be an objective
tool in monitoring of hyperthyroid cardiac dysfunction
References: 1.Suk JH , Cho KI, Lee SH et al.Prevalence of echocardiographic criteria for the diagnosis of pulmonary
hypertension in patients with Graves' disease:before and after antithyroid treatment.J Endocrinol Invest. 2011
Sep;34(8):e229-34
2.Abassi Z Karram T, Ellaham S et al.Implications of the natriuretic peptide system in the pathogenesis of heart
failure: diagnostic and therapeutic importance. Pharmacol Ther. 2004 Jun;102(3):223-41.
3.Robin P Choudhury John MacDermot.Heart failure in thyrotoxicosis, an approach to management.Br J Clin
Pharmacol. Nov 1998; 46(5): 421–424.
4.Thomas MR, McGregor AM, Jewitt DE, Left ventricle filling abnormalities prior to and following treatment
of thyrotoxicosis--is diastolic dysfunction implicated in thyrotoxic cardiomyopathy. Eur Heart J. 1993 May;14(5):662-8.
1
5.Vlase H , Lungu G, Vlase L. cardiac disturbances in thyrotoxicosis: diagnosis, incidence, clinical features and
management Endocrinologie. 1991;29(3-4):155-60
Disclosure of Interest: None declared
31
18.01
OPTIMIZATION OF SONOGRAPHIC MEASUREMENT OF IVC DIAMETER IN SHOCK
F. Abu-Zidan1,*
1
Surgery, College of Medicine, UAE University, Al-Ain, United Arab Emirates
Introduction: Point-of-care ultrasound has been increasingly used in evaluating shocked patients including the
measurement of inferior vena cava diameter (IVC). There have been conflicting opinions regarding the value of
measuring IVC diameter in shocked patients. This presentation aims to highlight some of the technical and clinical
difficulties encountered in measuring IVC and methods to optimize its value.
Materials & Methods: Accumulated personal experience in measuring IVC diameter in critically-ill and trauma
shocked patients as an acute care surgeon over the last 8 years and using it in making critical decisions.
Results: Operators should standardize their technique in scanning IVC. Relative changes are more important than
absolute numbers. Gross collapsibility is a more useful marker for hypovolemia than IVC collapsibility index. We
advise using the longitudinal view (B mode) to evaluate the gross collapsibility, and the short axis B mode and M
mode to measure the diameter of IVC. Combining the collapsibility and diameter will increase the value of IVC
measurement. This approach has been very useful in our hands. Pitfalls in measuring IVC include increased intrathoracic pressure by mechanical ventilation or increased right atrial pressure by pulmonary embolism or pulmonary
hypertension. The IVC diameter is not useful in cases of increased intra-abdominal pressure (ACS) or direct pressure
on the IVC like late pregnancy and acute gastric dilatation. The IVC diameter should be combined with focused
echocardiography and correlated with the clinical picture as a whole to be useful.
Conclusion: Bedside measurement of IVC is useful in evaluating and resucitaiting shocked patients. To achieve that,
the operator should be well-trained, use standarized techniques, understand ultrasound limitations, and finally
correlate the findings with the clincial picture as a whole.
Disclosure of Interest: None declared
32
18.02
PATIENTS WITH AN INCREASED LEUKOCYTE COUNT AT 24 AND 48 HOURS AFTER TRAUMA ARE MORE
LIKELY TO DEVELOP INFLAMMATORY COMPLICATIONS
L. Hesselink1, M. Heeres1, K. V. Wessem1, L. Leenen1, F. Hietbrink1,*
1
Surgery, University Medical Center Utrecht, Utrecht, Netherlands
Introduction: Organ failure (ARDS and/or MODS) is a relative frequent complication after severe trauma
and modulated by neutrophils (PMNs). A femur fracture and its treatment predisposes for the development
of these inflammatory complications. It is shown that leukocytes on presentation were related to 30-day
mortality. The aim of the present study is to investigate the relation between absolute numbers of
neutrophils (PMNs) and the incidence of inflammatory complications in multitrauma patients with as a
common factor a femoral fracture. Secondly, the morphological characteristics of the PMNs are
investigated.
Materials & Methods: A retrospective analysis is performed on multitrauma patients (ISS>16) who suffered a
femoral fracture. Demographics were recorded and the occurrence of ARDS and MODS were determined
on daily basis until the 28th day. ARDS was noted according to the Berlin definition, MODS was defined as
a Denver score >3. Leukocyte data was recorded at ED presentation and 6, 12, 24 and 48 hours after
admission
Results: In total, 85 patients were analyzed. Of these, 12 patients developed inflammatory complications, of
which 8 developed within the first 3 days. Leukocytes were elevated in all patients on admission and
decreased to normal levels at 12 hours. At 24 and 48 hours, patients who developed complications had
significantly higher leukocyte counts compared to patients without complications (P=0.01 and P=0.02
respectively).
Conclusion: In this population of multitrauma patients who have as a common factor a femur fracture, there
is a relation between increased leukocyte count at 24 and 48 hours after admission and the development of
inflammatory complications. Further analysis of leukocyte characteristics might provide insight in the
pathophysiology.
Disclosure of Interest: None declared
33
18.03
VALIDATION OF THORAX TRAUMA SEVERITY SCORE USING EARLY EMERGENCY DEPARTMENT
COMPUTED TOMOGRAPHY (MDCT 64 SLICE/MULTIROW DETECTOR
A. Rai1,*, S. kumar2, A. parihar3
1
2
3
surgery, suregery, radiology, king georges medical university, lucknow, India
Introduction:
Rapid and accurate assessment of the thoracic trauma is important to direct life saving and definitive management. In
traumatic lung injury patients till date thorax trauma Severity Score (TTSS) was calculated by using conventational Xray chest.MDCT 64 slice (Multirow Detector -CT) Scan has significantly shorter scanning time and higher injury
detection rate than conventional X-ray and Single slice CT Scan thorax. We observed role of early emergency
department CT scan Thorax in traumatic lung injury patients
Materials & Methods: Material & METHODS-: In this retrospective study, 80 patients of isolated chest injuries(blunt
and penetrating chest injury) having AISthorax >1 admitted to KING GEORGE'S MEDICAL UNIVERSITY TRAUMA
CENTRE Lucknow, between Jun-july 2012-13 who were scanned early in emergency department with MDCT 64 slice
and helical single slice CT scan using the standardized multiple trauma protocol(ATLS guidelines),were eligible for the
study .All records were noted from case sheet from time of admission and subsequently followed regarding suitable
management like surgical intervention or mechanical ventilation or thorax related complications or follow up
complications.
Results: Of the 80 patients included in the study, 52 (65%) developed thorax-related Complications. The overall inhospital mortality rate was 10%. The receiver operatingcharacteristic(ROC) curve for predicting mortality
demonstrated an adequate discrimination by a statistically significant higher Area under curve (AUC) in patientswho
died of thorax-related complications than in patients who survived (P =0.002,confidence interval [CI] 95% for
TTSSMDCT). In patients who developed ARDS theTTSS was significant higher (P = 0.0001, CI 95%).Area under
curve (AUC) of TTSS ROC curve was highest for MDCT (0.81)then forSingle slice CT (0.79 ) and least for x-ray(0.78
), indicating highest sensitivity,specificity and predictive ability of MDCT, then SSCT and conventional x-ray
forpredicting mortality in emergency department.
Conclusion: CONCLUSION-: The study validate the thorax trauma severity score with new emerging concept of
early emergency MDCT in secondary survey for predicting 'at risk'/mortality in critically ill thoracic injured patients.
TTSS on the basis of MDCT findings appears capable of predicting ARDS more precisely then TTSSx-ray .Thus the
significance of early emergency MDCT in diagnostics and treatment decisions in traumatic lung injured patients.
References:
1 Salim A, Sangthong B, Martin M, Brown C, Plurad D & Demetriades D (2006) Whole
body imaging in blunt multisystem trauma patients without obvious signs of injury: results
of a prospective study. Arch Surg 141(5): 468–473.
2 Nguyen D, Platon A, Shanmuganathan K, Mirvis SE, Becker CD & Poletti PA (2009)
Evaluation of a single-pass continuous whole-body 16-MDCT protocol for patients with
polytrauma. AJR Am J Roentgenol 192(1): 3–10.
3 Pape HC, Remmers D, Rice J, Ebisch M, Krettek C, Tscherne H. Appraisal of early
evaluation of blunt chest trauma: development of a standardized scoring system for initial
clinical decision making. J Trauma. 2000;49(3):496–504.
Disclosure of Interest: None declared
34
18.04
ADHERENCE TO GUIDELINE OF VENOUS THROMBOEMBOLISM PROPHYLAXIS IN TRAUMA IN THAILAND
O. Akaraborworn1,*, P. Chainiramol1, K. Kaewsaengrueang1, B. Sangthong1, K. Thongkhao1
1
Division of Trauma and Surgical Critical Care, Department of Surgery, Faculty of Medicine, Prince of Songkla
University, Songkhla, Thailand
Introduction: Venous thromboembolism events are common in trauma. Nowadays, the prevention of deep vein
thrombosis (DVT) in major trauma is a standard protocol of care. The recommended modality to prevent DVT in
trauma patients is pharmacological prophylaxis in patients without contraindications. However, the guideline is
reported to be underutilized in several countries including Thailand. This research aimed to study the adherence to the
DVT prophylaxis guideline in major trauma patients.
Materials & Methods: Retrospective data collection was done in all trauma patients who were admitted in
Songklanagarind Hospital for a period longer than 7 days. The prophylaxis guideline was adapted from the 9th ACCP
evidnce-based clinical practice guideline. According to the guideline, patients were catagorized into 3 groups. The
very high risk group required both pharmacological and mechanical prophylaxis and the high risk group required only
pharmacological prophylaxis. Patients who had any contraindications to pharmacological prophylaxis were requred to
have mechanical prophylaxis. Patient information was gathered from the trauma registry and medical records.
Results: Between January 2013 and December 2013, 355 patients met the criteria. One hundred and sixteen patients
were in the very high risk group and only 6 patients (5.2%) received both modalities of prophylaxis. In 104 patients
who were in the high risk group, the guideline was followined in only 19 patients (18.3%) who received
pharmacological prophylaxis. For 133 patients who had a high risk of bleeding, 77 patients (59.7%) received
pharmacological prophylaxis according to the guideline. Overall, the median time at which pharmacological
prophylaxis was initiated was 5 days after admission and mechanical prophylaxis was initiated at the first day of
admission.
Conclusion: Adherence to the guideline in Thailand increased from the previous reports. There was a reluctance to
use pharmacological prophalaxis for patients in the very high risk group.
Disclosure of Interest: None declared
35
18.05
INTRA-OPERATIVE ABDOMINAL VOLUME INDEX AS A PROGNOSTIC FACTOR FOR DETERMINING INTRAABDOMINAL HYPERTENSION
J. U. Macalino1,*, C. Uy1
1
Department of Surgery, Tondo Medical Center, Manila, Philippines
Introduction: Abdominal compartment syndrome (ACS) is a potentially lethal condition caused by events that
produce intra-abdominal hypertensin (IAH). it is salvageable if intervention is made early and during the rversible
phase. a method by which the likelihood of post-operative IAH and consequently, ACS, may be foretold during the
intra-operative phase is most helpful.
Materials & Methods: The study aims to establish a correlation between the Abdominal Volume Index (AVI) and
post-operative IAH and possible ACS. The term AVI is the ratio between the computed abdominal volume assuming
that the whole abdomen is an elliptical cylinder and the actual volume of water in the abdominal cavity measured
before closure. This formula is used. Volume of Elliptical Cylinder is 3.1416 ABH where; A is the measurement
from the umbilicus to the farthest area of the lateral wall B is the Antero-posterior diameter divided by 2 H is the
height measured from the subxyphoid to the pubis? Ptients admitted under the Department of Surgery of the Tondo
Medical Center ifrom January to September of 2012 with abdominal trauma were included in the study. The AVI ratio
were computed and correlated with the IA Pressure taken immediately post-operatively and eveery three hours until
the 24th hour. Actual values of the abdomnal pressure in mmUriine were treated as mmH2O and converted to mmHg
using the formula 1mmHg is 1.36 mmH2O.
Results: The average AVI ratio in the study is 6.06 with a range of 3.3 to 7.9. two distict groups are described:those
with AVI below 5 had an intra-abdominal pressure of normal (less than 12mmHg. Those with AVI of more than 5
correlated with IAH grade 1 to 2. The highest IAP during the 24 hour monitoring was noted to have started at the 6th
hour. AVI ratio and IAP were noted to be directly related and with high degree of correlation.
Conclusion: We report 10 patients who underwent exploratory laparotomy for trauma. The AVI correlated very well
And directly with intra-abdominal pressure measured via the bladder. The increase of prssures started usually during
the sixth hour post-operatively. Though small sample size is a limitation, we conclude that in this study, that AVI is a
very good prognosticator for patients who would possibly develop IAH in the post-opertive period. This method
therefore, has the potential of preventing the development of ACS during the intra-operative period.SPECIAL;
Disclosure of Interest: None declared
36
18.06
PROGNOSIS COMPARISON OF THE EXTENSIVE-BURN PATIENTS WHO ARE EVALUATED FROM THE RATIO
OF URINE VOLUME TO THE AMOUNT OF INFUSION
M. Hamaguchi1,*, Y. Murao1, T. Matsushima1, H. Nishiwaki1, I. Sakata2
1
2
Critical Care Medical Center, Kindai University Faculty of Medicine, Osakasayama, Bellland General Hospital, Sakai,
Japan
Introduction: Fluid infusion within 24 hours of burn injury is generally defined as initial fluid infusion. The initial
infusion volume for 24 hours after burn injury is determined using the Baxter formula, and once the fluid administration
is started, the infusion volume is adjusted using a target urine output of 0.5-1ml/kg/hr as an indicator.
Materials & Methods: 11 extensive-burn patients, those were managed only with infusion, were enrolled in this study.
They were examined by proportion of urine volume to the amount of infusion, the value of albumin for 24 hours after
burn injury and the Acute Physiology and Chronic Health Evaluation II score (APACHE II score) to hospitalization and
24 hours after burn injury.
Results: In patients in whom significantly larger infusion volumes than predicted are needed to maintain the
circulating blood volume during the course. When the percent urine output relative to the infusion volume is less than
10% at any point in time, or the percent urine output relative to the 24-hour infusion volume is less than 4.5%,
adjustment of the initial infusion volume and administration of colloidal preparations after checking the albumin level
and edema status should be considered. The APACHE II score at the time of hospitalization of death case and
survival case series were 14.0 and 15.4 respectively, with no significant difference. The APACHE II score at 24 hours
after burn injury was 25.8 in death cases, on the contrary those of survival case and was 16.4, with significant
difference (P=0.0146).
Conclusion: Reevaluation of the injury severity is desirable after completion of the initial infusion. APACHE II
score, which include the score for the item of general health status, and the percent urine output relative to the
infusion volume, are useful indicators in the reevaluation of the injury severity. Significantly increased APACHE II
score after completion of the initial infusion and percent urine output less than 4.5% relative to the 24-hour
infusion volume can be considered as poor prognostic factors.
Disclosure of Interest: None declared
37
18.07
PREVENTIVE EFFECTS OF RAMELTEON ON DELIRIUM IN MIXED ICU
J. Oda1,*, A. Sato1, S. Mishima1, K. Kawai1, K. Uchida1, H. Soeda2, T. Yukioka1, K. Azuma1
1
2
Emergency and Critical Care Medicine, Pharmacy, Tokyo Medical University, Tokyo, Japan
1)
Introduction: Delirium was an independent predictor of higher 6-month mortality and longer hospital stay . Then,
light sedation favorably affects subsequent patient mental health compared with deep sedation after critical illness2).
Ramelteon, an agonist of melatonin is effective for the treatment of insomnia although it is not sleeping drug or sleepinducing drug. We examined preventive effects of Ramelteon on delirium in intensive care unit.
Materials & Methods: 175 patients admitted to our intensive care unit were randomly assigned to Ramelteon (R)
group, or control (C) group. Patients in R group received Ramelteon (8mg/day) orally or enterally every night.
Patients in C group received conventional treatment for insomnia using zolpidem, or zopiclone. Sedation level was
evaluated by Richmond Agitation-Sedation Scale (RASS), and delirium was surveyed using CAM-ICU. In both group,
if patient developed insomnia or delirium, medication was performed.
Results: Delirium was observed in 18/85(21.2%) patients in R group and 26/90(28.9%) patients in C group
(p=0.296). Risk of delirium correlated with duration of ICU stay. The total number of days evaluated as delirium were
35/1122 days in R group and 80/1196 days in C group (p=0.009). Trauma patients was the most diagnosed as
delirium more than 2 days, followed by cerebral vascular disease, and gastrointestinal disease. The patients in R
group needed less additional sleeping drug and sedation drug. RASS was -4 or -5 in 40 times(R group) and 274
times(C group).
Image:
Conclusion: Administration of Ramelteon decreased the total days of delirium, and oversadation.
References: 1) Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated
patients in the intensive care unit. JAMA. 14;291(14):1753-62, 2004.
2) Treggiari MM, Romand JA, Yanez ND, et al. Randomized trial of light versus deep sedation on mental health after
critical illness. Crit Care Med. 37(9):2527-34, 2009.
Disclosure of Interest: None declared
38
18.08
THE IMPACT OF INTRAMEDULLARY NAILING OF TIBIA FRACTURES ON THE INNATE IMMUNE SYSTEM
F. Hietbrink1,*, L. Koenderman2, K. V. Wessem1, L. Leenen1
1
2
Surgery, Immunology and Inflammation, University Medical Center Utrecht, Utrecht, Netherlands
Introduction: The inflammatory response induced by trauma is aggravated by intramedullary nailing (IMN)
of a femur fracture, which predisposes for ARDS. This response is visualized by IL-6, but not by neutrophil
phenotype. These cells are already triggered by the injury of a femur fracture. A tibia fracture is mostly
caused by a more moderate injury and might allow a window for assessment of the inflammatory reaction
of the innate immune system caused by IMN.
Materials & Methods: A consecutive series of patients with a tibia fracture were included. The innate
immune reaction was measured before and after IMN by plasma IL-6, neutrophil Mac1, active FcRII
(FcRII*) and fMLF induced FcRII* expression and the percentage HLA-DR positive monocytes.
Results: Twenty-five patients were included. Six were multitrauma patients (ISS=20). In patients with an
isolated tibia fracture PMN fMLF induced FcRII* and the percentage HLA-DR positive monocytes were
slightly decreased. In multitrauma patients this was more pronounced. IMN was associated with a near
disappearance of HLA-DR positive monocytes. No changes in PMN phenotype were observed.
Conclusion: Injury severity determines the PMN phenotype visualized by the parameters measured. IMN of
a tibia fracture only influenced the percentage of HLA-DR positive monocytes in circulation, not PMN
phenotype.
Disclosure of Interest: None declared
39
18.09
PREVALENCE OF ACUTE TRAUMA COAGULOPATHY AND ITS IMPACT ON OUTCOMES OF TRAUMA
PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT.
Y. X. Teo1, F. H. Z. Chua2,*, S. S. Balasubramaniam2, J. Y. X. Cheng2, L. T. Teo2
1
2
Emergency Department, Alexandra Hospital, Jurong Health Services, Trauma Service General Surgery, Tan Tock
Seng Hospital, Singapore, Singapore
Introduction: We aim to determine the prevalence of acute trauma coagulopathy in severely injured trauma patients
presenting to the Emergency Department (ED) in our local urban hospital, and its association with mortality.
Materials & Methods: This is a retrospective observational cohort study of all patients presenting to the Emergency
Department (ED) of Tan Tock Seng Hospital in Singapore, with an Injury Severity Score (ISS) of greater than 15, over
a period of 1 year. Besides epidemiological data, International Normalized Ratio (INR) and activated prothrombin time
(aPTT) were collected. Acute Traumatic Coagulopathy (ATC) was defined as INR greater than 1.2 or aPTT value at
1.5 times greater than the normal upper limit according to local institution defined values. The association between
ATC and mortality was evaluated.
Results: There were 309 patients in the cohort. The prevalence of ATC was 18.8% and the median time for the first
blood investigation from the time of injury was 84 minutes. The on scene Revised Trauma Scoring (RTS) for the ATC
group of patients were significantly worse compared to the non-ATC group. The overall mortality rate for our cohort of
patients was 16.5%. Mortality rate in the ATC group was 46.6% and 9.6% in the non-ATC group. A higher proportion
(82.8%) of patients in the ATC group had abnormal base excess compared to the non-ATC group (79.2%), however
this was not statistically significant.
Conclusion: Our study demonstrates a similar prevalence of ATC in severely injured patients as established by
international studies, reflecting that ATC occurs early in the injury phase of resuscitation in the ED. We also found a
similar 5 fold increase in mortality rate of patients with ATC. The recognition of an early traumatic coagulopathy in the
injured patient at the ED raises importance of rapid emergency room hemostatic testing and corresponding expedient
goal directed resuscitation to improve patient outcomes.
References: 1. Frith D, Brohi K. The acute coagulopathy of trauma shock: Clinical relevance. The Surgeon 2010; 8;
159-163.
2. Frith D, Goslings JC, Gaarder C et al. Definition and drivers of acute traumatic coagulopathy: clinical and
experimental investigations. Journal of thrombosis and haemostasis 2010; 8; 1919-25.
Disclosure of Interest: None declared
40
18.10
THE ACTIVATION STATUS OF BLOOD AND BONE MARROW NEUTROPHILS IN A MODEL OF TRAUMA
SURGERY IN PIGS
M. Teuben1,*, M. Heeres1, R. Pfeifer2, T. Blokhuis1, E. Tan3, H. C. Pape2, L. Koenderman1, L. Leenen1
1
2
University Medical Center Utrecht, Utrecht, Netherlands, University Medical Center Aachen, Aachen, Germany,
3
University Medical Center Nijmegen, Nijmgen, Netherlands
Introduction: Activation and migration of polymorphonuclear neutrophils (PMNs) are key mechanisms in the
development of severe complications such as ARDS and MODS. The bone marrow (BM) plays an important role in
these processes by the mobilization of young neutrophils in response to surgical stress. The aim of this study was to
investigate the early neutrophil response to trauma surgery in both the bone marrow and peripheral blood of pigs.
Materials & Methods: Large male pigs (50-60kg) were subjected to extensive surgery for the duration of 3 hours. We
collected blood and bone marrow at baseline (BM from the left tibia) and after 3 hours of surgery (BM from the right
tibia). The receptor expression of CD11b (Mac-1), CD16 (FcyRIII), CD32 (FcyRII), CD62L (L-selectin), CD49D (VLA4) and CD184 (CXCR4) was measured by flowcytometry. We compared the activation status as well as the presence
of neutrophil subsets between baseline and after surgery.
Results: All animals survived three hours of trauma surgery. Absolute leucocyte count dropped significantly over time
and flowcytometry revealed a significant increase of CD11b expression and a decrease of CD62L expression of the
neutrophil population in blood. Furthermore the percentage of neutrophil subsets (identified by CD16/CD62L
expression profiles) increased significantly during the three hours of surgery. Moreover, a profound bone marrow
response was observed.
Conclusion: In line with the human situation, extensive trauma surgery in pigs results in transient activation of blood
neutrophils. Furthermore we identified different neutrophil subsets in peripheral blood of pigs in response to acute
inflammation. These porcine PMN subsets have similar morphological charactieristics, activation profiles and kinetics
of mobilization in peripheral blood as their human counterparts. Besides the neutrophil changes in peripheral blood,
also significant changes in bone marrow PMN subsets were encountered. This makes the porcine model of trauma
surgery very suitable for proof-of-principle interventions with novel therapeutic strategies for trauma.
Disclosure of Interest: None declared
41
18.11
PRE-HOSPITAL BLOOD TRANSFUSIONS: A 12-YEAR SINGLE INSTITUTION EXPERIENCE
C. A. Thiels1,*, Y. M. Baghdadi1, A. S. Fahy1, M. E. Parker1, M. A. Khasawneh1, E. B. Habermann2, S. P. Zietlow1, M.
1
D. Zielinski
1
2
Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester,
United States
Introduction: The practice of pre-hospital (pre-hosp) damage control resuscitation is becoming increasingly accepted.
However there is minimal literature on the outcomes and utilization of pre- hosp blood beyond the trauma population.
We aim to report our experience with of pre- hosp blood transfusions, hypothesizing that it is 1) safe, 2) being
appropriately utilized, 3) and that our protocol, which was designed for trauma patients, may need to be adapted to fit
the needs of non-trauma patients.
Materials & Methods: All patients who were transfused with blood products, packed Red Blood Cells (pRBC) or
plasma, in the pre-hosp environment between 2002 and 2014 were included. At our institution, plasma transfusion
was incorporated into our resuscitation protocol in 2009. Details on patient characteristics, transfusions rates, and
laboratory and procedural data were collected and analyzed using descriptive statistics.
Results: A total of 857 patients were transfused with pRBCs (648 patients), plasma (455 patients), or both (n=246)
during ground (115 patients) or air (723 patients) transport. Patients received an average of 1.6 units of pRBC (range
1 to 8) and 1.7 units of plasma (range 1 to 3) in the pre-hosp setting. Median patient age was 61 and 484 patients
were male. There were 266 (31%) trauma patients, with an average ISS of 23, and 591 (69%) non-trauma patients,
with the majority having a digestive (n= 228, 39%) or circulatory (n=139, 24%) diagnosis (Table 1). The most common
operation in the non-trauma patients was cardiovascular (53%), digestive (20%), or genitourinary/obstetric (6%).
Additional in-hospital blood transfusions were performed in 80% of patients, operations in 43% of patients, and
endoscopic procedures in 31% of patients. Only 5% (n=41) of patients did not require any of these interventions and
were alive at discharge. Thirty day mortality rate was 21% overall and only one patient (<0.01%) had a confirmed
allergic transfusion reaction.
Image:
Conclusion: Transfusion reactions were rare and the majority of the patients who received pre-hosp blood
transfusions required further interventions. However the majority of patients who receive pre-hosp blood transfusions
were non-trauma patients whose age, admission Hg and INR, and hospital course varied significantly compared to
trauma patients. Our data suggests that while our pre-hosp damage control resuscitation protocol is safe and being
utilized appropriately, the creation of non-trauma transfusion protocols should be considered.
Disclosure of Interest: None declared
42
18.12
TRAUMATIC BRAIN INJURY (TBI) AND BURNS: A DANGEROUS COMBINATION
T. L. Palmieri1,*, S. Taylor1, S. Sen1, D. G. Greenhalgh1
1
Burn Surgery, University of California Davis and Shriners Hospital for Children, Sacramento, United States
Introduction: Traumatic brain injury and burn injury are both devastating injuries; together, they pose unique
treatment challenges, yet data on outcomes for combined TBI/burn injuries are scarce. The purpose of this study is to
analyze outcome differences between TBI, burn, and combined TBI/burn injuries and identify targets for improving
outcomes.
Materials & Methods: A national trauma data base was obtained for the period 2002 through 2009. From these
records, we identified records for patients ≥18 years of age with a burn-related injury. These patients were further
identified as burns only (BU), trauma and burns without TBI (TR/BU), and trauma and burns with TBI (TBI/TR/BU). We
analyzed mortality via logistic regression. A generalized estimating equation approach was used to account for
possible correlation of outcomes among patients treated at the same facility. Mortality was modeled as a function of
burn size, age, inhalation injury, and trauma injury type. A series of models were evaluated and the best model
selected based on QICu values and parameter significances (p < 0.05).
Results: We identified 5,711 records for patients ≥18 years of age with a burn-related injury. Of these, 3,042 had BU,
1,958 had TR/BU, and 711 had TBI/TR/BU. The three groups were comparable in age (43.61 ± 17.26 years BU, 42.34
± 17.34 years TR/BU, 40.17 ± 16.68 years TBI/TR/BU), gender (74.3% male BU, 74.9% male TR/BU, 74.8% male
TBI/TR/BU), and burn size (0-20% TBSA in 83.7% BU, 81.6% TR/BU, 83.5% TBI/TR/BU; >20% in 16.3% BU, 18.4%
TR/BU, 16.5% TBI/TR/BU); inhalation injury occurred 14.9% of BU, 24.6% of TR/BU, and 23.1% of TBI/TR/BU
patients. Mortality was highest in TBI/TR/BU (17.3%), followed by the TR/BU (11.8%) and BU (6.2%). On modeling,
TBI/TR/BU patients with inhalation injury had the highest mortality probability compared to TR/BU or BU patients with
or without inhalation injury for all age groups. TBI/TR/BU patients aged 25-45 years with inhalation injury had
approximately double the mortality probability for burns <40% TBSA.
Conclusion: TBI, when combined with burn, trauma, and inhalation injury, has a higher mortality than any other
combination of trauma and burn injury. Competing priorities of care combined with hypoxia and resuscitation
requirements may contribute to this increased mortality. More studies are needed to better prioritize and optimize the
care of the patient with burn injury, trauma and TBI.
Disclosure of Interest: None declared
43
18.13
ALL AIS SCORES ARE NOT EQUAL: A COMPARISON OF RELATIVE RISKS OF MORTALITY BY INJURY
LOCATION, SEVERITY AND MECHANISM USING THE NATIONAL TRAUMA DATA BANK
E. B. Habermann1,*, S. F. Polites2, A. E. Wagie1, D. H. Jenkins2, M. D. Zielinski2
1
2
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgery, Mayo Clinic, Rochester,
United States
Introduction: The Abbreviated Injury Score (AIS) is the most widely used measure of injury severity. Scores of 1-6
are assigned to seven body regions: spine, thorax, abdomen, lower extremity, upper extremity, face, and head. These
scores are squared and summed, creating one Injury Severity Score (ISS) for an injured patient.
Though AIS values contribute equally to the ISS regardless of the mechanism of injury or body region injured, we
hypothesized that the mortality rate of each AIS score would vary across these factors.
Materials & Methods: The 2010-2012 National Trauma Data Bank (NTDB) was utilized to identify all adult patients
with blunt or penetrating injuries isolated to a single body region. We excluded patients with an AIS of 6, patients
who died in the emergency department, and patients who were transferred to another hospital.
In-hospital mortality rates were calculated for each AIS score by body region and mechanism (blunt or penetrating).
Within AIS values, relative risks were calculated by comparing the mortality for each body region relative to the
abdomen. These relative risks of mortality were further assesed by mechanism.
Results: From the NTDB, 910,814 patients were identified. The inpatient mortality rate for all patients with isolated
injuries was 2.1%. Mortality increased as the AIS increased, from 0.4% to 54.8% in patients with an AIS of 1 to 5,
respectively (p<0.01). The relative risk of mortality widely varied by injury location (Table); the greatest difference was
observed for head injuries with an AIS of 5, which had a relative mortality risk of 25.78 when compared to abdomen
injuries with an AIS 5 (p<0.01). Significant differences in mortality risk were also observed by body region when
injuries were stratified as blunt or penetrating injuries (Table). For example, in patients with an AIS of 1, the relative
risk of mortality for injuries to the head vs. abdomen was similar in blunt injuries (RR=1.48, NS) but greatly increased
for penetrating injuries (RR=12.35, p<0.05).
Image:
44
Conclusion: Mortality rates vary substantially between body regions and blunt vs penetrating injuries for a given AIS
score. As a result, the equal weighting of each body region that is provided for in the ISS calculation is invalid. Future
ISS calculations must be risk adjusted for body region and mechanism in order to provide any legitimacy to
comparisons among patients and institutions.
Disclosure of Interest: None declared
45
18.14
ABDOMINAL COMPARTMENT SYNDROME PREVENTION WITH A LITTLE INGENUITY
N. Ishimaru1,*, K. Matusda1, H. Kikuchi1, H. Endo1, E. Yamamura1
1
Trauma, Nippon Medical School Musashikosugi Hospital, kawasakishi kanagawakenn, Japan
Introduction: Abdominal Compartment Syndrome(ACS) reports have been increasing with changes in the
management of intensive care.The World Society of the Abdominal Compartment Syndrome(WSACS) suggest
Percutaneous Catheter Drainage(PCD) in ACS management.We introduce our management of ACS in our hospital
.We connect PCD with Ventricular Drainage(VD) to be used for ACS prevention and a liver packing effect.
Materials & Methods: We experienced that Patients with hemorrhagic shock due to rupture of Hepatocellular
carcinoma(HCC).We underwent Transcatheter Arterial Embolization(TAE) against arterial bleeding and then PCD
was placed to the Douglas' pouch and connected with VD . VD Pressure was set to 15-20mmhg.We connect VD to
drainage bottle.
Results: Intra-abdominal pressure did not exceed 20mmhg and new organ damage also did not developed and has
been managed without lowering.One month later he was operated liver resection.We went to the prevention of ACS in
the drainage by PCD.Intra-abdominal pressure was maintained at VD, and could packed hemostasis for venous
bleeding.
Conclusion: By connecting PCD with VD, there is a possibility of obtaining a liver packing effect and ACS
prevention.
References: １）Kirkpatrick AW et al：Intra-abdominal hypertension and the abdominal compartment syndrome:
updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment
Syndrome.Intensive Care Med 39:1190-206，2013
２）Cheatham ML et al：Is the evolving management of intra-abdominal hypertension and abdominal compartment
syndrome improving survival?.Crit Care Med.38(2):402-7, 2010
３）Corcos AC et al：Percutaneous treatment of secondary abdominal compartment syndrome. J Trauma.
51(6):1062-4，2001
Disclosure of Interest: None declared
46
18.15
CLINICAL PATTERN AND MANAGEMENT OF PENETRATING NECK TRAUMA
Y. Obadiel1,*
1
general surgery, Althawra modern general hospita, Sana,a, Yemen
Introduction: The neck is a relatively small and unprotected anatomic region with high density of vital structures, and
trauma to neck can cause variable and unpredictable injuries. In this review we studied patients with penetrating neck
trauma over a period of sixteenth months to assess the pattern of presentation and management principles of these
patients.
Materials & Methods: In this prospective study, 96 patients with penetrating neck trauma were reviewed. All patients
were evaluated according to basic trauma life support by primary survey then evaluated for clinical symptoms and
signs of injuries to various neck structures. Unstable patients were operated immediately, and stable patients were
managed according to the symptoms and zone of injury.
Results: Of the 96 patients, 95.8% were males and only 4.2% were females. The peak incidence of injury was
51.1% in the age group 21-30 years.The mechanism of trauma was gunshot in 60 patients (62.5%), stab wound in 30
patients (31.25%). Zone II injury was seen in 56.2%, zone I in 25% and zone III in 12.5% the remaining were multiple
zone injuries. Eighty four patients (87.5%) were unstable, 58(60.4%) were symptomatic and hematoma, bleeding and
subcutaneous emphysema were the commonest symptoms. Neck exploration was done in 58 patients (60.4%),
immediately in 41.7% and in 18.7% after diagnostic evaluation. Thirty eight patients (39.6%) were managed
conservatively. Of the operated patients, 55.2% had vascular injuries and 17.2% laryngotracheal injuries, with 13.8%
had negative exploration. Mortality was 4.2% (4 patients) and complications were reported in 10 patients (10.4%).
Conclusion: From this study, the majority of patients with penetrating neck trauma were young men, and gunshot
was the commonest cause as most cases occurred during conflicts due to unstable political conditions and crimes
inflected by terrorists. Selective management of penetrating neck injuries is an appropriate approach to avoid negative
exploration.
Disclosure of Interest: None declared
47
18.16
EVALUATION AND TREATMENT OF ESOPHAGEAL RUPTURE AND PERFORATION
-TRANS-ABDOMINAL APPROACHY. Murao1,*, M. Hamaguchi1, T. Uejima1, T. Nakao1, T. Matsushima1, K. Yokoyama1, T. Ishibe1
1
Emergency and Critical Care Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
Introduction: Esophageal rupture or perforation sometimes progresses to severe mediastinitis or sepsis without early
diagnosis and appropriate treatment.
Idiopathic rupture commonly occurs in the lower part of esophagus, however iatrogenic perforation occurs in the upper
esophagus to lower esophagus.
Materials & Methods: Evaluation and treatment of esophageal rupture or perforation of 10 cases were reviewed.
When the site of perforation was lower esophagus, trans-abdominal approach through esophageal hiatus to the
retromediastinum was selected.
Results: Nine patients were male and one female patient. The average age was 64 years old. There were seven
idiopathic esophageal perforations and two cases were caused by swallowing foreign bodies either a false teeth
bridge or a press through packaging (PTP). One case was perforation of reconstructed gastric tube. Lower esophagus
was the main site of perforation in idiopathic esophageal perforation.
Surgical approach for idiopathic esophageal perforation were trans-abdominal except in one case of re-perforation. In
cases with perforation into thoracic cavity, thoracic drainage or thoracotomy was also performed. In the case of
perforation by foreign bodies, when the site of the perforation was in the upper esophagus (caused by false teeth
bridge), drainage was introduced from neck. When the site of perforation was at the lower esophagus (PTP), drainage
for posterior mediastinum was introduced at abdominal approach through esophageal hiatus.
Conclusion: For the cases of lower esophageal perforation or abscess formation after esophageal perforation by
idiopathic reasons or caused by foreign bodies, abdominal approach was considered useful because of appropriate
drainage position, availability of omentum for covering, less invasive surgical stress, and easy access to intestinal
fistula for enteral feeding.
Disclosure of Interest: None declared
48
18.17
PERIPHERAL VASCULAR TRAUMA : AN EXPERIENCE FROM A LEVEL 1 TRAUMA CENTER IN DELHI, INDIA
S. Sagar1,*, A. B. 1, M. singhal1, A. gupta1, S. kumar1, P. ranjan1
1
Trauma Surgery, All India Institute of Medical Sciences, Delhi, India
Introduction: Peripheral Vascular Trauma poses a significant burden on economy and health resources. Despite
recent advances,
there is still lack of consensus in some areas, especially in developing countries. Lack of Peripheral Vascula trauma
database is an important hindrance in addressing these controversies
Materials & Methods: Records of Peripheral vascular trauma patients
presenting to our Level 1 trauma center over the last three years were collected and analyzed
retrospectively. Demography, treatment modalities, morbidity and mortality were studied
Results: 347 patients presented with vascular trauma over three years. Of these, 322 had PVT. Majority were young
males, victims of RTIs. Mean presentation time was 453 minutes. Forty eight percent (168) had isolated
injury; 179 (52%) had associated fractures. Primary survey was normal in more than 90% patients. Crush
injury was present in 6.1%, degloving in 8.4% (26) and traumatic amputation in 2.9 %. Management was
operative in 99 %( 320). Clinical examination warranted exploration in 52 %( 181) whereas Doppler in 13
%( 45) and CT Angio in 32 % (113). Interventions for arterial trauma were repair in 58(19.1%), Fogarty
and thrombectomy in 31(10.2%), EEA in 26(8.7%), interposition graft in 78 (26 %), and ligation in 18
(6%). Median reperfusion time was 420 minutes (105-700). Median ISS score 2; average MESS score 5(214); 271(79%) patients had MESS < 7. Overall, 221(73.6%) limbs could be salvaged. There was
reperfusion injury in 1.46 %. Sixteen percent (55) had delayed amputation. Average hospital stay was 14
days. Overall mortality was 6.4% (22).
Conclusion: Burden of Peripheral vascular trauma is substantial in terms of resource consumption and morbidity.
Building a Peripheral vascular trauma database prospectively can help in directing preventive programs and
addressing controversies effectively.
References: Pasch AR, Bishara, Lim LT, et al. Optimal limb salvage in penetrating civilian vascular trauma. J Vasc
Surg. 1986; 3:189.
Fackler ML. Wound ballistics: A review of common misconceptions. JAMA. 1988; 259:2730.
Amato JJ, Billy LJ, Gruber RP, et al. Vascular injuries: An experimental study of high and low velocity missile wounds.
Arch Surg. 1970; 101:167.
Mayer JP, Lim LT, Schuler JJ, et al. Peripheral vascular trauma from close-range shotgun injuries. Arch Surg. 1985;
120:1126.
White RA, Scher LA, Samson RH, et al. Peripheral vascular injuries associated with falls from heights. J Trauma.
1987; 27:411.
Guede JW, Hobson RW, Padberg FT, et al. The role of contrast arteriography in suspected arterial injuries of the
extremities. Am Surg. 1985; 51:89.
Lynch K, Johansen K. Can Doppler pressure measurementreplace "exclusion" arteriography in the diagnosisof occult
extremity arterial trauma? Ann Surg. 1991; 214:737-741.
Martin RR, Mattox KL, et al. Advances in treatment of vascular injuries from blunt and penetrating limb trauma.World J
Surg. 1992; 16:930-937.
Disclosure of Interest: None declared
49
18.18
RISKS OF COMPUTED TOMOGRAPHY BEFORE EMERGENCY THORACOTOMY OR LAPAROTOMY IN
SEVERELY INJURED TRAUMA VICTIMS: A NATIONWIDE OBSERVATIONAL STUDY
K. Nakatsutsumi1,*, Y. Otomo1, A. Shiraishi1
1
Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University hospital of Medicine, Tokyo,
Japan
Introduction: The efficiency of performing computed tomography (CT) in trauma treatment has been proved by many
reports. However, the effects of performing CT remain unclear in hemodynamically unstable patients requiring an
emergency surgery.
Materials & Methods: In this historical cohort study, we analyzed the database of the Japan Trauma Data Bank.
During 2004-2013, 159,157 patients were registered. We included patients who underwent emergency thoracotomy or
laparotomy along with CT within two hours of their arrival. We divided these patients into two groups: the surgery
group (underwent surgery before CT) and the CT group (underwent CT before surgery). We compared the patient
backgrounds and analyzed the relationship between in-hospital mortality rates and the two groups. We performed
multiple logistic regression analysis to adjust for demographic and clinical characteristics. We futher performed
systolic blood pressure (SBP) analysis and divided the patients into subgroups (SBP < 80mmHg or ≥ 80 mmHg).
Results: We included 830 patients, with 151 in the surgery group and 679 in the CT group. Vital symptoms and injury
severity scores were significantly worse in the surgery group than in the CT group. The probability of survival,
calculated by the trauma and injury severity score in the surgery group was also worse than in the CT group (67% vs.
95%, P < 0.001). The time period between arrival and surgery in the surgery group was significantly shorter than that
in the CT group (50 min vs. 90 min, P < 0.001). The mortality rate in the surgery group was higher than that in the CT
group [odds ratio (OR), 2.11; 95% confidence interval (CI), 1.45–3.08]. After obtaining the background, having the
surgery performed first was not associated with in-hospital mortality (adjusted OR, 0.709; 95% CI, 0.419–1.200). In
the subgroup with SBP < 80mmHg, having the surgery performed first significantly reduced in-hospital mortality
(adjusted OR, 0.311; 95% CI, 0.149–0.649).
Conclusion: For the patients who were injured very severely and needed an urgent surgery, performing the surgery
without CT could give a better outcome. The saying “CT scan is the tunnel of death” holds true for these patients.
References: American College of Surgeons Committee on Trauma: ATLS Advanced Trauma Life Support Program
for Doctors. Student Course Manual (8th edition). Chicago; 2008.
Huber-Wagner S, Lefering R, Qvick LM, Körner M, Kay MV, Pfeifer KJ, Reiser M, Mutschler W, Kanz KG: Effect of
whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009,
373:1455-1461.
Mackay A: Is the ‘tunnel of death’ a suitable modality for investigating the severely traumatized child? Aust N Z
J Surg 1999, 69:587-588.
Clarke JR, Trooskin SZ, Doshi PJ, Greenwald L, PhD, Mode CJ: Time to laparotomy for intra-abdominal bleeding
from trauma does affect survival for delays up to 90 minutes. J Trauma 2002, 52:420-425
Disclosure of Interest: None declared
50
18.19
A SECOND CHANCE OF LIFE: DAMAGE CONTROL SURGERY IN AN UNSTABLE POLYTRAUMA PATIENT.
K. Kessler1,*, A. AlNumairy1, M. AlNumairy1
1
General Surgery, Al Ain Hospital, Al Ain, United Arab Emirates
Introduction: The timely deployment of damage control surgery after a polytrauma has a detrimental effect on the
survival rate of trauma patients. This case describes the preoperative and intraoperative decision to go for damage
control surgery and post operative course of an unstable polytrauma patient.
Materials & Methods: A case report of interdisciplinary mangement of an unstable polutrauma patient
Results: A 22 year old man was brought into the Emergency department after being struck by a vehicle while
bicycling. He was drowsy, pale and tachycardic. Clinically he had a rigid abdomen, an instable pelvis, a femur fracture,
lacerations to the back, the perineum with layopen testicles, and bleeding laceration involving the anal sphincter.
FAST showed huge amount of free fluid. He was intubated and resuscitated but did not respond. He was taken to the
operating theatre without any further Imaging. Orthopedics started by fixating the pelvis with a C-Clamp, followed by
an exploratory laparotomy . Findings were at least 3 l blood intraabdominally due to a deep mesenteric tear at the root
with ongoing bleeding vessels and denudation of small bowelloops. Suturing of the bleeding mesenteric artery and
vein branches were performed. The denudated jejunum was resected. No anastomoses was performed, the abdomen
temporary closed. The testicles were replaced and fixed, the bleeding perineal wound including the sphinctertear was
packed. The left femur was treated with fixateur externe. During the surgery massive transfusion protocol was started
and continued after surgery in the ICU. Two days later after complete cardiopulmonal stabilization the patient was
taken for a second look laparotomy, reconnection of the small bowel, formation of a diverting colostomy and direct
sphincter and perianal repair. He stayed a total of 31 days in the ICU, during which the C Clamp was replaced by a
pelvic fixateur. He was extubated on day 29, medical and wound care continued for another month prior to his
discharge. On day 69 he was discharged from the hospital in good condition
Conclusion: This case demonstrates the importance of damage control surgery. It proves that proper deployment of
damage control surgery can change the outcome from a mortality to rebuilding a patient’s life following a catastrophic
event such as the accident this patient had. The key points in such a case is the indication to go to surgery and what
to what extent the surgeons are willing to repair in the emergency situation..
Disclosure of Interest: None declared
51
18.20
TWO CASE REPORTS OF SEVERE SEPTIC SHOCK FOLLOWING THE REMOVAL OF RETROPERITONEAL
PELVIC PACKING
T. Tsunoyama1,*, T. Fujita1, M. Kitamura1, Y. Uchida1, H. Ishikawa1, T. Sakamoto1
1
Trauma and Resuscitation center , Teikyo University, Tokyo, Japan
Introduction: The management of hemodynamically unstable pelvic fractures is challenging. Retroperitoneal pelvic
packing is a potential procedure to control hemodynamically unstable pelvic fractures. We herein report two cases of
severe septic shock following the removal of retroperitoneal pelvic packing.
Materials & Methods: Case 1 was a 67 year old male who had been in a motorbike accident. He was
hemodynamically unstable with positive FAST and unstable pelvic fractures. He underwent laparotomy and
retroperitoneal pelvic packing. After arteriography embolization, the patient was admitted to the ICU. He went back to
the OR for the removal of the retroperitoneal pelvic packing 72 hours after the laparotomy. The packing swabs were
removed. However, immediately after the abdominal closure, the patient became hemodynamically unstable and had
respiratory failure. The WBC was 700/mm³. We diagnosed the patient with septic shock and ARDS. Despite the ICU
management , the patient expired 12 hours after the abdominal closure. The patient’s serum endotoxin level was 4.7
pg/mL and the blood culture showed the presence of Enterococcus faecalis. Case 2 was a 47-year-old male who fell
from a great height. He was hemodynamically unstable with unstable pelvic fractures and positive FAST.He
underwent laparotomy and retroperitoneal pelvic packing and subsequently had a pelvic arteriography embolization.
After the operations, the patient was admitted to the ICU and the retroperitoneal pelvic packing swabs were removed
40 hours later. However, he became hemodynamically unstable and went into respiratory failure in the OR. The
patient returned to the ICU with temporary abdominal closures. His WBC was 1,600/mm³. However, the patient
expired the day after removing the retroperitoneal pelvic packing. The blood culture indicated the presence of
Pseudomonas aeruginosa.
Results: Both patients expired shortly after after removing the retroperitoneal packing.The blood cultures were
positive.
Conclusion: Retroperitoneal pelvic packing is an effective operation for controlling hemodynamically unstable pelvic
fractures. However, infection rates and multiple organ failure (MOF) following this operation are high. The presence of
large surgical swabs in the pelvis for a few days as well as the compromise of immune defense mechanisms in the
critically ill patients contribute to this effect. To prevent infection and MOF, the pelvic packing swabs should be
removed as soon as possible.
Disclosure of Interest: None declared
52
18.21
OUTCOMES OF PRE-HOSPITAL TRANSFUSION IN ACUTE GASTROINTESTINAL HEMORRHAGE: A SINGLECENTER EXPERIENCE
M. E. Parker1,*, M. khasawneh1, C. Thiels1, S. Zietlow1, D. Jenkins1, J. stubbs2, K. Berns2, M. Zielinski1
1
Department of Surgery, 2Mayo Clinic, Rochester, MN, United States
Introduction: Acute gastrointestinal (GI) bleeding is a common medical emergency with significant morbidity and
mortality. Remote damage control resuscitation in rural environments without access to blood products may be
beneficial for these unstable patients. We aimed to evaluate outcomes of acute GI bleed patients receiving blood
product transfusions during air ambulance transport in a rural setting.
Materials & Methods: We conducted a retrospective review of a prospectively maintained database for patients
transported to our rural tertiary care center for the management of acute GI bleeding, between 2010 and 2014. Data
are reported as mean with standard deviation (SD) or median with interquartile ranges(IQR) as appropriate.
Results: A total of 117 patients (59% male) with mean age 67 years (range 27-95) were identified as having received
packed red blood cells (PRBCs) or plasma during pre-hospital (pre-hosp) transport for acute GI bleeding. Transport
time was 36.8 minutes (IQR 21-42). Pre-hosp transfusion included a mean of 2.3 (SD 1.6) units PRBC, and 1.2 (SD
1.2) units plasma. Twenty seven (23%) patients were on chronic anticoagulation. In patients with international
normalized ratio (INR, n = 54) drawn both before and after transport, mean pre-transfusion INR was 1.8 (SD 1.2) and
post-transfusion INR was 1.5 (SD 0.8). Transfusion after arrival to our tertiary care center included a mean of 4.0 (SD
4.1) units PRBCs and 1.8 (SD 2.7) units plasma. Ninety-six patients (82%) underwent emergent endoscopy within 6.9
hours (IQR 3-13.4) of admission; 85 patients (73%) underwent upper GI endoscopy and 26 patients (22%) underwent
colonoscopy. Hemostasis was achieved endoscopically in 68 (67%) of patients. Thirty one (27%) patients required
angiographic intervention, and 18 (15%) underwent operative exploration. One hundred and seven (91%) patients
were admitted to the ICU, with a median hospital stay of 5 days (IQR 4-8). Sixteen (14%) patients had a re-bleeding
episode within thirty days, requiring either readmission or repeat endoscopy during their index hospital stay. Thirty-day
mortality included 13 (11%) deaths, 10 of of which occurred in-hospital.
Conclusion: Initiating damage control resuscitation prior to hospital arrival was associated with an improvement in
coagulopathy in acute GI bleed patients. Prospective trials are required in order to assess the role of pre-hospital
transfusion in improving outcomes for patients with acute GI bleeding.
Disclosure of Interest: None declared
53
18.22
NATURE AND SEVERITY OF INJURIES IN MOTOR VEHICLE CRASH VICTIMS ATTENDING THE EMERGENCY
DEPARTMENT OF A LARGE HOSPITAL IN DOUALA, CAMEROON.
A. Chichom-Mefire1,*, A. SAMA2, M. Ngowe Ngowe2
1
2
Faculty of Health Sciences, University of Buea and Regional Hospital Limbe, Cameroon, Faculty of Health Sciences,
University of Buea, Buea, Cameroon
Introduction: Low and middle-income countries carry most of the burden of traffic-related injuries in the world.
Current policies to reduce this burden generally focus on preventive measures. Consequently the management of
injury cases tends to be neglected. Data on types and severity of injuries as well as their management modalities and
their outcome is scarce. In the absence of such data no efficient policy of control of traffic related injuries can be
implemented. This study aims at analyzing the nature and severity of injuries sustained on the road in Douala with the
idea of identifying which scoring system is the most feasible and reliable in a low-income setting.
Materials & Methods: This is a prospective pilot cohort analysis conducted in the largest hospital in the city of Douala
in Cameroon. During a two months period all victims of traffic related injury attended to in the emergency department
were included and followed-up until death, referral or discharge from hospital. The lesions identified were recorded
and used to estimate severity using three different scoring systems (ISS, NISS and RTS). The outcome was analyzed
to identify which of the scoring systems would more feasible in our settings. the accuracy of scores was assessed
using the area under the curve of a ROC plot.
Results: A total of 192 (149 males and 43 females) patients were included in the study. Mean age was 34.72 ± 14.85
years. The large majority of patients (91.7%) were aged between 16 and 59 years. Most victims were involved in
motorcycle vs tourist car (n=97) and motorcycle vs motorcycle collision (n=39). On initial assessment in the
emergency department, a total of 337 injuries were identified in our patients giving a mean of 1.76 injuries per patient.
The most frequent locations of injuries were the limbs (n=161) and the head and neck (n=80). The most frequently
recorded injuries were lesions of soft tissues and bone fractures involving most often the lower limb. The mean
severity scores were 5.45 for ISS, 7.03 for NISS and 7.59 for RTS. The overall in-hospital mortality was 5.72%. All
three scoring systems proved to be accurate predictors of outcome though ISS and NISS required heavy paraclinical
work-up.
Conclusion: This pilot study suggests that most traffic related injuries usually involve soft tissues and head and neck,
but are of moderate severity. Fractures of long bones of the lower limb are also a frequent lesion. These findings need
to be confirmed by another study involving a larger number of patients.
Disclosure of Interest: None declared
54
18.23
DOES EARLY SURGERY FOR ADOLESCENT FEMUR FRACTURES SHORTEN HOSPITAL LENGTH OF STAY?
R. M. Dorman, MD1,2,*, J. J. Kuiper, MD1, T. P. Bryan, MD3, A. B. Nordin, MD1, C. Blum, MD3,4, K. D. Bass, MD1,2, W.
1,5
J. Flynn, MD
1
2
Department of Surgery, SUNY at Buffalo, Department of Pediatric Surgery, Women and Children's Hospital of
3
Buffalo, Department of Orthopaedics, SUNY at Buffalo, 4Department of Pediatric Orthopedics, Women and Children's
Hospital of Buffalo, 5Department of Surgery, Erie County Medical Center, Buffalo, NY, United States
Introduction: Femur fractures are the most common fracture requiring hospitalization in pediatric subjects. In our
region we have one Adult Level 1 Trauma Center (ATC) and one Pediatric Level 1 Trauma Center (PTC), and patients
of an intermediate age may be referred to either. We hypothesize that time to OR at the ATC is shorter, and that this
leads to shorter length of stay. Demographic, transport, mechanism, and injury factors are examined and treatment
approaches are compared.
Materials & Methods: A retrospective review of the trauma registry was performed for subjects 14 to 17 years old
with femur fractures admitted to the local ATC from 2003 to 2012 or PTC from 1998 to 2008. Statistical methods
included ANOVA, t-test, Fisher’s Exact or Chi-squared. Significance level was 0.05.
Results: Of 115 subjects that met inclusion criteria, 108 were included for analysis; 75 were treated at the PTC and
33 at the ATC. Subjects presenting to the ATC versus the PTC were on average eight months older, although weight,
ISS, and difference in distance to each hospital were not statistically different. All penetrating wounds presented to the
ATC. All subjects with significant developmental disorders or congenital conditions predisposing to fracture were
treated at the PTC. Sport-related injuries were much more likely to present to the PTC (p<0.001). At the PTC casting
was more common. Flexible IM nailing was only used at the PTC. Sixty three (84%) PTC subjects and 31 (94%) ATC
subjects underwent operative intervention (p=0.22). All subjects but one were taken to the OR within 48 hours. Mean
time to OR was 3 times longer at the PTC (19.9 hours, range 2.3-47.7 hours) versus ATC (6.0 hours, range 1.4-15.3
hours, p<0.001). The proportion of cases begun between 0700 and 1900 was 87% at the PTC, and 47% at the ATC,
(difference 40.4%, 95% CI 21.3%>59.6%, p<0.001). Mean hospital length of stay in days was not different between
hospitals for all comers (ATC 3.82, PTC 4.14, p=0.59) but for isolated femur fractures taken to the OR within 6 hours
of presentation LOS was 0.7 days shorter (95% CI 0.1-1.3 days).
Conclusion: Mechanism of injury, presence of a congenital disorder, and age predicted treating facility. Adolescents
presenting to the ATC were seen by the orthopedic service and taken to the OR sooner. Early operative intervention
did not significantly shorten LOS for multiply-injured patients. However, patients with isolated femur fractures requiring
operation left the hospital earlier if the operation began within 6 hours.
Disclosure of Interest: None declared
55
18.24
PREDICTING THE UNPREDICTABLE – PEDIATRIC TRAUMA VARIES MARKEDLY WITH TIME, AND
OVERNIGHT AND SUMMER ADMISSIONS ARE ASSOCIATED WITH INCREASED MORTALITY
A. Fahy1,*, S. Polites2, C. Thiels2, M. Ishitani1, C. Moir1, D. Jenkins2, M. Zielinski2
1
2
Department of Pediatric Surgery, Department of Trauma, Critical Care and General Surgery, Mayo Clinic,
Rochester, United States
Introduction: This study aimed to determine if there were predictable temporal patterns in occurrence and severity of
pediatric trauma as identification of these patterns would aid preparedness of pediatric trauma centers and inform
injury prevention programs.
Materials & Methods: We reviewed all pediatric trauma activations between 2003 and 2012 at a level 1 pediatric
trauma center. Data were collected from the prospectively maintained trauma registry and analyzed by distribution and
association trends in a univariate and multivariate approach using Chi-squared tests for distributions, Fisher's exact
test for associations and p values set at p<0.05
Results: Of a total of 3957 trauma activations, injured children were most likely to present in the evening (18:0021:00, 24%) and least likely to present in the morning (06:00-09:00, 3%; OR8.7, 95% CI = 7.7-10.2). Saturday was the
peak day of the week while Wednesday was the nadir (20 vs 11%, OR1.75, 95% CI 1.7-1.8). The most pediatric
trauma activations occurred in June and the least in November (13 vs 5%, OR2.4, 95% CI 2.3-2.5). Seasonally,
summer activations were over twice as frequent as winter activations (table 1). Variation in mortality (adjusted for ISS)
was analyzed - overnight and summer activations were associated with increased mortality.
Table 1: Increased mortality associated with overnight or summer admissions
Trend
n (total = 3957) (%)
ISS >25 (%) Mortality (%)
Temporal
06:00 - 17:59 (Day)
1832 (46.1)
5.6
0.63
18:00 - 05:59 (Night)
2134 (53.9)
6.7
1.1
Statistical analysis on
p = 0.06
p <0.001
night/day
Season
Summer
1365 (35)
6.8
0.63
Fall
1085 (27)
5.1
0.3
Winter
679 (17)
8.0
0.28
Spring
828 (21)
5.3
0.53
Statistical analysis on
p<0.001
Chi-squared (2, n=2044) =
summer/winter
67, p<0.001
Conclusion: Pediatric trauma incidence varies markedly over time. Both seasonal and daily variations in pediatric
trauma activations exist, with evening/nighttime, Saturdays, and summer associated with significantly greater numbers
of activations. Overnight and summer admissions were associated with higher mortality. Staffing, resources and
department preparedness should be optimized at these times of higher volume and higher mortality. Pediatric injury
prevention programs should particularly focussed on awareness and prevention of injuries during summer months.
Disclosure of Interest: None declared
56
18.25
SURGICAL STRATEGY FOR CHEST STAB INJURY
T. Terada1,*, Y. Mizobata1, H. Yamamura1, N. Shinyama1, S. Kaga1, K. Uchida1
1
Department of Traumatology and Critical Care Medicine, Osaka City University
Osaka, Japan
Graduate School of Medicine,
Introduction: Chest stab injury can be life threatening if it reaches thoracic organs. Although prompt decision is
crucial for critical patients, the optimal indication for thoracotomy is controversial. We had implemented the
management strategy depending on the hemodynamic status, wound lesion, and CT findings.
This study was designed to evaluate our surgical strategy for chest stab injuries.
Materials & Methods: A retrospective 5-year review of patients who were transported to our department due to chest
stab injury was performed. The physiological status on arrival, injury severity score (ISS), performed examinations and
procedures, and outcomes were investigated. Patients arrived without life signs were excluded.
Results: A total of 17 patients were included in this study. Fifteen patients were male and the median age was 45
years old (range 22-74).
The physiological statuses on arrival were shock in 7, normal in 10 patients. The shock index(SI), revised trauma
score (RTS) and ISS were 0.90±0.24(mean±SD), 7.34±0.68, and 10.4±9.8, respectively. Initial volume of infused
crystalloid was 1186±807ml.
In 11 patients, CT images were obtained and the others were evaluated only by chest X-ray and ultrasound
sonography. The wounds reached thoracic cavity in 10 and chest tube drainage was performed in 5 and emergent
thoracotomy was performed in 7 patients. The wounds were directly sutured in patients who didn’t undergo
thoracotomy.
The indications for thoracotomy were physiological instability and thoraco-abdominal lesion in 4, residual cutlery,
massive bleeding, and air leakage in 1 patient, respectively. Performed procedures were partial lung lobectomy in 5,
diaphragm repair in 4, and concomitant lapalotomy in 5 patients.
There were no hospital death and major complication including delayed thoracotomy for patients who didn’t require
thoracotomy at the initial assessment.
Conclusion: All of the 4 patients who underwent thoracotomy due to thoraco-abdominal lesion had diaphragm injuries
and this indicates our strategy for chest stab injury including enterprising thoracotomy for thoraco-abdominal lesion is
acceptable.
All the patients who underwent thoracic drainage and direct wound closure completed non thoracotomy management
and this supports the validity of our surgical indication for upper thoracic injury.
We concluded the outcome of chest stab injuriy in this series was satisfactory and our operative management strategy
for chest stab injury depends on patient’s status and injured region was reasonable.
Disclosure of Interest: None declared
57
18.26
TWO CASES OF BLADDER RUPTURE ; THE USEFULNESS OF CT CYSTOGRAPHY
H. Endo1,*, E. Yamamura1, K. matsuda1, N. ishimaru1, H. kikuchi1, T. mochizuki1 on behalf of Department of
Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital
1
Emergency Care Medicine, Nippon Medical School Musashikosugi Hospital, kawasaki-city, kanagawa, Japan
Introduction: BACKGROUND; This study was intended to report our recent experience of bladder injuries due to a
fall and a traffic accident , and review the literature regarding diagnosis about CT cystography and conventional
cystography.
Materials & Methods: Two cases of intraperitoneal rupture of urinary bladder; Comparison between CT cystography
and conventional cystography in the diagnosis of bladder injury.
Results: Two cases with pelvic fractures and bladder ruptures which were firstly unclear by conventional cystography
were found. But bladder ruptures were diagnosed by CT cystography.
Conclusion: In the diagnosis of bladder rupture, CT cystography is more useful than conventional cystography.
References: Ulus Travma Acil Cerrahi Derg. 2014 Sep;20(5):371-5. A practice report of bladder injuries due to
gunshot wounds in Syrian refugees. Inci , Karakuş , Rifaioglu
AJR Am J Roentgenol. 2006 Nov;187(5):1296-302. CT cystography with multiplanar reformation for suspected
bladder rupture: experience in 234 cases.Chan DP, Abujudeh HH, Cushing GL Jr, Novelline RA.
Urol Ann. 2014 Oct;6(4):370-2. Conservatively managed spontaneous intraperitoneal bladder perforation in a patient
with chronic bladder outflow obstruction.Jones AL1, Armitage JN1, Kastner C1.
J Urol. 2000 Jul;164(1):43-6.Computerized tomography cystography for the diagnosis of traumatic bladder
rupture.Deck AJ1, Shaves S, Talner L, Porter JR.
Arch Ital Urol Androl. 2012 Dec;84(4):224-6.Spontaneous rupture of urinary bladder: a case report and review.Albino
G1, Bilardi F, Gattulli D, Maggi P, Corvasce A, Marucco EC.
Disclosure of Interest: None declared
58
18.27
SEVERITY EVALUATION OF FOURNIER'S GANGRENE
M. Noda1,*, S. Mori1, K. Baba1, Y. Kita1, H. Okumura1, S. Ishigami1, S. Natsugoe1
1
digestive surgery, breast and thyroid surgery, Kagoshima University, Kagoshima, Japan
Introduction: Fournier’s gangrene is the necrotizing fasciitis of the perineum, that usually progresses rapidly.
Patients need appropriate treatment including surgical debridement during early stage. It is said that Fournier’s
gangrene severity index (FGSI) is useful tool of predicting prognosis. In 2007, Yilmazkar published a paper
about Uldag Fournier’s gangrene severity index(UFGSI) , which increased several items in FGSI.
Materials & Methods: The aim of this study is to evaluate characteristic and severity of Fournier's gangrene. We
experienced and evaluated 7 patients with Fournier’s gangrene who underwent emergency surgery in our department
between January 2012 and May 2014, and we collected 101 Japanese cases from literature between 2008 and 2013.
We analyzed the clinical findings of 108 cases in total retrospectively.
Results: In our 7 cases, Two out of seven patients with high score of FGSI and UFGSI died peri-operative
period. In 108 cases, almost of patients were men and average age was 59.4 years. Mortality rate was 10%.
Almost of patients (85%) had preoperative complications and most frequent complication was diabetes.
Anaerobic bacteria infection was related to 35% of patients and a lot of patients had various mixed infections.
Conclusion: Regarding the treatment of Fournier’s gangrene, enough open drainage and debridement were essential
and administration of broad antibiotics and local control of wound were also important under intensive care. FGSI and
UFGSI scores are useful for evaluation of severity and prediction of prognosis for the patients with Fournier’s
gangrene.
References: 1.Fournier JA: Gangrene foundroyante de la verge. Sem Med.1883; 3: 344-346,
2.Laor E, Palmer LS, Tolia BM, et al: Outcome Prediction in Patients with Fournier's Gangrene. J Urol. 1995;
154; 89-92
3.Yilmazlar T, Ozturk E, Ozguc H, et al: Fournier's gangrene: an analysis of 80 patients and a novel scoring
system. Tech Coloproctol.2010; 14: 217-23
4. Myers RA, Lucas P, Jhaveri A, et al: Management of Fournier’s disease –necrotizing soft tissue infections of the
genitalia. In: Kawashima M (ed). Program and Abstracts, 3rd Conference US-Japan Panel on Aerospace, Diving
Physiology & Technology and Hyperbaric Medicine. Nakatsu Japan; 2008; pp53
Disclosure of Interest: None declared
59
18.28
LAPAROSCOPIC SPLENECTOMY: AN INITIAL EXPERIENCE OF MANAGEMNET OF ISOLATED BLUNT
TRAUMATIC SPLENIC INJURY.
A. Ghasoup1,*, T. Al Qurashi1, S. E. Mohmmed1, O. Sadieh1
1
Surgical Department, Security Forces Hospital Makkah, Makkah, Saudi Arabia
Introduction: Objectives: To evaluate outcome of laparoscopic splenectomy (LS) for isolated blunt traumatic splenic
injury (TSI).
Background: Minor splenic injuries from blunt trauma can be treated conservatively, whereas high-grade injuries
require surgical treatment and usually removal of the organ. Although splenectomy is nowadays routinely performed
laparoscopically for the treatment of hematological pathologies, in an emergency the operational procedure is
performed through conventional laparotomy worldwide, Progress in surgical skill and new developments in equipment
allow us to manage also patients with severe splenic blunt trauma laparoscopically.
Materials & Methods: The study included 11 patients with isolated blunt TSI. All patients underwent full
history taking, complete physical examination, CT examination for grading of splenic injury according to
Moore et al. surgical interference was indicated when there was deterioration of patient’s hemodynamic
parameters and/or if there is progressive or massive decrease of hemoglobin concentration. All
splenectomies were performed using 3-trocar procedure through lateral approach 9 cases and two cases
supine position, Intraoperative and postoperative (PO) data were collected.
Results: : CT examination defined 2 patient of grade V, 5 patients of grade IV, 4 patients of grade III . All patients
passed uneventful intraoperative course without conversion to open splenectomy with a mean operative time of
60±20.7 minutes and mean amount of total blood loss of 280.6±140.1 ml. All patients required blood transfusion with
mean number of blood units of 3.4±1.1; range: 3-5 units.nine patients passed uneventful postoperative course, one
patients developed wound infection and one patient developed chest infection that responded to medical treatment.
Mean duration of hospital stay for was 5.7±2 days. All patients completed their follow-up for a mean duration of
14.1±4.7 months. No follow-up complications were recorded during follow-up period.
Conclusion: LS is a feasible, safe and effective therapeutic modality for cases of blunt TSI providing short recovery
times and hospital stay without extensive morbidities nor mortalities. It is recommended for management of cases
needing emergency surgical interference or not responding to non-operative management.
Disclosure of Interest: None declared
60
18.29
SCAPULOTHORACIC DISSOCIATION: 12 YEARS EXPERIENCE IN KING CHULALONGKORN MEMORIAL
HOSPITAL
A. Wangpatravanich1,*, R. Pak-art1
1
Surgery, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
Introduction: Scapulothoracic dissociation is uncommon in trauma. It results from sudden and severe blunt force
hitting and distracting the shoulder away from chest wall. This mechanism also causes subclavian vascular trauma
and brachial plexus injuries. The management of this injury is controversial. The aim of this study was to demonstrate
the presentation, x-ray finding, and management of blunt subclavian artery injuries.
Materials & Methods: Medical records of patients who sustained blunt injuries of subclavian artery in King
Chulalongkorn Memorial Hospital from January 2002 to December 2013 were reviewed. Demographic data,
presentation, details of treatment and outcome were collected.
Results: There were 19 patients who had blunt subclavian artery injuries during the study period (mean age = 26.52).
All patients except one were male and motorcycle accidents were the cause of trauma in 18 patients. The injuries
were found on right in 10 patients and left in 9. Brachial plexus injuries were detected in all cases. The x-ray films of
every patient revealed lateral displacement of the affected scapulas and clavicular fracture/dislocation.(as in figure)
The managements of these patients were primary repair with PTFE graft (7), primary repair with saphenous vein graft
(5), primary repair with end-to-end anastomosis (1), ligation (4), and no operative intervention (2). Six patients
required arm amputation due to severe soft tissue infection and limb ischemia. One patient died from severe lung
trauma. Of these nineteen injuries, twelve arms were preserved with major neurological deficit of brachial plexus
injuries.
Image:
Conclusion: Subclavian vascular injury and brachial plexus injury were the major prognostic factors of
scapulothoracic dissociation.
Disclosure of Interest: None declared
61
62
18.30
THE LONG ROAD TO IMPROVE CARE FOR HIP FRACTURE PATIENTS
A. H. K. Riemen1,*, C. MacEachren1
1
Orthopaedics, University of Aberdeen, Aberdeen, United Kingdom
Introduction: National guidelines are unanimous in recommending each patient admitted to have access to and formal acute
Orthogeriatric assessment from the point of admission as well as for patients to have a formal falls assessment. The recent UK hip
fracture audit showed that less than fifty percent were assessed by and orthgeritriacian but over 92% had a falls assessment prior
to discharge.
Materials & Methods: Radiographs of all patients admitted to the trauma unit were reviewed to identify those with hip fractures.
Their medical and nursing records were reviewed to identify Geriatrics and other speciality input as well as the components of falls
assessments.
Results: One hundred and forty-eight patients were admitted with hip fractures in the first round of the audit. Six patients under 65
were excluded. A total of 139 patients were included and the mortality at three month was 10%. Only 20% of patients were
reviewed by a geriatrician, none pre operatively.
88% of patients had a ward falls assessment with the majority being high risk. Other components such as a full neurological and
cardiovascular assessment were incompletely performed in 75% and 54% respectively. No patient had postural Blood Pressure
measurements nor did they have and assessment of home hazards.
In the second round a further fifty patient records were analysed. Despite the introduction of significant changes to the
orthogeriatric service and the documentation record for hip fracture patients no significant improvements could be identified.
Conclusion: Overall the results show that although multiple guidelines exist practical implementation has taken time however
good audit data can affect change. Since the first round audit was presented to the Geriatric Departmental Meeting the trauma unit
now has been allocated two consultant Geriatricians who will review patients twice a weekly. We have also introduced formal
admission forms to improve history and examination and initiate pathways such as a Delirium pathway from time of admission.
Despite this the second round of the audit cycle identified not significant improvements in the documentation in medical records.
Affecting changes and impacting the care of patients can be a long and difficult road.
Disclosure of Interest: None declared
63
18.31
INFECTED HARDWARE AFTER SURGICAL STABILIZATION OF RIB FRACTURES: OUTCOMES AND
MANAGEMENT EXPERIENCE
C. A. Thiels1,*, T. P. Nickerson1, J. M. Aho1, H. J. Schiller1, D. S. Morris1, B. D. Kim1
1
General Surgery, Mayo Clinic, Rochester, United States
Introduction: Surgical stabilization of rib fractures (SSRF) is a commonly used means for treating rib fractures. The
reported risk of hardware infection is low and reports of the risk factors, incidence, and management of infection
following SSRF is limited. Our aim was to review our experience with hardware infection following SSRF in an effort to
better understand risk factors and develop an optimal management strategy for these patients.
Materials & Methods: Review of a prospectively collected rib fracture database of all patients who underwent SSRF
from 8/2009 until 3/2014. Patients who underwent SSRF and subsequently developed hardware infection were
identified. Standard descriptive analyses was performed.
Results: Of the 130 patients who underwent SSRF, 5 (3.8%) were found to have a hardware infection. The patients
who developed hardware infection had an average of 4.2 ribs plated (range 3 to 5) and 4 patients had flail segment.
No patients who had infected hardware had diabetes and 1 smoked. Two had chest tubes placed in the field without
prophylactic antibiotics. The remaining patients had chest tube placed during the index SSRF and received
perioperative antibiotics.
All five patients were returned to the OR for management of the hardware infection. One patient underwent immediate
hardware removal. The remaining 4 patients underwent antibiotic bead placement and all but one eventually had the
hardware removed at an average of 136 days after fixation (range 22 to 192). Negative pressure wound therapy was
utilized in 3 patients. Average return to the OR was 14 days after index SSRF (range 3 to 18). Patients with infections
required an average of 2 additional operations (range 2 to 3).
Cultures grew gram positive organisms including staphylococcus (3), streptococcus (1), and an anaerobic gram
positive coccus (1). All patients received antibiotics prior to removal followed by suppressive antibiotics. Average
follow up was 6.8 months (range 5 to 9) and all patients were alive at last follow up. The infection had clinically
resolved in all patients and all were off antibiotics at last follow up. No patient required re-intervention for stabilization
after hardware removal and bony healing was demonstrated in all patients.
Conclusion: Although rare, hardware infection following SSRF carries a significant morbidity and necessitates
additional operations as well as long term antibiotics. Favorable outcomes result from a combination of surgical,
antibiotic, and wound care strategies.
Disclosure of Interest: None declared
18.32
PREOPERATIVE PREDICTORS OF ILEOCECAL RESECTION OR RIGHT-SIDED HEMICOLECTOMY FOR THE
TREATMENT OF ACUTE APPENDICITIS
F. Saida1,*, S. Matsumoto1, M. Kitano1
1
Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama Ctiy, Japan
Introduction: Acute Appendicitis is one of the most common diseases of the abdomen, resulting in acute abdominal
surgery. Simple appendectomy has been the primary surgical treatment. However, owing to disease severity, it is
sometimes necessary to perform extensive resection (ER), such as ileocecal resection or right-sided hemicolectomy
under general anesthesia. Preoperative predictors of ER for acute appendicitis are unknown. The aim of the present
study was to determine predictors of ER in patients undergoing surgical treatment of acute appendicitis.
Materials & Methods: We retrospectively reviewed records of 927 patients who underwent immediate surgery for
acute appendicitis at our hospital over a 7-year period.
Various clinical data parameters were collected, including demographic characteristics, preoperative examination,
blood test and CT findings, onset day, operation time, and hospitalization length, and preoperative prediction
performance of these parameters for the necessity of ER was evaluated.
Results: A total of 927 patients were statistically evaluated. ER was noted in 40 (4.3%) patients.
Univariate analysis of the total patient data (ER and non-ER groups) revealed a statistically significant difference in
parameters, such as age, onset day, CRP, some CT findings (presence of abscess, ascites and free air, unidentified
appendix, and thickness of appendix wall), operation time and hospitalization length between the two groups.
Multivariable regression analysis demonstrated that all of the following increased the risk of ER: age (≥45 years) (OR
4.82; 95% CI, 2.02–11.5; P < 0.01),onset day (≥3 days) (OR 5.25; 95% CI, 1.98–13.9; P < 0.01), presence of abscess
(OR 17.6; 95% CI; 6.56–47.1;P < 0.01) and unidentified appendix (OR 8.84; 95% CI; 2.61–30.0; P < 0.01).
Conclusion: In this study, age (≥45 years), onset day (≥3 days), presence of abscess and unidentified appendix on
CT were the preoperative predictors of ER for acute appendicitis.
Recognition of these factors may be helpful in planning the surgical treatment for acute appendicitis.
64
Disclosure of Interest: None declared
65
18.33
SELECTIVE MANAGEMENT OF PENETRATING NECK INJURIES IN KING CHULALONGKORN MEMORIAL
HOSPITAL
J. Choadrachata-Anun1,*, S. Preechayudh1
1
Department of Surgery, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
Introduction: Selective management has played an important role and has been a standard management in
penetrating neck injuries since this approach has been shown to reduce unnecessary exploration. The purpose of this
study is to evaluate outcomes of selective management in King Chulalongkorn Memorial Hospital.
Materials & Methods: A retrospective study was performed in patients who had penetrating neck injuries in King
Chulalongkorn Memorial Hospital between Jan 2003 to Dec 2013. The patients with hard signs of neck injury (i.e.,
active bleeding, significant hematoma, and obvious airway injury) were treated by immediate neck exploration, while
patients with soft signs (other symptoms) and asymptomatic patients were considered candidates for selective
management. Data collection included demographic data, emergency department parameters, detail of neck injuries,
and outcomes in terms of mortality, negative exploration rate, and missed injury rate.
Results: A total of 86 penetrating neck injuries were included in the study (64 stab wounds, 12 gunshot wounds, 4
shotgun wounds and 6 other causes). Thirty-seven patients presented with hard signs and underwent immediate neck
exploration, negative exploration was found in 2 patients. Twenty-five patients presented with soft signs underwent
selective investigation and management, 6 patients required surgical interventions due to positive results of the
investigation with one negative exploration. Twenty-four patients were asymptomatic and underwent close
observation, none required subsequent neck exploration. There was no missed injury found in the present study.
Successful selective non-operative management was carried out in 43 patients (50%). The overall negative
exploration rate was 7 % (3 in 42 patients requiring neck exploration). Two patients with hard signs undergoing neck
exploration died from exsanguination (mortality rate 2 %).
Conclusion: Selective management of penetrating neck injuries based on physical examination and selective use of
investigation is safe and applicable with low negative exploration rate and no missed injury.
Disclosure of Interest: None declared
66
18.34
TUBE THORACOSTOMY: WHAT IS THE SAFEST ANGLE OF ATTACK?
M. Hernandez1,*
1
Surgery, Mayo Clinic - Rochester, Rochester, United States
Introduction: Background: Tube thoracostomy (TT) is not a benign, procedure. Complications are diverse and
remain to be defined uniformly. There is little quality evidence on which to base guidelines for insertion and
management. We aim to determine if angle of attack during placement of TT is associated with increased risk of
complication
Materials & Methods: Materials and Method: All trauma patients who necessitated TT at Mayo Clinic St. Mary’s
Campus over a 2 years month period were included. Among the all of the patients included (197 patients), a total of
334 were tubes placed in the emergent setting using standardized approach. Anteroposterior (AP) or posteroanterior
(PA ) radiographic images were reviewed for angle of attack of TT. Angle of attack was measured relative to chest
wall and subcutaneous structures using PACS. A defined complication list was utilized and complications were
recorded. Univariate statistics were utilized to compared complicated vs uncomplicated TT.
Results: Results: After TT placement all patients (n=197) had radiographic imaging performed. Placement occurred
at the trauma bay, surgical floor, or the surgical ICU. Placements of TT were performed by both surgical operators and
emergency department operators. Complication rate over the 24 month period were 20% in total. Uncomplicated chest
tubes 80%. One[JMA1] tailed T test was completed to determine a difference between the complicated and
uncomplicated groups. Angle of attack >60 degrees on the radiograph viewer was associated with increased rate of
complication, p < 0.00001.
Conclusion: Conclusion: Tube thoracostomy insertion is inherently a dangerous procedure with a significant
variability in performance and complication rates. Utilization of the chest tube angle immediately after insertion is
associated with increased risk of complication. Further prospective studies with intervention based on angle of attack
are needed to determine if increase angle of attack causes complications.
References: Ball et al. Chest tube complications: How well are we training our residents?
Can J Surg. Dec 2007; 50(6): 450–458.
Disclosure of Interest: None declared
67
18.35
WHICH CAUSE OF COMMUNITY ACQUIRED PERITONITIS IS THE DEADLIEST IN THE TROPICS? AN
ANALYSIS OF 305 CASES FROM SOUTH-WEST CAMEROON
A. Chichom-Mefire1,*, V. S. Verla2, A. T. Fon2, M. Ngowe ngowe2
1
2
Faculty of Health Sciences, University of Buea and Regional Hospital Limbe, Cameroon, Faculty of Health Sciences,
University of Buea, Buea, Cameroon
Introduction: The causes of generalized peritonitis vary widely from one setting to another and seem to be related to
mortality. Early prognostic evaluation of patients with acute generalized peritonitis is desirable to select high-risk
patients for intensive management. The aim of this study is to identify the most common causes of acute generalized
peritonitis and estimate their relative contributions to the death toll in a low-income setting.
Materials & Methods: In this retrospective analysis covering a period of seven years, we reviewed the records of
patients admitted and operated on for an acute diffuse peritonitis in two level III institutions located in the Fako division
in the South-West Region of Cameroon. For each patient admitted, we recorded data regarding clinical presentation
and diagnosis, operative findings with identification of the cause of peritonitis, and outcome. We analyzed mortality
related factors comparing the different causes of the acute generalized peritonitis.
Results: A total of 305 files could be analyzed. These included 168 males and 137 females, giving a sex-ratio of
1.23/1. Their ages ranged from 3 to 82 years with a mean of 30.6 ± 16.0 years. The five most common causes of
peritonitis identified during laparotomy included peptic ulcer perforation (22.6%), complications of acute appendicitis
(17.4%), post-abortum peritonitis following illegal abortions (14.4%), spontaneous perforations of terminal ileum
complicating a typhoid fever (14.1%) and abdominal injuries (12.5%). A total of 142 complications were recorded in 96
patients (31.5% complication rate). The overall mortality rate was 15.1% and the highest contributors to the death toll
were spontaneous perforations of terminal ileum (34.7%), post-abortum peritonitis (19.5%) and peptic ulcer
perforations (15.2%). Mortality was highly correlated to the Mannheim Peritonitis Index (P<0.001). Spontaneous
perforation of the terminal ileum, fecal peritonitis from volvulus of the sigmoid colon and complications of septic
abortions were the deadliest conditions.
Conclusion: Spontaneous perforation of terminal ileum (usually typhoid fever related), illegal abortion and peptic
ulcer perforations seem to be the highest contributors to the death toll of acute generalized peritonitis in our setting.
Patients in whom one of these causes is anticipated should be considered high risk and given special attention to
reduce the risk of complications and death.
Disclosure of Interest: None declared
68
18.36
WHAT ARE THE LIMITS OF NONOPERATIVE MANAGEMENT FOR PENETRATING SPLENIC TRAUMA?
R. Spijkerman1,*, M. Teuben1, F. Hoosain2, L. Taylor2, T. Hardcastle3, T. Blokhuis1, B. Warren2, L. Leenen1
1
2
Trauma, University medical center Utrecht, Utrecht, Netherlands, Trauma, Tygerberg Hospital, Cape Town,
3
Trauma, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
Introduction: Selective nonoperative management (NOM) for the treatment of blunt splenic trauma is safe. In
penetrating injuries it is clear that selective nonoperative management is feasible for liver injuries, but little is known
about the treatment of penetrating injuries in the spleen. Furthermore, it is still unclear whether preserving methods
for penetrating splenic injuries (PSI) can be applied. The aim of this study was to investigate the treatment and
outcome of selective NOM and surgical spleen preserving treatment for penetrating splenic injuries.
Materials & Methods: A dual-center study is performed in two level one trauma centers. We identified all patients
treated for PSI with a minimum age of 14 years. Individuals with both stab wounds (SW) and gunshot wounds (GSW)
were included. Patients were grouped based on the treatment they received. Group one consisted of splenectomized
patients, the second group included patients treated by a spleen preserving surgical intervention and group 3 included
those patients who were treated by NOM. Differences between groups were calculated with Fisher’s Exact Test and
Chi-square Test for ordinal data and 2-tailed T-test and Mann Whitney U test for continuous data.
Results: A total of 118 patients with a median age of 27 and a median ISS of 25 (IQR 16-34) were included. Ninetysix patients required operative intervention, of whom 45 underwent a total splenectomy and 51 were treated with
spleen preserving procedures. Seventeen of the 51 patients were treated by hemostatic techniques and 34 of the 51
patients underwent an operative intervention for the treatment of their abdominal injuries without the need to actively
treat the splenic injury. Splenectomy was more frequently performed in patients suffering from gunshot wounds
(SW=10/53 vs. GSW=35/65). Furthermore a total of 22 patients (SW=12/53 vs. GSW=10/65), were treated by NOM.
There were several anticipated significant differences in the baseline encountered. The median hospitalization time
was 8 (5-12) days, with no significant differences between the groups. The splenectomy group had significant more
ICU (2(0-6) vs. 0(0-1)) and ventilation days (1(0-3) vs. 0(0-0)) compare to the NOM group. Mortality was only seen in
the splenectomy group.
Conclusion: Spleen preserving surgical therapy for PSI injury is a safe treatment modality and not associated with
increased mortality. Moreover, a carefully selected group of patients with gunshot and stab wounds can be treated
without any surgical intervention at all.
Disclosure of Interest: None declared
69
18.37
EPIDEMIOLOGY, SEVERITY OF INJURIES AND RISK FACTORS OF ROAD TRAFFIC
ACCIDENT (RTA) CASES AT A GENERAL SURGICAL UNIT OF A TERTIARY CARE HOSPITAL IN SRI LANKA
W. A. K. Bandara1,*, K. Senanayake2, T. L. Premathilake1, W. N. T. Wijesundara1, S. M. M. Niyas1
1
Surgery, Teaching Hospital Kandy, Kandy, 2Department of Surgery, Rajarata University of Sri Lanka, Anadhapura,
Sri Lanka
Introduction: RTA has become an important cause of morbidity and mortality in Sri Lanka. Rapidly developing roads,
increasing number of speeding vehicles, increasing road users and rise in alcohol and narcotic usage are some of the
causes. Further studies at regional level needed, because of the pattern of injury may vary in different regions
Materials & Methods: This is a preliminary analysis using 116 RTA patients from an ongoing descriptional
prospective study of road traffic accidents, at General Surgical Unit II, General Hospital (Teaching) Kandy, from
10.09.2014 to 31.10.2014. Study Instrument was the interviewer administered questionnaire. Severity of injuries was
assessed using Injury Severity Score (ISS).
Results: There were 1302 of total admissions and 8.9% were RTA. 62% were male. Highest affected age group is 21
to 40 years (49.5%). Most of accidents occurred during daytime (74.3%) and 64.2% while raining. 45.7% following bus
accidents, 28% motor bicycles and 21.4% three-wheelers. Out of them 58.7% passengers, 26.3% drivers and 14.9%
pedestrians. 8.3% of RTA victims were alcohol users. All had less severe injuries (ISS <15) only 27.5% had
polytrauma.
Conclusion: Younger age groups and males were predominantly victimized by RTA. Most accidents occurred during
the daytime and while raining. However injury severity is less in this cohort. It needs further evaluation and urgent
attention to prevent RTA by educating the affected groups. Adding road safety to school curriculum will be helpful.
Disclosure of Interest: None declared
70
18.38
EPIDEMIOLOGY OF HAND INJURIES IN THE UNITED ARAB EMIRATES
M. Grivna1, H. Eid2, F. Abu-Zidan2,*
1
2
Community Medicine, Surgery, College of Medicine, UAE University, Al-Ain, United Arab Emirates
Introduction: We aimed to study epidemiology, risk factors and outcome of hospitalized patients with hand injuries in
order to give recommendations for prevention.
Materials & Methods: We studied all trauma patients with hand injuries admitted to Al Ain Hospital for more than 24
hours, or died after arrival to the hospital over 3 years. Demography, location, time, and severity of injury, injured body
regions, hospital and ICU stay, and outcome were studied.
Results: 297 patients having a mean age of 31 years were studied. 92.9% were males and 64% from the Indian
subcontinent. The annual incidence of hospitalization was 15.5/100 000 person per year. The most common location
for injury was work (52.5%), followed by road (26.3%) and home (11.8%). Injury from road traffic crash was the most
common mechanism (27.6%), followed by machinery (26.9%) and heavy objects (15.8%). Patients who were injured
at home were younger (p < 0.001) and had more females (p < 0.001).
Conclusion: Males from the Indian subcontinet are at a higher risk of injury at work, while UAE nationals at traffic or
home. Safety education and programs, use of personal protective equipment including gloves, and proper
enforcement of the safety guidelines could reduce hospitalizations and disability from these injuries.
Disclosure of Interest: None declared
71
18.39
IMPROVEMENT OF EMERGENCY MEDICINE IN THE REPUBLIC OF UZBEKISTAN
A. Khadjibaev1, K. Anvarov1,*
1
Surgery, Republican Research Centre for Emergency medicine, Tashkent, Uzbekistan
Introduction: Nowadays multiple types of injuries take the second place in the structure of mortality in Uzbekistan
after cardiac diseases. Meanwhile, the significant part of mortality can be prevented. The general lethality level
depends on the level of ambulance specialists’ skills, on managing of ICU assistance on spot, and on quality and
timeliness of emergency care.
Materials & Methods: In the year 2014 during various disasters in Uzbekistan more than 1200 people suffered, over
160 (13%) of them died. Analysis shows that mortality on spot makes up till 60%, on the way to hospital – 25%, in the
hospital – not more than 15 % from the total lethality.
For the last decades the system of phased emergency medical care to victims has been formed in
Uzbekistan.
Results: The first level (most important for further prognosis) means emergency medical care on spot including first
medical aid and qualified medical assistance provided by ambulance doctors.
The second level is medical aid providing on the way to hospital.
The third one is medical aid at the hospital.
Emergency medicine service (EMS) in Uzbekistan is consecutive and successive structure directed on the fast
patients and victims sorting and increasing of providing service ‘s quality. This system has three levels: primary
(primary health care link, ambulance service); middle level (172 emergency subbranches); and the high one (RRCEM
and its 13 regional branches).
Conclusion: Adequate medical supplying on the spot is the background to significant reducing of lethality.
There are some unsolved issues especially at providing medical aid at “golden” hour.
Consecutiveness and successiveness of performing medical aid at EC provides timeliness evacuation, sorting and
transporting of patients and victims.
Reasonability of transferring EC service from simple statement of fact of EC to the analysis of their reasons, creating
emergency medicine at all levels is obvious.
Disclosure of Interest: None declared
72
18.40
ROAD TRAFFIC ACCIDENTS IN A SELECTED AREA IN SOUTHERN SRI LANKA : ASSOCIATION BETWEEN
AETIOLOGICAL FACTORS AND OUTCOME
K. Jayasuriya1,*, A. Perera1, T. Mahanama1, P. Udara1, S. Widanapathirana1, D. Weerasekara2
1
2
Department of Surgery, Base Hospital Tangalle , Tangalle, Department of Surgery, University of Sri
Jayawardanapura, Colombo, Sri Lanka
Introduction: In Sri Lanka 103 Road Traffic Accidents (RTA) occur per day(2). Six victims are killed in RTAs each day
in Sri Lanka (2).
A number of factors contribute to the risk of collision; human factors and environmental factors are the main two arms
of the problem. In Sri Lanka main human factors involved are alcohol, fatigue, reckless driving, sleepiness, visual and
auditory acuity, decision making ability and not obeying road rules(5). Environmental factors play a major role as
aetiology for RTAs in Sri Lanka. Status of vehicles, road quality and multiple users of roads are few of them. As a
result of increasing number of vehicles and poor development of road infrastructure the incidence of traffic accident in
Sri Lanka shows an ever increasing trend with an alarming number of fatalities(3).
In 2010 of 2,515 fatal accidents, 722 involved motor cycles, 372 lorries, 314 private buses, 277 three wheelers and the
rest were with other vehicles such as cars and heavy vehicles.(2). There is no accurate central trauma registry in Sri
Lanka yet. Necessity of provincial trauma registries is also obvious since the local factors involved are different from
province to province.
Materials & Methods: Data were collected from the trauma data base using a data abstract form from 1st November
2013 to 31st October 2014. Data were analysed using the SPSS analytical package.
Patients with Injury severity Score (ISS) of 8 and above; aged 13 and above; due to RTA during the defined period
admited to the Emergency Treatment Unit were analysed.
Results: Of 405 victims, males (75.3%) aged 19-45 (65%) are mostly vulnerable to RTAs. Motor bike (n212, 52.4%)
accidents are main contributor for RTAs. 26.4% of them were not wearing helmets and 43.6% of helmet wearing riders
misused the helmet belts. 25% of drivers were under the influence of alcohol and 24% of victims were not having
driving license. Personal characteristics of victims; low economic status (71.4%) and low educational status (88%) are
significantly associated with incidence and poor outcome of road traffic injuries (P<0.05). Head and limb injuries are
common (60%). In a univariate analysis, Low educational status and poor economic status are significaltly associated
with incidence of RTA (P<0.05).
Conclusion: Most victims of RTAs were young males. The commonest victims are motor bike riders. Head injuries
are common among motor bike accidents and associated with misusing of helmets. Personal characteristics of
victims are significant contributors to an RTA.
References: 1. Haegi M.A new deal for road crash victims. British Medical Journal 2002;324:1110
2. Arasarathnam K. Current satus of accidents ; measures taken by police to minimize the problem. Proceeding of
124th Annual Scientific Session of Sri Lanka Medical Association 2011.
3. Somasundaram A K. Accidents statistics in Sri Lanka. IATSS reseach2006;30(1):115-17
4. WHO World report on Road Traffic Injury Prevention. Chapter 3 Risk Factor;2004.
5. Peethambaram Jeepara. Road Traffic Accidents in Eastern Sri Lanka: Analysis of admissions and outcome. The Sri
Lanka Journal of Surgery 2011:29(2):72-76
Disclosure of Interest: None declared
73
18.41
DISTRACTION-RELATED ROAD TRAFFIC COLLISIONS
H. Eid1, F. Abu-Zidan1,*
1
Surgery, College of Medicine, UAE University, Al-Ain, United Arab Emirates
Introduction: We aimed to prospectively study distraction-related road traffic collision injuries, their contributory
factors, severity, and outcome.
Materials & Methods: Data were collected on all road traffic collision (RTC) patients admitted to Al-Ain and Tawam
Hospitals over one and half years. Driver’s inattentive behaviors preceding the collision were prospectively collected
by interviewing the admitted patients.
Results: There were 444 drivers in the registry. 330 alert drivers had complete data on distraction prior to collision,
out of these only 44 (13%) were distracted. Most of distracted drivers were males (91%) having a median (range) age
of 28 (16-57) years. Nineteen (5.8%) drivers were distracted by using mobile phones, 12 (3.6%) were preoccupied
with deep thinking, six (1.8%) were talking with other passengers, four (1.2%) were picking things in the vehicle, and
three (0.9%) were using entertainment systems. The maximum distraction occurred during the time of 6 am to 12
noon when the traffic was crowded. There were no significant differences between distracted and non-distracted
drivers in demographical and physiological factors, injured regions, and outcome.
Conclusion: Majority of distracted drivers involved RTC in our setting were males using mobile phones. Prevention of
distraction-related RTC should focus on campaigns for safety promotion followed by law enforcement.
Disclosure of Interest: None declared
74
18.42
EPIDEMIOLOGY OF ROAD TRAFFIC INJURIES PRESENTING TO A TERTIARY HOSPITAL IN HYDERABAD,
INDIA
I. W. Howley1, S. Tetali2, J. K. Lakshmi2, S. Wadhwaniya3, M. Rao2, S. Gupta3, A. A. Hyder3, K. A. Stevens1,*
1
2
Surgery, Johns Hopkins University, Baltimore, United States, Indian Institute of Public Health, Hyderabad, India,
3
International Health, Johns Hopkins University, Baltimore, United States
Introduction: Road traffic injuries (RTI) kill more people in India than in any other country in the world, and these
numbers are expected to rise with increasing population density and motorization. Official statistics regarding RTI
incidence and fatalities are likely subject to significant underreporting. This study presents results of a hospital-based
surveillance program at a public tertiary hospital in Hyderabad, India.
Materials & Methods: Subjects included all consenting patients who presented to the casualty ward of a large public
tertiary hospital in Hyderabad, India following an RTI. Interviews were performed and data abstracted from clinical
records by trained research assistants. Data was collected for nine months, and included demographics, injury
characteristics, risk factors, safety behaviors, and clinical characteristics. Univariate and bivariate analyses were
performed.
Results: A total of 5,298 patients were enrolled; their mean age was 32.4 years (SD 13.8) and 87.3% were male.
58.2% of patients were injured while riding a motorcycle or scooter, 22.5% were pedestrians, and 9.2% used autorickshaws. The most frequent collision type was skid or rollover (40.9%). Male victims were younger than females and
were overrepresented among motorized two-wheeler users. Patients were most frequently injured between 16:00 and
midnight. 27.3% of patients were admitted. Hospital mortality was 5.3%, and 48.2% of these patients were motorized
two-wheeler users.
Image:
Conclusion: This appears to be the largest prospective hospital-based study of RTI epidemiology in India. The
patient population in this study was similar to prior hospital-based studies. When compared to government
surveillance systems, this study showed motorized two-wheeler users to be more frequently represented both in the
overall population and amongst fatalities. Further research needs to be completed and interventions developed to
decrease mortality associated with two-wheeled vehicles in India.
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Peden MM, World Health O, World B, (2004) World report on road traffic injury prevention World Health
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Peden M, (2010) Road safety in 10 countries. Injury Prevention 16:433-433.
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National Crime Records Bureau Accidental Deaths & Suicides in India 2013 (2014) Ministry of Home Affairs,
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hospital in south India. Int J Inj Contr Saf Promot 19:47-51.
28.
Agrawal A, (2011) Injury surveillance or trauma registry: Need of hour and time to start. Indian Journal of
Neurotrauma 8:37-40.
29.
Gururaj G, (2006) Road Traffic Injury Prevention in India, National Institute of Mental Health & Neuro Sciences,
Bangalore, India.
Disclosure of Interest: None declared
76
18.43
GENDER ADVANTAGES FOR TRAUMA CARE IN JAPAN
A. Tomonaga1,*, T. Fujita1, Y. Uchida1, T. Tsunoyama1, M. Kitamura1, T. Sakamoto2
1
2
Trauma and Resuscitation Center, Emergency Medicine, Teikyo University, Tokyo, Japan
Introduction: There have been some publications about the advantage for survival of females. However, there
has not been such a report for trauma care from Asian countries. We hypothesized that adult females, aged 15
to 45, in the hormonally active phase of life, are at lower risk for mortality than males after blunt and penetrating
trauma
Materials & Methods: This study used the data in the Japan Trauma Data Bank2004-2013 for 30229 patients
were transferred directly to the hospital without data deficits for hospital day, Injury Severity Score (ISS), age
and crude in-hospital survival. The population was divided by gender. The female included 7714 patients. The
male included 23515 patients. The Cox regression analysis was applied for the 30 days mortality by gender.
Results: The mean age with a 95% confidence interval (female vs. male) was 29.3(29.1-29.5) vs.29.7 (29.629.8) (p=0.001). The mean ISS was 15.4(15.1-15.6) vs. 15.4(15.3-15.6) (p=0.615). The crude in-hopsital survival
rate was 0.95(0.94-0.95) vs. 0.95(0.95-0.95) (p=0.076). Adjusted hazard ratio of 30 days mortality by Cox
regression was 1.006(95%C.I.:1.000-1.012, p=0.038) for age, 1.082(95%C.I.:1.079-1.084, p<0.001) for ISS,
0.972(95%C.I.:0.865-1.092, p=0.635) for female.
Image:
77
Conclusion: Cox hazard regression analysis did not demonstrated a positive value for the improving outcome in
a child-bearing population in Japan. This was the different results from previous study of Caucasian and
Hispanic rich cohort. It might be depended on the hormonal status by ethnic background of individual trauma
patients. Further investigation should be needed about this subject.
References: Napolitano LM, Greco ME, Rodriguez A, Kufera JA, West RS, Scalea TM:
Gender differences in adverse outcomes after blunt trauma. J Trauma 50:274–
280, 2001.
Disclosure of Interest: None declared
78
18.44
PATTERNS OF TRAUMA AND UTILIZATION OF SURGICAL RESOURCES BY PEDIATRIC TRAUMA PATIENTS
IN YAOUNDÉ: OPPORTUNITIES FOR INTERVENTION
C. Juillard1,*, M. K. Ngamby2, J. Cox3, M. E. Monono4, G. A. Etoundi Mballa2, R. A. Dicker1, A. A. Hyder3, K. Stevens3
1
2
Surgery, University of California, San Francisco, San Francisco, United States, Ministry of Public Health, Yaounde,
3
Cameroon, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States, 4World Health Organization,
Brazzaville, Congo
Introduction: Children comprise approximately 875,000 traumatic deaths annually worldwide, over 50% of which
occur in low- and middle-income countries (LMIC). As patterns of injury in the pediatric population may differ from
those in adults, risks specific to children in LMIC need to be identified for effective injury prevention and treatment. A
hospital-based trauma registry in Yaoundé, Cameroon, was used to explore patterns of pediatric injury to inform injury
prevention efforts and targeted health care resource allocation.
Materials & Methods: Data were collected from April through October 2009 on all trauma patients presenting to the
Emergency Ward of the Central Hospital of Yaoundé (CHY), the busiest trauma center in Cameroon's capital.
Information on demographics, injury context, injury severity score (ISS), clinical management, and outcomes were
recorded. Univariate, bivariate, and multivariate analyses were used to explore patterns of injury and relationships
between variables in the pediatric subset (age < 20 years).
Results: A total of 543 pediatric trauma patients presented during the 6-month period. Over half (53.4%) of patients
were victims of road traffic injuries, 53.1% of which were pedestrians. Pediatric patients were more likely to fall, get
burned, or get bitten by an animal than their adult counterparts (p<0.001), as well as more likely to be injured at home
(26.7% vs 13.2%). Major or minor surgical intervention was necessary for 17.9% and 20.8% of patients, respectively.
One third of patients (32.4%) had an ISS ≥9 and these children were more likely to need surgery in the multivariate
analysis (OR 10.2, p<0.001).
Image:
Conclusion: Opportunities exist for targeted prevention efforts in this context to reduce children’s specific vulnerability
to injury from falls, burns, and as pedestrian road users. Surgery comprises a significant portion of care delivered to
pediatric trauma patients, especially those most seriously injured. Resources should be allocated to strengthen
surgical delivery at centers receiving a large volume of trauma in Cameroon.
References: Ozgediz D, Hsia R, Weiser T, Gosselin R, Spiegel D, Bickler S, Dunbar P, McQueen K. Population
health metrics for surgery: effective coverage of surgical services in low-income and middle-income countries. World J
Surg. 2009 Jan;33(1):1-5. doi: 10.1007/s00268-008-9799-y.
Mock C, Abantanga F, Goosen J, Joshipura M, Juillard C. Strengthening care of injured children globally. Bull World
Health Organ. 2009 May;87(5):382-9.
Disclosure of Interest: None declared
79
18.45
CALL-TRIAGE SERVICES IN TOKYO MAY WORK APPROPRIATELY FOR EMERGENCY CARE OF HEAD
INJURY ?
-REVIEW BASED ON THE EMERGENCY MEDICAL CONSULTATION CENTER, TOKYO FIRE DEPARTMENTH. Ishikawa1,*, T. Ishihara,1, N. Morimura1, T. Sakamoto1 on behalf of Working Group of Emergency Medical
Consultation Center, Committee of Emergency Medicine, Tokyo Metropolitan Medical Association
1
Tokyo Metropolitan Medical Association, Tokyo, Japan
Introduction: We examined whether emergency triage by telephone might be successfully applied to head-injured
patients based on data obtained from emergency calls placed to the Emergency Medical Consultation Center, Tokyo
Fire Department, established June 1, 2007.
Materials & Methods: We investigated appropriateness of protocols for head injury. Analysis was carried out for
79,338 of all medical consultations in our center in 2011. For operation of the consultation center, more than one
hundred protocols are provided for equality and guarantee of consultations. After telephone-receptionists respond to
callers, nurses select protocols (including head injuries) for each medical consultation supported by on-site doctors.
Results: Among all consultations, 4,873 (6.14 %) were related children’s head injury while 1,407 (1.77 %) were
related adults’ head injury. Only 150 children were carried by ambulance while 671 children were recommended using
ambulance by the prepared protocol for child. Final degree of urgency at hospitals: 13 needed admission, 137 without
admission. On the other hand 220 adults were carried by ambulance while 661 adults were recommended using
ambulance by the prepared adult’s protocol for adult. Final degree of urgency at hospitals: 1 needed intensive care, 68
needed admission, 151 without admission. Admission rate was higher in adults (31.3 %) than in children (8.1 %).
Conclusion: The consultations about head injury in the center were judged and categorized for admission almost
appropriately. The low rate of admission (especially in children) should be discussed while adherence to given
protocols may prevent undervalued triage, even in the absence of actual examination.
Disclosure of Interest: None declared
80
18.46
ASSESSMENT OF QUALITY OF LIFE IN THE ELDERLY TRAUMA PATIENTS AT 6 MONTHS AFTER INJURY: A
PROSPECTIVE COHORT STUDY
N. Tamura1,*, H. Okamoto1, A. Kuriyama1, H. Uchino1, T. Kaihara1, T. Fukuoka1
1
Emergency medicine , Kurashiki central hospital, Kurashiki, Japan
Introduction: Previous research has shown a higher mortality and complication rate in the elderly trauma patients.
However, health-related quality of life (HRQOL) after injury in such patients has not fully been investigated. The aim of
our study was to assess HRQOL of elderly trauma patients using SF-36 Health Survey and the rate of return to the
workplace.
Materials & Methods: A prospective cohort study was performed in our tertiary care hospital from November 2013 to
November 2014. All consecutive trauma patients who were admitted to our department were included. Patients under
age of 18, with cognitive impairment and who deceased were excluded. All the data, including SF-36 and return to the
workplace, were obtained through interviews based on a standardized protocol by one emergency physician at
discharge and 6 months after injury. The Patient were divided into two groups with age ≧65 (elderly group) and <65
years old (younger group), and compared HRQOL and the rate of return to the workplace between the groups.
Results: During the 12-month period, complete data collection was achieved in 47 patients, and 26 (55%) of them
were ≧65 years old. Median age was 68 years (IQR; 48, 75), and 28 (59%) were male. Median ISS (Injury Severity
Score) was 17 (IQR; 13, 24), length of stay at our department was 13 days (IQR; 4, 48), and total length of hospital
stay was 54 days (IQR; 16, 104). There was significant (p<0.05) decrease in four of eight SF-36 domains: Physical
Functioning, Role-Physical, Social Functioning and Role-Emotional between two groups. Six patients (66%; n=6/9) in
elderly group and 4 patients (27%; n=4/15) in younger group did not return to their workplace at the follow-up.
Conclusion: Japanese elderly trauma patients had lower HRQOL domains and lower rate of return to the workplace
at 6 months after injury compared with younger trauma patients. Further research is needed to elucidate the long term
impact of trauma in HRQOL and job status in the elderly trauma patient.
Disclosure of Interest: None declared
81
18.47
FORCASTING THE OUTCOME OF SEVERELY TRAUMATIZED PATIENTS
Z. Lausevic1,*, B. Stojimirovic2, M. Gvozdenovic3, M. Lausevic2
1
2
Medical Faculty, University of Belgrade, Center for emergency surgery, Clinical Center of Serbia, Medical Faculty,
3
University of Belgrade, Clinic of Nephrology, Clinical Center of Serbia, Center of Emergency Surgery, Clinical Center
of Serbia , Belgrade, Serbia
Introduction: Trauma triggers a complex cascade of events important in predicting the outcome.
The study aim was to evaluate prognostic values of C reactive protein (CRP), interleukin 6 (IL-6), interleukin 10 (IL10), immunoreactive phospholypase A2 group II (PLA2-II), Simplified Acute Physiology Score (SAPS II), Injury Severity
Score (ISS) score, systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) and to develop
survival predictive models.
Materials & Methods: Study included 65 severely injured patients (ISS > 18), age 16- 65, admitted to hospital within
first 24 hours after the injury, survival longer then 48 h.
Concentration of CRP, PLA2-II, IL 6 and IL 10 were determined within the first, second, third, seventh and tenth day of
hospitalization. Criteria for SIRS, SAPS II and ISS score and multiple organ failure (MOF) development were assesed.
Univariate analysis and multivariate logistic regression model were used.
Results: Survived and deceased groups significantly differed in average values of: CRP, IL-6 for the four initial days,
IL-10 for the first, second, third and tenth day, PLA2 II for the first four days, and in the number of positive SIRS criteria
for the day 1, 4. and 5 and SAPS II score value on hospital admittance. The most important predictors of the survival
were the values of SAPS II, CRP for the day 2, mutually combined.
Table 1: Multivariate logistic regression model 1
SAPS II
B
0,122
CRP 2
0,008
Const.
6.179
S.E.
0,03
5
0,00
3
1.46
1
Wald
12.31
6
5.083
sign
0,0001***
R2
0,341
0,024*
0,410
17.89
6
0,0001
Ø
Y=-6.179 + 0,122 × SAPS II+ 0,008 x CRP 2
Conclusion: Positive SIRS characteristics, SAPS II score,as well as values of: CRP, IL-6, IL-10, PLA2 II can point to
the outcome. Predictive model that includes CRP for second hospital day and SAPS II score is important for survival
prediction.
Disclosure of Interest: None declared
82
18.48
DIRECT TRANSPORT VERSUS INTER HOSPITAL TRANSFER OF SEVERELY INJURED TRAUMA PATIENTS
S. Mans1,*, E. Reinders Folmer2, M. de Jongh1, K. Lansink1
1
2
St. Elisabeth Hospital, Tilburg, St. Elisabeth Hospital, Utrecht, Netherlands
Introduction: Several studies have suggested that severely injured patients should be transported directly to a
trauma centre bypassing the nearest hospital. Nevertheless, our trauma region employs a system in which these
patients are initially transported to the nearest hospital for treatment. Only if further treatment is required, patients are
transferred to a trauma centre. Patients suspected of Traumatic Brain Injury (TBI) are transported directly to a trauma
centre with neurosurgical care. The purpose of this study was to examine the benefits in terms of mortality of direct
transport to a trauma centre versus primary treatment in a level II or III centre followed by inter hospital transfer to a
trauma centre for severely injured patients without TBI.
Materials & Methods: We used the regional trauma registry and included all patients with an Injury Severity Score
(ISS) >15 and an abbreviated Injury Score (AIS) <4 for head injury. Patients who died in the emergency or operating
room of a level II or III centre were included as potential transfers (died before transportation to a designated trauma
centre could occur). A multiple logistic regression analysis was performed with potential confounders to produce an
adjusted odds ratio for mortality.
Results: A total of 439 patients were included. The majority of patients (79%) were transported directly to the trauma
centre. Of the 808 patients that were transported to a level II or III centre, 81 (10%) were eventually transferred to the
trauma centre and 9 patients (1.1%) died in the emergency room. There were no significant differences in baseline
and injury characteristics between groups. Overall, 60 patients died in-hospital, 41 patients (12%) in the direct group
and 19 (21%) in the transferred group. After adjusting for the Revised Trauma Score, the adjusted odds ratio of death
was 2.26 (95% CI 1.03-4.98).
Conclusion:
The results of this study suggest a lower risk of death for patients who are directly transported to a level 1 trauma
centre than patients who receive primary treatment in a level II or III centre and are transferred to a trauma centre
after initial management.
Disclosure of Interest: None declared
83
18.49
INJURY EPIDEMIOLOGY AND MORTALITY IN TWO COLOMBIAN TERTIARY-CARE TRAUMA CENTERS: DATA
FROM THE PAN-AMERICAN TRAUMA REGISTRY SYSTEM
A. Ramachandran1,*, A. Ranjit1, C. K. Zogg1, J. P. Herrera-Escobar2, L. F. Pino3, M. B. Aboutanous4, A. H. Haider1, C.
2,3
A. Ordonez
1
Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Department of
Surgery, Brigham and Women’s Hospital, Boston, MA, United States, 2Department of Surgery, Clinical Research
Center, Fundacion Valle del Lili, 3Department of Surgery, Hospital Universitario del Valle, Universidad del Valle, Cali,
4
Colombia, Division of Acute Care Surgery, Virginia Commonwealth University Trauma Center, Virginia
Commonwealth University Medical Center, Richmond, VA, United States
Introduction: Each year an estimated 5.8 million people die as a result of traumatic injuries, accounting for 10% of
deaths worldwide (32% more than the number of fatalities that result from malaria, tuberculosis, and HIV/AIDS
combined). In low- and middle-income countries (LMIC) where the burden of traumatic injuries is especially high, use
of standardized trauma registries has the potential to revolutionize the provision of trauma care. By facilitating
monitoring and evaluation of patient need, it helps to inform future treatment decisions and promotes improved
resource allocation. In the Americas, the Pan-American Trauma Registry System (TRS) is being developed for that
purpose. Using data from two of the first included tertiary-care trauma centers in Colombia, the aim of this study was
to describe the epidemiology of traumatic injuries and compare mortality in an LMIC setting.
Materials & Methods: January 1-December 31, 2012, data from the Hospital Universitario Del Valle (HUV, public)
and Fundacion Valle Del Lili (FLV, private) in Cali, Colombia, were considered. Differences in demographic and
clinical information were compared using descriptive statistics. Multivariable logistic regression was used to compare
risk-adjusted odds of mortality, accounting for potential confounding due to age, gender, insurance type, employment,
ISS score, heart rate, BP, and presence of hypotension (SBP<90).
Results: HUV (8,539; 78% male) and FLV (10,456; 60% male) had a combined total of 18,995 trauma cases in 2012
with comparable mean ages of 29.7y. Differences in demographic and clinical characteristics are presented in the
table. Overall (ED and inpatient) mortality was 4.10% and 1.09%, respectively. While the crude odds of death in HUV
relative to FLV were 4.28 times higher (95%CI 3.02-5.89; p<0.001), multivariable regression revealed that after
accounting for underlying differences in the case mix of the populations, no significant difference in the odds of death
was found (OR 0.77; 95%CI 0.27-2.18).
Image:
Conclusion: The study helped to establish the utility of the TRS and revealed important trends in patient
demographics, injury epidemiology, and mortality, which can be used to target trauma initiatives throughout the region.
It underscores the profound importance that differences in case mix play in the risk of trauma-related mortality, further
emphasizing the need to monitor and evaluate unique aspects of trauma in LMIC.
Disclosure of Interest: None declared
84
28.01
CME WITH CVL IN LAPAROSCOPIC SURGERY FOR TRANSVERSE COLON CANCER
Y. Koga1,*, A. Nomura1, H. Noshiro1
1
Surgery, Saga University, Faculty of Medicine, Saga, Japan
Introduction: Complete mesocolic excision (CME) with central vascular ligation (CVL) has recently been recognized
as a principle of colonic cancer surgery. However, CME with CVL for transverse colon cancer remain some difficulties
caused by anatomical complexities, such as vascular variations, lymphatic stream along gastro-colic trunk and 3dimensional (3D) structure of transverse mesosolon. In order to solve these troubles, we preoperatively examine the
image of vascular variations using 3D computed tomography with colonography (3-D CTC). Additionally, laparoscopic
surgery is usually performed using superior combined with medial approach. The aim of this study was to assess
surgical and oncologic outcomes of these approaches in laparoscopic surgery for transverse colon cancer.
Materials & Methods: Participants in the study comprised 41 patients with transverse colon cancer received curative
surgical treatment at our institute from 2011 to 2014. The 3D-CTC was performed prior to surgery.
Surgical procedures
1. Open omental bursa and dissect anterior layer of transverse mesocolon from stomach and pancreas (block of
upper lymphatic stream using superior approach)
2. dissect in the plane between the right and/or left mesocolon and parietal fascia (CME using medial approach)
3. encircle and ligate middle colic artery (CVL)
Results: All patients had a single ileocolic artery examined by 3D-CTC. One middle colic artery (MCA) was present in
84 % and two were present in 16 % of patients. The accessary MCA and ascending branch of left colic artery was
present in 20% and in 76%, respectively. Right hemicolectomy, transverse colectomy and left hemicolectomy were
performed in 39%, in 37% and in 24% of patients, respectively. The median operative time was 273 min, and blood
loss during operation was 65 ml. The median number of harvested nodes was 29. There were 7 postoperative
complications (17%). There was no conversion to open surgery. The median hospital stay after surgery was 9 days.
Conclusion: In conclusion, preoperative evaluation of vascular variations by 3D-CTC and laparoscopic surgery using
superior integrated with medial approach could contribute to perform an accurate CME and CVL for transverse colon
cancer.
Disclosure of Interest: None declared
85
28.02
THE USEFULNESS OF KI-67 INDEX AS PREDICTIVE FACTOR FOR THE RECTAL CANCER WITH
PREOPERATIVE CHEMO-RADIOTHERAPY.
K. Yoshikawa1,*, M. Shimada1, J. Higashijima1, T. Tokunaga1, T. Nakao1, M. Nishi1, H. Kashihara1, C. Takasu1
1
Department of Surgery, The University of Tokushima, Tokushima, Japan
Introduction: Preoperative chemo-radiation therapy (CRT) for advanced low rectal cancer has been shown to
increase the tumor resectability, improve sphincter preservation rate, decrease local recurrence and improve both
DFS and OS. The aim of this study is to evaluate the usefulness of the Ki-67 index as predictive factor for the rectal
cancer with preoperative chemotherapy.
Materials & Methods: Eighty-one patients who underwent surgery after preoperative CRT for rectal cancer were
examined. The resected specimen was evaluated for effectiveness of the CRT by grade and Ki67 index was
examined in immunohistochemistry. Next, stage II/III patients (n=56) were divided into positive and negative group.
(cut off line: 30%)
Results: In chemo-radiation effective grade, Ki-67 index is tend to be lower in Grede 2 compared with Grade
0/1.(31% vs 40% p=0.09). In stage II/III patients, the Ki-67 positive group had 29 and Ki-67 negative group had 17
patients. There was no significant difference between two groups in clinicopathological factors. The disease free
survival of Ki-67 positive group is significantly lower than Ki-67 negative group. (5 year 47% vs 97% p=0.02) and
overall survival of Ki-67 positive group is significantly lower than Ki-67 negative group. ( 5 year 71% vs 100%)
Conclusion: Ki-67 index is the predictive factor for rectal cancer with CRT.
Disclosure of Interest: None declared
86
28.03
NEW APPOARCH TO ENCHANCED RECOVERY COLON CANCER PATIENTS UNDER LAPAROSCOPIC AND
TRADITIONAL SURGERY
M. M. Pliss1,2,*, M. G. Pliss3
1
2
Faculty Surgery, FIRST ST.PETERSBURG MEDICAL UNIVERCITY I.P.PAVLOV, Surgery dep., St.Lucas clinical
3
hospital, Biophysics lab, FIRST ST.PETERSBURG MEDICAL UNIVERCITY I.P.PAVLOV, St.Petersburg, Russian
Federation
Introduction: Melatonin is involved in the regulation of multiple functions including external and autonomic control of
gastrointestinal system Melatonin exerts its physiological effects through specific receptors. regulating immune,
antinociceptive and number of other systems.
We propose, that preoperative treatment by melatonin can increase immunoresistivity, that is suppresed in case of
colon cancer, make shorter postoperative colon paresis, increase reparation of colon motility, that must leed to
decreased reabilitation period in patients.
Materials & Methods: We evaluated the immune status by measuring IL-6,2,10 levels in serum – before and after
surgical treatment in different patient groups – with and without melatonin preconditioning (3 mg per day orally during
1 week before surgical procedure).
68 patients suffering from colon cancer(with resectable colon cancer, excluding low rectal
localisations) were under melatonin preoperational treatment.
The control group of 32 patients with colon cancer had routine preoperational period and were under same surgical
treatment.
Patients were operatied by both laparoscopic and open technique.
Vital and physiological data were tested daily.
Blood plasma probes for IL were taken before surgical treatment, on first, third, seventh day after surgery.
Results: The results of preoperative treatment display decreased postoperative colon paresis period(decreasing of
paresis in open surgery group by 15%, in laparoscopic group by 28%),increased reparation of colon motility and
substansially shorter reabilitation period in patients and proved enhanced immune status.
Conclusion: Preoperational treatment by Melatonin decreasing postoperative pain, colon paresis enchancing
recovery period in case both open and laparocsopic colon surgery.
Disclosure of Interest: None declared
87
28.04
THE PROGNOSTIC SIGNIFICANCE OF A POSTOPERATIVE SYSTEMIC INFLAMMATORY RESPONSE IN
PATIENTS WITH COLORECTAL CANCER
M. Shibutani1,*, K. Maeda1, H. Nagahara1, H. Ohtani1, T. Toyokawa1, H. Tanaka1, K. Muguruma1, K. Hirakawa1
1
Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan
Introduction: Recently, a preoperative systemic inflammatory response has been reported to be a prognostic factor in
patients with colorectal cancer (CRC). However, the prognostic significance of a systemic inflammatory response in
the early stage after surgery in patients with CRC is unknown. The aim of this retrospective study was to evaluate the
prognostic significance of a postoperative systemic inflammatory response in patients with CRC.
Materials & Methods: Two hundred and fifty-four patients who underwent potentially curative surgery for stage II/III
CRC were enrolled in this study. Univariate and multivariate analyses were performed to evaluate the relationship
between the prognosis and clinicopathological factors, including the neutrophil to lymphocyte ratio (NLR) and Glasgow
Prognostic Score (GPS), which were measured within two weeks before operation and at the first visit after leaving the
hospital.
Results: The overall survival rates were significantly worse in the high preoperative NLR/preoperative
GPS/postoperative NLR group. A multivariate analysis indicated that only a postoperative NLR and the number of
lymph node metastases were independent prognostic factors for a poor survival.
Conclusion: The postoperative NLR is an independent prognostic factor in patients with CRC who underwent
potentially curative surgery.
Disclosure of Interest: None declared
88
28.05
DETECTION OF EPCAM AND CD44 DOUBLE POSITIVE CELLS FROM PERIPHERAL BLOOD IN PATIENTS
WITH GASTRIC CANCER TO USE OF FLOW CYTOMETER
T. Watanabe1,*, T. Okumura1, K. Hirano1, T. Yamaguchi1, S. Sekine1, T. Nagata1, K. Tsukada1
1
Department of Surgery and Science, Graduate School of Medicine & Pharmaceutical Sciences for Research,
University of Toyama, Toyama, Japan
Introduction: There were reports that Circulating tumor cells (CTCs) detected by Epithelial cell adhesion molecule
(EpCAM) were biomarker of metastasis, recurrence, and prognostic factor for solid tumor. On the other hand, we had
reported that CD44 was gastric cancer stem cell marker.The aim of this study was to detect EpCAM and/or CD44
positive cells from patients’ peripheral blood with gastric cancer(GC) and whether these are useful for biomarker of
metastasis, response evaluation, and prognosis.
Materials & Methods: This study intended for 16 patients with gastric cancer admitted of our hospital from April to
August 2014. 10 healthy volunteers were used as negative control.We took 3ml peripheral blood from each case and
counted EpCAM-APC and/or CD44-FITC labeled positive cells in flow cytometeter. And we evaluated them with these
patients’ clinicopathological factor.As a case of GC, we sorted and examined EpCAM-APC/CD44-FITC labeled
positive cells with transmitted light and fluorescence microscope.
Results: EpCAM positive cells were detected in all case and these count were 7.6±5.6 (healthy volunteers ) vs
11.4±84.5(patients) (P=0.0038). EpCAM/CD44 double positive cells were detected in only 2 cases of healthy
volunteers and these count were 0.4±0.96. On the other hand, these were detected in all patient with GC and these
count were 77.0±55.3.(p=0.0001)Moreover, EpCAM alone positive cell numbers were observed correlation with any of
the pathological factors, whereas EpCAM/CD44 double positive cell numbers were observed correlation with pStage,
pT, and v factor.We confirmed that there were expression of EpCAM and CD44 in Immunohistochemistry of all
primary tissue.In all case, EpCAM-APC/CD44-FITC labeled positive cells were decreased after treatment.
Conclusion: EpCAM / CD44 co-positive cell number was correlated with the degree of progress and venous invasion
than EpCAM alone-positive cell number.Thus, EpCAM / CD44 co-positive stain was more useful as CTC marker than
EpCAM alone-positive, and it was suggested potentially Circulating tumor stem cells.
Disclosure of Interest: None declared
89
28.06
EARLY EXPERIENCE OF DELTA-SHAPED ANASTOMOSIS IN TOTALLY LAPAROSCOPIC DISTAL
GASTRECTOMY
W. Yu1,*, O. K. Kwon1
1
Gastric Cancer Center, Kyungpook National University Medical Center, Daegu, Korea, Republic Of
Introduction: Gastroduodenostomy is widely performed as a reconstruction method after distal gastrectomy.
Innovative technique of delta-shaped anastomosis was first reported by Kanaya et al. in 2002. Here we introduce our
early experience of delta-shaped anastomosis.
Materials & Methods: From January 2013 to May 2014, 109 patients underwent laparoscopic distal gastrectomy in
Kyungpook National University Medical Center. Among them, 53 patients underwent extracorporeal Billroth I
anastomosis and 56 patients underwent intracorporeal delta-shaped anastomosis. We compared surgical outcome,
medical expense and postoperative 6 month quality of life using EORTC QLQ C30 and STO-22 between two groups.
Results: There was no significant difference in gender, mean age, body mass index, operation time, postoperative
hospital stay, width of proximal and distal resection margins, retrieved lymph node count and anastomosis-related
complications. There were two anastomotic leaks (Grade IIIb and II) in the extracorporeal anastomosis group and one
anastomotic leak (grade II) and one anastomotic edema (grade II) in the intracorporeal anastomosis group. Total
medical cost of the intracorporeal anastomosis group was higher than that of the extracorporeal anastomosis group
(11.7%; p<0.001). There was no difference in quality of life assessed 6 months after operation between groups except
for higher diarrhea scale in the intracorporeal anastomosis group (p=0.01).
Conclusion: When compared to conventional laparoscopy-assisted distal gastrectomy with extracorporeal
anastomosis, intracorporeal delta-shaped anastomosis seems to be comparable in feasibility, safety and short-term
quality of life, except for higher medical cost. Larger number of patients and further follow-up data will be need for
more precise comparison between the two methods.
Disclosure of Interest: None declared
90
28.07
INDOCYANINE GREEN (ICG) FLUORESCENCE ANGIOGRAPHY FOR THE RECONSTRUCTED GASTRIC TUBE
DURING ESOPHAGECTOMY
Y. Kumagai1,*, T. Ishiguro1, M. Fukuchi1, K. Ishibashi1, T. Kawano2, H. Ishida1, E. Mochiki1, J. Sobajima1
1
2
Digestive tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Surgery, Tokyo
Medical and Dental University, Tokyo, Japan
Introduction: To clarify the factors that affect the blood flow at the tip of the gastric tube using ICG fluorescence
angiography during esophagectomy.
Materials & Methods: We evaluated blood flow in the gastric tube using ICG fluorescence imaging in 47 patients
undergoing gastric tube reconstruction.
We measured the time from initial enhancement of the root of the right gastro-epiploic artery until enhancement of the
tip of the gastric tube as a substitute of the blood flow at the tip of gastric tube. We divided the patients into two groups
according to the anastomosis between the right and left gastro-epiploic vessels (r-l GV) as “present” (n=30) and
“absent” (n=17), or according to the anastomosis between the left gastro-epiploic vessels and short gastric vessels (l-s
GV) as “present” (n=18) and “absent” (n=29). We investigated the relations between these two observations and blood
flow at the tip of gastric tube. We also investigate the factors that affect the blood flow at the tip of the gastric tube
using multivariate analysis.
Results: The gastric tube was divisible into three zones according to the dominant arteries present in the greater
curvature using ICG fluorescence (i.e. Zone 1: the area that was dominated by the right gastro-epiploic vessels. Zone
2: the area that was dominated by the left gastro-epiploic vessels. In all cases, the left gastro-epiploic artery was
enhanced in a direction opposite to that of physiological blood flow. Zone 3: the area that was initially perfused with
short gastric vessels.). The median period of enhancement at the tip of gastric tube was significantly shorter in
“present” group (P=0.023) when divided according to the anastomosis between l-s GV. However, there was no
significant difference between “present” and “absent” groups when divided according to the anastomosis between r-l
GV (P=0.72). Presence of anastomosis between l-s GV and arteriosclerosis-related diseases were significant factors
affecting prolonged blood supply to the gastric tube by univariate analysis. On multivariate analysis, presence of
anastomosis between l-s GV was identified to be only dependent significant factor affecting prolonged blood supply
(p=0.023, OR=2.26).
Conclusion: It is essential to preserve the whole vessel arcade of the greater curvature to achieve
good blood perfusion in the gastric tube. Arteriosclerosis-related diseases are also crucial for safe
anastomosis in gastric tube reconstruction.
Disclosure of Interest: None declared
91
28.08
CLINICO PATHOLOGICAL FEATURES, TREATMENT PATTERNS AND OUTCOMES OF GASTROINTESTINAL
STROMAL TUMOUR
P. Shivanna1,*, P. Ramanathan1, S. V. S. Deo1, N. K. Shukla1, A. Sharma2, S. Thulkar3
1
2
3
Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India, Radiology, All India Institute of Medical
Sciences, New Delhi, India
Introduction: We present our analysis of clinicopathological features, treatment patterns and outcomes of
Gastrointestinal stromal tumours(GIST) in a tertiary care centre in India.
Materials & Methods: A prospectively maintained database in the Department of Surgical Oncology , BRA IRCH ,
AIIMS , New Delhi, India from 1995 to 2014 was retrospectively analysed. All the patients with the histopathologically
proven GIST were included for analysis.
Results: A total of 10,415 cancer patients undergone surgery from 1995 to 2014 including 1035 with soft tissue
sarcoma and 1750 with Gastro Intestinal malignancies. A total of 20 patients of GIST were identified contributing to
0.19% of the total operated cancer patients , 1.93% of soft tissue sarcomas and 1.14% of gastrointestinal
malignancies. The mean age of presentation was 51years (13 – 71) with a male preponderance ( M:F= 17:4). The
most frequent sites of involvement are stomach (7) followed by small bowel (6). Four patients received neo-adjuvant
Imatinib therapy due to locally advanced disease. Complete Radical resection was feasible in 17 out of 20 (85%) . As
far as histopathology details are concerned , majority belonged to Stage I ,the average tumour size was 7.7cms (2 to
17), and majority were of spindle cell histology variants. Ten of the surgically treated patients received adjuvant
Imatinib therapy. During follow-up 7 out of 17 (41%) patients had relapse including distant spread predominantly to
liver. The median overall survival was 26months (3 – 229).
Conclusion: Gastrointestinal stromal tumours are rare tumours constituting about 1% of gastrointestinal
malignancies. Stomach is the predominant site followed by small intestine. Curative resection could be performed in
85% . Despite aggressive surgery and adjuvant therapy one third of GIST patients relapse.
Disclosure of Interest: None declared
92
34.01
MUSCLE VOLUME RECOVERY AFTER CURATIVE RESECTION FOR COLORECTAL CANCER IS A NOVEL
PROGNOSTIC FACTOR.
Y. Yoshikawa1,*, K. Okabayashi1, H. Hasegawa1, M. Tsuruta1, T. Kondo1, T. Shimada1, M. Matsuda1, Y. Kitagawa1
1
Department of Surgery, Keio University, Tokyo, Japan
Introduction: A wealth of evidence has demonstrated that regular physical activity is associated with a lower risk of
death, all-cause mortality and cancer recurrence. Furthermore, several recent researches has reported that skeletal
muscles can represent an important source of inflammatory cytokines. These findings might suggest that skeletal
muscles is associated with tumor progression. However, it has not been established that muscle volume has the
impact on survival after surgery for colorectal cancer (CRC). The aim of this study is to evaluate the impact of muscle
volume on recurrence among CRC patients who underwent curative tumor resection.
Materials & Methods: Between December 2007 and December 2013, a total of 185 patients with stage I/II/III CRC
underwent curative resection in our institution. Skeletal muscle volume was measured by computed tomography (CT)
2
2
at the level of L3 vertebra, and normalized by stature (L3 lumber skeletal muscle index; SMI (cm /m )). We assessed
SMI pre- and post-operatively with CT taken before operation and at the first surveillance, and named SMI-pre and
SMI-post respectively. Then, we calculated SMI ratio (SMI-post / SMI- pre × 100 (%)) to evaluated correlation between
muscle volume change by tumor resection and recurrence. The impact of these variables on postoperative diseasefree survival (DFS) were analyzed using univariate and multivariate analyses.
Results: 130 male and 55 female were included. A median patient age was 69 (49 - 87) years. The pathological stage
was stage I in70 patients, stage II in 69 and stage III in 46. During 48.6 (6.3 - 94.1) months of median follow-up period,
recurrence was identified in 23 patients and overall 5-year DFS was 34.1% (63 / 185 patients). On univariate analysis,
neither SMI-pre nor SMI-post showed a significant difference for DFS (SMI-pre: Hazard ratio (HR) 0.98 [0.93-1.03], p
= 0.35, SMI-post: HR 1.00 [0.95-1.05], p = 0.96), but SMI ratio showed a significant difference （HR: 1.03 [1.01 –
1.05]，p < 0.01）. On multivariate analysis, it was shown that only SMI ratio was the independent prognostic factor for
DFS in all the variables （HR: 1.03 [1.01 – 1.05]，p < 0.01）.
Conclusion: A higher ratio of preoperative muscle volume to postoperative one is a novel
prognostic factor of CRC patients. Given that patients with advanced CRC frequently have
relatively large muscle volume loss, this finding might indicate the influence of large cytokines
excretion during postoperative muscle recovery on recurrence.
Disclosure of Interest: None declared
93
34.02
COLORECTAL CANCER IN A DEVELOPING COUNTRY WITH HIGH HIV PREVALENCE
Z. Moolla1,*, S. K. Pillay1, T. E. Madiba1
1
General Surgery, University of KwaZulu-Natal, Durban, South Africa
Introduction: There appears to be increasing incidence and differing clinical and pathological spectrum of colorectal
cancer (CRC) among indigenous Black patients in South Africa particularly with regard to the earlier age of
presentation. In a diverse ethnic population of approximately 53 million and with an estimated 12% prevalence of HIV
infection, predominantly affecting ages 25-40, the association of HIV and non-AIDS defining malignancies requires
1
investigation . Our aim was to compare the epidemiological and histological variation of CRC in HIV infected and
uninfected individuals.
Materials & Methods: Data of patients with CRC referred to Inkosi Albert Luthuli Central Hospital, Durban, South
Africa between 2005 and 2014 was collected prospectively. Demographic information, HIV status, CD4 count,
antiretroviral (ART) use, tumor location, histology and TNM stage were analyzed.
Results: Voluntary counselling and testing was performed on 236 (20%) of 1205 CRC patient referrals. One hundred
and eighty six patients (79%) tested negative and 50 (21%) tested positive for HIV of which 17 (34%) were on ART.
HIV infected patients were diagnosed with CRC at a significantly younger mean age (44 ±15 years) than HIV
uninfected individual (54 ±15 years) p <0.001. The male-female ratio was 2:1 in HIV negative patients compared to 3:5
in HIV positive patients. Left sided tumors were more common in both HIV infected and uninfected patients. Forty
seven percent of HIV positive patient presented with Stage IV disease compared to 29% of HIV negative patients.
Tumors were resectable in 106 (57%) of HIV negative patients compared to 22 (44%) of HIV positive patients.
Moderately differentiated tumors were most common in both groups with poorly differentiated tumors more common in
HIV infected patients (12% vs 3%).
Conclusion: In HIV infected patients with CRC there are several significantly poorer clinical and pathological features
compared to HIV uninfected patients. These findings strongly support a possible association between HIV and CRC.
References: 1. Shisana, O, Rehle, T, Simbayi LC, Zuma, K, Jooste, S, Zungu N, Labadarios, D, Onoya, D et al.
(2014) South African National HIV Prevalence, Incidence and Behaviour Survey, 2012 Cape Town, HSRC Press.
Disclosure of Interest: None declared
94
34.03
ASSOCIATION OF WT1 SINGLE NUCLEOTIDE POLYMORPHISMS RS16754 IN THAI COLORECTAL CANCERS
S. Sangkhathat1,*, W. Maneechay2, W. Chaiyapan3, S. Kanngern4, T. Boonpipattanapong5 on behalf of Tumor Biology
Research Unit, Faculty of Medicine, Prince of Songkla University
1
2
3
Department of Surgery, Central Research Laboratory, Faculty of Medicine, Prince of Songkla University, Biomedical
4
Science Program, Department of Biomedical Science, Faculty of Medicine, Hat Yai, Anatomical Pathology,
Bumrungrad International Hospital, Bangkok, 5Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
Introduction: Colorectal cancer (CRC) is one of the leading causes of cancer related death in Thai population. Our recent study
has demonstrated that expression of WT1 was associated with surgical outcomes in CRC patients (Bejrananda T 2010). This study
aimed to examine genetic association between single nucleotide polymorphism in WT1 gene, rs16754, and occurrence of CRC
using age-matched case-control model. In addition, correlation between the genotypes and WT1 expression was studied.
Materials & Methods: Genomic DNA samples from 104 CRC cases, aged 15-65 years, and 208 controls were genotyped for
rs16754 using Taqman genotyping method.
Results: Genotype distribution was not deviated from the Hardy-Weinberg Equilibrium (p-value 0.80). Minor allele frequency
(MAF) of the rs16754 (allele A) was 0.33. The MAF in CRC cases (0.39) was significantly higher than that of controls (0.31) (pvalue 0.03). The AA genotype was significantly associated with the disease at the odds ratio of 2.51 (95% confidence interval 1.245.07, p-value 0.01). Cases with AA genotype had significantly poorer 3-year overall survival (60%), compared to GG/GA genotypes
(80%) (Log-rank p-value < 0.01). Real-time reverse transcription PCR showed that expression of WT1 in tumor tissue was higher
than that of its normal counterpart. However, there was no significant difference in the expression among different genotypes in
neither mRNA nor protein level. Immunohistochemical scores (Allred score) in the AA group (6.4) and GA group (6.7) were not
significantly differed from that in GG group (5.9).
Conclusion: In summary, rs16754 was associated with the occurrence and prognosis of CRC in our populations.
References: Bejrananda T, Phukaoloun M, Boonpipattanapong T, Wanitsuwan W, Kanngern S, Sangthong R, Sangkhathat S.
WT1 expression as an independent marker of poor prognosis in colorectal cancers. Cancer Biomark. 2010-2011;8:35-42.
Disclosure of Interest: None declared
95
34.04
INCIDENTAL FINDING GALLBLADDER CANCER: AN 11 YEARS REVIEW.
P. -.- Sutthatarn1,*
1
Medicine, Chulalongkorn university, Bangkok, Thailand
Introduction: Incidental finding gallbladder cancer (iGBC) is the gallbladder cancer that was diagnosed from tissue
pathology with no pre-operative or intraoperative suspicion of malignancy. LC is now the gold standard for benign GB
disease and the difficulty of diagnosed, for these reasons the incidence of IGBC has increased. But the use of
laparoscopic approach in Gallbladder cancer(GBC) remains controversial and long term effect after LC in IGBC
remain unknown.
Materials & Methods: All patients who underwent a cholecystectomy were identified and retrospectively review of all
patients which were diagnosed GBC after cholecystectomy with benign condition from histopathological report at
th
KCMH between January 2002 - December 2013 and then follow up end point at 31 December 2014. Their medical
records, imaging data, operative notes, pathological reports and survival data were retrospective reviewed.
Results: The incidence of iGBC was 0.48% (n=29) for all cholecystectomy cases, but 0.22% at LC. There were 35
patients diagnosed iGBC but 6 patients excluded due to incomplete data record. Thus 29 patients were enrolled and
analysed in this study. Eighteen patients were women and 11 were men, with a median age 70 years (range: 36-96).
Of the 29 patients preoperative imaging showed gallstone in 18 patients, acute cholecystitis in 2 patiets, empyema
gallbladder in 3 patients, gallbladder polyp in 3 patients, adenomyomatosis in 1 patient and focal gallbladder wall
thickening in 1 patients. The GBC was staged as T1b in 2 patients, T2 in 9 patients, T3 in 14 patients and T4 in 4
patients. There were 12 patients that received second second operation in 10-90 day after cholecystectomy and the
study were founded carcinomatosis in 3 patients underwent LC before. The 5 year survival rates in T1b stage, T2
stage, T3 stage ,and T4 stage were 50%, 51.4%, 12% and 0% respectively.
Conclusion: The survival rate of iGBC is associated not only with depth of invasion and nodal status but also grading
of differentiation. LC is affected on adverse outcomes, for example carcinomatosis. Size of gallstone and polyp may
not associated with staging of the disease.
References: 1.Goetze TO, Paolucci V. Prognosis of incidental gallbladder carcinoma is not influenced by the primary
access technique: analysis of 837 incidental gallbladder carcinomas in the German Registry. Surg Endosc 2013
2.Steinert R, Nestler G, Sagynaliev E, Muller J, Lippert H, Reymond MA. Laparoscopic cholecystectomy and
gallbladder cancer. J Surg Oncol 2006;93:682-9
3.Goetze TO, Paolucci V. Benefits of reoperation of T2 and more advanced incidental gallbladder carcinoma: analysis
of the German registry. Ann Surg 2008;247:104-8
4.Dixon E, Vollmer CM, Jr., Sahajpal A, Cattral M, Grant D, Doig C, et al. An aggressive surgical approach leads to
improved survival in patients with gallbladder cancer: a 12-year study at a North American Center. Ann Surg
2005;241:385-94
Disclosure of Interest: None declared
96
34.05
MARGINAL ULCER PERFORATION - A SINGLE CENTER 5-YEAR EXPERIENCE
S. K. Natarajan1,*, K. Anbalakan2, D. CHUA2, V. G. SHELAT1
1
2
DEPARTMENT OF SURGERY, TAN TOCK SENG HOSPITAL, YONG LOO LIN SCHOOL OF MEDICINE,
SINGAPORE, Singapore
Introduction: Marginal ulcer or Anastomotic ulcer is defined as ulcer at the margins of the Gastro-jejunostomy (GJ),
mostly on the jejunal side. Most marginal ulcers are managed medically but those with complications like bleeding or
perforation require intervention. Different surgical options are offered for marginal ulcer perforation – Omental patch
repair, Revision of GJ, etc. The aim of this case series is to study the clinical presentation and management of
perforated marginal ulcers.
Materials & Methods: 332 patients who underwent emergency surgery for perforated peptic ulcer at our
institution over 5yrs were studied. Their demographic, clinical and outcome data was collected and analyzed.
Results: Nine patients (2.7%) presented with marginal ulcer perforation. Their median age was 71yrs (range 4480yrs) and the majority of patients were male (7/9, 77.8%). All patients had GJ done for previous complicated peptic
ulcer or gastric malignancy. All the patients presented with abdominal pain and the duration of pain was <24hrs in 4
(44.4%). Six (66.7%) had free air on erect chest x-ray. Seven patients (77.8%) had omental patch repair, one patient
(11.1%) each had revision of GJ and jejunal serosal patch repair. There were no leaks, intra-abdominal abscess or
reoperation. 7 patients (77.8%) had empirical treatment for H. Pylori. There were no malignancies evident and nil 30day mortality.
Conclusion: The etiology of marginal ulcer is unclear. Several factors contribute to acid peptic disease: H. pylori,
smoking, non-steroidal anti-inflammatory drugs, local ischemia and anastomotic tension. Surgery is indicated when
marginal ulcer is complicated by perforation. Omental patch repair is sufficient in majority of patients. Biopsy of
marginal ulcer is mandatory to exclude malignancy. Life long Proton pump inhibitor therapy is indicated to prevent
recurrence.
Disclosure of Interest: None declared
97
34.06
TREATMENT STRATEGY FOR ESOPHAGOGASTRIC JUNCTION CANCER
M. Yura1,*, H. Takeuchi1, E. Nakamura1, T. Takahashi1, N. Wada1, H. Kawakubo1, Y. Saikawa1, Y. Kitagawa1
1
Department of Surgery, Keio University School of medicine , Tokyo, Japan
Introduction: Esophagogastric junction carcionma incidence is increasing world wide. However, surgical strategies
for this cancer remain contraversial.This study aimed to clarify the optimal surgical strategy for EGJ cancer.
Materials & Methods: We retrospectively reviewed a data base of 123 consecutive patients with EGJ carcinoma
【Japanese classification of gastric carcinoma (Nishi's definition):N=111 and Siewert classification: type I, N=11; type
Ⅱ, N=81; type Ⅲ, N=6 ; adenocarcinoma (AD), N=98; squamous cell carcinoma (SCC), N=25】who underwent
curative surgical resection at Keio University Hospital between Junuary 2000 and December 2013. Pathological stage
of the depth of invasion was that pT1a (M), N=17; pT1b (SM), N=25; pT2 (MP), N=18; pT3 (SS or AD), N=49; pT4
(SE/SI or AI), N=14.
Results: The lymph node (LN) metastasis with superficial carcinoma (pT1a and pT1b) was observed in 1 patient
(16.7%) with Siewert type I and 1 patient (3.2%) with type Ⅱ. All type Ⅲ patients had T2 and/or depper lesion.
According to the Nishi's definition, supersicial carcinoma was observed in 36 patients (SCC,N=4; ad, N=32). 28.6%
(4/14, SCC=4) of the patients with tumor center located above the EGJ had LN metastasis and 9.1% (2/22, ad=2) was
obeserved in the patients with tumor center was located below the EGJ. Of all patients, mediastinal LN
metastasis was observed in 3 patients (27.3%) with Siewert type I, 3 patients (3.7%) with typeⅡ and 14 patients
(12.6%, SCC=8, AD=6) with EGC defined by Nishi's classification. As for all these patients, the tumor center was
above the EGJ. The mean length of the tumor invasion to the esophagus with Siewert type I is 37.6mm (mediastial LN
metastasis was negative,MLN-) vs 51.8mm (mediastinal LN metastasi positve, MLN+), with typeⅡ is 7.89mm (MLN-)
vs 23.3mm (MLN+) and with EGC defined by Nishi's clasiffication is 11.6mm (MLN-) vs 27.8mm(MLN+). Sentinel LN
(SN) resection was performed in the 15 patients with cT1a or cTlb. 14 patients had no metastasis of SN and they
showed same result (N0) with final pathological report.
Conclusion: Even if it is superfical carcinoma, EGC with tumor center located above EGJ showed relatively high rate
LN metasitasis. MLN dissection seems unncessary when the tumor center is located below the EGJ. In that case, we
can choose low invasive surgeries such as the laparoscopic proximal gastrectomy. MLN metastasis may have the
relation with the length of tumor invasion to the esophagus. SN resection may useful to decide optimal LN dissection.
References: 1. Blot WJ, Devesa SS, Kneller RW, Fraumeni JF Jr. Rising incidence of adenocarcinoma of the
esophagus and gastric cardia. JAMA. 1991;265:1287-9.
2.Matsuda T, Takeuchi H, Kitagawa Y. Optimal surgical management for esophagogastric junction carcinoma. Gen
Thorc Cardiovasc Surg. 2014;62:560-566.
Disclosure of Interest: None declared
98
34.07
SURGICAL STRATEGY FOR GASTRIC CANCER IN OVER 85-YEAR-OLD PATIENTS
Y. Saito1,*, H. Takeuchi1, K. Fukuda1, R. Nakamura1, T. Takahashi1, N. Wada1, H. Kawakubo1, Y. Kitagawa1
1
Department of Surgery, Keio University School of Medicine, Tokyo, Japan
Introduction: To evaluate the outcome of surgery for the gastric cancer in elderly patients, we compared 80 to 84year-old patients and over 85-year-old patients.
Materials & Methods: This follow-back study included a total of 127 patients aged 80 or older who underwent
gastrectomy from January 2000 to December 2012. 97 patients were 80 to 84 years old (early-80s group) and 30
patients were over 85 years old (over-85 group). The average age was 82.8 years old (a range of 80-92), and 85 men
and 42 females were included.
Results: Fifty five patients were early gastric cancer (early-80s group, n= 39; over-85 group, n=16), and 72 patients
were advanced gastric cancer (n=58; n=14). Three-year survival rate was 67.6% in early cancer (early-80s 96.3%;
over-85 72.7%) and 89.5% in advanced cancer (72.4%; 50.0%). Non-relapse mortalities of both early cancer and
advanced cancer were higher in over-85 group than in early-80s group (5.13%, 18.8% in early cancer; 3.45%, 7.14%
in advanced cancer). Most common complications in both groups were arrhythmia (27.6 %), and aspiration
pneumonia (8.7 %). Incidence of arrhythmia did not differ between the two groups. Incidence of aspiration pneumonia
was significantly higher (5.2% vs 20.0%; p=0.012) in over-85 group. 54.2% patients underwent limited
lymphadenectomy and 18.1% patients underwent function preserving limited gastrectomy. Survival rate after
gastrectomy did not differ between standard surgeries and limited surgeries. Rate of limited lymphadenectomy and
function preserving limited gastrectomy in early cancer were significantly higher in over-85 group than in early-80s
group (p=0.001; p=0.007).
Conclusion: An appropriate limited surgery can be one of the options for gastric cancer treatment with over 85-yearold patients, because non-relapse mortality was higher and neither limited lymphadenectomy nor function preserving
limited gastrectomy resulted in worsening of survival rate. Over 80-year-old patients often had arrhythmia after
surgery, therefore electrocardiographic monitoring was important. For high risk of aspiration pneumonia in over 85year-old patients, test of swallow function after surgery can be helpful to reduce the complication.
Disclosure of Interest: None declared
99
34.08
ERCP BY LAPAROSCOPIC TRANSGASTRIC ACCESS IN PATIENTS WITH GASTRIC BYPASS PRESENTING
WITH BILIARY DISEASE
J.-P. M. Magema1,*
1
Digestive and Metabolic Surgery, CHU Dinant- Godinne UCL Namur, Dinant, Belgium
Introduction:
Preexisting biliary disease in morbidly obese patients can lead to biliary complications because of rapid weight loss
after Roux-en-Y gastric bypass (RYGBP). The conventional endoscopic access to the biliary tract is limited principally
for anatomic reasons. ERCP with balloon assisted enteroscopy has been reported to be feasible but has several
limitations as a time-consuming procedure, with failures to identify the anastomosis site and the lack of adapted
accessories. ERCP by laparoscopic transgastric access (ERCP-LTA) represents an alternative.
Materials & Methods: We report all patients with RYGBP who experienced biliary complications (mainly
choledocolithiasis) and were managed by ERCP-LTA. After creating a laparoscopic pneumoperitoneum, an incision
was made in the anterior and distal part of the bypassed stomach close to the pylorus. A side-viewing endoscope was
introduced through a 15 or 18-mm trocar on the left-upper quadrant and after creating a purse-string suture on the
greater curvature of the gastric remnant. ERCP with sphincterotomy was performed under fluoroscopic guidance.
Carbon dioxide gas was used for endoscopic insufflation. After removal of the scope, gastrostomy incision was closed.
If necessary, laparoscopic cholecystectomy was performed. Antibiotics were given for 7 days.
Results: Twenty patients underwent ERCP-LTA between May 2008 and Apr 2013 (17 women and 3 men with a mean
age of 53 y, range 26-80). Biliary stones or sludge extraction after sphincterotomy could be achieved in 19 patients. In
the 20 patient sphincterotomy was performed for papillary stenosis. A concomitant laparoscopic cholecystectomy was
performed in 14 patients. The mean endoscopic procedure duration was 53 min (range 15-120). No complications
occurred, Mean hospital stay was 3.3 days (range 2-5). Laparoscopic access was converted to a minilaparotomy in 1
patient with multiple previous surgeries due to bypass complications.
th
Conclusion: ERCP-LTA is a feasible approach for the management of common bile duct stones in post-RYGBP
patients and allows for ERCP and cholecystectomy to be performed consecutively in a single procedure.
Disclosure of Interest: None declared
100
39.01
EVALUATION OF EXTRAHEPATIC PORTACAVAL SHUT CREATION IN CANINE USING NOVEL MAGNETIC
ANASTOMOSIS RINGS
X. Yan1,2,3, J. Lu1,2,3,*, J. Ma4, X. Zheng1,2,3, J. Li2,3,5, F. Ma2,3, H. Wang2,3, Y. Lv 1,2,3
1
2
Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi’an Jiaotong University, XJTU Research Institute of
3
Advanced Surgical Technology and Engineering, Regenerative Medicine and Surgery Engineering Research Center
of Shaanxi Province, Xi’an Jiaotong University, 4Department of Surgical Oncology, 5Department of Oncology Surgical,
Third Affiliated Hospital, Xi’an Jiaotong University (Shaanxi Provincial People’s Hospital), Xi’an, China
Introduction: The hand-sewn anastomosis has been playing an important role in extrahepatic portacaval shut since
introduced initially. However, hand-sewn anastomosis procedures by means of laparoscope or other less invasive
devices are more time-consuming and technically demanding. In this study we evaluated a novel technique to create
extrahepatic portacaval shut using magnetic anastomosis rings in canine.
Materials & Methods: 18 dogs were randomly divided into 2 groups (n=9 per group) in the 9th week after their partial
portal vein ligation. In the study group, animals underwent extrahepatic portacaval shut achieved by magnetic rings,
while the control group dogs underwent traditional method. The operating time, portal vein pressure and serum
biochemical indices were observed. Anastomotic patency was evaluated by means of color doppler imaging,
venography, gross and histological examinations at 24 weeks later.
Results: The time required for anastomosis was significantly shorter for the magnamosis than for hand sewing
(4.12±1.04 minutes vs. 24.47±4.89 minutes, p<0.01). Although no anastomotic leakage occurred in the two groups,
the anastomotic stoma in the control group became larger than envisioned. The portal vein pressure of the study
group showed higher stability than the control group. The blood ammonia level of study group was significantly lower
at 24 weeks after shunt. Gross and histological observations indicating the smoothness and continuity of the vascular
intima were better in the study group.
Image:
Conclusion: The magnamosis technique for portacaval shunt is safer, faster, and may be clinically potential for the
treatment of portal hypertension.
Disclosure of Interest: None declared
101
39.02
HOSPITAL OF DIAGNOSIS FOR PANCREATIC CANCER INFLUENCES SURGERY RATE AND SURVIVAL IN A
NATIONWIDE ANALYSIS: A PLEA FOR FURTHER CENTRALIZATION
M. Bakens1,2,*, Y. van Gestel2, M. Bongers 1, M. Besselink3, C. Dejong4, V. Lemmens2, I. de Hingh1 on behalf of Dutch
Pancreatic Cancer Group
1
Surgery, Catharina Hospital Eindhoven, The Netherlands, 2Netherlands Cancer Registry, Comprehensive Cancer
Organisation Netherlands, Eindhoven, 3Surgery, Academic Medical Center, Amsterdam, 4Surgery, Maastricht
University Medical Center, Maastricht, Netherlands
Introduction: Since surgical resection is the only chance for long-term survival, determining the resectability of a
pancreatic tumor is a crucial step. Although centralization for surgical expertise has improved the resection rates of
pancreatic cancer in recent years, diagnostic work-up for M0-pancreatic cancer patients is not centralized in the
Netherlands. The current study investigated whether the hospital of initial diagnosis influenced the chance of
undergoing surgery and the effect on survival.
Materials & Methods: All patients diagnosed with M0-pancreatic cancer between 2005 and 2012 in The Netherlands
were included. Population-based data were obtained from the nationwide Netherlands Cancer Registry. All 97
hospitals were classified as either “pancreatic center” or “non-pancreatic center”, based on high-volume (>20/year)
pancreatoduodenectomies performed in 2012. Groups were compared using chi-square tests. The relationship
between diagnostic center and the chance of undergoing surgery was analysed by multivariable logistic regression.
The influence of hospital of diagnosis on overall survival was assessed using multivariable Cox regression analysis.
Results: Seventeen hospitals were designated as a pancreatic center (17.5%). Of the 7276 included patients, 2657
(36.5%) underwent surgery with a curative intent. This proportion was 51% of patients diagnosed in pancreatic centers
and 30% for non-pancreatic centers. Actual resection was done in 42% for pancreatic centers and 23.2% for nonpancreatic centers. In multivariable analysis, patients diagnosed in a pancreatic center were more likely to undergo
surgery with a curative intent (OR 2.11 95%CI 1.88-2.36). Diagnosis in a pancreatic center was associated with
improved survival compared to diagnosis in a non-pancreatic center (HR 0.93; 95%CI 0.88–0.99).
Conclusion: In this nationwide analysis, patients diagnosed with M0-pancreatic cancer in a pancreatic center were
more likely to undergo a potentially curative resection and had better survival. This suggests that patients with M0pancreatic cancer who are not referred for resection should undergo assessment by a specialized team.
Disclosure of Interest: None declared
102
39.03
RANDOMIZED CLINICAL TRIAL OF LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS VERSUS
LAPAROSCOPIC SLEEVE GASTRECTOMY FOR PATIENTS WITH BMI 40-50 KG/M2
P. Chanswangphuvana1,*, R. Tanompetsanga1, N. Boonyagard1, P. Vichajarn1, S. Udomsawaengsup1
1
Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Introduction: Obesity becomes a widely recognized public health problem. Bariatric surgery has been accepted as a effective treatment
for morbidly obese patients. Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is currently considered the gold standard bariatric
procedure with documented safety and effectiveness. Laparoscopic Sleeve Gastrectomy (LSG) is a relatively innovative procedure being
done with increasing in popularity as a sole bariatric procedure. Randomized comparative trials of both procedures are limited. We
present the prospective randomized trial comparing safety and 1-year result of LSG and LRYGB in the Thai
population.
Materials & Methods: From January 2011 to December 2013, sixty eligible patients with body mass index (BMI) 40-50 kg/m2 were
randomized to LRYGB (30 patients) or LSG (30 patients). Both groups were comparable regarding age, gender, body mass index (BMI)
and co-morbidities. Patients were monitored for at least 1 year postoperatively. Percent excess weight loss (%EWL), morbidity, mortality,
improvement of obesity related co-morbidities and nutritional deficiencies were compared between groups.
Results:
There was no mortality and no significant difference in early morbidity (13.3% after LRYGB and 16.7% after LSG, p >
0.05) or late morbidity (33.3% after LRYGB and 26.7% after LSG, p > 0.05). Weight loss in term of %EWL was
significantly better after LRYGB at 1 year of follow-up. (68.5% after LRYGB and 57.9% after LSG, p = 0.038). There
was no significant difference in the improvement of Type 2 Diabetes (88.9% after LRYGB and 81.8% after LSG, p >
0.05) and nutritional deficiencies (23.3% after LRYGB and 20% after LSG, p > 0.05).
There was no mortality and no significant difference in early morbidity (13.3% after LRYGB and 16.7% after LSG, p >
0.05) or late morbidity (33.3% after LRYGB and 26.7% after LSG, p > 0.05). Weight loss in term of %EWL was
significantly better after LRYGB at 1 year of follow-up. (68.5% after LRYGB and 57.9% after LSG, p = 0.038). There
was no significant difference in the improvement of Type 2 Diabetes (88.9% after LRYGB and 81.8% after LSG, p >
0.05) and nutritional deficiencies (23.3% after LRYGB and 20% after LSG, p > 0.05).
Conclusion: Laparoscopic Roux-en-Y Gastric Bypass is significantly more effective than Laparoscopic Sleeve Gastrectomy in weight
reduction at 1 year of follow-up for Thai population. However, both procedures are not only safe but also have high success rate of
glycemic control.
Disclosure of Interest: None declared
103
39.04
RANDOMISED CONTROLLED TRIAL OF PERIOPERATIVE SIMVASTATIN THERAPY IN MAJOR COLORECTAL
SURGERY
P. Singh1,*, D. Lemanu1, M. Soop2, I. Bissett3, J. Harrison4, A. A. Hill1
1
2
3
4
Surgery, The University of Auckland, Surgery, North Shore Hospital, Surgery, Auckland City Hospital, Pharmacy,
The University of Auckland, Auckland, New Zealand
Introduction: Statins have numerous benefits relevant to abdominal surgery, such as decreasing peritoneal
inflammation and improving survival in abdominal sepsis. In clinical studies, their use has been associated with a
reduction in the systemic inflammatory response syndrome (SIRS), wound infection and anastomotic leak following
colorectal surgery. However, this clinical evidence is limited to retrospective studies. This study aimed to prospectively
investigate whether perioperative statin therapy can attenuate the surgical pro-inflammatory response and reduce
complications following major colorectal surgery.
Materials & Methods: A multi-centre, double blind, parallel-group, randomised controlled trial was conducted at three
tertiary hospitals in the Auckland Region of New Zealand between October 2011 and August 2013. Patients
undergoing elective colorectal resection for any indication or reversal of Hartmann’s procedure were randomised to
receive either 40mg oral simvastatin or an identical placebo once daily for 3-7 days before surgery till 14 days after
surgery. The primary outcome was the total incidence of complications for 30-days postoperatively. Secondary
outcomes included the systemic and peritoneal cytokine response (IL-1α, IL-1β, IL-6, IL-8, IL-10, TNFα), measured in
venous blood and samples of abdominal drain fluid on postoperative day 1, respectively. Concentration of C-reactive
protein (CRP) and the presence of SIRS was evaluated on postoperative days 1 to 3.
Results: There were 132 patients included in the study, with 65 patients allocated to the simvastatin group and 67
patients to the placebo group. There were no significant differences between the two groups at baseline with regards
to patient, operation and disease characteristics. There were no significant differences between the two groups in the
incidence, grade and type of postoperative complications. Systemic levels of IL-6, IL-8 and TNFα, and peritoneal
concentrations of IL-6 and IL-8, were significantly lower in the simvastatin group postoperatively. CRP levels were
significantly lower in the simvastatin group on postoperative days 1 to 3. A lower number of patients in the simvastatin
group exhibited SIRS on day 1 and 2 postoperatively, but this difference did not reach statistical significance.
Conclusion: Perioperative simvastatin therapy in major colorectal surgery attenuates the early pro-inflammatory
response to surgery but does not reduce postoperative complications.
Disclosure of Interest: None declared
104
39.05
IMPACT OF REOPERATION AFTER MAJOR HEPATECTOMY ON THE SHORT AND LONG-TERM OUTCOME
FOR HEPATOCELLULAR CARCINOMA
W. H. She1,*, A. C. Chan1, T. T. Cheung1, K. S. Chok1, S. C. Chan1, R. T. Poon1, C. M. Lo1
1
Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
Introduction: Despite advancement in operative techniques for major hepatectomy over the last
decade, postoperative morbidity rate remained significant at around 20%. Early reoperation for
complications imposed significant risk and surgical stress to patients. We sought to determine the
short- and long-term impact of reoperation after major liver resection of hepatocellular carcinoma
(HCC).
Materials & Methods: From January 1989 to December 2013, the postoperative and oncological
outcomes of all patients who received reoperation within 30 days after major hepatectomy for HCC
in Queen Mary Hospital were reviewed. Survival analysis was performed by Kaplan Meier
methods and compared between subgroup with log-rank test. Risk factors for reoperation were
determined by Cox regression model.
Results: A total of 1001 patients underwent major hepatectomies for HCC during the study period. 47 patients
required reoperation within 30 days from the initial operation. These patients had similar baseline characteristics and
liver functions. However, patients with reoperations were more likely to have higher indocyanine green clearance test
at 15 minutes (12.65% vs 10.4%, p=0.006) preoperatively, more intraoperative blood loss (1.4l vs 1l, p=0.016), and
higher blood transfusion requirements (44.7% vs 29.9%, p=0.031). The number of abdominal drain placed in both
groups were similar (51.1% vs 40.6%, p= 0.51). Hemorrhage was the commonest cause for reoperation (n=26/47,
55.3%). coagulopathic bleeding from raw area (n=12, 46.2%) and injury to diaphragmatic vein (n=6, 23.1%) were the
main culprits for hemorrhage. Hospital stay for the re-operated patients were significantly longer (21 vs 11 days,
n<0.0001) and the 30-day mortality rate was also higher (n=18, 38.3%, p<0.0001). Nonetheless, reoperation had no
impact on the long-term survival after hepatectomy (5-year overall survival: non-reoperation 46.2% vs reoperation
49.6%, p=0.411).
Conclusion: Careful perioperative management and meticulous haemostasis remained the
important elements in hepatectomy as postoperative hemorrhage was associated with high
mortality. Oncological outcome was not jeopardized by reoperation.
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Jin S, Fu Q, Wuyun G, Wuyun T. Management of post-hepatectomy complications. World journal of
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Lim C, Dokmak S, Farges O, Aussilhou B, Sauvanet A, Belghiti J. Reoperation for post-hepatectomy
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Yang T, Li L, Zhong Q, Lau WY, Zhang H, Huang X, et al. Risk factors of hospital mortality after relaparotomy for post-hepatectomy hemorrhage. World journal of surgery. 2013;37(10):2394-401.
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Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben-Porat L, Little S, et al. Improvement in perioperative
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Poon RT, Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, et al. Improving perioperative outcome expands the
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patients from a prospective database. Annals of surgery. 2004;240(4):698-708; discussion -10.
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Du ZG, Wei YG, Chen KF, Li B. An accurate predictor of liver failure and death after hepatectomy: a single
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Fukushima K, Fukumoto T, Kuramitsu K, Kido M, Takebe A, Tanaka M, et al. Assessment of ISGLS
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Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, Yeung C, et al. Hepatectomy for hepatocellular carcinoma:
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Fan ST. Precise hepatectomy guided by the middle hepatic vein. Hepatobiliary & pancreatic diseases
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Melendez JA, Arslan V, Fischer ME, Wuest D, Jarnagin WR, Fong Y, et al. Perioperative outcomes of major
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Liu CL, Fan ST, Lo CM, Wong Y, Ng IO, Lam CM, et al. Abdominal drainage after hepatic resection is
contraindicated in patients with chronic liver diseases. Annals of surgery. 2004;239(2):194-201.
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Nagasue N, Kohno H, Chang YC, Taniura H, Yamanoi A, Uchida M, et al. Liver resection for hepatocellular
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25.
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26.
Vauthey JN, Klimstra D, Franceschi D, Tao Y, Fortner J, Blumgart L, et al. Factors affecting long-term
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Sheen PC, Lee KT, Chen HY, Chen JS, Ker CG. Conservative hepatic resection for hepatocellular
carcinoma of cirrhotic patients. International surgery. 1996;81(3):280-3.
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2009;250(5):720-8.
Disclosure of Interest: None declared
106
39.06
WIDE RESECTION MARGIN IMPROVES SURVIVAL IN PATIENTS WITH EARLY INTRAHEPATIC
CHOLANGIOCARCINOMA
K. MA1,*, T. Cheung1
1
Surgery, Queen Mary Hospital, Hong Kong, China
Introduction: ICC is known for its lethal disease nature, studies had focused on factors that might affect disease
survival; among these factors, resection margin status remains one of the few modifiable factors that a surgeon could
possibly alter the disease outcome. However, the significance of clear margin and margin width remain controversial.
This study serves to share our opinion on this issue.
Materials & Methods: A retrospective review of a prospectively maintained database was performed in Department
of Surgery, Queen Mary Hospital, University of Hong Kong. Consecutive patients diagnosed to have ICC and with
surgical resection performed in curative intent were retrieved, while patients with cholangiohepatocellular carcinoma,
Klaskin tumour, tumour of extrahepatic bile duct and uncertain tumour pathology were excluded. Clinico-pathological
data were analysed statistically.
Results: From 1991 to 2013, there were 107 patients underwent hepatectomy for ICC. Gender predilection was not
observed with 59 males and 48 females, median age of the patients was 61. The median tumour size was 6cm (117cm) and most of them (43%) were moderately differentiated adenocarcinoma. Clear resection margin were
achieved in 95 patients (88.8%) and the median margin width was 0.5cm (0-4cm). The Hospital length of stay and
operative mortality were eleven days and 2.8% respectively. The disease free survival and overall survival were 17.5
months (0.5-276.3) and 25.1 months (0.2-276.3) respectively. Multivariate analysis showed that margin width was an
independent factor associated with disease free survival (P= 0.015, 95% C.I. 0.4-0.9). Subgroup analyses showed
that the increase resection margin to 0.84 cm was associated with improved overall survival in patients with solitary
tumour (P=0.029) and node negative disease (P=0.017). Discriminant analysis showed that the overall survival
increased from 42 months to 185 months when margin width was greater than 0.84cm (p=0.015) in patients with both
solitary tumour and node negative disease.
Conclusion: Aggressive resection to achieve wide margin maximize chance of cure in patient with early ICC.
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2. Khan SA, Toledano MB, Taylor-Robinson SD. Epidemiology, risk factors, and
pathogenesis of cholangiocarcinoma. HPB (Oxford) 2008;10(2):77–82.
3. Yamasaki S. Intrahepatic cholangiocarcinoma: macroscopic type and stage
classification. J Hepatobiliary Pancreat Surg 2003;10(4):288–91.
4. Koh KC, Lee H, Choi MS, et al. Clinicopathologic features and prognosis of
combined hepatocellular cholangiocarcinoma. Am J Surg 2005;189(1):
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5. DeOliveira ML, Cunningham SC, Cameron JL, et al. Cholangiocarcinoma: thirtyoneyear experience with 564 patients at a single institution. Ann Surg 2007;
245(5):755–62.
6. Paik KY, Jung JC, Heo JS, et al. What prognostic factors are important for resected
intrahepatic cholangiocarcinoma? J Gastroenterol Hepatol 2008;23(5): 766–70.
7. Endo I, Gonen M, Yopp AC, et al. Intrahepatic cholangiocarcinoma: rising frequency, improved survival, and
determinants of outcome after resection. Ann Surg 2008;248(1):84–96.
8. Tan JC, Coburn NG, Baxter NN, et al. Surgical management of intrahepatic
cholangiocarcinoma: a population based study. Ann Surg Oncol. 2008;15:600–
608.
9. Berdah SV, Delpero JR, Garcia S, et al. A Western surgical experience of peripheral cholangiocarcinoma. Br J
Surg. 1996;83:1517–1521.
10.Chu KM, Lai EC, Al-Hadeedi S, et al. Intrahepatic cholangiocarcinoma. World J Surg. 1997;21:301–305.
11. Weimann A, Varnholt H, Schlitt HJ, et al. Retrospective analysis of
prognostic factors after liver resection and transplantation for cholangiocarcinoma. Br J Surg. 2000;87:1182–1187.
12. Farges O, Fuks D. Clinical presentation and management of intrahepatic
cholangiocarcinoma. Gastroenterol Clin Biol. 2010;34:191–199.
13. Jonas S, Thelen A, Benckert C, et al. Extended liver resection for intrahepatic
cholangiocarcinoma: a comparison of the prognostic accuracy of the fifth and
sixth editions of the TNM classification. Ann Surg. 2009;249:303–309.
14. Madariaga JR, Iwatsuki S, Todo S, et al. Liver resection for hilar and peripheral
cholangiocarcinomas: a study of 62 cases. Ann Surg 1998;227(1):70–9.
15. Weber SM, Jarnagin WR, Klimstra D, et al. Intrahepatic cholangiocarcinoma:
resectability, recurrence pattern, and outcomes. J Am Coll Surg 2001;193(4):
384–91.
16. Nakagawa T, Kamiyama T, Kurauchi N, et al. Number of lymph node metastases
is a significant prognostic factor in intrahepatic cholangiocarcinoma. World J
Surg 2005;29(6):728–33.
107
17.Guglielmi A, Ruzzenente A, Campagnaro T, et al. Intrahepatic cholangiocarcinoma:
prognostic factors after surgical resection. World J Surg 2009;33(6): 1247–54.
18. Lang H, Sotiropoulos GC, Sgourakis G, et al. Operations for intrahepatic cholangiocarcinoma: single-institution
experience of 158 patients. J Am Coll Surg 2009;208(2):218–28
19. Nathan H, Aloia TA, Vauthey JN, et al. A proposed staging system for intrahepatic
cholangiocarcinoma. Ann Surg Oncol 2009;16(1):14–22.
20. Shen WF, Zhong W, Xu F, et al. Clinicopathological and prognostic analysis of
429 patients with intrahepatic cholangiocarcinoma. World J Gastroenterol
2009;15(47):5976–82.
21. de Jong MC, Nathan H, Sotiropoulos GC, et al. Intrahepatic cholangiocarcinoma:
an international multi-institutional analysis of prognostic factors and lymph node assessment. J Clin Oncol
2011;29(23):3140–5.
22. Inoue K, Makuuchi M, Takayama T, et al. Long-term survival and prognostic
factors in the surgical treatment of mass-forming type cholangiocarcinoma.
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23. Nakagohri T, Kinoshita T, Konishi M, Takahashi S, Gotohda N.Surgical outcome and prognostic factors in
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surgical resection: association of lymph node metastasis and lymph node dissection with survival. Ann Surg Oncol.
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25. Farges O, Fuks D, Le Treut YP, et al. AJCC 7th edition of TNM staging accurately
discriminates outcomes of patients with resectable intrahepatic cholangiocarcinoma:by the AFC-IHCC-2009 study
group. Cancer 2011;117(10):2170–7.
26. Farges O, Fuks D, Boleslawski E, et al. Influence of surgical margins on outcome
in patients with intrahepatic cholangiocarcinoma: a multicenter study by the
AFC-IHCC-2009 study group. Ann Surg 2011;254(5):824–9 [discussion: 830].
27. Cherqui D1, Tantawi B, Alon R, Piedbois P, Rahmouni A, Dhumeaux D, Julien M, Fagniez PL. Intrahepatic
cholangiocarcinoma. Results of aggressive surgical management. Arch Surg. 1995 Oct;130(10):1073-8
28. Chou FF1, Sheen-Chen SM, Chen YS, Chen MC, Chen CL. Surgical treatment of cholangiocarcinoma.
Hepatogastroenterology. 1997 May-Jun;44(15):760-5
29. Tamandl D1, Herberger B, Gruenberger B, Puhalla H, Klinger M, Gruenberger T. Influence of hepatic resection
margin on recurrence and survival in intrahepatic cholangiocarcinoma. Ann Surg Oncol. 2008 Oct;15(10):2787-94. doi:
10.1245/s10434-008-0081-1. Epub 2008 Aug 7.
30. Shimada K, Sano T, Sakamoto Y, et al. Clinical impact of the surgical margin
status in hepatectomy for solitary mass-forming type intrahepatic cholangiocarcinoma without lymph node metastases.
J Surg Oncol. 2007;96:160–165
31. Murakami S, Ajiki T, Okazaki T, Ueno K, Kido M, Matsumoto I, Fukumoto T, Ku Y. Factors affecting survival after
resection of intrahepatic cholangiocarcinoma. Surg Today. 2014 Oct;44(10):1847-54. doi: 10.1007/s00595-013-08259. Epub 2014 Jan 23
32. Puhalla H, Schuell B, Pokorny H, Kornek GV, Scheithauer W, Gruenberger T. Treatment and outcome of
intrahepatic cholangiocellular carcinoma. Am J Surg. 2005 Feb;189(2):173-7.
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cholangiocarcinoma: a Western experience. J Hepatobiliary Pancreat Surg. 1999;6(2):122-7
Disclosure of Interest: None declared
108
39.07
INVESTIGATORY STUDY OF RISK STRATIFICATION MARKERS AFTER CURATIVE RESECTION OF STAGE II
OR III GASTRIC CANCER
T. Oshima1,*, T. Yamada1, N. Yamamoto1, N. Yukawa1, Y. Rino1, M. Masuda1
1
Department of Surgery, Yokohama City University, Yokohama, Japan
Introduction: Standard treatment for stage II or III gastric cancer is curative resection followed by adjuvant
chemotherapy. However, treatment outcomes are expected to be further improved by individualized therapy based on
biomarker analysis. We extracted mRNA from frozen specimens of gastric cancer to establish a cDNA bank and have
analyzed markers for recurrence risk stratification of after curative resection of stage II or III gastric cancer. We report
our currently available results.
Materials & Methods: We studied 255 patients who underwent curative resection of stage II or III gastric cancer and
were followed up for at least 5 years after surgery. The patients were divided into 2 cohorts: a training set consisting of
145 patients and a validation set consisting of 110 patients. A total of 104 genes were selected as candidate
biomarkers on the basis of comprehensive screening by DNA microarray, extraction by SAGE library analysis, and
target molecules and their families, including the results of preclinical research. The relative expression levels of each
gene in gastric cancer tissue were measured by quantitative polymerase chain reaction. Genes that were found to be
independent predictors of poor outcomes in the training set were verified in the validation set, using Cox proportionalhazards models.
Results: In the training set of stage II or III gastric cancer, 38 genes were selected as independent predictors of poor
outcomes. On verification analysis using the validation set, the following 11 genes were selected as candidate
markers for recurrence risk stratification (P<0.2): SPARC, INHBA, HRBB2, VSNL1, CXCR4, EZH2, CCR7, PDGFRB,
P53, MMP11, and CEACAM7. Good reproducibility was obtained for 5 of these genes: SPARC, INHBA, HRBB2,
VSNL1, and CXCR4 (P<0.05).
Conclusion: Candidate markers for recurrence risk stratification were identified in patients who underwent curative
resection of stage II or III gastric cancer. At present, these markers for recurrence risk stratification are being analyzed
at the protein level by tissue microarray, using specimens from two different cohorts of about 500 patients. Our
ultimate goal is the development of a rapid test kit for recurrence risk stratification based on combinations of these
markers in patients who have undergone curative resection of stage II or III gastric cancer.
Disclosure of Interest: None declared
109
39.08
IS ADJUNCTIVE THERAPY FOR STAGE II AND III RECTAL CANCER BENEFICIAL IN THE ELDERLY? A
NATIONAL CANCER DATA BASE (NCDB) REVIEW.
J. R. Bergquist1,2,*, C. A. Thiels1,2, C. R. Shubert1,2, A. V. Hayman3, K. L. Mathis4
1
2
General Surgery, Robert and Patricia Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester,
3
MN, Colon and Rectal Surgery, Oregon Health Sciences University, Portland, OR, 4Colon and Rectal Surgery, Mayo
Clinic, Rochester, MN, United States
Introduction: Current United States treatment guidelines for Stage II and III rectal cancer from the National
Comprehensive Cancer Network (NCCN) indicate neoadjuvant chemoradiation followed by curative intent surgery and
post-surgical adjuvant chemotherapy. There are clear data showing survival benefit of neoadjuvant chemoradiation for
younger patients with rectal cancer. It is unclear whether this benefit can be extrapolated to patients over 80. We
hypothesized that there is no clinically significant survival benefit to justify the cost and morbidity associated with
neoadjuvant therapy for Stage II and III rectal cancer in patients over 80 years of age.
Materials & Methods: The American College of Surgeons National Cancer Data Base (NCDB), a national cancer
treatment dataset, was queried for patients with stage II and III rectal cancer. Patients over 80 at date of diagnosis
were identified. Overall survival was the primary outcome. Patients were divided into groups based on whether they
received neoadjuvant therapy followed by curative intent surgery or surgery first followed by post-resection adjuvant
chemotherapy. A comparison of patient groups can be seen in the table. Wilcoxon rank-sum test was used to
compare survival between these groups. Kaplan-Meier survival analysis was performed.
Results: Of 323,329 patients identified, 1,782 cases were octogenarians with Stage II or Stage III disease. Of 754
octogenarians with Stage II disease, 545 received neoadjuvant chemoradiation whereas 209 had the surgery first
approach. Of 1,014 octogenarians with stage III disease, 432 underwent neoadjuvant chemoradiation whereas 582
underwent a surgery first approach. In patients with stage II disease, mean overall survival in the group which
underwent surgery first was 39 months, compared to 35 months in the group that underwent neoadjuvant
chemoradiation (p = 0.058). In patients with stage III disease, mean overall survival was 35 months compared to 32
months in patients who underwent neoadjuvant chemoradiation (p = 0.015). Kaplan-Meier analysis showed no
significant difference in overall survival between groups (see Figure).
Image:
Conclusion: Our analysis of NCDB outcomes-based survival data for Stage II and III rectal cancer in patients over 80
suggests that a surgery first approach is associated with improved overall survival. Based on the data presented here,
neoadjuvant chemoradiation does not appear to offer a benefit in terms of overall survival in the elderly.
Disclosure of Interest: None declared
110
39.09
PROGNOSTIC IMPACT OF LAPAROSCOPIC RESECTION OF PRIMARY TUMOR WITH D3 LYMPH NODE
DISSECTION FOR STAGE Ⅳ COLORECTAL CANCER
H. Kawahara1,*, K. Watanabe1, M. Tomoda1, S. Hojo1, T. Misawa1, T. Akiba1, K. Yanaga2
1
Surgery, Kashiwa Hospital, Jikei Universiry, Chiba, 2Surgery, Jikei University, Tokyo, Japan
Introduction: Prognostic impact of laparoscopic primary tumor resection with D3 lymph node dissection (LND) for
stage Ⅳ colorectal cancer remains unknown.
Materials & Methods: Between January 2001 and December 2010, 19 patients who underwent laparoscopic D3 LND
for stage Ⅲc (n=8) or Ⅳ (n=11) colorectal cancers at Kashiwa hospital were studied. In stage Ⅳ, ten patients had liver
metastasis only, and the other one had liver, lung, and bone metastasis. The medical records of all patients were
reviewed retrospectively.
Results: There were no significant differences between stage Ⅳ and Ⅲc in operative duration, intraoperative
bleeding, post-operative hospital stay, and post-operative complications. Although there were no significant
differences between the two groups in tumor diameter, depth of tumor invasion, and pathological type, the number of
metastatic lymph nodes in stage Ⅲc was significantly larger than that of stage Ⅳ. Three patients in stage Ⅳ received
conversion therapy, and two of them remain alive. The 5-year survival rates were 85.7% for stage Ⅲc, and 27.2% for
stage Ⅳ. Post-operative local recurrences have not been encountered in either group for more than four years after
surgery.
Conclusion: Laparoscopic primary tumor resection with D3 LND for stage Ⅳ colorectal cancer is oncologically
acceptable provided that treatment of metastatic lesions is appropriately given after surgery.
Disclosure of Interest: None declared
111
41.01
BRAF MUTATION IS ASSOCIATED WITH REDUCED DISEASE FREE SURVIVAL IN PAPILLARY THYROID
CANCER
S. Fraser1,*, A. Aniss1, S. Sidhu1, L. Delbridge1, D. Learoyd2, R. Clifton-Bligh2, A. Gill3, M. Sywak1
1
2
3
Endocrine Surgery, Endocrine Medicine, Anatomical pathology, Royal North Shore Hospital, Sydney, NSW,
Australia
V600E
mutation is a well-recognised molecular marker in papillary thyroid cancer (PTC), with
Introduction: The BRAF
V600E
an incidence between 30 and 80%. BRAF
aberrantly activates the MAPK pathway, a central regulator of cell
growth and proliferation.
V600E
Previous studies have reported conflicting data regarding the impact of the BRAF
mutation on the clinical and
pathological features of PTC.
V600E
The aim of this study is to determine whether BRAF
status can be used as a prognostic biomarker in PTC.
Materials & Methods: A cohort study of consecutive patients undergoing surgery for PTC was undertaken. The
primary outcome measure was disease free survival based on the development of structural PTC recurrence in the
follow up period. Secondary outcome measures were tumour size, nodal positivity and rate of I-131 ablation.
V600E
All cases included were re-examined to confirm the diagnosis of PTC. Specific immunohistochemistry for BRAF
mutation was performed on tissue microarrays and interpreted as positive if there was any positive cytoplasmic
staining in neoplastic cells. A single experienced endocrine pathologist, blinded to all clinical and pathological data,
interpreted staining.
Results: Consecutive patients diagnosed with PTC were included in the study (n=496). Of these, 309 (62%) had
V600E
V600E
BRAF
positive PTC. Primary tumour size was similar between the two groups: 21.3 mm for BRAF
positive
V600E
V600E
tumours and 23. 2 mm for BRAF
negative tumours (p=0.23). BRAF
positive PTCs were from significantly
older subjects at first operation (mean age 45 to 49 years, p=0.003). BRAFV600E positive PTCs had a significantly
higher rate of disease recurrence (12.9% compared to 5.6%, p=0.004). In addition BRAFV600E positive PTCs had a
higher rate of lymph node metastasis (44% versus 29.4%, p=0.004). Five year disease free survival was 89.6% for
patients with BRAFV600E positive tumours and 96.3% for BRAFV600E negative tumours, p=<0.001.
There was no statistical difference between groups for gender, size of primary tumour, vascular invasion, rate of extrathyroidal spread or multifocal disease. The median follow up interval was 57 months for both groups.
Conclusion: BRAFV600E status predicts an increased risk of lymph node metastasis and reduced disease free survival
and can be incorporated as a useful prognostic biomarker in papillary thyroid cancer.
Disclosure of Interest: None declared
112
41.02
CLINICAL ANALYSIS OF FAMILIAL NON-MEDULLARY THYROID CARCINOMA
Z. Qiang1,*, Y. Shuai1, M. Xianying1, P. Renzhu1
1
the first hospital of Jilin University, changchun, China
Introduction: To discuss and analyze the clinical features of familial non-medullary thyroid carcinoma(FNMTC), in
order to provide evidence for early diagnosis and treatment
Materials & Methods: Clinical data of 78 patients of NMTC from 31 families were retrospectively analyzed compared
with 3445 control cases of sporadic non-medullary thyroid carcinoma (SNMTC) who has been treated in the First
Bethune Hospital of Jilin University between September 2006 and September 2013
Results: There were no significant differences in gender, age and tumor size between FNMTC and SNMTC, but it
had statistical significance in number of focus, capsule invasion and lymph node metastasis between the two
groups.71.8%（56/78） of FNMTC and 46.3%（1595/3445） of SNMTC were mulifocality, 64.1%（50/78）of
FNMTC and48.5%（1670/3445）of SNMTC had capsule invasion, 52.6%（41/78）of FNMTC and 33.3%
（1148/3445） of SNMTC suffered neck lymph node metastas, 30.8%（24/78）of FNMTC and 20.0%（689/3445）
of SNMTC were coexisted with chronic lymphocytic thyroiditis.
Conclusion: Compared with SNMTC, the patients of FNMTC have poorer prognosis and more easily to have
mulifocality, capsule invasion, lymph node metastasis and coexistence with chronic lymphocytic thyroiditis.
Disclosure of Interest: None declared
113
41.03
CHARACTERISTICS OF PERSISTENT HYPERPARATHYROIDISM AFTER RENAL TRANSPLANTATION
T. Yamamoto1,*, Y. Tominaga1, M. Okada1, T. Hiramitsu1
1
Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
Introduction: Persistent hyperparathyroidism (HPT) after renal transplantation (RTx) (tertiary HPT; THPT) is one of
the complication in patients with RTx and may affect bone disease and cardiovascular events. However, risk factors
and operative procedure for THPT remain poorly understood.
Materials & Methods: We performed a retrospective study to analyze 525 patients who underwent RTx between
2001 and 2011 at our hospital without pretransplant parathyroidectomy. These risk factors, including gender, age at
RTx, BMI, the duration of dialysis prior to RTx, maximum parathyroid size at RTx, rate of using cinacalcet before RTx,
Ca, P, ALP, iPTH at RTx and after two weeks since performed RTx (pre-Ca, P, ALP, iPTH/ post-Ca, P, ALP, iPTH)
were analyzed between THPT and non-THPT groups. And, we also retrospectively analyzed 29 patients with THPT
who underwent total parathyroidectomy with foremen autograft (PTx). Pre- and postoperative(1 year after PTx)
laboratory results were analyzed for investigating the efficacy of PTx.
Results: Compared with non-THPT group, THPT group demonstrated longer duration of dialysis (128.1 +/- 93.6 vs
38.0 +/- 66.0 months, p<0.001), bigger maximum parathyroid size(13.1 +/- 4.3 vs 4.5 +/- 2.7 mm, p<0.001), more rate
of using cinacalcet before RTx (21.0 vs 0.93%, p<0.001), higher pre-Ca(10.1 +/- 0.7 vs 9.1 +/- 0.9 mg/dl, p<0.001),
higher pre-P(6.1 +/- 1.6 vs 5.6 +/- 1.5 mg/dl, p=0.031), higher pre-iPTH(364.5 +/-308.0 vs 225.2 +/- 199.7 pg/ml,
p<0.001), higher post-Ca(10.3 +/- 0.8 vs 9.4 +/- 0.7, p<0.001), lower post-P(1.9 +/- 0.7 vs 2.6 +/- 0.8, p<0.001), higher
post-iPTH(220.6 +/- 153.0 vs 96.8 +/- 66.5, p<0.001) and higher post-ALP(297.7 +/- 134.7 vs 236.5 +/- 97.1, p<0.001).
PTx was significantly recovered serum Ca (10.9 +/- 1.1 → 9.8 +/- 0.8 mg/dl, p<0.001), P (2.7 +/- 0.5 → 3.6 +/- 0.7,
p<0.001) , iPTH (220.0 +/- 201.5 → 59.8 +/- 49.9, p<0.001), ALP(415 +/- 194 → 208.7 +/- 96.2, p<0.001) at a year
after PTx. There was no statistical difference serum Cre (1.31 +/- 0.38 mg/dl → 1.35 +/- 0.42 mg/dl, p=0.44).
Conclusion: Longer duration of dialysis, bigger maximum parathyroid size, using cinacalcet before RTx, higher pre
and post-Ca and iPTH, pre-P and post-ALP and lower post-P seems to be important risk factors for development
THPT. PTx for THPT showed a tendency of more decrease of serum Ca, iPTH and ALP and more increase of serum
P after PTx. There was no statistical difference renal function after PTx. Therefore, PTx as surgical approach seems
appropriate for patients with THPT.
Disclosure of Interest: None declared
114
41.04
THE EFFICACY AND SAFETY OF TOTAL PARATHYROIDECTOMY AND AUTOTRANSPLANTATION FOR THE
TREATMENT OF HYPERPARATHYROIDISM IN MULTIPLE ENDOCRINE NEOPLASIA TYPE 1
D. Takeuchi1,*, K. Nakanishi1, M. Shibata1, H. Hayashi1, T. Kikumori1, T. Imai2
1
2
Breast and Endocrine Surgery, Nagoya University, Nagoya, Endocrine surgery, Aichi Medical University, Nagakute,
Japan
Introduction: Incidence of hyperparathyroidism in patients with multiple endocrine neoplasia type 1 (MEN1) is
virtually 100%. There are several options for surgical intervention for hyperparathyroidism (HPT) e.g. subtotal
parathyroidectomy (SPx) or total parathyroidectomy (TPx) with autotransplantation. However, definitive procedure has
been disputed for a long time. The aim of this study is to analyze outcomes of MEN1 patients who underwent initial
TPx at single institution.
Materials & Methods: Between January 1994 and April 2014, 27 patients with MEN1 underwent initial TPx for HPT.
Autotransplantation of parathyroid glands into the muscle of a nondominant forearm was concomitantly performed.
Since 2006 in addition of TPx, we have employed removal of cervical portion of thymus and tissue resection around
the trachea similar to central neck dissection for thyroid cancer (cervical soft tissue resection group: R group). We
analyze rate of recurrence and persistent hypoparathyroidism and operation safeties.
Results: Twenty seven patients consisted of 14 men and 13 women. The median age was 44. Seventeen patients
(63%) underwent tissue dissection around the trachea and thymectomy. The initial biochemical improvement was
achieved in 26 patients (96%). During follow-up period (2-137, median: 56months), one patient had recurrence of
HPT. He did not undergo tissue resection around the trachea, the recurrence occurred at 111 months. He underwent
additional cervical parathyroidectomy, thereafter his intact-PTH returned to normal. One patient developed persistent
hypoparathyroidism requires supplementation of calcium and vitamin D for 1 year after surgery, and his intact-PTH is
improving. R group had longer operation time than non-R group (275 min vs 240 min, p=0.09), R group had more
amount of bleeding (113 ml vs 64 ml, p=0.06), non-R group had longer postoperative hospital stay (11 days vs 8 days,
p=0.08), but there were no statistically significant differences in all of them.
Conclusion: In terms of the recurrence rate and incidence of persistent hypoparathyroidism, TPx with
autotransplantation is efficacious and safe surgical approach for HPT with MEN1.
Disclosure of Interest: None declared
115
41.05
FDG PET/CT SCAN AND PATIENTS WITH CORTISOL-SECRETING ADRENAL TUMORS: A PILOT STUDY FOR
LATERALIZATION
D. Patel1,*, S. K. Gara1, R. J. Ellis2, M. Boufraqech1, N. Nilubol1, C. Millo3, C. Stratakis4, E. Kebebew1
1
2
Endocrine Oncology Branch, National Institutes of Health, Bethesda, Surgery, University of Pennsylvania,
3
4
Philadelphia, PET Department, National Institutes of Health, Eunice Kennedy Shriver National Institute of Child
Health and Human Development, Bethesda, United States
Introduction: Patients with Cushing’s Syndrome (CS) and Conn’s Syndrome with bilateral adrenal masses pose a
dilemma. Uptake of 18F-FDG by hyperfunctioning adrenal glands has not been previously reported and may help
lateralize in difficult cases. The aim of this pilot study was to determine if 18F-FDG-PET/CT scan could potentially
identify hyperfunctioning adrenal masses and determine a biological basis for the differential 18F-FDG uptake.
Materials & Methods: Eight patients with nonfunctional adenomas, six with CS, and four with Conn’s syndrome
underwent an 18F-FDG-PET/CT scan with a volume of interest circumscribing each mass to obtain a maximal
standardized uptake value (SUVmax). Twenty-three adrenal masses were analyzed. Genome-wide expression data
from an independent cohort was analyzed in nonfunctioning adrenocortical tumors (n=20), Conn’s syndrome (n=29),
and CS (n=24) focusing on GLUT transporter genes. For genes differentially expressed, immunohistochemistry was
performed on available tissue samples.
Results: Cortisol-secreting masses (n=10) had a higher average SUVmax of 6.8 compared to nonfunctioning masses
(n=8, average SUVmax 4.2) and aldosterone hypersecreting masses (n=5, average SUVmax 3.2) (p=0.002). SUVmax
cut-off of 4.75 had 90.0% sensitivity and 75.0% specificity in localizing a cortisol-secreting mass. Genome-wide
expression data showed GLUT3 expression was 2.2-fold higher in patients with CS compared to patients with
nonfunctioning adenomas, and Conn’s syndrome. GLUT3 immunohistochemistry showed 2.2-fold higher staining in
CS tumor samples compared to nonfunctioning adenomas.
Image:
Conclusion: Differential 18F-FDG-PET/CT uptake was observed in patients with nonfunctioning, aldosterone
hypersecreting, and cortisol-secreting adrenal masses. GLUT3 overexpression in cortisol-secreting tumor likely
accounts for the differential uptake. Future studies will need to be conducted to determine if these findings can help
lateralize cortisol-secreting adrenal masses in patients with bilateral adrenal masses.
Disclosure of Interest: None declared
116
41.06
EXPECTED HIGH RATE OF RECURRENT HYPERCALCEMIA AFTER SUBTOTAL PARATHYROIDECTOMY IN
MULTIPLE ENDOCRINE NEOPLASIA TYPE 1
P. Hellman1, E. Fyrsten1,*, P. Stålberg1, O. Hessman1
1
Department of Surgery, University Hospital, Uppsala, Sweden
Introduction: Primary hyperparathyroidism (pHPT) in multiple endocrine neoplasia type 1 (MEN1) is treated with
subtotal parathyroidectomy (SPX) usually removing 3-3,5 out of 4 glands or total parathyroidectomy with
autotransplantation (TPX+AT). Results of long-term results have previously demonstrated a moderate risk for
recurrence afer SPX, as well as need for long-term substitution after TPX+AT. We have investigated a cohort of 70
operated patients with up to 30 years of follow-up.
Materials & Methods: Seventy patients with pHPT and MEN-1 referred to the University Hospital in Uppsala were
screened. Outcome of surgery including number and type of reoperations and need for substitution were monitored.
Results: Only 8 patients were initially operated with TPX+AT, while another 19 had a completion TPX+AT. Of these, 3
were reoperated with graft resection du to recurrence (risk for recurrence after TPX+AT 11%) . Of all, 62 were initially
operated with SPX, 27 needed at least one, 10 at least two and 3 a third reoperation (risk for recurrence after SPX
43%). Among the patients undergoing a 2nd reoperation, two underwent sternotomy and one resection of a fifth gland.
After long-term follow-up (4-30 years) there was no need for substitution (calcium and/or vitamin D) in patients after
SPX, while 4 (15%) after TPX+AT.
Conclusion: SPX leads to high risk for recurrence, high risk for reoperation and TPX higher risk for long-term
substitution therapy. The long-term follow-up in this series indicate that the ratio of hypoparathyroidism diminish over
time.
Disclosure of Interest: None declared
117
46.01
MEDICAL STUDENTS CAREER INTENTIONS FOR SURGERY: A STUDY OF DEMOGRAPHIC AND
CURRICULUM INFLUENCES.
M. P. Lyndon1,2,*, M. A. Henning3, T.-C. W. Yu3, H. Alyami2,4, S. Krishna2, B. Su'a2, A. G. Hill2
1
Ko Awatea - Centre for Health System Innovation and Improvement , Counties Manukau District Health Board ,
2
South Auckland Clinical Campus, 3The Centre for Medical and Health Sciences Education, The University of
Auckland, 4Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
Introduction: Medical students’ career intentions toward surgery have been shown to be influenced by a number of
factors including gender, mentorship, and concerns about work-life balance.
The aim of this study was to examine the differential impact of programme curricula (traditional versus revised) and
student demography on career intentions for surgical or non-surgical specialties. A revised curriculum was
implemented with the aim of improving self directed learning and integration of basic science and clinical practice.
Materials & Methods: A comparative cohort study was conducted of two undergraduate medical programme curricula
at The University of Auckland. The class of 2012 (n=437) under the traditional curriculum and the class of 2013
(n=446) under a revised curriculum. Measures included type of curricula, demographic characteristics (age, gender,
admission, entry into medical school) and career intention (grouped as surgical, non-surgical, unsure). Descriptive
statistics and Chi-square tests were used to compare curricular and demographic variables with career intentions.
Results: The response rate was 49 percent. 16 percent of study participants reported a career intention for a surgical
specialty, 39 percent a non-surgical specialty, and 45 percent were unsure of specialty.
Gender was found to have a significant impact on career intention [X2 (2, N=427) =2.04 p=.015]. 60 percent of
students who reported an intention for a surgical specialty were male and 40 percent were female. In comparison, 59
percent of students who reported an intention for a non-surgical specialty were female and 41 percent were male. A
greater proportion of students who were unsure of career intention were also female (56 percent) compared with 44
percent for males. There was no significant relationship between other demographic variables (age, admission,
graduate or undergraduate entry into medical school) with respect to career intention.
There were no significant main effects with respect to career intention and a change in curriculum [X2 (2, N=427)
=2.04 p=.360]. There was no significant differences in career intention between students in the preclinical and clinical
phases of the curriculum [X2 (2, N=427) =2.15 p=.340].
Conclusion: Consistent with previous studies, an association between gender and the career intention for surgery
was demonstrated. However, a significant proportion of students were unsure of their career intention. No significant
association between type of curriculum and career intention was found.
Disclosure of Interest: None declared
118
46.02
THE DEMISE OF THE GENERAL SURGEON AND THE RISE OF THE EMERGENCY SURGEON
M. H. Cotton1,*, J. A. Henry2
1
2
Urgences, Centre hospitalier Universitaire Vaudois, Lausanne, Switzerland, Lausanne, Switzerland, Executive
Director, G4 Alliance, New York, United States
Introduction: The audit of the UK Emergency Laparotomy Network (1) highlights some, but only some of the
deficiencies that currently exist in British Emergency Surgical care.
There is no doubt that the days of the omniscient, and omnipresent doctor are long gone, although vestiges
of this species may linger on in remote parts of the globe.
Materials & Methods: In UK, as elsewhere, the general surgeon has fought a rearguard action, but the sum
total of knowledge available and needed, the impossibility of doing all things for all people, and the inevitable
break-up of surgery into its constituent parts has forced him into perpetual retreat.
Or so it seemed...
The sub-specialties have never managed to define precisely their sphere of work, meaning there are always
shady areas of overlap at their edges. At the same time they have guarded zealously their area of expertise,
denying access to any but their own. However, the impossibility of having one of each sub-specialty available
at each hospital in any country, let alone the poorer, and the inexorable increase in numbers of sub or even
sub-sub-specialty, has resulted in dangerous gaps in overall surgical care, except perhaps in well-equipped
large tertiary centres.
For elective surgery, arrangements can be made to shift the requisite surgeon around, or, more often, to
require the longsuffering patient to shift himself to find the elusive surgeon.
For emergency surgery, such arrangements are at best stop-gaps, and at worst a disaster.
Results: Without denigrating the enormous achievements in the realm of surgery over the last 30 years, it
remains that effective emergency surgery is, in the public eye, the acme of the profession.
The Royal College therefore needs to take the lead in espousing emergency surgery. It has taken the lead in
training, in courses, in promoting excellence, but it must also facilitate the development of this specialty.
The methods of emergency surgery are quite different to elective surgery.
Conclusion: We have come full cycle. Unless there is an emergency surgeon in the A&E department,
surgeons will eventually be seen as mere technicians, to practice on patients when they are deemed made
ready by emergency physicians, necessarily internists.
We propose a definition of Basic Essential Surgery, to establish groundwork for a specialist in this field to
encompass. Unless measures are put in place now to establish the pedigree of this new type of general
surgeon, we will rue the day when we need his services.
References: (1) Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ. Variations in mortality after
emergency laparotomy: the first report of the UK Emergency Laparotomy Network. Br J Anaesth.
2012;109(3):368-375.
doi: 10.1093/bja/aes165
Disclosure of Interest: None declared
119
46.03
TECHNIQUE OF STORY-TELLING IN PATIENT CARE WITH REFERENCE TO ENDOCRINE SURGERY
S. Mayilvaganan1,*, N. Bansal1, S. Mishra1, P. Bharghav1
1
Department of Endocrine and breast surgery, Sanjay Gandhi Institute of Medical Sciences, Lucknow, India
Introduction: In the modern day busy clinical practice the communication between patient/relative and care giver is at
minimal level. The patients and relatives feel apprehensive when advised about the surgical/interventional treatment.
In such situation they feel the need of detail information from the care givers which on many occasions is not
available. Story telling is such a technique of health communication made out in common man language which can be
made animated and interactive using virtual characters and can operate in a virtual environment eliminating the need
of health professionals. We intended to study the efficacy of storytelling technique on patients undergoing
Hemithyroidectomy for benign cytology.
Materials & Methods: A story of a lady(cartoon version) aged 25 years with a benign thyroid nodule who underwent
uneventful Hemithyroidectomy is depicted in this movie including the history, clinical examination, investigations,
counseling and the operative procedure and the running time of the animation movie is four minutes. For developing
this movie, high end graphic computer work station and various multimedia authoring tools like Adobe Flash,
Photoshop, Captivate, Maya and Final Cut Pro were used. The story was shown to patients with clinically solitary
thyroid nodules who were provisional candidates for surgery in the outpatient department .The patients filled in the
evaluation of Multimedia animation questionnaire at the time of discharge.
Results: 20 patients filled the questionnaire.19 found the movie useful and their remaining questionnaire was
analyzed. Mean age was 35.45±12.8 years.15 (75%) were females. All patients were euthyroid. The mean weight was
40.80 ± 20.79gms. The final histopathology was colloid in majority. In the questionnaire, the mean score for improved
understanding of the disease was 73.9 ± 14.7(P=0.003), better organization of treatment was 78.6±13.1 (p=0.000),
stimulated interest in the relatives was 70.8±15.8 and saved unnecessary discussion with the consultant was
55.5±7.8.
Conclusion: Story telling is a useful tool in health communication. With widespread availability of high speed internet
and affordable mobile computing devices such kind of information can be of use to the patients and relatives in
decision making and also saves valuable time of the treating consultant. Future studies with larger numbers are
needed.
Disclosure of Interest: None declared
120
46.04
SYSTEMATIC REVIEW OF POSTGRADUATE SURGICAL EDUCATION IN LOW AND MIDDLE INCOME
COUNTRIES
J. Rickard1,2,*
1
2
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, United States, Department of
Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
Introduction: Surgical care is recognized as an important component of public health, however many low and middle
income countries (LMIC) are faced with a shortage of trained personnel. In response to the high need for surgical care
and a shortage of trained surgeons, many countries have developed local surgical training programs. We sought to
characterize postgraduate surgical training in LMIC.
Materials & Methods: PubMed, EMBASE, IMSEAR, and African Index Medicus databases were searched for articles
related to postgraduate general surgery education in LMIC. LMIC income status and region were defined according to
the World Bank classification. Articles published before 1990 were excluded. Titles and abstracts were reviewed for
relevance to postgraduate general surgery education in LMIC. Articles describing postgraduates visiting from highincome countries were excluded.
Results: There were 73 articles discussing aspects of postgraduate surgical education in LMIC. Programs in 27
different countries and 6 different regions were represented. Eleven articles (18%) described programs in low-income
countries, while the remainder were from middle-income countries.
Thirty-eight (38) articles described the structure of the local postgraduate training program. Most trainees complete an
undergraduate medical degree, followed by a internship period. The criterion for entering into postgraduate surgical
training varies, with some programs requiring an entrance exam or interview. At the completion of postgraduate
training, trainees must pass an exam, with varying formats including oral, written and clinical exams. Postgraduate
general surgery programs range from 2-6 years.
Twelve articles described short-term educational programs: five on laparoscopic skills, two on basic surgical skills, and
one on trauma. Three articles described incorporation of online curricula or distance learning and six discussed
nontechnical skills. Thirteen programs (18%) involved collaboration with a high-income country.
Conclusion: Postgraduate surgical education is one mechanism to increase surgical capacity with LMIC. Techniques
for postgraduate surgical education include local training programs as well as short-term courses from collaborative
programs. While training programs across continents vary, similar challenges are encountered. Many different
innovative strategies have been employed to improve surgical education in many LMIC and learning from these
programs can optimize surgical education across teaching sites.
Disclosure of Interest: None declared
121
46.05
INTRODUCING SURGICAL RESIDENTS TO CRITICAL OPERATING THEATRE PRACTICE - THE OPERATING
THEATRE ORIENTATION COURSE AS A INTER-PROFESSIONAL EDUCATIONAL PLATFORM
A. Vijayan1,*, M. H. Lim2, W. N. Seek2
1
2
General Surgery, Tan Tock Seng Hospital, General Surgery Residency Program, National Healthcare Group,
Singapore, Singapore
Introduction: The Operating Theatre (OT) is a complex clinical environment where Inter-professional teams provide
surgical care in. Errors, in processes and practices, here may lead to adverse events involving patients and/or care
providers. Until recently, junior surgical residents in our institution developed knowledge of these process and
practices in an informal, ad-hoc manner leading to unsatisfactory levels of competency with potential for errors. The
OT Orientation Course was introduced in 2013 as a formal training platform for them to become effective and safe
members of the OT team.
Materials & Methods: The OT environment and work processes were analysed and grouped into 4 critical learning
areas namely; OT environment and hazards, critical work processes in perioperative phases of care, inter-professional
teamwork and communications and critical or adverse events management. A curriculum with 13 components of the
above 4 areas was developed utilising didactics, problem-based learning, surgical procedures simulations and
teamwork in a simulated OT. Prototypical courses were conducted in 2011 and 2012. After review, the formalised
half-day OT Orientation Course was introduced in 2013. Participants were first-year general surgery residents and
junior OT nurses. Faculty included surgeons, anaesthetists and nurse educators. Participants undertook pre-course Elearning on related topics and MCQs to determine their level of knowledge in the 4 areas. Critical events related to
patient’s status and processes of perioperative care were simulated to allow participants to practice concepts learnt incourse, reinforced by facilitated feedback with videos of the simulation.
Results: Forty-five residents and nurses participated in 4 courses from in 2011 and 2014. Pre-course surveys
indicated that 0% of the residents but 95% of the nurses had formal training in OR processes. Pre-course MCQs
revealed that 25% - 58% of participants demonstrated inadequate knowledge in 7 of 13 components of the 4 learning
areas described above. Most (90%) of the participants found the curriculum relevant to their OT work, citing the interprofessional interactions and the pedagogical approaches to be effective in acquiring the knowledge.
Conclusion: No prior curriculum had formally addressed these critical areas of surgical practice. A structured
curriculum in an inter-professional learner-friendly environment facilitates competency development in working safely
and effectively as an OT team member.
Disclosure of Interest: None declared
122
54.01
PERIPHERAL VASCULAR INJURIES - INCIDENCE, AMPUTATION RATES AND MORTALITY
J. J. Jørgensen1,2,*, P. A. Næss1, J. O. Sundhagen2, T. Eken3, Ø. Risum2, J. J. Jørgensen2, C. Gaarder1
1
2
3
Department of Traumatology, Department of Vascular Surgery, Oslo University Hospital Trauma Registry, Oslo
University Hospital, Oslo, Norway
Introduction: 40-70% of all vascular injuries are peripheral, are a rare cause of death in civilian practice, but have
significant impact on morbidity with amputation rates for blunt and penetrating injuries of 6.5–20% and 0.4–4%,
respectively. Oslo University Hospital-Ullevål (OUH-U) is a major European trauma center. We wanted to investigate
peripheral vascular injuries treated at OUH-U.
Materials & Methods: We analyzed data from the OUH-U Trauma Registry and patient charts for the period 20022012. All patients admitted with limb threatening arterial injuries were included. Iatrogenic injuries and patients
admitted later than 24 hours after injury were excluded. Ethics approval was obtained.
Results: Of a total of 11058 patients, 133 patients (1.2%) fulfilled the inclusion criteria, with a total of 149 arterial
injuries in 140 extremities. Median age was 33 (IQR 24, 46) years and 79% were male. Median ISS was 15 (IQR 10,
29). The MOI was penetrating in 56 of 149 arteries (38%). The more centrally located subclavian (n=16) and iliac
arteries (n=15) were most commonly injured in blunt trauma whereas the more peripheral brachial (n=10) and femoral
arteries (n=11) dominated in penetrating.
Twenty-five patients underwent 29 amputations of which 12 (41%) were amputated upon admission due to mangled
extremity or associated injuries.
Amputation rates were 6% (3/52) for penetrating and 18% (14/76) for blunt trauma. Of the 17 secondary amputations,
13 were attempted revascularized with grafts and 3 were mangled and treated with ligation, embolization or
observation. One late presentation with a popliteal artery injury was amputated due to sepsis. Median time to surgery
for the subsequently amputated limbs was 210 (IQR 150, 280) minutes and median operating time was 350 (IQR 260,
475) minutes. Amputations were performed up to day 29 due to the extent of injury, compartment syndrome, multiple
organ dysfunction syndrome (MODS) or sepsis. Graft patency at time of amputation was 77% (10/13).
The 30-day mortality was 14% (19/133) and the vascular injury contributed in 10 of these patients.
Conclusion: Limb threatening vascular injury is a rare entity in our institution and is associated with significant
morbidity and mortality. The most frequently injured arteries in penetrating trauma were the brachial and the femoral
arteries, whereas the subclavian and iliac arteries dominated in blunt trauma. Minimizing time to revascularization is
essential for limb salvage and a key element in reducing morbidity in this group of patients.
Disclosure of Interest: None declared
123
54.02
PREDICTING THE NEED FOR DEPENDENT CARE AFTER DISMISSAL IN GERIATRIC TRAUMA PATIENTS
Y. M. K. Baghdadi1, J. M. Leonard1,*, A. Choudhry1, C. A. Thiels1, D. H. Jenkins1, S. P. Zietlow1, M. D. Zielinski1
1
Department of Surgery, Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN, United
States
Introduction: Elderly injured patients have a substantial risk for the need for dependent care (DC) placement (i.e.
nursing home, swing bed) out of proportion to equally injured but younger patients. We aimed to develop risk factors,
present on admission, for the need for DC placement.
Materials & Methods: All patients 65 years or older who were admitted after injury between 01/2008 and 08/2014
were identified. Patients who had unknown discharge destination, in-hospital death, or admitted from a DC facility,
were excluded. Patient characteristics, complications, and discharge destinations were analyzed. The 11-factormodified-frailty index (FI), derived from the Canadian Study of Health and Aging and validated in the ACS-NSQIP
database, was used to categorize pre-existing factors associated with physiologic frailty and the likelihood of DC
disposition (Table 1). The effect of patient characteristics, frailty and comorbidities on the need DC after dismissal
analyzed using multivariable logistic regression techniques.
Results: Of the 3035 patients, 1524 (50%) were dismissed to a DC facility. In the multivariable model, age (OR: 1.09,
95% CI: 1.07 - 1.10, p<0.0001), female gender (OR: 1.88, 95% CI: 1.51 - 2.33, p<0.0001), and patient who lives alone
(OR: 1.43, 95%CI: 1.16 -1.77, p=0.009) were statistically significant predictors for the DC placement among geriatric
trauma patients. Patients having none (OR: 0.53, 95%CI: 0.34 - 0.80, p=0.0025), or one preexisting condition (OR:
0.61, 95%CI: 0.40 -0.91, p=0.0147), had statistically significant lower odds for the need of DC placement compared to
patients having three or more on the modified-FI. Patients who were fully or partially assisted (OR: 2.38, 95%CI: 1.29
– 4.52, p=0.0049), had history of cerebrovascular event (OR: 2.65, 95%CI: 1.36 – 5.36, p=0.004), or history of
congestive heart failure (OR: 1.50, 95%CI: 1.03 – 2.21, p=0.0344) were at higher risk for the need of DC placement
after hospital discharge.
Image:
Conclusion: The increased likelihood for the need of a DC placement among geriatric trauma patients was
independently associated with several risk factors presented on admission including parameters of the modified-FI.
The modified-FI can serve as a useful adjuvant tool for overall risk assessment and hospital discharge planning
among geriatric trauma patient population.
Disclosure of Interest: None declared
124
54.03
THE CONCEPT OF TRIMODAL DISTRIBUTION OF TRAUMA DEATHS IS STILL VALID IN JAPAN
K. Takahashi1,*, T. Fujita1, Y. Uchida1, T. Tsunoyama1, M. Kitamura1, T. Sakamoto2
1
2
Trauma and Resuscitation Center, Emergency Medicine, Teikyo University, Tokyo, Japan
Introduction: There were unfavorable reports about the trimodal distribution of trauma deaths. However it has
become standard teaching in the Japan Advanced Trauma Evaluation and Care or JATEC course. The purpose of this
study was to determine whether the classical trimodal model is still applicable in Japan.
Materials & Methods: We use the data set of Japan Trauma Data Bank (JTDB) 2004-2013. The patients’
demographic data, mechanism of injury, times to death after admission, age and injury body region and Injury
Severity Score (ISS) were analyzed.
Results: There were 7638 cases of cardiopulmonary arrest on arrival (CPAOA) and 16461 in-hospital death in this
period. Within 24 hours, we lost 9153 cases (55.6% of in-hospital death). During the first period of classic model within
the first hour of injury, 16791 death (69.7 % of death include the CPAOA) were registered. We lost 4184 cases (25.4%
of in-hospital death) from hospital day2 to 7 and 3124 case (19.0% of in-hospital death) in the third peak (after 1
week).In 9153 deaths within 24 hours, 5217 cases were able to determine the time to death. We had data deficits
about time to death in 3936(43%) among this 5217 cases. We lost 702(7.7%) within one hour in the first peak,
3774(41.2%) in the second peak (one to 6 hours) and 741(8.1%) in 6 to 24 hours. The prevalence of trauma death
was exponentially decreased hour by hour within 24 hours and day by day after 24 hours.
Image:
125
Conclusion: The trimodal distribution was not also demonstrated in JTDB. However, the second peak of trauma
deaths in classical trimodal model was the dominant period of earl death in JTDB. This intelligible concept is still
valid focusing on the trauma education beyond one hour of JATEC or Advanced Trauma Life Support.
References: Demetriades D, Kimbrell B, Salim A, et al., JTrauma Deaths in a Mature Urban Trauma System:
Is “Trimodal” Distribution a Valid Concept? J Am Coll Surg 2005;201:343–348
Disclosure of Interest: None declared
126
54.04
TERTIARY TRAUMA SURVEY, AN ONGOING PROCESS
S. Ferree1,*, R. M. Houwert2, J. J. van Laarhoven1, D. P. Smeeing1, L. P. Leenen1, F. Hietbrink1
1
2
Surgery, University Medical Hospital, Surgery, Trauma center UMC, Utrecht, Netherlands
Introduction: As mortality rates decrease, due to better trauma care and resuscitation, increased emphasis on
morbidity is warranted. Due to prioritization in the initial phases of acute trauma care, non-life threatening injuries are
often diagnosed in a later phase. Timely diagnosis, especially extremity injuries, is important for rehabilitation and
long-term functional outcome. The aim of this study is to provide an overview of the delayed diagnosed injuries found
during a standardized tertiary survey protocol and to determine the time of diagnosis for these injuries. In addition, risk
factors associated with delayed diagnosing of injuries in polytrauma patients are analyzed.
Materials & Methods: Retrospective cohort study. All polytrauma patients, Injury severity score ≥16 injury to ≥2 body
regions, ≥16 years, admitted to the University Medical Center Utrecht from January 2007 until December 2012 were
included. All hospital charts were reviewed to identify time of diagnosis and subsequent treatment of delayed
diagnosed injuries. Patients with and without delayed diagnosed injuries are compared to identify risk factors
associated with delayed diagnosing in polytrauma patients.
Results: A total of 1416 polytrauma patients were included in this study. In 169 patients (12%) a delayed diagnosed
injury was found. Most delayed diagnosed injuries were found during admission after the formal tertiary trauma survey
(64%) with an average duration of 7 days untill diagnosis. Extremity injuries were the most frequently found delayed
diagnosed injuries (81%). Hand and foot injuries were most frequently found at a later stage (54% and 38%
respectively). Risk factors for delayed diagnosed injuries were high energy trauma, extremity injury and length of
hospital stay. Altered consciousness was not a risk factor associated with delay in diagnosis.
Conclusion: Polytrauma patients are at risk for delayed diagnosed injuries, especially extremity injuries in the
“functional regions”, hand and foot. Most delayed diagnosed injuries were found after the formal tertiary trauma
survey. Therefore tertiary survey should be an ongoing process. Patients who sustained a high energy trauma, those
with extremity injuries and patients with a longer hospital admission duration had a higher rate of delayed diagnosed
injuries. Altered level of consciousness was not associated with delayed diagnosis. We hypothesize this is attributable
to the standardization of the tertiary survey.
References: Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI: The tertiary trauma survey: a
prospective study of missed injury. J Trauma 1990, 30:666-9.
Holbrook TL, Anderson JP, Sieber WJ, Browner D, Hoyt DB: Outcome after major trauma: 12-month and 18-month
follow-up results from the Trauma Recovery Project. J Trauma 1999, 46:765-71.
Pape HC, Probst C, Lohse R, Zelle BA, Panzica M, Stalp M et al.: Predictors of late clinical outcome following
orthopedic injuries after multiple trauma. J Trauma 2010, 69:1243-51.
Giannakopoulos GF, Saltzherr TP, Beenen LF, Reitsma JB, Bloemers FW, Goslings JC et al.: Missed injuries during
the initial assessment in a cohort of 1124 level-1 trauma patients. Injury 2012, 43:1517-21.
Probst C, Pape HC, Hildebrand F, Regel G, Mahlke L, Giannoudis P et al.: 30 years of polytrauma care: An analysis
of the change in strategies and results of 4849 cases treated at a single institution. Injury 2009, 40:77-83.
Disclosure of Interest: None declared
127
54.05
AN SMARTPHONE APP TO ASSESS SEATBELT COMPLIANCE AMONG ROAD USER WORLDWIDE: A PILOT
35’000 OBSERVATIONS, 6 COUNTRIES TRIAL
D. Bracco1, T. Razek2,*, M. Shah3, S. Devkota4, J. Al-Oweis5, B. Kela3, M. Joshipura6, S. Muhammad7,8
1
2
Anesthesiology, Critical Care and Trauma, Department of Surgery and Trauma, Montreal General Hospital,
3
Montreal, Canada, Department of Surgery and Trauma, V.S. General Hospita, Ahmedabad, India, 4Department of
Surgery and Trauma, Katmandhu, Katmandhu, Nepal, 5Department of Surgery and Trauma, AL Imam University,
Riyadh, Saudi Arabia, 6Orthopedic surgery and Medical Director, Appollo Hospital, Ahmedabad, India, 7Pak Red
8
Crescent Medical and Dental College, Dina Nath, Pak Red Crescent Teaching Hospital, Dina Nath, Lahore, Pakistan
Introduction: Seat belt use halve the rate of death and severe injury after road accident and are promoted as a part of the WHO
road safety decade. Assessment of seatbelt use requires roadside users and significant resources. The objectives of this study are
to test an iPhone based roadside observation/geomapping system and to observe seatbelt compliance in various area.
Materials & Methods: The App called iBuckle up, get the date/time/GPS location through the iPhone system. The observer
enters the sex, position in the car and seat belt compliance. The system has a one clic acquisition for cars. Architecture and
interface allow a one clic acquisition for cars and 2 clics otherwise. Data are stored in the iPhone and send by batches. Data is
send to a central database and latitude longitude is mapped through google map API XML interface.
Results: During the test phase, a total of 35’050 road user were observed in 1072 different GPS locations in 6
countries. All data could be mapped successfully. Overall seat belt use was 66.6%. Median GPS horizontal and
vertical precision were 10m and 6m respectively. Seat belt use is highly variable by country (figure).
Image:
128
Conclusion: The iPhone app iBuckle Up allows to observe seatbelt use by road user and rapidly map these observations. By
expanding roadside observers and the easy data transfer and mapping this system allows precise mapping of seatbelt use
worldwide.
Disclosure of Interest: None declared
129
54.06
WHOLE BLOOD PLATELET FUNCTION DEGRADES QUICKLY AFTER STORAGE: IN VITRO COMPARISON OF
FRESH WHOLE BLOOD, STORED WHOLE BLOOD, AND RECONSTITUTED WHOLE BLOOD
S. F. Polites1,*, M. S. Park1, J. R. Stubbs2, R. L. Emery2, D. A. L. Haugen3, D. H. Jenkins1, M. D. Zielinski1
1
2
3
Department of Surgery, Department of Laboratory Medicine and Pathology, Department of Anesthesia, Mayo Clinic,
Rochester, United States
Introduction: Fresh whole blood (FWB) is an ideal resuscitation fluid for exsanguinating patients, especially in
austere environments where component therapy is scarce. Additionally, 1:1:1 transfusion of components, or
reconstituted whole blood (RWB), may not be as effective as other whole blood preparations such as FWB and stored
whole blood (SWB). We hypothesize that FWB has a superior coagulation profile compared to SWB and RWB.
Materials & Methods: Four healthy O males donated blood. FWB samples were collected directly from the reservoir,
then the blood was processed through a platelet-sparing, leukocyte-reducing filter (Imuflex WB-SP filters) and stored
at 1- 6ºC in CPD for up to 21 days to create SWB (Days 0, 2, 7, 14 and 21; SWB0-21). Four RWB units were created
using packed red blood cells, thawed plasma, and apheresis platelets in a 1:1:1 ratio. Complete blood count,
thromboelastography (TEG), rotational thromboelastometry (ROTEM), calibrated automated thrombogram, and
platelet aggregometry (Chrono-log, Stago) were performed and results compared between WFWB, RWB and SWB021. Two-sample t tests were performed.
Results: Mean hemoglobin of RWB (9.0±0.7) was significantly lower than FWB (13.7±0.5) and SWB0 (13.0±0.7;
p<.05) but platelet counts were similar (213±36 vs 173±47 vs 166±42 x103/µL, respectively; p>.05). Relative to RWB
and FWB, platelet function declined over time in SWB starting on day 2 (Figure). The initiation phase of clotting (TEG
reaction time), however, remained similar in all groups (6.8±0.8 vs 5.8±0.3 vs 7.4±0.9 minutes, respectively; p>.05).
Peak thrombin generation in platelet-poor plasma was greater in RWB (154.2±36.2 nM) when compared to FWB
(47.9±11.4 nM; p=.005) and SWB0 (35.4±14.4 nM; p=.01). Furthermore, peak thrombin generation increased over
time in SWB from 216.7±88.9 nM on day 2 to 337.2±87.4 nM on day 21.
Image:
Conclusion: FWB is an effective alternative to RWB based on its in vitro coagulation profile; however, platelet
function is not maintained over time once processed and stored. These data suggest that SWB must be transfused
soon after processing and storage processes require further study to determine if platelet function can be stabilized.
Disclosure of Interest: None declared
130
64.01
THE EFFECTIVENESS AND MECHANISM OF PREOPERATIVE LUGOL SOLUTION FOR REDUCING THE
BLOOD FLOW IN THE EUTHYROID PATIENTS WITH GRAVES’ DISEASE
S.-M. Huang1,*
1
Department of Surgery, National Cheng-Kung University, Medical College, Tainan , Taiwan
Introduction: In order to reduce intra- and post-operative complications
preoperative prepartion with Lugol solution in Graves’ disease has been known to 1)
rapid decrease thyroitoxicosis and 2) decrease the vascularity of the thyroid gland. Usually decreasing the vascularity
will come along with decreasing the severity of thyrotoxicosis. However, when the thyroid of Graves’ disease is in
euthyroidism, the sold effect and mechanism of Lugol solution for decreasing the blood flow is not well investigated
before.
Materials & Methods: 25 euthyroid patients with Graves’ disease admitted for preoperative Lugol solution for 10 days
.We measured such following diameter before Lugol solution administration and the operative day: 1)Thyroid blood
flow (of superior thyroid artery 2)Systemic angiogentic factor (VEGF) 3) Systemic inflammative factor (IL16)
Results: All the blood flow, serum VEGF, and serum IL16 were very significantly deceasing 10 days after taking Lugol
solution , compared with the level of pre- Lugol solution ( p<0.0001) . The average dropping rate were 40%, 55% , and
60% for blood flow(0.29 vs o.17 L/min;p< 0.001 ), serum VEGF (0.020 vs 0.009 pg/mL;p=0.0009 ), and Serum IL16 (
8340 vs 3725 ; pg/mL;p=0.0094) respectively.
Conclusion: We conclude that Lugol solution very effectively reduces the blood flow, angiogentic factor (VEGF), and
inflammative factor(IL-16) even in the euthyroid patients with Graves’ disease. Preoperative routinely using is highly
advocated for all the patients with Graves’ disease.
Disclosure of Interest: None declared
131
64.02
OUTPATIENT PARATHYROIDECTOMY: BILATERAL NECK EXPLORATION COMPARED TO FOCUSEDAPPROACH
C. M. Kiernan1,*, C. Isom1, S. Kavalukas1, C. Schlegel1, M. F. Peters2, C. C. Solorzano3
1
2
3
General Surgery, Anesthesia, Surgical Oncology/Endocrine Surgery, Vanderbilt University, Nashville, United States
Introduction: Bilateral neck exploration (BNE) is considered the gold standard operation for primary sporadic
hyperparathyroidism (HPT). Yet the BNE approach has become unappealing for patients with clearly localized
parathyroid glands, due to the perceived need for overnight stay, increased risks and costs. This study examines a
single surgeon’s experience with each operative approach and compares perioperative outcomes.
Materials & Methods: A retrospective review of prospectively collected data on 449 patients who underwent
parathyroidectomy over a 4.5-year period was performed. PTH monitoring was used in all cases. Focused
parathyroidectomy was the preferred approach during the first two years and BNE was the preferred approach in the
later two years. Outpatient parathyroidectomy was offered to all patients during both eras. Only patients with clearly
positive localization were included in the analysis. Patients who underwent previous parathyroid operations and those
requiring concurrent thyroid procedures were excluded.
Results: Among the 449 patients, 240 patients met inclusion criteria. 126 (53%) underwent parathyroidectomy during
the focused era and 114 (47%) during the BNE era. There were no differences in age, gender, ASA class,
preoperative calcium, PTH, and vitamin D levels between groups. When compared to the focused era, patients in the
BNE era were more likely to have >1 gland removed (35% vs. 18%, p<0.003), longer operative times (median 50 vs.
40 mins) and were less likely to have transient hypocalcemia (0% vs. 4%, p=0.03). There were no differences in the
rate of same day discharge (88% vs. 89%, p=0.778), post-op emergency department visits (4% vs. 2%,p=0.712), and
readmissions (3% vs. 0%, p=0.106). There were no postoperative hematomas. The rate of normocalcemic
postoperative PTH elevation was similar (13% vs. 18%, p=0.651). The operative failure rate for both approaches was
1% and one patient in the focused era had permanent hypoparathyroidism.
Conclusion: In this study, routine bilateral neck exploration for HPT was associated with excision of a greater number
of parathyroid glands and slightly longer operative times. However, bilateral neck explorations had similar rates of
same day discharges, emergency department visits and readmissions. BNE has a similar safety profile when
compared to focused parathyroidectomy and does not preclude same day hospital discharge.
Disclosure of Interest: None declared
132
64.03
TRUST YOUR EYES INSTEAD OF THE LABS: A PROSPECTIVE COMPARISON OF FOUR GLAND
EXPLORATION WITH AND WITHOUT USE OF IOPTH
E. Rudolf1, H. Chen1, D. Schneider1, B. Sippel1, C. Balentine1,*, D. Elfenbein1
1
surgery, Univeristy of Wisconsin-Madison, Madison, United States
Introduction: Parathyroid surgery has evolved after the introduction of intraoperative parathyroid hormone testing
(ioPTH) and targeted approaches. Use of ioPTH has become ubiquitous, even used in some cases to verify that all
hyperfunctioning tissue was resected when all four parathyroid glands are visualized. The aim of this study was to
evaluate the added value of ioPTH in cases when all four glands are visualized in patients with primary
hyperparathyroidism.
Materials & Methods: In a prospective manner, we followed consecutive patients with primary hyperparathyroidism
who underwent four-gland exploration between 1/2013-4/2014. Surgeons at our high-volume practice decided after
identifying all four glands whether to simply conclude the operation, or whether to wait for ioPTH levels. Re-operative
parathyroidecomy cases were excluded, and all patients had ioPTH levels drawn. The cases in which the surgeon
concluded before ioPTH values returned were defined as “no wait” cases. Patient demographics, preoperative
calcium and PTH levels, OR time, and whether patients met criteria for cure by ioPTH were recorded (50% drop).
Results: Of 409 parathyroidectomies during the study period, four gland exploration was done in 93 (22%). The
surgeon did not wait for ioPTH values in 63/93 (68%). Age, gender, baseline Calcium and PTH, indications for
surgery, and use of sestamibi imaging were similar between groups. Single adenoma was the etiology in just 44%,
and this did not differ between groups. The mean OR time was 64minutes for “no wait” vs. 83 minutes (p = 0.009). An
inadequate drop in ioPTH was found in two (3%) “no wait” cases, but at six month follow up, cure rates were 100% in
the “no wait” group vs 93% when ioPTH values were used (p=0.04.)
Conclusion: Waiting for ioPTH has no added value when an experienced surgeon definitively visualizes all four
parathyroid glands, it lengthens operative time by almost 20 minutes, and may even lend a false sense of security as
6 month cure rates were lower in the group where ioPTH was used.
Disclosure of Interest: None declared
133
64.04
4D CT PROVIDES AN ADVANTAGE COMPARED TO STANDARD LOCALIZATION PROCEDURES IN PRIMARY
HYPERPARATHYROIDISM PATIENTS WITH NORMAL AND MILDLY ELEVATED SERUM PARATHYROID
HORMONE LEVELS
M. Elsayed1,*, K. M. Day2, J. M. Monchik3
1
Warren Alpert Medical School of Brown University, Providence, United States, 2Department of Surgery, 3Department
of Endocrine Surgery, Warren Alpert Medical School of Brown University, Providence, United States
Introduction: 4-Dimensional Computed Tomography (4D CT) is increasingly utilized as a localization technique for
primary hyperparathyroidism, though its precise role is not defined. Mild primary hyperparathyroidism is associated
with smaller parathyroid glands that are less likely to be localized by ultrasound (US) and sestamibi scan (STS). We
examine the effectiveness of 4D CT for localization in this group of patients.
Materials & Methods: We conducted a retrospective analysis of 915 patients who underwent parathyroid surgery by
a single endocrine surgeon from January 2003 to September 2013. Patients with PTH values above and below 65
pg/ml (the upper limit of normal) and 100 pg/ml who failed to localize with US and STS are the subject of this study.
The accuracy and cost of 4DCT was examined in this setting.
Results: There were 62 patients with preoperative PTH levels less than 65 pg/ml and 280 patients with preoperative
PTH levels less than 100 pg/ml. Compared with higher PTH levels, the mean gland weight, volume, and localization
rate with US and STS were lower among patients with PTH levels less than 65 pg/ml (p=.0062; p=.095; p=.0001) and
less than 100 pg/ml (p=.0001; p=.0007; p=.0001). Conventional imaging with US and STS was unsuccessful in
localizing glands of 22.6% (n=14) and 14.3% (n=40) of patients with preoperative PTH values below 65 and 100
pg/ml, respectively. 4D CT was successful in localizing 87.5% (n=7) and 76.2% (n=16) of hyperfunctional parathyroid
glands among patients with PTH values less 65 pg/ml and 100 pg/ml, respectively. The U.S. Medicare reimbursement
for both US and STS was $531.8 compared to $373.25 with 4DCT, representing a 29.8% reduction in localization
cost.
Image:
Conclusion: Patients with normal or mildly elevated PTH levels are more likely to have failed imaging with US and
STS. 4D CT is accurate in localizing hyperfunctional glands in this population. The increased accuracy and savings of
4D CT indicates this would be a cost-effective primary imaging method in this patient population.
Disclosure of Interest: None declared
134
64.05
SUBTOTAL PARATHYROIDECTOMY WITH INDOCYANINE GREEN (ICG) ANGIOGRAPHY DEMONSTRATES
THE GOOD FUNCTION OF THE PARATHYROID REMNANT
J. Vidal Fortuny1,*, V. Belfontali1, S. Guigard1, W. Karenovics1, F. Triponez1
1
Thoracic and endocrine surgery, University Hospitals of Geneva, Geneva, Switzerland
Introduction: The two major complications of subtotal parathyroidectomy are persistent hyperparathyroidism and
definitive hypoparathyroidism. We report our first five patients in which the vascularization of the parathyroid remnant
was verified by intraoperative parathyroid angiography before resecting the 3 other enlarged glands.
Materials & Methods: Between May and November 2014, 29 patients underwent parathyroidectomy in our center
including 5 who underwent subtotal parathyroidectomy with intraoperative angiography using the fluorescent dye ICG
(3 patients with renal HPT including one with simultaneous total thyroidectomy, one patient with Lithium-induced
primary HPT and one patient with MEN1 associated primary HPT). Calcium and parathormone levels were measured
at day one, ten and 3.7 ± 1.6 month postoperatively. All patients received systematic Calcium (1 gr tid) and 1.25-OHVitamin D (1ug bid) supplementation.
Results: ICG angiography showed a well vascularized remnant in all patients. PTH levels dropped 77 ± 6.8% from the
preoperative levels. At follow-up, all patients had calcium (2.07 – 2.36 mmol/l) and PTH levels in the normal range (3.0
– 5.8 pmol/l).
Conclusion: Intraoperative angiography demonstrates the good perfusion and good function of the parathyroid
remnant in subtotal parathyroidectomy. It is currently the only available tool that can intraoperatively assess the
function of the remnant.
Disclosure of Interest: None declared
135
64.06
IS THE QUALITY OF LIFE OF THYROID CANCER SURVIVORS ANY BETTER THAN THAT OF SURVIVORS OF
OTHER CANCERS?
M. K. Applewhite1,*, B. C. James1, B. Aschebrook-Kilfoy2, S. Kaplan1, P. Angelos1, E. L. Kaplan1, R. H. Grogan1
1
2
Surgery, Health Studies, University of Chicago, Chicago, United States
Introduction: The incidence of thyroid cancer is increasing worldwide. As such, the number of survivors is also rising,
and little is known about their quality of life (QoL). Understanding QoL is of critical importance in providing optimal
care to cancer patients, improving the way we communicate the diagnosis, and helping set realistic expectations for
recovery. We recently conducted a large-scale survivorship study that showed thyroid cancer survivors have a
significant decrease in QoL, which was previously not recognized. In this study, we aim to compare these findings with
the QoL reported by survivors of other types of cancers, all of which have an overall worse prognosis than thyroid
cancer.
Materials & Methods: Thyroid cancer survivors were recruited from a collaborative network of endocrine surgery
clinics, survivorship groups, and social media. Participants filled out a validated questionnaire that assessed their
overall QoL and QoL in four subcategories: physical, psychological, social, and spiritual. These data were then
analyzed and compared using two-tailed t-tests to the QoL of survivors of colon, glioma, breast, and gynecologic
cancers that had been previously reported in the literature using the same QoL scale.
Results: In total, 1,174 participants with thyroid cancer were recruited. 89.9% were female and the average age was
48 years. Mean time from diagnosis was 5 years. The mean overall QoL was 5.56 out of 10 (on a scale of 0-10 with
10 being the best score). Overall QoL of patients with thyroid cancer was similar to that of patients with other types of
cancer: colon (mean 5.2 p=0.097), glioma (mean 5.96 p=0.27), gynecologic (mean 5.59, p=0.49) and worse than
patients with breast cancer (mean 6.51 p <0.0001). All subcategories demonstrated equivalent or worse QoL in thyroid
patients except the social QoL when compared to gynecologic cancer survivors (mean 6.35 compared to 5.52, p
<0.0001), in which thyroid cancer survivors had a better QoL.
Conclusion: Using this validated survey, we found the QoL of thyroid cancer survivors is equal to or worse than the
QoL of survivors of other types of cancer. The decrease in QoL associated with such a high survival rate suggests that
prognosis may not be the only predictor of QoL in cancer survivors and highlights the need for further research in this
field. In the future, we plan to create assessment tools, which will aid in improving our ability to take care of thyroid
cancer patients by addressing QoL concerns.
Disclosure of Interest: None declared
136
77.01
AUDITING SURGICAL RESIDENTS OPERATIVE ACTIVITY IN A BUSY LEVEL 1 TRAUMA UNIT IN SOUTH
AFRICA
R. Spence1,1,2,2, E. Zargaran3, E. Zargaran4, L. Roodt2, M. Hameed4, S. Sobnach2, M. Hutter1, D. Chang1, P.
5,*
5
5
6
5
Navsaria , P. Navsaria , A. Nicol , D. Kahn , A. Nicol
1
Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, United States,
2
University of Cape Town, Cape Town, South Africa, 3General surgery, 4Surgery, University of British Columbia,
Vancouver , Canada, 5Trauma Surgery, Groote Schuur Hospital, 6General Surgery, University of Cape Town, Cape
Town, South Africa
Introduction: In an era where surgical outcomes have been shown to differ by provider, the following study describes
prospectively audited surgical activity for general surgery residents rotating through Groote Schuur Hospitals Level 1
trauma unit (GSH).
Materials & Methods: During a 6 month period July 2014- December 2014, admission, operative and discharge
summaries generated on the recently implemented electronic Trauma Health Register (eTHR) as part of a
multifaceted trauma quality improvement program, were reviewed. A descriptive analysis of 4 surgical trainees' and 1
rotating relief surgeons' operative activity and the outcomes thereof was performed. Primary outcomes audited were
in-hospital morbidity and mortality. Secondary outcomes included length of stay, admission to ICU, incidence of
unplanned reoperation and readmission. Factors considered in the American College of Surgeons' Trauma Quality
Improvement Program were analyzed to assess comparability between operative cohorts.
Results: During the 6 month period the surgical residents performed 445 operations. After Relook laparotomies and
minor procedures were excluded, 336 major trauma operations were included. The most common operation
performed was exploratory laparotomy for penetrating injury to the abdomen (124 cases) followed by sub-xiphoid
window to exclude penetrating cardiac injuries (51 cases). Residents were only supervised in 28.5 % of cases. Each
cohort was considered comparable after analysing patients' initial vital signs on admission, age, gender, race, transfer
status, mechanism of injury, referral institution, AIS severity by individual body region and individual comorbitities.
Overall in-hospital morbidity and mortality rates were 24% and 3% respectively.
Residents' operative activity during 6 month period at GSH
Operation
Surgeon
Surgeon
Surgeon
Surgeon
Surgeon Relief
Tota
A
B
C
D
l
Above knee amputation
2
1
0
1
0
0
Axillary artery repair
4
1
2
0
1
0
Brachial artery repair
13
3
4
3
2
1
Closure colostomy
13
4
4
2
2
1
Damage control laparotomy
23
5
6
7
3
2
Diagnostic laparoscopy
10
3
2
2
3
1
Emergency room
5
1
0
2
1
1
thoracotomy
Exploratoray laparotomy
148
26
23
49
32
18
Neck exploration
10
3
0
4
2
1
Popliteal artery repair
3
0
1
1
1
0
Split skin graft
23
6
5
2
6
4
Sternotomy
5
2
0
1
2
0
Subclavian artery repair
3
1
1
0
1
0
Sub-xiphoid window
51
12
8
12
14
5
Thoracotomy
16
4
2
4
3
3
VATS
10
3
2
2
1
2
Total
75
56
92
74
39
336
VATS: Video Asssisted Thorascopic Surgery
Image:
137
Conclusion: Risk-adjusted surgical outcomes per surgical trainee are feasible in a busy level 1 trauma unit for
benchmarking and training purposes.
References:
1. Newgard CG et al.Methodology and Analytic Rationale for the American College of Surgeons
Trauma Quality Improvement Program. Journal of the American College of Surgeons Volume 216, Issue 1 Jan 2013.
Disclosure of Interest: None declared
138
77.02
USING TRAUMA REGISTRY DATA TO INFORM PREHOSPITAL TRAUMA CARE IMPROVEMENTS IN A
DEVELOPING COUNTRY
C. Juillard1,*, M. K. Ngamby2, E. Shetter3, G. A. Etoundi Mballa2, M. E. Monono4, A. A. Hyder3, K. Stevens3
1
2
Surgery, University of California, San Francisco, San Francisco, United States, Ministry of Public Health, Yaounde,
3
Cameroon, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States, 4World Health Organization,
Brazzaville, Congo
Introduction: Trauma is a major source of global mortality and morbidity, disporportionately affecting low- and middleincome countries (LMIC). Most LMIC trauma systems have little prehospital organization. Careseeking and prehospital
transportation data from a pilot trauma registry in Yaoundé, Cameroon were explored to inform preliminary
organization of prehospital trauma care.
Materials & Methods: A pilot trauma registry was instituted over 6 months in 2009 at the Central Hospital of Yaounde
(CHY), the primary trauma facility in Cameroon’s capital. Information on care-seeking behavior, method of transport to
CHY, injury severity, clinical care, and outcomes were collected. Injury severity was quantified by Injury Severity Score
(ISS) and Kampala Trauma Score (KTS). Bivariate and multivariate regression analyses were used to explore
relationships between variables.
Results: Care-seeking behavior was available for 2,783 (97.5%) of the 2,855 patients seen. Nearly one fifth (18.6%)
of patients sought care elsewhere prior to arrival. In the adjusted analysis, these patients were more likely to reside
outside of Yaoundé (OR 3.2, p<0.001), to have severe injuries (OR 1.16, p<0.016), and less likely to go home after
their emergency ward visit (as opposed to being admitted, transferred out of the emergency ward, or dying,
OR=0.462, p<0.001). Patients who first sought care elsewhere went primarily to district hospitals or health clinics
(83%), but 10% sought home care or traditional remedies. Taxis comprised the majority of prehospital transport
(62.1%), followed by private cars (22.3%), then police and ambulance (4.6% and 2.5%, respectively).
Image:
Conclusion: While high-income countries often have integrated trauma systems with ambulance-supported
prehospital care, the majority of trauma patients in this LMIC setting arrive by taxi cabs or layperson cars. A significant
subset of those presenting at the trauma center seek care elsewhere prior to arrival and tend to be more severely
injured than those coming directly to CHY. These findings provide areas for possible improvement in prehospital care
by building on the existing informal transport system, such as training taxi drivers in basic first aid. Additionally,
formalizing triage guidelines and streamlining referral patterns from outlying facilities could facilitate timely transfer of
injured patients to the city trauma center.
References: Hashmi ZG, Haider AH, Zafar SN, et al. (2013). "Hospital-based trauma quality improvement initiatives:
first step toward improving trauma outcomes in the developing world." J Trauma Acute Care Surg 75(1):60-68;
discussion 68.
Mock CN, Jurkovich GJ, nii-Amon-Kotei D, et al. (1998). "Trauma mortality patterns in three nations at different
economic levels: implications for global trauma system development." J Trauma 44:804 - 814.
Disclosure of Interest: None declared
139
77.03
DYNAMIC CHANGES IN PHYSIOLOGIC AND CLINICAL PARAMETERS PRECEDE HEMORRHAGE IN THE
STICU
J. F. Calland1,*, T. Moss2, D. Lake2, J. R. Moorman3
1
2
Department of Surgery, University of Virginia , Charlottesville, VA, Department of Medicine, UVA Health System,
3
Charlottesville, Department of Medicine, UVA Health System, Charlottesville, VA, United States
Introduction: Introduction
Occult hemorrhage in the surgical / trauma intensive care unit (STICU) patients is common and may lead to circulatory
collapse. Continuous monitoring of bedside physiological data may allow for early identification and treatment, and
could improve outcomes.
Materials & Methods: Materials & Methods
We studied 3,937 consecutive admissions to the STICU at the University of Virginia from March 2011 to September
2014. An electronic data warehouse archived the details of the transfusions of packed red blood cells (PRBC),
laboratory results, mortality, length of stay (LOS), and other clinical parameters. We collected physiologic data
captured by bedside monitors and then calculated the means and standard deviations of vital signs, and their crosscorrelations. We tested the hypothesis that a transfusion requirement of 3 or more PRBC transfusions in a 24 hour
period is preceded by dynamical changes in these physiologic and clinical measures and performed stepwise logistic
regression modeling with adjustment for repeated measures. We excluded observations of patients with any
transfusion requirements in the 24 hours preceding an event.
Results: Results
Within the population, we identified 256 hemorrhage events (6.5%). For patients with and without events, the inhospital mortality was 20% and 5% respectively and the median ICU LOS was 5.5 and 1.67 days respectively. An
optimal multivariate predictive model included increasing heart rate (HR), falling diastolic blood pressure (DBP), the
pulse oxygen saturation (SpO2) and its variability, the cardiorespiratory coupling, time since last hematocrit (Hct), and
the following laboratory results: blood urea nitrogen (BUN), arterial blood gas oxygen (ABG O2) saturation, Hct,
hemoglobin (Hgb), and lactic acid. The model had a c-statistic of 0.834 for a time to event window of 4 hours.
Image:
Conclusion: Conclusion
In STICU patients, a multivariate model predicted increases in the risk of hemorrhage and the need for transfusion in
the following 4 hours based on vital sign data currently available on bedside monitors and lab results. Earlier
detection of hemorrhage might improve outcome by allowing earlier resuscitation and investigation of bleeding sites in
surgical and trauma patients.
Disclosure of Interest: None declared
140
77.04
TRAUMA CARE IN TOP 20 HIGH VOLUME TRAUMA CENTERS IN JAPAN
T. Fujita1,*, Y. Uchida1, T. Tsunoyama1, M. Kitamura1, H. Ishikawa1, T. Sakamoto2
1
2
Trauma and resuscitation Center, Emergency Medicine, Teikyo University, Tokyo, Japan
Introduction: There have been many publications about the volume-outcome relationship. The purpose of this study
was to determine whether there was a positive value for Trauma Care in Top 20 High Volume Trauma Centers in
Japan.
Materials & Methods: This study used the data in the JTDB2004-2013 for 93842 patients without data deficits for
their Injury Severity Score (ISS), age and crude survival. The population was divided into two groups for the analysis.
The high volume (HV) group included 34129 patients from top 20 institutes. The low volume (LV) group
included 59713 patients from the other institutes in JTDB. The Cox regression analysis was applied for the 30 days
mortality of the two groups.
Results: The mean age with a 95% confidence interval (Top20 vs. others) was 53.7(53.4-53.9) vs.53.0 (52.8-53.2)
(p=0.682). The mean ISS was 14.6(14.5-14.7) vs. 15.9(15.8-16.0) (p<0.001). The crude in-hospital survival rate was
0.93(0.93-0.94) vs. 0.91(0.91-0.91) (p<0.001). Adjusted hazard ratio of 30 days mortality by Cox regression was
1.017(95%C.I.:1.018-1.021, p<=0.001) for age, 1.068(95%C.I.:1.067-1.069, p<0.001) for ISS, 0.784(95%C.I.:0.7450.826, p<0.001) for Top 20.
Image:
141
Conclusion: Cox hazard regression analysis demonstrated a positive value for the improving outcome in top 20 high
volume trauma centers in Japan. If we can concentrate the trauma patients to Top 20 high volume centers, we will
have 2% of survival advantage in nationwide. This result about the volume-outcome relationship might help in
allocating trauma resources and designating the hierarchy of trauma center.
Disclosure of Interest: None declared
142
77.05
CIVILIAN AIRWAY TRAUMA: A SINGLE-INSTITUTION EXPERIENCE
A. Madani1,*, N. Pecorelli1, T. Razek1, J. Spicer1, L. Ferri1, D. S. Mulder1
1
Surgery, McGill University, Montreal, Canada
Introduction: Injuries to the airway in the neck and thorax are uncommon, but may be potentially life threatening. Few
reports describe the evaluation and management of patients with such injuries. The objective of this study is to
determine the characteristics, management and outcomes for patients with airway injury.
Materials & Methods: From 1974-2014, a prospectively entered trauma database at a level 1 trauma center was
accessed to identify patients with injuries to the larynx, cervical trachea or thoracic airway. Hospital charts were
reviewed to obtain data on demographics, presentation, injury management, short-term (<30 day) and long-term (>30
day) morbidity and in-hospital mortality. Multivariate logistic regression was used to estimate predictors of mortality
and long-term morbidity. Data expressed as N (%) and mean (SD).
Results: One-hundred and twenty patients were included (age: 35 (18), male: 84%), injury severity score: 21 (13)).
There were 65 (54%) blunt and 55 (46%) penetrating injuries, with 90 (75%) suffering multiple injuries. Sixteen (13%)
patients died from associated injuries (7: in ER; 9: after admission). Fiberoptic bronchoscopy was invaluable for early
diagnosis or selective bronchial intubation in 23 (19%) patients, as well as for tracheobronchial toilet. Injuries were
located in the cervical airway (101 (84%)), thoracic airway (21 (18%)) or both (2 (2%)). Eighty-eight (73%) patients
were managed surgically (Table 1). All but 1 patient with thoracic airway injury (20 (95%)) underwent surgery for
primary repair, 3 of which had a tracheoesophageal fistula and only 1 required subsequent re-operation. Amongst
patients with cervical injuries, 26 (25%) had fractures of the larynx, 10 (8%) had complete laryngeal disruption and 37
(36%) suffered long-term morbidity in the form of aphonia, dysphonia, airway stenosis or vocal cord
paralysis. Predictors of in-hospital mortality included hemodynamic instability (OR 6.5, 95% CI 1.1-37.1) and GCS <8
(OR 4.1, 95% CI 1.9-6.3) upon presentation. Fracture of cricoid or thyroid cartilages was a strong predictor of longterm vocal cord injury (OR 5.0, 95% CI 1.6-15.6).
Table 1: Surgical management
Tracheostomy
36
(30%)
Larynx
Simple repair
35
(29%)
Montgomery stent
8 (7%)
Reconstruction
11
(9%)
Trachea
Simple repair
16
(13%)
Reconstruction
5 (4%)
Hypopharynx repair
17
(14%)
Sternotomy
4 (3%)
Thoracotomy
17
(14%)
Conclusion: Airway trauma remains a major challenge for early diagnosis, airway control and management of both
acute life-threatening injury and long-term morbidity.
Disclosure of Interest: None declared
143
78.01
CONVERSION FROM HORMONE RECEPTOR-POSITIVE BREAST CANCER TO EITHER HER2-POSITIVE OR
TRIPLE-NEGATIVE BREAST CANCER CAN BE AN INDEPENDENT PROGNOSIS FACTOR FOR RECURRENT
BREAST CANCER.
S. Shiino1,*, T. Kinoshita1, M. Yoshida2, T. Ochi1, T. Ogura1, K. Jimbo1, S. Asaga1, T. Hojo1
1
Breast surgery division, 2Department of Pathology and Clinical Laboratories, National cancer center hospital, Tokyo,
Japan
Introduction: Treatment decisions for patients with breast cancer are usually based on the immunohistochemical
expression status of hormone receptor [HR, i.e. estrogen receptor (ER) and progesterone receptor (PR)] and HER2
status. Retrospective studies have recently reported discordance in these statuses and subtype between primary and
recurrent tumors. However, it is unknown whether discordance is associated with patient prognosis.
Materials & Methods: We reviewed the records of 7,248 patients who underwent surgery for primary breast cancer at
the National Cancer Center Hospital between 1991 and 2013. There were 153 patients that underwent either core
needle biopsy or surgical excision for recurrent breast tumor. We re-performed immunohistochemistry (IHC) for all
tumor specimens using standardized methods with an autostainer. Two experienced pathologists diagnosed all these
specimens in a blinded fashion. HR status was judged as positive if more than 10% of tumor cells were stained. HER2
positivity was assessed by IHC (score 3+) or FISH amplification (HER2 / CEP 17 ratio ≥ 2.0). We evaluated overall
survival (OS) using Kaplan-Meier method and the log-rank test. The Cox proportional hazard regression model was
used to perform multivariate of the independent prognostic factors on OS.
Results: Among 153 patients, 104 patients had local recurrences and 49 patients had distant metastasis. The
discordance rates in ER, PR and HER2 were 18 %, 26 %, and 7 %. When the cases were classified into four subtypes
according to HR and HER2, the subtype changes were found in 32 patients (21 %). Especially, HR-positive subtype
converted to HR-negative/HER2-negative (i.e. triple negative, TN subtype) in 15 patients (9.7 %) and HR-positive
subtype converted to HR-negative/HER2-positive (i.e. HER2 subtype) in 6 patients (4 %). Discordant group which HRpositive subtype converted to either TN or HER2 subtype had a worse prognosis than HR-positive concordant group
in a multivariate analysis (HR 3.20; 95% CI 1.30–7.85, P = 0.01). In addition, OS in this discordant group was not
different from either HER2 or TN subtype concordant group (P = 0.87).
Conclusion: Our results raised the possibility that conversion from HR-positive subtype to either HER2 or TN subtype
was independently associated with patient prognosis. Therefore, tissue sampling for recurrent breast tumors may be
useful for devising new treatment strategies for recurrent breast cancer.
References: Liedtke C, Broglio K, Moulder S, Hsu L, Kau SW, Symmasn WF, et al. Prognostic impact of discordance
between triple-receptor measurements in primary and recurrent breast cancer. Ann Oncol 2009; 20 (12): 1953-8.
Dieci MV, Barbieri E, Piacentini F, Ficarra G, Bettelli S, Dominici M, Conte PF, Guarneri V, et al. Discordance in
receptor status between primary and recurrent breast cancer has a prognostic impact: a single-institution analysis.
Annals of Oncology 2013; 24: 101-108.
Thompson AM, Jordan LB, Quinlan P, Anderson E, Skene A, Dewar JA, Purdie CA, et al. Prospective comparison of
switches in biomarker status between primary and recurrent breast cancer: the Breast Recurrence In Tissues Study
(BRITS). Breast Cancer Research 2010; 12: R92.
Amir E, Miller N, Geddie W, Freedman O, Kassam F, Simmons C, Oldfield M, et al. Prospective study evaluating the
impact of tissue confirmation of metastatic disease in patients with breast cancer. J Clin Oncol 2011; 30: 587-592.
Disclosure of Interest: None declared
144
78.02
COMPARING AXILLARY BURDEN IN NODE-POSITIVE BREAST CANCER PATIENTS DETECTED BY FINENEEDLE ASPIRATION CYTOLOGY WITH THOSE DETECTED BY A SENTINEL LYMPH NODE BIOPSY – HOW
BIG IS THE DIFFERENCE?
M. R. Boland1,*, R. Ni Cearbhaill1, D. Evoy1, J. Geraghty1, C. Quinn2, A. O'Doherty3, E. W. McDermott1, R. S. Prichard1
1
Breast and Endocrine Surgery, 2Pathology, 3Radiology, St Vincents University Hospital, Dublin 4, Ireland
Introduction: Axillary status remains an important prognostic indicator in breast cancer patients. Recent evidence
indicates that breast cancer (BC) patients found to have a positive sentinel node may not benefit from axillary
clearance (AC) as axillary disease burden is low. However there remains uncertainty as to whether such an approach
could be applied to the cohort of patients found to have axillary metastases on ultrasound guided fine needle
aspiration cytology. The aim of this study was to determine axillary nodal burden in patients with positive axillary
ultrasound-guided fine needle aspiration cytology (FNAC) compared with those who had a positive sentinel lymph
node biopsy (SLNB).
Materials & Methods: A retrospective study was performed involving all patients with BC between 2007 and 2013
who had either pre-operative ultrasound guided FNAC or SLNB. Patient and tumour characteristics as well as nodal
burden were examined in all patients who proceeded to axillary clearance.
Results: 784 patients were eligible for analysis. 348 (44%) had positive FNAC and 436 (56%) had a positive SLNB.
There was no significant difference in age between the SLNB group and the FNAC group (Mean age: 56.03 vs 54.91;
Unpaired t-test p=0.14). Patients in the FNAC group were more likely to undergo mastectomy (Chi Square test;
p<0.001), have lymphovascular invasion (p=0.007), a negative oestrogen receptor status (p<0.001) and a positive
HER2 status (p<0.001). The median total number of lymph nodes (LNs) excised during AC was 23 in both groups
(Unpaired t-test; p=0.46). The median number of involved LNs was 4 (range 1-47) in FNAC-positive patients vs. 2
(range 1-37) in SLN-positive patients (Unpaired t-test; p<0.0001). The median number of involved lymph nodes in
level 1 was 3 in FNAC positive patients vs. 1 in SLNB positive patients (Unpaired t-test; p<0.0001). 49% of SLNpositive patients had only 1 involved LN, 28% had 2, and 23% had ≥3. 13% of FNAC-positive patients had 1 involved
LN, 12% had 2, and 74% had ≥3.
Conclusion: FNAC positive patients have a higher axillary burden than patients with a positive SLNB. Over 75% of
the SLN positive patients may fulfill ACOSOG Z0011 trial criteria and may not require further surgery.
Disclosure of Interest: None declared
145
78.03
VIRTUAL ENDOSCOPIC MODE OF 3D-CT CAN NAVIGATE VIDEO-ASSISTED BREAST SURGERY.
K. Yamashita1,*, H. Takei1
1
Breast Surgery, NIPPON MEDICAL SCHOOL, Bunkyo-ku, Tokyo, Japan
Introduction: The conventional breast surgery, including breast conserving surgery (BCS), makes many large wound
scars on the breast with granulated ugly scars. We devised endoscopic video-assisted breast surgery (VABS) to
perform partial and total mastectomy without any wound on the breast. We have performed on more than 400 patients
since 2001. To obtain the minimum clear surgical margins and to improve the aesthetics of the breast after surgery,
we tried to navigate VABS by the virtual mode of 3D-CT with endoscopic ultrasonographic probe. We evaluated the
efficacy of the new navigation techniques.
Materials & Methods: VABS consists of BCS, mastectomy, sentinel node (SN) biopsy, axillary node dissection, and
breast reconstructions. It uses periareolar approach and/or axillary approach. Trans-axillary retromammary approach
(TARM) is a single port surgery with an axillary skin incision. The each wound length is usually 2.5cm, but 1cm for SN
biopsy. We cut the mammary gland with clear surgical margin from behind the mammary gland. The virtual
endoscopic mode of 3D-CT images are overlaid on the endoscopic view to navigate precise SN biopsy and clear
cutting at surgical margin of mammary gland. The endoscopic ultrasonographc probe can show precise position of the
tumor and surgical margin from the backside of the mammary gland. The postoperative aesthetic results were
evaluated by ABNSW.
Results: The endoscopic SN biopsy was performed on 400 patients, and 3D-CT lymphography on 300 patients. The
virtual navigation helped to detect precise SN successfully. BCS was performed on 300 patients and skin-sparing
mastectomy on 50 patients. The operative cost is very low as the conventional one. There was no significant
difference in operational infestation. There was no serious complication after surgery. Surgical margin was minimally
positive in 2 patients. The original shapes of the breast were preserved well. Intraoperative fast frozen section studies
of surgical margin were positive on 8 cases of 224 patients (3.6%) by planned 20 mm of free mamrgin, on 5 of 49
(3.9%) by 10 mm, and 3 of 49 (6.1%) by 5 mm. However, there was no positive surgical margin by the permanent
pathological study after surgery. We have not experienced the reoperation. The postoperative esthetic results were
excellent and better. All patients expressed great satisfaction.
Conclusion: The virtural endoscopic mode of mammary 3D-CT can be useful for navigating partial mastectomy of the
video-assisted breast surgery.
Disclosure of Interest: None declared
146
78.04
POST-NEO-ADJUVANT CHEMOTHERAPY VERSUS PRIMARY SENTINEL LYMPH NODE BIOPSY FOR LARGE
OPERABLE/ LOCALLY ADVANCED BREAST CANCERS: RESULTS OF A COMPARATIVE VALIDATION STUDY.
S. Rajan1,*, S. Gambhir2, P. Lal3, N. Krishnani4, S. Kheruka2, G. Agarwal1
1
2
3
4
Endocrine & Breast Surgery, Nuclear Medicine, Radiation Oncology, Pathology, Sanjay Gandhi Postgraduate
Institute of Medical Sciences (SGPGIMS), Lucknow, India
Introduction: Sentinel lymph node biopsy (SLNB) is the standard of care for staging N0 early breast cancers (EBC)
patients undergoing primary surgery. Majority of patients in developing countries present with large & locally advanced
cancers (LABC) that are treated with neo-adjuvant chemotherapy (NACT). The accuracy of SLNB in staging stage III
but N0 patients, and post-NACT N0 patients is uncertain. In this prospective validation study conducted on stage III
patients, we compared the accuracy of SLNB between patient groups undergoing primary surgery versus those
undergoing post-NACT surgery.
Materials & Methods: Following IRB approval, 50 consecutive T3/T4,N0 pts undergoing primary surgery & 70 noninflammatory st.III (index stage) pts treated with NACT & N0 at time of operation were inducted. Validation SLNB was
99m
performed using low-cost dyes- methylene-blue &
Tc-Antimony-colloid in both groups. The SLN identification (IR)
& false negative (FNR) rates were compared between the two groups. In post-NACT group- sub-group analysis was
done according for the index tumor & axillary nodal stage before NACT. Factors predicting SLN IR & FNR in postNACT pts were analyzed.
Results: SLN IR & FNR (Table-1) in post-NACT group were significantly inferior to the T3/T4 primary surgery group.
SLNB results in T3,N0 patients undergoing primary surgery were comparable to our earlier validation SLNB results in
EBC (data not shown). In subgroup analysis (Post-NACT), factors predictive of unidentified SLN & false negative
SLNB included young age, LVI, extra-nodal spread & UOQ tumors.
T3/T4 N0 Primary surgery group (n=50) Post NACT N0 group (n=70) p-value
SLN Identification rate
47(94%)
58 (82.8%)
<0.05
False negative rate
T3=41/43(95.3%)
T3, N0/N1: 13/14(92.8%)
T4b=6/7(85.7%)
2(4.2%)
T4b, any N: 19/28(67.5%)
N2a, any T: 10/16(62.5%)
T4b, N2a: 5/12(41.7%)
6(10.3%)
T3=1/41(2.4%)
T3, N0/N1: 0/13(0%)
T4b=1/7(14.2%)
Not
significant
<0.001
<0.05
Not
significant
T4b, any N: 3/19(15.7%)
N2a, any T: 2/10(20.0%)
<0.001
T4b, N2a: 1/5(20.0%)
Conclusion: SLNB results in primary surgery setting for T3,N0 tumors are comparable to those for EBC. In postNACT patients, SLN identification rates are lower & false negative rates higher in presence of skin involvement or
matted axillary lymph nodes, probably due to obliteration of cutaneous & efferent lymphatics. In absence of skin
involvement or matted nodes, the SLNB identification & accuracy in post-NACT patients are similar to EBC patients
undergoing primary surgical treatment.
Disclosure of Interest: None declared
147
78.05
VARIATION IN THE WORKUP OF ASYMPTOMATIC PATIENTS DIAGNOSED WITH INVASIVE BREAST CANCER
A. Chagpar1,*, G. Babiera2, J. Aguirre3, K. Hunt2, T. Hughes4 on behalf of American College of Surgeons Communities
on behalf of American College of Surgeons Communities
1
2
3
Yale University, New Haven, CT, MD Anderson Cancer Center, Houston, TX, United States, Hospital de los Valles,
4
Quito, Ecuador, McPherson Hospital, McPherson, KS, United States
Introduction: Breast cancer is one of the most frequently diagnosed malignancies worldwide, and while there have
been guidelines regarding the workup of asymptomatic patients, variation remains in terms of practice patterns. We
sought to determine, in an international survey of surgeons, factors associated with this variation.
Materials & Methods: An anonymous web-based survey was distributed to surgeons via the online platform
American College of Surgeons Communities. Statistical analyses were conducted using IBM SPSS Statistics (Version
21).
Results: 238 surgeons from 8 countries and 44 US states/territories responded to the survey; 93.6% were from the
US. 17.7% were in academic practice, 39.1% were hospital employed, and 43.2% were in private practice. 55.8%
claimed that more than 50% of their practice was breast-related; and 30.8% were had solely breast practices. We
asked how often surgeons would use each of a series of tests in the workup of an otherwise healthy asymptomatic
patients, presenting with a non-palpable mammographic abnormality and a core needle biopsy showing invasive
breast cancer (see figure). Tremendous variation was seen. For example, 23.5% of respondents stated they always
would obtain a breast ultrasound (u/s), 17.2% stated they never would. In addition, 33.5% would always order a chest
x-ray, regardless of symptoms, despite this not being recommended by NCCN. Workup of patients did not vary
significantly based on number of years in practice nor practice setting across any of the tests listed. However, those
whose practice was >50% breast were more likely to state that they would always order a breast u/s (32.5% vs.
12.9%, p<0.001). While they were also less likely to state they would never order a breast MRI (3.4% vs. 25.8%,
p<0.001), the proportions of surgeons who would always order a breast MRI was similar in the two groups (3.4% and
3.2%, respectively). Interestingly, surgeons working outside of the US were more likely to always order a bone scan
(26.7% vs. 2.5%, p=0.004) and an u/s of the liver (13.3% vs. 0.5%, p=0.001); their use of other tests did not vary
significantly from their American counterparts.
Image:
Conclusion: These data highlight the lack of uniformity in the workup of asymptomatic patients presenting with nonpalpable breast cancers, and point to potential areas for reducing cost and improving value by minimizing variability
through accepted international practice standards.
Disclosure of Interest: None declared
148
78.06
UTILIZATION OF CORE NEEDLE BIOPSY FOR BREAST DIAGNOSIS IN A COMPREHENSIVE BREAST
CENTER: IMPLICATIONS FOR DEVELOPMENT OF QUALITY INDICATORS
C. Holloway1,*, L. Al-Riyees2, R. Saskin3
1
2
Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada, Surgery, Kind Abdulaziz Medical City, King Fahad
3
Nation Guard Hospital, Riyadh, Saudi Arabia, Biostatistics, Institute for Clinical Evaluative Sciences, Toronto, Canada
Introduction: Core Needle Biopsy (CNB) is the standard of care for diagnosis of breast lesions. Rates of excisional
biopsy for breast diagnosis in Northa America have been reported at approximately 35%, although significant regional
variation exists. A target rate of CNB for diagnosis of breast abnormalities is needed to facilitate quality improvement.
We sought to describe the use of CNB in a referral practice, the clinical scenarios prompting CNB or surgical biopsy
(SB), and the accuracy and rate of CNB by indication to inform the ultimate development of a benchmark rate for CNB
in breast diagnosis.
Materials & Methods: Female patients age 18-90 years old, referred to Sunnybrook Health Sciences Centre, a large
teaching hospital affiliated with the University of Toronto, with a breast lesion prompting tissue diagnosis with SB
and/or CNB between 2002 and 2009 were studied. Each biopsied lesion was characterized by method of biopsy:
CNB, SB, or CNB followed by SB. For each lesion we collected data on patient demographics and breast cancer risk,
reason for referral, imaging characteristics (BI-RADS classification, full description, presumed diagnosis before
biopsy) and pathology from each biopsy method. We report concordance between the presumed diagnosis pre-biopsy
and the CNB diagnosis with the final surgical diagnosis where applicable.
Results: 1032 lesions were biopsied, 993 (96%) with CNB. The clinical features by biopsy method is reported in the
Table.
Biopsy Method
Lesion Characteristics
CNB (n=438) SB (n=39) CNB+SB (n=555)
N (%)
N (%)
N (%)
Mass
230 (36)
25 (4)
368 (58)
Calcification
127 (52)
0
119 (48)
Stromal distortion
2 (40)
0
3 (60)
Density
4 (33)
0
8 (67)
Non-mass enhancement
31 (53)
2 (3)
26 (44)
Architectural distortion
5 (45)
0
6 (54)
Hypoechoic area
14 (61)
2 (9)
7 (30)
Mass-like enhancement
5 (7)
0
2 (29)
Other
14 (41)
9 (26)
1 (32)
The benign:malignant ratio for the entire cohort was 560:472 = 1.2:1. Presumed diagnosis was concordant with final
pathology in 675/862 (78%) and CNB diagnosis was concordant with SB pathology in 80/555 (86%). The reasons for
SB without CNB were required pathologic evaluation of the entire lesion (n=19), patient choice (n=7), technical (n=4),
planned mastectomy (n=3), other biopsy technique used (n=5) and other (n=6).
Conclusion: The vast majority of lesions requiring tissue diagnosis can be accurately diagnosed with CNB.
Benchmarks for rates of CNB of 90% or greater may be considered for performance measurement in appropriate
populations.
References: 1. Holloway CM, Saskin R, Brackstone M, Paszat L.Variation in the use of percutaneous biopsy for
diagnosis of breast abnormalities in Ontario. Ann Surg Oncol. 2007 Oct;14(10):2932-9. 2. Silverstein MJ, Recht A,
Lagios MD, Bleiweiss IJ, Blumencranz PW, Gizienski T, Harms SE, Harness J, Jackman RJ, Klimberg VS, Kuske R,
Levine GM, Linver MN, Rafferty EA, Rugo H, Schilling K, Tripathy D, Vicini FA, Whitworth PW, Willey SC., ImageDetected Breast Cancer: State-of-the-Art Diagnosis and Treatment J Am Coll Surg. 2009;209(4):504-20.
Disclosure of Interest: None declared
149
80.01
FOLFOXIRI REGIMEN BRINGS EARLY “CONVERSION” AND BETTER LONG-TERM OUTCOME IN PATIENTS
WITH INITIALLY UNRESECTABLE COLORECTAL LIVER METASTASES
M. Shimada1,*, Y. Morine1, S. Imura1, T. Ikemoto1, Y. Saito1, S. Yamada1, J. Higashijima1, C. Takasu1
1
Department of Surgery, Tokushima University, Tokushima, Japan
Introduction: Hepatectomy is the first choice for colorectal liver metastases (CLMs)whenever future remnant
liver is over 35 % in volume. Recently, FOLFOXIRI (5-FU/LV+Oxaliplatin+Irinotecan) plus bevacizumab (Bev)
regimen was reported to lead to high rate of pathologic responses of CLMs without increasing liver toxicity [1].
We have also recently reported Bev improved splenomegaly and decreased production of hyaluronic acid after
L-OHP based chemotherapy [2]. The aim of this retrospective study is to clarify impact of FOLFXIRI regimen on
initially unresectable CLMs.
Materials & Methods: Among 81 patients with initially unresectable CLMs, 59 had chemotherapy (CTx),
consisting of 10 old CTx (-2003) and 49 new CTx (2004- ) using new drugs such as oxaliplatin. Regimen of
FOLFOXIRI was applied to 14 patients together with molecular target drugs, consisting of Bev in 12 and C/Pmab in 2. “Conversion” rate and the period until “Conversion”, and overall survival (OS) were compared between
FOLOFOXIRI group and other regimen group. Pathological response and grade of sinusoidal obstruction
syndrome (SOS) were also examined.
Results: “Conversion” was not obtained in old CTx group. In new CTx group, “Conversion” was achieved in 21
patients (43%). OS in “Convresion” group was better than “non-conversion” group (3-year survival: 70 % vs. 15 %).
“Conversion” rate in FOLFOXIRI group was higher than that in other regimen group (64% vs. 34%). The period until
“Conversion” in FOLFOXIRI group was shorter than that in other regimen group (6.2 cycles vs. 16.1 cycles).
Furthermore, tumor necrosis rate in FOLFOXIRI group (80 %) was higher than that in other regimen group (47 %).
Prognosis after “Conversion” in FOLFOXIRI group was better than that in other regimen group (3-year survival: 80 %
vs. 33 %). In addition, time to surgical failure (TSF) in FOLFOXIRI group tended to be better than that in other regimen
group. In FOLFOXIRI group, all cases having Bev did not show more than grade 2 of SOS, on the other hand, one of
two cases having C-or P-mab suffered from the blue liver (Grade 3 of SOS).
Conclusion: FOLFOXIRI regimen is highly effective in order to obtain early "Conversion" and better long-term
outcome after ”Conversion” for initially unresectable CLMs. In addition, Bev could reduced oxaliplatin-induced liver
damage even in the FOLFOXIRI regimen.
References: 1. Loupakis F, et al. .Histopathologic evaluation of liver metastases from colorectal cancer in patients
treated with FOLFOXIRI plus bevacizumab.Br J Cancer. 108(12):2549-56, 2013.
2. Arakawa Y, Shimada M, et al. Bevacizumab improves splenomegaly and decreases production of hyaluronic acid
after L-OHP based chemotherapy. Anticancer Res. 34(4):1953-8, 2014.
Disclosure of Interest: M. Shimada Grant/Research Support from: YakultHonsha Co.,Ltd., Tokyo, Japan. Chugai
Pharmaceutical Co., Ltd. Tokyo, Japan. , Y. Morine: None declared, S. Imura: None declared, T. Ikemoto: None
declared, Y. Saito: None declared, S. Yamada: None declared, J. Higashijima: None declared, C. Takasu: None
declared
150
80.02
EFFICACY OF NEOADJUVANT CHEMOTHERAPY FOR INTRAHEPATIC MICROMETASTASES AND
OUTCOMES IN PATIENTS WITH COLORECTAL CARCINOMA LIVER METASTASIS
K. Yuza1,*, J. Sakata1, Y. Hirose1, K. Miura1, K. Takizawa1, M. Nagahashi1, T. Kobayashi1, T. Wakai1
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
Niigata, Japan
Introduction: Hepatectomy offers the hope of a cure in selected patients with colorectal carcinoma liver metastases
(CRLM). Recent evidence indicates an increasing trend of the use of neoadjuvant chemotherapy (NAC) in patients
with resectable CRLM. This study aimed to investigate the incidence and distribution of intrahepatic micrometastases
and to evaluate the effect of NAC on outcomes in patients treated with or without NAC for CRLM.
Materials & Methods: Seventy-nine patients (26 treated with NAC and 53 without) with CRLM underwent radical
resection at our hospital. Intrahepatic micrometastases were defined as microscopic lesions spatially separated from
the gross tumor. The distance from these lesions to the border of the hepatic tumor was measured on histological
2
specimens and the density of intrahepatic micrometastases (number of lesions/mm ) was determined in regions close
to (<1 cm) the gross hepatic tumor.
Results: In all, 288 intrahepatic micrometastases were detected in 48 patients (61%). Intrahepatic micrometastases
were less frequently detected in NAC treated patients than in untreated patients (8/26 vs. 40/53; P < 0.001). There
were no significant differences in the distance and density of intrahepatic micrometastases between the two groups (P
= 0.360 and P = 0.422, respectively). In all 79 patients, 5-year survival after hepatectomy was 77%. NAC treated
patients were characterized by higher prevalence of advanced stage of primary tumor (P < 0.001), synchronous
metastasis (P < 0.001), multiple liver tumors (P = 0.005), and large size of liver tumor (P < 0.001) compared with
untreated patients. There were no significant differences in both recurrence-free survival (P = 0.913) and survival (P =
0.768) after hepatectomy between the two groups. Recurrence-free survival after hepatectomy was significantly worse
for patients with intrahepatic micrometastases than for those without based on both univariate (P = 0.047, Figure 1)
and multivariate (relative risk, 2.847; P = 0.019) analyses. Survival after hepatectomy was comparable between the
two groups (P = 0.205).
Image:
Conclusion: NAC reduces the incidence of intrahepatic micrometastases in patients with CRLM, but NAC has no
significant effect on their distribution. Intrahepatic micrometastasis predicts an increased risk of recurrence after
hepatectomy. Considering that NAC treated patients tended to have more aggressive tumor characteristics, NAC
appears to enhance survival after hepatectomy in patients with CRLM.
Disclosure of Interest: None declared
151
80.03
BENEFIT AND LIMITATION OF LIVER RESECTION FOR MULTIPLE COLORECTAL METASTASES.
R. Amemiya1,*, Y. Abe1, O. Itano1, M. Shinoda1, M. Kitago1, H. Yagi1, T. Hibi1, Y. Kitagawa1
1
Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
Introduction: Liver resection for colorectal liver metastases is considered the only potential curative therapy.
Technical advances in liver resecton and modern preoperative chemotherapy in patients with initially unresectable
liver metastases have expanded the indications for liver resection; however, the limitation of the effect of the surgery
combined with chemotherapy has not yet become clear. This study examined clinical outcomes following liver
resection for colorectal liver metastases and assessed the benefit and the limitation of liver resection.
Materials & Methods: Between 1998 and 2014, 187 patients underwent initial liver resection for colorectal
metastases. Patients were divided into three groups by the degree of hepatic metastases stipulated by the Japanese
classification of colorectal carcinoma, i.e. H1, number of tumors ≤ 4 and maximum liver tumor size ≤ 5 (n=143); H3,
number of tumors ≥ 5 and maximum liver tumor size > 5 (n=6); H2, others (n=38). 58 patients underwent repeat liver
resection (with or without local ablation therapy, such as RFA, MCT, or Cryoablation) of recurrent liver tumors, of
whom 42 underwent second liver resection, 10 third resection, 3 fourth resection and 3 fifth resection.
Results: The 5-year overall survival rates after the first liver resection were 52.5%.
The 5-year survival rate of patients in H1, H2 and H3 groups were 56.7%, 40.3% and 0%, respectively. 11 patients in
H2 (29%) were disease-free, especially 8 patients were alive with more than 2-year disease-free. Out of the 8
patients, one patient had more than 15 tumors, 3 patients had the tumor larger than 8cm in the first liver resection.
The 5-year survival rate of patients who underwent second time, third time, fourth time and five time liver resection
were 41.7%, 49.2%, 66.7% and 100%, respectively.
Conclusion: Although some patients in H2 group had more than 15 tumors or the tumor larger than 8cm, they could
get long-term survival. In addition, repeat liver resection of recurrent metastases could contribute to improve
prognosis. These results justify the aggressive surgical approach for patients in H2 group. On the other hand, all 6
patients in H3 died with recurrence detected within 2 years. It is necessary to clarify the optimal setting of
multidisciplinary care for patients in H3 group.
Disclosure of Interest: None declared
152
80.04
LIVER SURGERY IN ALVEOLAR ECHINOCOCCOSIS - RESULTS AND OPEN QUESTIONS
D. Henne-Bruns1,*, B. Gruener2, A. Hillenbrand1
1
2
Department of General and Visceral Surgery, Division of infectious Disease, University of Ulm, Ulm, Germany
Introduction: Alveolar echinococcosis (AE) of the liver is a serious infectious disease, which leads without adequate
treatment to a slow but continous progression to the destruction of the organ. Because anti-infective medication is
unable to achieve a complete eradication, only a liver resection (in combination with postoperative albendazole
therapy) offers a chance for cure. According to the literature this liver resection should be performed with an AE free
resection of > 2cm to avoid recurrence.
Materials & Methods: In our study we retrospectively evaluated those 121 patients from our database, which had
been operated in a curative intention. 92 of these patients could be followed regarding the long-term outcome. The
median age of these 92 patients at initial diagnosis was 40.5 years (11-73 years). All patients are alive with a median
follow-up after the primary operation of 8.3 years (5 months - 43 years).
Results: 41 patients underwent major liver resections (4-6 segments), 39 patients underwent minor liver resections
(1-3 segments) and 12 patients atypical resection or enucleation. A wide resection margin (> 2 cm) was achieved in
12 patients, a resection margin of 10-19 mm was achieved in 16, a margin of 1-10 mm in 21 patients and in 43
patients a resection margin of only 0-1 mm was observed. Out of 92 patients 15 experienced recurrence in a range
from 4 months to 24 years postoperatively.
Conclusion: Liver resection can safely be performed in patients with AE. According to our data a resection margin of
> 10 mm is sufficient to prevent recurrence. A postoperative albendazole treatment also seems to be important to
prevent recurrence. The duration of the therapy should be correlated to the extent of the resection margin.
Disclosure of Interest: None declared
153
80.05
POLOXAMER REVERSIBLE GEL MARKER FOR PRECISE HEPATECTOMY
J. Li1,*, F. XUE1, X. XU1, J. LU1, A. SHI1, F. MA1, Y. LV1
1
Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi’an Jiaotong University, XI'AN, China
Introduction: Poloxamer 407, an innoxcious polymer approved by the FDA, presents with a predominant feature of
gelatinizing at body temperature in certain concentration and degelatinizing below critical point. The ideal
concentration ranges from 15% to 25%. Utilizing this character, a mixture with poloxamer and methylene blue is
expected to occlude the blood flow temporary and dye the target resection region synchronously.
Materials & Methods: 6 dogs were randomly assigned. The control group (n=2) underwent partial
hepatectomy with Pringle maneuver. Catheterizing to the target lobe via a branch of splenic vein,
the experimental group (n=4), of which 2 were for instant assessment and the rest were for longterm observation, got partial hepatectomy assisted with colour-labelled thermosensitive gel
administration at the speed of 1ml/s. Blood specimens (blood routine test, liver function and
coagulation profile), angiogram and necropsy (liver, lung, heart and kidney) were tested
periodically.
Results: The resection margins were clearly visualized. The average surgical time were 20.3 and 16.1 minutes
respectively in the control and experimental groups. Hemorrhage volume were less than a gauze. The average
AST/ALT level 3-day postoperation were 116.2/127.6 and 79.9/64.0 U/L in the control and experimental groups. The
rest laboratory data were close in both groups. Angiogram showed effective occlusion at the target region after the gel
administration. Angiogram and necropsy showed no evidence of abnormities 3 months after the operation.
Image:
Conclusion: The poloxamer and methylene blue gel provides an effective alternative for colour-
labelled reversible blood occlusion in liver resection.
Disclosure of Interest: None declared
154
80.06
SAFETY AND FEASIBILITY OF HYBRID LAPAROSCOPY-ASSISTED LIVER RESECTION USING TWOSURGEON TECHNIQUE IN HIGH THROMBOEMBOLIC RISK PATIENTS WITH CONTINUATION OF
ANTIPLATELET THERAPY.
T. Fujikawa1,*, Y. Yoshimoto1, S. Tada1, A. Tanaka1
1
Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
Introduction: In our perioperative management of patients with high thromboembolic risks such as drug-eluting
coronary stent implantation, the protocol included preoperative continuation of aspirin monotherapy and postoperative
early reinstitution to prevent fatal postoperative thromboembolic complications(1). We assessed the safety and
feasibility of hybrid laparoscopy-assisted liver resection (LALR) using two-surgeon technique(2) under continuation of
antiplatelets in patients with high thromboembolic risks.
Materials & Methods: A series of patients who had undergone LALR using two-surgeon technique under continuation
of preoperative antiplatelets were reviewed. Surgical Technique: Target liver lobe was first mobilized laparoscopically,
and a 7-10cm mini-laparotomy incision was selected to be placed either subcostally or on the upper midline. Large
gauzes were placed under the diaphragm to move the target tumor just under the mini- incision, and liver parenchymal
transection using two-surgeon technique with saline-linked monopolar dissecting sealer, coagulating sears, and
ultrasonic dissection was applied in the same fashion as an open hepatectomy. For left lateral sectorectomy or
hemihepatectomy, hanging method was also used but routine inflow occlusion was not used.
Results: LALRs were performed on 10 patients under continuation of preoperative antiplatelet therapy. We have
performed partial liver resection in 8, lateral sectorectomy in 1, and left hemihepatectomy in 1. No patients were
converted to open surgery. The median of operative time and estimated blood loss were 170min and 50mL,
respectively. None suffered from excessive bleeding intraoperatively, and neither bleeding nor thromboembolic
complications occurred postoperatively. Unfortunately, one patient undergoing uneventful partial LALR, who had an
excellent early postoperative course, developed sudden cardiopulmonary arrest of unknown cause and expired 10
days after surgery.
Conclusion: Hybrid LALR using two-surgeon technique can be performed safely and satisfactorily even under
continuation of single antiplatelet for patients with high thromboembolic risks, although this challenging group needs to
be carefully managed to prevent fatal postoperative complications.
References: 1. Fujikawa T et al. Effect of antiplatelet therapy on patients undergoing gastroenterological surgery:
Thromboembolic risks versus bleeding risks during its perioperative withdrawal. World J Surg 39: 139-149, 2015.
2. Aloia TA, et al. Two-surgeon technique for hepatic parenchymal transection of the noncirrhotic liver using salinelinked cautery and ultrasonic dissection. Ann Surg 242:172-177, 2005.
Disclosure of Interest: None declared
155
80.07
PURE LAPAROSCOPIC PARENCHYMAL SPARING ANATOMICAL LIVER RESECTION OF SEGMENT 7 (S7)
UTILIZING 3D COMPUTER ASSISTED SURGERY PLANNING AND NAVIGATION
O. Itano1,*, M. Shinoda1, M. Kitago1, Y. Abe1, T. Hibi1, H. Yagi1, Y. Kitagawa1
1
Department of Surgery, Keio University School of Medicine, Tokyo, Japan
Introduction: We have recently performed “laparoscopic parenchymal sparing anatomical liver resection”, which
indicates the liver resection for only the area of minimum required corresponding Glisson’s pedicles of the liver tumor.
This video show pure laparoscopic parenchymal sparing anatomical liver resection utilizing 3D computer assisted
surgery planning and navigation for HCC located in segment 7, one of posterosuperior segments reported to be a
hard-to-approach anatomic location.
Materials & Methods: The patient in the video was a 52 year old man who was diagnosed as hepatocellular
carcinoma located in segment 7. Firstly, the preoperative 3D computer assisted surgery planning was performed and
decided the ideal transection plane according vascular anatomy and tumor location. It also identified the appearing
vessels on the transection plane as check points. The operation started by isolating and ligating the corresponding
pedicle by approaching from the hilum. The parenchymal transection started along the foot side of the demarcation
line. Following appearing vessels sequentially enables to keep a precise transection plane. After dissecting the pedicle
of S7, transection continued along the right hepatic vein and finished.
Results: The operative time was 501 minutes and the estimated blood loss was 500 ml. No blood transfusion and no
conversion to laparotomy were necessary. The patient’s postoperative course was uneventful. Histological
examination of resected specimens revealed curative status with clear margins.
Conclusion: 3D computer assisted surgery planning and navigation allows us to approach the corresponding
pedicles from the hilum and ligate them within the liver, and guide the plane of resection. We conclude that this
operation is feasible and safe.
Disclosure of Interest: None declared
156
80.08
PURE LAPAROSCOPIC EXTENDED SECTIONECTOMY OF THE LIVER COMBINED WITH MAJOR HEPATIC
VEIN RESECTION AT ITS ROOT
Z. Morise1,*
1
Surgery, Fujita Health University School of Medicine, Banbuntane Houtokukai Hospital, Nagoya, Japan
Introduction: Although the reports of laparoscopic major liver resection are increasing, the tumors close to the liver
hilum, major hepatic veins are still considered contraindications and there are very few reports of laparoscopic liver
resection (LLR) for these lesions. In our knowledge, there is virtually no technical report of LLR procedures for the
tumors which involve major hepatic veins. We herein present our method of handling pure laparoscopic extended
sectionectomy of the liver combined with the major hepatic vein resection at its root.
Materials & Methods: We experienced 7 cases of pure laparoscopic extended sectionectomy of the liver combined
with the major hepatic vein resection at its root (6 hepatocellular carcinomas and 1 colorectal metastases; 3 right
anterior, 3 left medial and 1 right posterior sectionectomies; tumor sizes are in 27-75 (median: 50) mm).
Results: The operating time, intraoperative blood loss, and postoperative hospital stay are in 341-625 (median: 466)
min, 100-1250 (350) ml, and 8-44 (21) days. There was no mortality and 1 patient developed postoperative pleural
effusion to be treated with drain insertion. Another patient had 44 days postoperative hospital stay with his unstable
warfarin-control after surgery, which had been given for his cardiac pacemaker before surgery, and without any other
specific complications.
Conclusion: For this procedure, we propose that the steps listed below are useful, taking advantages of the
laparoscopy-specific view from caudal to cranial with the good magnified vision of hilar and dorsal areas of the liver.
1. Encircle and clamp of the Glissonian pedicle of the section.
2. Liver transection on the ischemic line, as straight as possible, from caudal to cranial.
3. During transection, the clamped Glissonian pedicle and the peripheral part of hepatic vein are divided at the time of
the transection line reaching to the level of the structures on both sides.
References:
1. Yoon YS, Han HS, Cho JY, Kim JH, Kwon Y. Laparoscopic liver resection for centrally located tumors close to
the hilum, major hepatic veins, or inferior vena cava. Surgery 2013;153:502-9.
2. Tomishige H, Morise Z, Kawabe N, Nagata H, Ohshima H, Kawase J, Arakawa S, Yoshida R, Isetani M.
Caudal approach to pure laparoscopic posterior sectionectomy under the laparoscopy-specific view. World J
Gastrointest Surg. 2013;5:173-7.
Disclosure of Interest: None declared
157
82.01
THORACOSCOPIC DIVISION OF VASCULAR RINGS IN INFANTS AND CHILDREN
A. Razumovskiy1, V. Rachkov1, K. Bataev1, N. Stepanenko1,*
1
Thoracic Surgery Department, Filatov Children Hospital, Moscow, Russian Federation
Introduction: Congenital anomalies of the aortic arch such as a double aortic arch and a right-sided aortic arch can
result in a severe respiratory failure, which requires emergency surgery. Modern equipment and accumulated
experience make it possible to perform thoracoscopic surgery for this type of pathology.
Materials & Methods: A total of 14 children (age from 6 months to 17 years, weight from 7 to 64 kg) who underwent
thoracoscopic division of vascular rings from 2008 to 2014 in Filatov Pediatric Clinical Hospital №13 were included in
the study. The timing of surgery depended on the clinical picture and the severity of the respiratory failure. There were
two types of vascular rings: double aortic arch - 8 children (57%), right-sided aortic arch with Botallo's duct - 6 children
(43%).
Results: Mean operating time was 57 minutes. The average length of stay was 11 days. There was no intraoperative
complications. In early postoperative period there was bleeding in one child due to failure of clipping the the distal
segment of the aortic arch which required thoracotomy. Postoperative chylothorax was observed in one child, which
was treated conservatively.
Conclusion: The latest advances in surgical methods allowed to make thoracoscopic division of vascular rings in
infants and children the method of choice with detailed intraoperative visualisation of the anatomy of the defect and
secure mobilization of large vessels. Thoracoscopic surgery for congenital anomalies of the aortic arch is feasible to
improve the postoperative outcomes and reduce the time of hospitalization.
Disclosure of Interest: None declared
158
82.02
VASCULARIZED BOWEL SEGMENT FOR RECONSTRUCTION OF THE PHARYNX IN CHILDREN WITH
CICATRICIAL STENOSIS
A. Razumovskiy1, K. Bataev 1,*, V. Rachkov1, A. Abdumanap1, N. Stepanenko1
1
Thoracic Surgery Department, Filatov Children Hospital, Moscow, Russian Federation
Introduction: Isolated cicatricial stenosis of pharynx in children usually occur after ingestion of potassium
permanganate crystals and subsequent burns. The treatment of this group of patients is complex, since the surgeon is
challenged not only to return the deglutition function but also respiration.
Materials & Methods: From 1992 to 2014 we have performed 12 pharyngeoplasties with free vascularized bowel
segments in children of age between 10 months and 11 years. The indications for the surgical correction of cicatric
stenosis in children, in our opinion, are unsatisfactory results of conservative therapy (dilatation with large caliber
dilators or olives) for six months. In 10 children we used the jejunum and in the rest two the sigmoid colon was
transfered as a free graft.
Access to the stenotic pharynx was through a horizontal incision made between the hyoid bone and the thyroid
cartilage. Then the incision was extended along the inner border of the right sternocleidomastoid muscle for dissection
the recipient site vessels. All the scar tissue was excised including the part of epiglottis changed by scars. Then the
right common carotid artery and the internal jugular vein were exposed. As the next stage a free bowel grafts was
mobilized. The diameter of the vessels were 2 mm (artery) and 3 mm (vein) in all cases. Then the bowel graft was
brought to the neck and the vessels were anastomosed with the right common carotid artery and the right internal
jugular vein (in that order) in an end-to-side fashion. In performing pharyngeoplasty (8 children) the bowel segment
was opened as a flap along the anti-mesenteric border and the posterior and the lateral walls of the pharynx were
formed by the thus modeled “flap. The border of the laryngeal entrance was sutured to the root of the tongue. In one
child with stenosis of the pharynx and the cervical part of esophagus the bowel segment was not opened like a flap (4
children).
Results: We were able to achieve good functional results in all the children. In between a period from 10 days to 1
year after surgery all children showed satisfactory respiratory and deglutition functions.
Conclusion: Replacement of pharynx and cervical esophagus with free vascularized bowel segment can be the
method of choice in the surgical treatment of isolated pharyngeal cicatric stenosis.
Disclosure of Interest: None declared
159
82.03
BRAIN OXYGENATION DURING THORACOSCOPIC REPAIR OF LONG GAP ESOPHAGEAL ATRESIA
L. Stolwijk1,*, P. Lemmers2, S. Tytgat1, D. van der Werff3, M. Benders2, M. van Herwaarden1, D. van der Zee1
1
2
3
Pediatric Surgery, Neonatology, Anesthesiology, Wilhelmina's Children Hospital, University Medical Center Utrecht,
Utrecht, Netherlands
Introduction: Long gap esophageal atresia (LGEA) is a rare congenital anomaly. Elongation and subsequent repair
of the esophagus can be done thoracoscopically in 4-6 days, even shortly after birth. Little is known about adverse
effects of the repetitive procedures on the neonatal brain. Near Infrared Spectroscopy (NIRS) measures regional
cerebral oxygen saturation (rScO2) and can be used to monitor continuously cerebral oxygenation. We evaluated the
effect of the CO2-insufflation on rScO2 during the consecutive thoracoscopic procedures in repair of LGEA.
Materials & Methods: Observational study of 5 infants undergoing thoracoscopic elongation with traction sutures and
subsequent primary anastomosis of the esophagus. A CO2-pneumothorax was installed in every procedure with a
maximum pressure of 5 mmHg and flow of 1 L/min. Depth of anesthesia, respiration and inspired oxygen
concentration (FiO2) were adapted to maintain physiologic values of etCO2 and SpO2. Parameters influencing cerebral
oxygenation MABP, FiO2, arterial saturation, arterial CO2 were monitored and for analysis 5 representative time
periods of 10 minutes during surgery were selected.
Results: Postmenstrual mean age at time of 1th surgery was (median[range]) 35+4[33+6-47+3] weeks; weight
2270[1570-4300]grams. Four infants needed three surgeries for elongation and repair and one four. Mean time of
insufflation was overall 142[22-425] minutes.
During all consecutive procedures the rScO2 remained mostly in the normative range (rScO2 55 - 85%) and was not
different from earlier procedures within a patient (figure).
The values below 55% in patient 1 were related with a low hemoglobin (Hb 5.1mmol/l) and increased after transfusion.
The same was true for patient 5 during all procedures (mean Hb 5.8 mmol/l) with a rScO2 in the lower normal range,
except for a substantial increase at the end of second procedure due to a high CO2 of 10kPa.
Patient 4 had rScO2>85% during the first two procedures due to a fraction of inspired oxygen of 45%.
None of the children had substantial brain injury on the postoperative MRI .
Image:
Conclusion: In this observational study no substantial longstanding cerebral hypoxia or hyperoxia were seen during
the repetitive installation of CO2-pneumothorax in young infants. The outliers in cerebral oxygenation could be
explained by Hb, CO2 and FiO2 and normalized after interventions of the anesthetist.
Disclosure of Interest: None declared
160
82.04
PEDIATRIC PER-ORAL ENDOSCOPIC MYOTOMY (POEM) FOR ACHALASIA
S. Chao1,*, R. Wright1, W. Berquist2, J. Wall1
1
2
Pediatric Surgery, Gastroenterology, Stanford University, Stanford, United States
Introduction: Per-oral Endoscopic Myotomy (POEM) is a transmural endoscopic surgical technique that is gaining
widespread adoption in the management of adult achalasia. The endoscopic approach offers excellent access to the
muscular wall of the esophagus enabling division of the abnormal circular fibers. The procedure offers the benefits of
being incisionless, preserving the outer longitudinal esophageal muscle fibers and avoiding a hiatal dissection.
Functional luminal imaging measures the diameter and pressure of the esophagus allowing intraoperative assessment
of the endoscopic myotomy. We describe our experience introducing these techniques to the pediatric population.
Materials & Methods: Over the past year, four pediatric POEM procedures were performed at our institution under
IRB approval. The average age of the patients was 16 years 1 month. Three patients underwent intraoperative luminal
imaging to measure pre- and post-operative diameter, pressure and distensibility of the lower esophageal sphincter
(LES).
Results: POEM was successfully completed in all four cases without any major complications. All patients had
significant improvement in Eckardt scores from an average of 7.5 pre-operatively to 1.8 at one-month follow-up.
Average cross-sectional area of the LES was increased by 1.6 fold after POEM and average distensibility was
2
2
increased from 1.26 mm /mmHg preoperatively to 3.05 mm /mmHg post-operatively.
Conclusion: POEM is a feasible procedure for trained pediatric specialists. Initial follow-up reveals symptomatic
relief in all patients. While intra-opeerative functional luminal imaging shows improvement in LES diameter and
distensibiliy, long-term follow-up is needed to characterize the outcomes of POEM in pediatric achalasia.
Disclosure of Interest: None declared
161
82.05
LAPAROSCOPIC TRANSCYSTIC COMMON BILE DUCT EXPLORATION IN AN INFANT
S. Chao1,*, D. Worhunsky2, J. Wall1, S. Dutta1
1
2
Pediatric Surgery, General Surgery, Stanford University, Stanford, United States
Introduction: Choledocholithiasis in infants is rare, but can pose a management dilemma. Pediatric endoscopic
retrograde cholangiopancreatography (ERCP) expertise is limited given lack of formal training programs in therapeutic
endoscopy for pediatric gastroenterologists and low case volumes, even in pediatric referral centers. ERCP in small
infants (weight <8-10kg) is particularly rare and poses additional endoscopic technical challenges. While laparoscopic
cholecystectomy became the new gold standard in children for cholelithiasis, the application of laparoscopy to
pediatric choledocholithiasis is variable. There are no reports of laparoscopic management of large common bile duct
stones in small infants. We describe our experience performing a laparoscopic transcystic common bile duct
exploration in a small infant.
Materials & Methods: A two-month-old (5.0kg) infant presented with a 1cm common bile duct stone causing intraand extra-hepatic biliary dilatation. The infant had acholic stools and exhibited serologic evidence of biliary
obstruction. The patient underwent laparoscopic transcystic common bile duct exploration using an over the wire
endoscopic balloon tipped catheter under fluoroscopic guidance.
Results: Clearance of the common bile duct stone was successful with immediate improvement in symptoms and
serologic test results. The patient had no post-operative complications and minimal post-operative pain. Follow-up
ultrasound demonstrated resolution of choledocholithiasis and abnormal biliary dilatation.
Conclusion: Laparoscopic transcystic common bile duct exploration using balloon tipped catheters and fluoroscopy is
a practical and safe approach to removing common bile duct stones in small infants.
Disclosure of Interest: None declared
162
100.01
LAPAROSCOPIC ADRENALECTOMY VERSUS RADIOFREQUENCY ABLATION FOR ALDOSTERONEPRODUCING ADENOMA
S. Y. W. Liu1,*, C. M. Chu2, C. C. H. Lam1, W. Y. So3, S. K. H. Wong1, P. W. Y. Chiu1, E. K. W. Ng1
1
2
3
Department of Surgery, Diagnostic Radiology & Organ Imaging Department, Department of Medicine &
Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
Introduction: Radiofrequency ablation (RFA) is an emerging treatment for primary aldosteronism
(PA) due to aldosterone-producing adenoma (APA) with high reported treatment success rate of
95.8%. No literature evidence is available in comparing RFA to laparoscopic adrenalectomy (LA).
This study aims to compare the treatment outcomes and safety between LA and RFA in treating
APA.
Materials & Methods: We conducted a retrospective comparative analysis on consecutive patients
with unilateral APA undergoing either LA or CT-guided percutaneous RFA for early treatment
outcomes and safety. All patients were also prospectively evaluated for long-term resolution rates
of PA, hypokalemia and hypertension.
Results: Between August 2004 and August 2012, 63 APA patients underwent treatment by LA
(n=27) and RFA (n=36) in our unit. There were no differences between LA and RFA for age,
gender, duration of hypertension (HT), APA size, laterality, preoperative aldosterone-to-renin ratio
and rate of hypokalemia. LA was successfully accomplished in all patients (100%) with histological
confirmation. RFA was technically completed with CT confirmation by single and two RFA
sessions in 33 (91.7%) and 3 (8.3%) patients respectively. For short-term outcomes, RFA had
significantly shorter operating time (12.1±0.9 vs 124.4±34.0mins, P<0.001), earlier dietary
resumption (median 0 vs 1 day, P<0.001), lower oral analgesic requirement (median paracetamol
consumption 0 vs 4g, P<0.001), lower need of parenteral analgesia (2.8% vs 22.2%, P=0.036) and
shorter hospital stay (2.4±1.0 vs 3.9±1.5 days, P<0.001) than LA. There were no significant
differences for rates of intraoperative hypertensive crisis (7.5% vs 19.4%, P=0.279), major
morbidity (3.7% vs 2.8%, P=0.677), minor morbidity (11.1% vs 16.7%, P=0.720) and mortality (0%
vs 0%, P=1.00) between LA and RFA. In long-term follow-up of 68.5±30.1 months, PA was
resolved in 100% (n=27) of LA and 91.7% (n=33) of RFA patients (P=0.253). Persistent PA was
present in 3 RFA patients who all refused repeat RFA or salvage adrenalectomy. Hypokalemia
was resolved in all patients. There was significantly higher number of patients having HT resolved
in LA (70.4%) than RFA (36.1%) group (P=0.007) though treatment type was not independently
associated with persistent HT on logistic regression analysis.
Conclusion: Radiofrequency ablation is effective in treating APA with better short-term outcomes,
comparable safety and similar long-term efficacy than those of laparoscopic adrenalectomy.
References: Liu SYW, Ng EKW, Lee PSF, Wong SK, Chiu PW, Mui WL, So WY, Chow FC. Radiofrequency ablation
for benign aldosterone-producing adenoma: a scarless technique to an old disease. Ann Surg 2010; 252(6): 10581064.
Disclosure of Interest: None declared
163
100.02
A PROSPECTIVE STUDY ON ROLE OF ORAL CALCIUM AND VITAMIN D IN PREVENTION OF POST
THYROIDECTOMY HYPOCALCEMIA
K. Ravikumar1,*, S. Muthukumar1, D. Sadacharan1, G. Mohanapriya1, Z. Hussain1, R. Suresh1
1
Endocrine Surgery, Madras Medical College, Chennai, India
Introduction: Postoperative transient hypocalcemia is sequelae of total thyroidectomy (TT),which is observed in up to
30-50% of patients.Routine oral calcium and vitamin D (Vit.D) supplementation have been proposed to prevent
symptomatic hypocalcemia facilitating early discharge.
Materials & Methods: One hundred and twenty eight patients with non toxic benign thyroid disorders, undergoing TT
were serially randomized into 4 groups
Group A-No intervention
a
Group B-Oral Calcium given
b
Group C-Oral calcium and Calcitriol are given
Group D-Oral calcium, Calcitriol and Cholecalciferolc are given
a)Calcium carbonate 2 g/day in 4 divided doses
b)1,25 di-OHVit.D 1 mcg/day in 4 divided doses
c)25 OH Vit.D 60000 IU once a day
Patients were monitored for clinical and biochemical hypocalcemia(serum calcium,Sr.Ca <8mg/dl), along with serum
intact PTH(iPTH) and magnesium 6 hours after surgery and Sr.Ca every 24hours. Intravenous (IV) calcium infusion
was started, if any of the above 4 group exhibit frank hypocalcemia. Patients are followed up with Sr.Ca and iPTH at 3
and 6 months
Results: All groups were age and sex matched.Hypocalcemia was observed in 44/128(34.4%) cases.Incidence of
hypocalcemia was higher in group A(56.2%) &group B(50%) compared to group C(15.6%)& group
D(15.6%).Hypocalcemia necessitating IV calcium occurred in 31/128(24.2%) patients. IV calcium requirement
exceeded in group A(45.2%) & group B(38.7%) compared to Group C(9.7%) & group D(6.4%).There was no statistical
difference in basal levels of serum vit.D,Calcium,Magnesium,iPTH and 6 hours after surgery.Permanent
Hypoparathyroidism developed in 2 patients on follow up.
Parameter
Group A
Group B
Group C
Group D
P
(n=32)
(n=32)
(n=32)
(n=32)
Value
Pre op Vit.D (ng/ml)
21.63±7.46
20.58±5.68
20.65±7.0
20.32±4.91
0.85
Post op PTH
18.71±10.39 19.34±9.46 19.51±8.67 18.37±8.09
0.95
(pg/ml)
Sr.Ca 0 POD
8.51±0.5
8.60±0.58
8.57±0.62
8.71±0.55
0.55
(mg/dl)
Sr.Ca 1POD
8.30±0.73
8.39±0.69
8.71±0.72
8.88±0.76
0.005
(mg/dl)
Sr.Ca 2POD
8.48±0.64
8.50±0.64
8.86±0.54
9.04±0.61
<0.001
(mg/dl)
Sr.Ca 3POD
8.79±0.42
8.79±0.48
9.06±0.48
9.09±0.42
0.008
(mg/dl)
Sr.Ca 4POD
9.05±0.35
8.99±0.43
9.17±0.43
9.25±0.43
0.06
(mg/dl)
Sr.Ca 5POD
9.12±0.33
9.04±0.41
9.18±0.41
9.27±0.39
0.12
(mg/dl)
Hypocalcemia
18(56.2)
16(50)
5(15.6)
5(15.6)
<0.001
n(%)
IV Calcium given
14(45.2)
12(38.7)
3(9.7)
2(6.4)
<0.001
n(%)
mean ± SD,POD-Post Operative Day
Conclusion: Post operative supplementation of oral calcium and vit.D will help in prevention of post thyroidectomy
transient hypocalcemia significantly. Pre operative vit.D levels do not predict post operative hypocalcemia.
References: 1.Amal Alhefdhi, Haggimazeh, Herbert Chen et al. Role of Postoperative Vitamin D and/or Calcium
Routine Supplementation in Preventing Hypocalcemia after Thyroidectomy: A Systematic Review and Meta
Analysis,The Oncologist2013;18:533–542
2.Sanabria A, Dominguez LC, Vega V et al. Routine postoperative administration of vitamin D and calcium after total
thyroidectomy: A meta-analysis.Int J Surg 2011;9(1):46 –51
3.Kurukahvecioglu O, Karamercan A, Akin M et al. Potential benefit of oral calcium/vitamin D administration for
prevention of symptomatic hypocalcemia after total thyroidectomy. Endocr Regul 2007; 41(1):35–3
164
4.Bellantone R, Lombardi CP, Raffaelli M, et al. Is routine supplementation therapy (calcium and vitamin D) useful
after total thyroidectomy? Surgery 2002; 132:1109 –12
5.Moore FD Jr. Oral calcium supplements to enhance early hospital discharge after bilateral surgical treatment of the
thyroid gland or exploration of the parathyroid glands. J Am Coll Surg 1994; 178:11–16.
6.Choe JH, Kim WW, Lee SK et al. Comparison of calcitriol versus cholecalciferol therapy in addition to oral calcium
after total thyroidectomy with central neck lymph node dissection: A prospective randomized study. Head Neck
2011;33(9):1265–127
7.Lindblom P, Westerdahl J, Bergenfelz A. Low parathyroid hormone levels after thyroid surgery: a feasible predictor
of hypocalcemia. Surgery 2002; 131: 515–20
Disclosure of Interest: None declared
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100.03
MULTIMODALITY IMAGING 123I/99TC-SESTAMIBI SUBTRACTION, SPECT, AND SPECT/CT FOR
PREOPERATIVE LOCALIZATION IN PRIMARY HYPERPARATHYROIDISM IS OF LIMITED BENEFIT
G. Lee1,*, T. J. McKenzie1, B. P. Mullan2, D. R. Farley1, G. B. Thompson1, M. L. Richards1
1
2
Department of Surgery, Department of Radiology, Mayo Clinic, Rochester, United States
Introduction: Focused parathyroidectomy in primary hyperparathyroidism (1HPT) is possible with accurate
preoperative localization and intraoperative PTH monitoring (IOPTH). Institutions have initiated the multimodality
123 99
imaging technique of I/ Tc-sestamibi with SPECT and SPECT/CT to improve preoperative localization. The added
benefit of this multimodal imaging technique is unknown. An assessment of this standard practice was necessary to
identify opportunities to decrease cost.
Materials & Methods: A prospectively collected database of patients with 1HPT, who underwent parathyroidectomy
with IOPTH in 2012-2014 at a single institution, was retrospectively reviewed to identify patients with multimodal
123 99
imaging including I/ Tc-sestamibi subtraction scintigraphy, SPECT, and SPECT/CT. Each imaging modality was
independently assessed for sensitivity, accuracy, and efficacy for individualized localization techniques.
Results: 401 patients (76% women, mean values: age 61 years, PTH 119 pg/ml, calcium 11.0mg/dl) were identified
and a curative operation was performed in 96%. The incidence of multiglandular disease was 16%. Imaging analysis
showed 123I/99Tc-sestamibi had a sensitivity of 86% (95% CI 82-90%), positive predictive value (PPV) 93% and
accuracy 81%. SPECT had a sensitivity of 77% (95% CI 72-82%), PPV92% and accuracy 72%. SPECT/CT had a
sensitivity of 75% (95% CI 70-80%), PPV of 94% and accuracy 71%. There were 3/45 (7%) patients with negative
sestamibi imaging that had an accurate SPECT and SPECT/CT. Of the 312 patients (87%) with uptake on sestamibi
(93% true positive, 7% false positive) concordant findings were present in 86% SPECT and 84% SPECT/CT. In
cases where imaging modalities were discordant, but at least one method was true-positive, 123I/99Tc-sestamibi was
significantly better than both SPECT and SPECT/CT (p<0.001). There was no difference between SPECT and
SPECT/CT (p=0.2). The exclusion of SPECT and SPECT/CT from sestamibi imaging protocols can decrease cost by
59%.
Sensitivity (%)
123 99
I/ Tc-sestamibi
8
7
7
8
7
6
SPECT
SPECT/CT
(95% CI 8290)
(95% CI 7382)
(95% CI 7180)
PPV
(%)
93
Accuracy
(%)
81
Cost (%)
92
73
+41.5
93
71
+58.6
-
123 99
Conclusion: I/ Tc-sestamibi subtraction imaging is highly sensitive for preoperative localization in 1HPT. SPECT
and SPECT/CT are commonly concordant with123I/99Tc-sestamibi and rarely increase the sensitivity. Routine inclusion
of this multimodality imaging technique adds minimal clinical benefit and increases cost.
Disclosure of Interest: None declared
166
103.01
INNOVATION WITHOUT FRUSTRATION – HOW TO USE SUPRATHEL IN A SUCCESSFUL WAY
J. L. Suss1,*
1
Pediatric surgery, Katholic Childrens Hospital Wilhelmsstift, Hamburg, Germany
Introduction: Since 2003 we use Suprathel in Germany. It is a high innovative product and it seems like a miracle,
when it comes on the market. There was no other product with the same promise of pain reduction, support of skin
healing and reduction of costs. So nearly everyone try to use it. The problem was to find the right time of application
and preparing the wound ground. Otherwise it swims off and you only have costs, frustration and no innovation in the
treatment.
Materials & Methods: After initial dressing of the acute burn wound the first change is after 2-4 days. If the dressing
is earlier, it is a high risk that the exudation of the wound is too much and there could be an early loose of Suprathel.
After 2 days the risk is minimized. At this point it is important to make a carefully debridement of the wound ground. If
there is a little bleeding on the ground, the surface is well prepared to place the Suprathel on the skin. Over the
Suprathel comes a fatty gauze twice and than a normal dressing, which can absorb the wound exudation well. Over
joints and fingers it is an advantage to make the dressing with a slightly compression. The next superficial change of
nd
dressing is after 2-4 days, if there are very deep areas of 2 degree, where there could be a loss of Suprathel.
Otherwise the next change of dressing is after 5-7 days. Then normally most of the skin is healed and you can do the
dressing in the outpatient department.
Results: With the use of Suprathel the patients have less pain during dressing. The healing process is supported very
well, because after the application of Suprathel there is no need for another manipulation of the wound. Together with
the minimal risk of wound infection the cosmetically results are very good.
Conclusion: Suprathel is a very innovative product. With the right use and the carefully wound preparation it is worth
to use it by the costs. It is not only an innovative product for acute burn wounds. It also can be used in the context of
cell spray. By this it is very close to the border of split skin graft and in some cases it can be used similar to skin graft
in this special combination.
Disclosure of Interest: None declared
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103.02
SKIN SUBSTITUTE WITH SUPRATHEL: WHERE IS THE BORDER TO THE SPLIT SKIN GRAFT?
J. L. Suss1,*
1
Pediatric surgery, Katholic Childrens Hospital Wilhelmsstift, Hamburg, Germany
Introduction: Suprathel is a synthetic skin substitute for the treatment of burns. It is a high innovative product and
brings a remarkable success in the treatment of 2nd degree burns. It is in use in Germany since 2003. It initialized a
change from the early necrectomy and skin grafting to a more patient treatment of burn wounds. There is a
significantly reduce of pain, dressing and area of skin transplantation since using Suprathel. But is not a miracle
product. There is a clear boarder for the transplantation of split skin graft. And Suprathel is able to show us this
boarder.
Materials & Methods: In our clinic we treat more than 200 children with Suprathel each year. Only in clearly 3rd
degree burns we don’t use it. We use it like a skin substitute and treat dermal wounds after 2 days with Suprathel after
a wound debridement. Next dressing without remove of the Suprathel is after 2-4 days. After 7-14 days normally the
wound is healed. If there is still a wound, this is the area which has a problem and where is to think of a split skin graft.
Results: With Suprathel the cosmetically result of skin healing is very good and also the comfort of the patient. It is
due to the reduction of pain and a better healing process. The need of skin transplantation is significantly reduced.
Conclusion: Suprathel is one of the most innovative products in the treatment of burn wounds in the last 11 years. It
is pushing back the boarder of skin transplantation. But it is not the same than a split skin graft and can’t heal a very
deep 2nd degree burn wound. This is still the boarder we have to accept.
Disclosure of Interest: None declared
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103.03
THE METHOD OF BURN WOUNDS TREATMENT IN MOIST CONDITIONS
N. Karyakin1,*, I. Klemenova1, S. Chernyshev 1, A. Lusan1
1
Privolzhsky Federal Medical Research Centre of the Russian Ministry of Health, Nizhny Novgorod, Russian
Federation
Introduction: Aim: to investigate the effectiveness of second- and third-degree burns treatment in moist conditions.
Materials & Methods: Methods: clinical study of results of thermal burn wounds treatment in the conditions of
continuous presence in moist environment made of 0.9% sodium chloride. As part of the study analysis of cell
composition and microorganisms quantity in the solution was conducted. The research of microcirculation in the burn
wound was done every day by the means of laser Doppler flowmetry and thermal imaging techniques.
Results: Results: in accordance with Local Ethics Committee permission observation of 10 adult patients with
thermic burn wounds of limbs was conducted. The surface of burn wounds was 0.5 – 3% of the whole body surface. 9
patients had second-degree burns, 1 patient had third-degree burn. At hospitalization burn wounds were placed into
special container with 0.9% sodium chloride. In the course of the treatment burn wounds were constantly placed in
sodium chloride with daily container and sodium refresh.
Total exposition for the second-degree burns patients was 3-7 days, for the third-degree patient – 14 days. At 6th day
third-degree patient`s weeping eschar was removed. The treatment in moist conditions ceased after wound
epithelialization. All patients have almost no pain in the wound even during bandaging. The examination of
microcirculation and thermal imaging research revealed positive dynamics.
Conclusion: Conclusions: Applying of moist conditions made of 0.9% sodium chloride allows to treat second- and
third-degree burn wounds painlessly.
Disclosure of Interest: None declared
169
103.04
USE OF NATIONAL DATABASES TO MONITOR IMPROVEMENTS IN BURN CARE AND GUIDE PREVENTION
ACTIVITIES
B. A. Pruitt, Jr.1,*, B. T. King2, L. C. Cancio2
1
2
Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, Burn Center, U.S. Army
Institute of Surgical Research, Ft. Sam Houston, Texas, United States
Introduction: Databases of national scope can be used to identify epidemiologic and demographic characteristics
and changes in burn injury. Such data when combined with published reports of high risk populations and causative
agents provide focus to prevention activities.
Materials & Methods: The WISQARS database of the U.S. Center for Disease Control and Prevention was utilized to
characterize the epidemiology of burn injury and the American Burn Association National Burn Repository was utilized
to define those burn patients admitted to burn centers. Common and newly emerging causative agents were
cataloged by review of selected biomedical publications.
Results: Even though the population of the United States has increased 38% since 1981, the incidence of both fatal
and non-fatal burn injury has steadily decreased but remains variable among different age groups. In this century the
overall number of fatal burns has decreased from 3,907 (1.39/100,000) in 2000 to 2911 (0.93/100,000) in 2012, which
represented 1.5% of all injury deaths in that year. The overall number of non-fatal fire/burn injuries has decreased
from 554,360 (197/100,000) in 2000 to only 405,327 (128.22/100,000) in 2013, which represented 1.3% of all nonfatal injuries and the 14th most common cause of non-fatal injury in that year. Over two-thirds of patients admitted to
U.S. Burn Centers are males with burns of less than 10% TBSA most of which are sustained in the home. Systematic
review of published studies identified high risk populations (children, the elderly, and military personnel), high risk
occupations, high risk geographic areas, and specific causative agents including the newly identified glass fronted gas
fireplaces.
Conclusion: Coordinated use of national databases and information generated by review of burn related publications
provides an annual characterization of burn epidemiology and demography which identifies changes in burn incidence
and outcome and provides focus for prevention efforts.
References: 1. Centers for Disease Control and Prevention WISQARS™ (Web-based Injury Statistics Query and
Reporting System) http://www.cdc.gov/injury/wisqars/facts.html January 10, 2015
2. American Burn Association, National Burn Repository 2014 Version 10.0
http://www.ameriburn.org/2014NBRAnnualReport.pdf January 11, 2015
3. Wibbenmeyer L, Gittelman MA, Kluesner K et al. A multicenter study of preventable contact burns from glass
fronted gas fireplaces. J Burn Care Res 2015; 36:240-245.
Disclosure of Interest: None declared
170
111.01
RANDOMISED CNTROLLED TRIALS FOR SURGICAL PROCEDURES ARE NOT THE GOLD STANDARD
N. Abraham1,* on behalf of Ned is a Professor of Surgery, UNSW Australia who graduated with Honors in 1985, holds
the Degrees of a MM & PhD (Surgery) Sydney University & is a Fellow of RACS, RCS & CSSANZ, a colorectal
surgeon & a officer in the Australian Army Reserve.
1
Surgery, UNSW Australia, Coffs Harbour, NSW, Australia
Introduction: Despite the lack of supportive evidence, the claim that randomised trials (RCT’s) is the Gold Standard
is unfortunately too popular to be questioned. This is a presentation of original research exposing the fallacies of
RCT’s in surgery.
Materials & Methods: A prospective study of enrolment patterns in the the largest completed Australian RCT for
laparoscopic surgery for colorectal cancer (ALCCaS) was conducted for a six month period and the results compared
with those form other international studies. This was followed by a comparison of the results an RCT and a case
control study performed at the same centre by the same investigators and around the same time. Two
contemporaneous meta-analyses of RCT’s and of non-randomised comparative studies (NRCS’S) of the same
procedure were then conducted and their results were statistically compared.
Results: At best, 45% of eligible patients are enrolled in RCT’s of surgical procedures. The most commonly recorded
reason for failure to enrol was a preference for one form of surgery or the other. 18% of accredited surgeons never
recruited any patients and a further 29% ceased to be involved halfway into the trial. There is a strong suggestion that
systematic differences between enrolled and eligible but not enrolled patients do exist.
There is a suggestion that a NRCS of surgical procedure may exaggerate the effect estimate compared with and RCT
but the evidence for this is week.
The results of the meta-analysis of 12 RCT’s (2512 resections) and those of the meta-analysis of 49 NRCS's (6438
resections) for 13 variables common between the two meta-analyses, were more than 95% similar.
Conclusion: There may really be no need for us to bother with RCT’s for surgical procedures as the results of their
meta-analyses are probably just as accurate or just as inaccurate as those of NRCS’s
Disclosure of Interest: None declared
171
111.02
A RISK SCORE FOR PREDICTING COMPLICATED RECURRENCE OF DIVERTICULITIS
V. Sallinen1,*, J. Mali1, A. Leppäniemi1, P. Mentula1
1
Department of Abdominal Surgery, Helsinki University Central Hospital, Helsinki, Finland
Introduction: As a common disease with a tendency to recur, acute diverticulitis creates a burden to health care systems. Stage
of the acute diverticulitis will determine the morbidity and mortality involved in acute attacks. Prophylactic sigmoid resection has
been used to prevent recurrent diverticulitis, but patient selection for the procedure has been highly variable across different
centers and continents. Earlier two recurrent diverticulitis was considered as an indication for elective sigmoid resection, but this
approach has been questioned lately. Although first diverticulitis is usually the most severe one, small portion of patients will
developed complicated recurrence. Prediction of this event is of paramount importance. The aim of this study was to identify risk
factors predicting recurrence of acute diverticulitis.
Materials & Methods: Data of patients treated for acute diverticulitis in our institution during 2006-2010 were extracted from a
retrospective database established earlier. Cox uni- and multivariate regression was used to identify risk factors and hazard ratios
(HR) for uncomplicated and complicated recurrence of acute diverticulitis. Based on regression coefficients (B) of these risk factors
a score was formed. ROC analysis and Kaplan-Meier with Log-Rank test was used to test the performance of the score.
Results: 512 patients were included in the study. History of diverticulitis was identified as an independent risk factor for
uncomplicated recurrence of diverticulitis (1-2 earlier diverticulitis HR 1.6, 3 or more - HR 3.2). History of diverticulitis (HR 3.3, B
1.2), abscess (HR 6.2, B 1.8), and corticosteroid medication (HR 16.1, B 2.8) were independent risk factors for complicated
recurrence. Based on these risk factors and their regression coefficients, risk scoring was created: 1 point for history of diverticulitis,
2 points for an abscess, and 3 points for corticosteroid medication. ROC analysis showed that the score was unable to predict
uncomplicated recurrence (AUC 0.48), while it had prognostic value in predicting complicated recurrence (AUC 0.80). Patients were
divided into low-risk (0 - 2 points) and high-risk groups (> 2 points). Low-risk patients had 3% 5-year complicated recurrence rate,
while high-risk patients had 43% risk for complicated recurrence at 5 years (Figure).
Image:
Conclusion: Risk of complicated recurrence can be assessed using risk score. The risk for uncomplicated recurrence increases
along with the number of recurrences.
Disclosure of Interest: None declared
172
111.03
COMPLICATION PATTERN ACCORDING TO HOSPITAL SIZE IN A PROSPECTIVE RANDOMIZED TRIAL SAKK
40/04 COMPARING COLON-J-POUCH, SIDE-TO-END ANASTOMOSIS, AND STRAIGHT COLOANAL
ANASTOMOSIS AFTER TME
G. Curti1 on behalf of SAKK, M. Zuber2 on behalf of SAKK, M. Graf 3, S. Hayoz4 on behalf of SAKK, B. Gloor5 on behalf
of SAKK, F. Grieder6 on behalf of SAKK, C. Hamel7 on behalf of SAKK, W. R. Marti1,* on behalf of SAKK
1
Surgery, Kantonsspital Aarau, Aarau, 2Surgery, Kantonsspital Olten, Olten, 3Surgery, LUKS, Luzern, 4SAKK
Coordinating Center, 5Surgery, Insel University Hospital, Bern, 6Surgery, Kantonsspital Winterthur, Winterthur,
7
Switzerland, Surgery, Kreiskrankenhaus Lörrach, Lörrach, Germany
Introduction: The in the literature reported morbidity in rectal cancer surgery is 40% and more. We assessed the
perioperative complications following coloanal reconstruction utilizing the standard form of total mesorectal excision
(TME) and three currently practiced techniques for rectal reconstruction: 5 cm colon-J-pouch, the side-to-end
anastomosis, and the straight coloanal anastomosis. The frequency and pattern was analyzed according hospital size
and function.
Materials & Methods: In this prospective randomized trial we categorized the participating centers into University
Hospital (UH), referral non-University Hospital (rnUH) and peripheral Hospital providing primary care (pH) and
compared the frequency of complications accordingly. Complications of different organ system complications, stoma
complications, infections or thromboembolic events were registered and compared between groups with the Chisquare test.
As the focus in this report was on surgical parameters, analyzes were based on the safety population in which all
patients were analyzed according to the treatment which was performed and not according to the treatment
randomized to.
Results: A total of 336 patients were included. Of these patients, 112 were randomized into each treatment arm,
however only 65 received a 5 cm colon J-pouch, 123 a side-to-end anastomosis and 134 a straight coloanal
anastomosis. In total 15 centers randomized patients into this trial. The 4 UH included 104 (7-40) patients, 4 rnUH 151
(27 – 44) patients and 7 pH 80 (1-33) patients. Overall the complication rate was 50.1%. UH had the lowest rate
(43%), compared with rnUH (48%) and pH (63%) (p=0.03). The analysis according type of reconstruction or type of
complication did not yield any significant differences. However the highest complication rate was observed for J-pouch
reconstruction in pH of 70% compared with UH of 41% and in rnUH of 46% (p=0.2).
Conclusion: Based upon our short term results tertiary referral hospitals are providing best care. However, in analysis
of individual type of complications the sample size was small, therefore no significant differences could be detected.
Disclosure of Interest: None declared
173
111.04
CLINICAL SIGNIFICANCE OF EXTRAMURAL TUMOR DEPOSITS WITHOUT LYMPH NODE STRUCTURE IN THE
LATERAL PELVIC AREA IN LOWER RECTAL CANCER
R. Yagi1,*, Y. Shimada1, H. Kameyama1, T. Kobayashi1, S. Kosugi1, Y. Takii2, T. Kawasaki3, T. Wakai1
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
2
Department of Surgery, 3Department of Pathology, Niigata Cancer Center Hospital, Niigata, Japan
Introduction: Extramural tumor deposit without lymph node structure (EX) is an important prognostic factor in patients
with colorectal cancer treated with curative intent surgery. However, to date, the site-specific clinical significance of EX
has not been investigated. In particular, the clinical significance of EX in lateral pelvic lymph nodes (LP-EX) remains
unclear. The aim of this study was to determine the prognostic implications of LP-EX in patients with lower rectal
cancer.
Materials & Methods: This retrospective study involved 172 consecutive patients with stage II or III lower rectal
cancer who had undergone curative intent surgery, including lateral pelvic lymph node dissection, between 2000 and
2012. EX was defined as a tumor nodule without histological evidence of lymph node structure. We classified the
patients into the following three groups according to the status of the lateral pelvic lymph node area: without
metastasis in the lateral pelvic lymph node area (no LP metastasis), with lateral pelvic lymph node metastasis (LPLNM), and with lateral pelvic EX (LP-EX). Potential prognostic factors of overall survival (OS), including LP-EX, were
identified in univariate and multivariate analyses.
Results: This study included 52 (30%) and 120 patients (70%) with stage II and III cancer, respectively. LP-LNM and
LP-EX were observed in 27 (16%) and 14 patients (8%), respectively. LP-EX was significantly associated with
lymphatic permeation (P = 0.044), venous permeation (P = 0.006), and nodal stage (P = 0.005). The 5-year OS rates
in the no LP metastasis, LP-LNM, and LP-EX groups were 80.3%, 61.1%, and 34.9%, respectively (P < 0.001).
Multivariate Cox proportional hazards model analysis revealed that the presence of LP-EX was an independent
prognostic factor of OS (hazard ratio, 3.15; 95% confidence interval, 1.39–7.17; P = 0.006).
Image:
Conclusion: LP-EX is an important prognostic factor in patients with stage II or III lower rectal cancer. The clinical
significance of EX in the lateral pelvic lymph node area is enhanced when the metastasis in the area is subclassified
as LP-LNM or LP-EX.
Disclosure of Interest: None declared
174
111.05
CLINICAL SHORT AND LONG TERM OUTCOMES OF LAPAROSCOPIC VERSUS OPEN D3 COLECTOMY FOR
STAGE II, III COLON CANCER IN JAPAN
M. Inomata1,*, T. Akagi1, M. Watanabe2, F. Konishi3, S. Yamamoto4, S. Saito5, S. Fujii6, S. Kitano7
1
2
Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Kitasato University School of
3
4
Medicine, Sagamihara, Surgery, Nerima Hikarigaoka Hospital, Colorectal Surgery, National Cancer Center, Tokyo,
5
Colon and Rectal Surgery, Shizuoka cancer center, Shizuoka, 6Yokohama City University Medical Center,
Yokohama, 7Oita University, Oita, Japan
Introduction: In recent 25 years, laparoscopic surgery for colorectal cancers (CRC) has been widespread in the
world. The benefits of laparoscopic surgery (LAP) compared with open surgery (OP) have been suggested; however,
the long-term survival of LAP for advanced CRC is still unclear. We evaluated clinical short- and long-term outcomes
in phase III trial of LAP versus OP.
Materials & Methods: Accredited surgeons from 30 Japanese institutions participated. Eligibility
criteria included histologically proven CRC; tumor located in the cecum, ascending, sigmoid or
rectosigmoid colon; T3 or deeper lesion without involvement of other organs. Patients with
pathological stage III received adjuvant chemotherapy with fluorouracil plus leucovorin. The
planned sample size was 1050 patients.
Results: A total of 1057 patients were recruited (533 LAP and 524 OP) between 2004 and 2009.
Conversion to OP was needed for 30 (5.7%) patients undergoing LAP. Patients assigned LAP had
less blood loss compared with those assigned OP (median 30 ml vs 85 ml, p<0.0001), although
LAP lasted 52 minutes longer than did OP (p<0.0001). A number of resected lymph nodes did not
differ between groups. A rate of D3 resection in central review committee using surgical photos
was 99% in each group, respectively. LAP was associated with earlier recovery of bowel function
(p<0.0001), shorter hospital stay (p<0.0001), and less wound-related complications (p=0.0069),
compared with OP. 5-year OS was 90.4% (95%CI: 87.5-92.6%) in OP, and 91.8% (89.1-93.8%) in
LAP. 5-year RFS was 79.7% (76.0-82.9) in OP and 79.3% (75.6-82.6) in LAP (HR: 1.07 [95%CI:
0.82-1.38]).
Conclusion: The non-inferiority of laparoscopic D3 colectomy in OS was not demonstrated for stage II,III CRC.
However, since OS of both arms are almost identical and better than expected, LAP is acceptable as a treatment
option for stage II,III CRC.
Disclosure of Interest: None declared
175
111.06
LAPAROSCOPIC SURGERY FOR LOCALLY RECURRENT RECTAL CANCER. -REPORT OF AN EARLY
RESULTSM. Ikeda1,*, S. Mitsugu1, M. Miyake1, N. Haraguchi1, M. Miyazaki1, A. Miyamoto1, M. Hirao1, S. Nakamori1
1
Surgery, Osaka National Hospital, Osaka, Japan
Introduction: Local recurrence is the most common type of recurrence after resection of advanced low rectal cancer.
Radical resection is one of a few means of cure. Problems of surgical intervention for locally recurrent rectal cancer
(LRRC) are major amount of bleeding and complications relating to postoperative infection such as pelvic sepsis,
abscess, and other surgical site infections (SSI). The purpose of the study was to evaluate the feasibility and safety of
laparoscopic surgery for LRRC.
Materials & Methods: Thirty patients with LRRC without recurrence at anastomotic site were evaluated. Operative
and perioperative outcome between open (N=17) and laparoscopic (n=13) groups were compared.
Results: In the open surgery group, total pelvic exenteration (TPE) was performed in 9 patients, and concomitant
sacral resection was done in 7 patients. Whereas, only 3 patients underwent TPE, and concomitant sacral resection
was done in 3 patients in the laparoscopic group. Median operation time in the open and laparoscopic group was
comparable (582 vs. 628 min, p=0.75). Median estimated blood loss was significantly smaller in the laparoscopic
group (2600 vs. 280 ml, p<0.0001). Two patients and 4 patients suffered pelvic sepsis and pelvic abscess,
respectively in the open group. In the laparoscopic group, no patients suffered either pelvic sepsis or abscess.
Superficial SSI was found 4 and 2 patients in the open and laparoscopic group, respectively. As for the complications
according to Clavien-Dindo classification, 5 in the grade II, 5 in the grade III, 2 in the grade IIIb, and one in the grade V
in the open surgery group. In the laparoscopic group, 3 patients in the grade II were found, and no patients with
greater than grade II were found.
Conclusion: Although patients back grounds and operational procedures were different, laparoscopic surgery for
LRRC was safe and feasible. Especially, its potential for minimizing blood loss and postoperative complications was
highlighted.
Disclosure of Interest: None declared
176
111.07
CLINICAL SIGNIFICANCE OF IMMUNOHISTOCHEMICAL STAINING FOR DETECTING TUMOR BUDDING IN
PATHOLOGICAL T1 COLORECTAL CANCER
T. Okamura1,*, Y. Shimada1, H. Nogami2, H. Kameyama1, Y. Tajima1, M. Nakano1, T. Wakai1, Y. Ajioka3
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
2
Department of Surgery, Niigata Cancer Center Hospital, 3Division of Molecular and Diagnostic Pathology, Niigata
University Graduate School of Medical and Dental Sciences, Niigata, Japan
Introduction: Tumor budding in pT1 colorectal cancer has been reported as an important risk factor for lymph node
metastasis. Therefore, surgical dissection of regional lymph nodes is recommended after endoscopic mucosal
resection in patients with pT1 colorectal cancer with tumor budding. However, practical issues remain regarding the
pathological assessment of tumor budding; specifically, detection of tumor budding by hematoxylin and eosin (HE)
staining may be difficult because of difficulties distinguishing between cancer cells and fibroblasts.
Immunohistochemical (IHC) staining may be useful in the objective diagnosis of tumor budding. In the present study,
we determined the cut-off value of tumor budding detected by IHC staining in predicting the risk of lymph node
metastasis, and compared the accuracy for lymph node metastasis between tumor budding detected by IHC staining
and that by HE staining.
Materials & Methods: Samples from 310 pT1 colorectal cancer patients who underwent surgery with lymph node
dissection were evaluated in the present study. Paraffin-embedded blocks showing the deepest tumor invasion were
selected, and two 3-µm serial sections were cut from each block: one for HE staining and one for IHC with CAM5.2
monoclonal antibody. Tumor budding was defined as an isolated single cancer cell or a cluster of less than five cancer
cells in the stroma of the invasive front area. One field in which budding counts were the most intensive was chosen,
and budding counts were evaluated in this area using a x20 objective lends. To evaluate the accuracy of HE and IHC
staining for predicting lymph node metastasis, receiver operating characteristic (ROC) curves were used to establish
cut-off values for budding counts determined by HE and IHC staining.
Results: Lymph node metastases were observed in 31 (10%) patients. The mean (±SE) budding counts detected by
HE and CAM5.2 staining were 3.5±0.2 and 8.4±0.5, respectively (P < 0.001). ROC curve analysis revealed cut-off
values for budding counts for predicting lymph node metastasis of 5 and 8 for HE and CAM5.2 staining, respectively.
Moreover, the accuracy for predicting lymph node metastasis for HE and CAM5.2 staining was 73.2% and 59.7%,
respectively.
Image:
177
Conclusion: Budding counts are greater when evaluated using IHC rather than HE staining. However, the accuracy
of HE staining for predicting lymph node metastasis is greater than that of CAM5.2 staining.
Disclosure of Interest: None declared
178
112.01
TRANSORAL ENDOSCOPIC THYROIDECTOMY VESTIBULAR APPROACH: A SERIES OF THE FIRST 60
HUMAN CASES
A. Anuwong* 1
1Department
of Surgery, Police General Hospital, Bangkok, Thailand
Introduction: Various approaches to endoscopic thyroidectomy have been accepted for over a decade. Recently,
Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been adopted for thyroid surgery because of it’s
potential for scar-free operation. However, the previous transoral endoscopic thyroidectomy technique still has some
limitations. Thus, we present our initial experience with TransOral Endoscopic Thyroidectomy Vestibular approach
(TOETVA) which has provided the best cosmetic result among various other procedures.
Materials & Methods: From April 2014 to January 2015, the inclusion criteria were a benign tumor of less than 10 cm
in diameter, a malignant thyroid nodule of less than 1 cm with no evidence of metastasis. We used a three-port
technique, one 12-mm port for a rigid laparoscope and two additional 5-mm ports for instruments. These were inserted
though the oral vestibule under inferior lip. The CO2 insufflation pressure was set at 6 mm Hg. An anterior cervical
subplatysmal space was created from the oral vestibule down to sternal notch. This method provides an excellent
cranio-caudal view.
Results: A series of 60 consecutive procedures have been accomplished successfully. Thirty-four patients had single
thyroid nodule and lobectomy was performed. Twenty-two patients had multinodular goiter and two patients had
Graves’ disease, total thyroidectomy or Harley-Dunhill procedure were performed. Two patients had papillary thyroid
carcinoma and total thyroidectomy with central node dissection was performed. The median operative time was 115.5
minutes (range, 75.0-300.0 minutes) The median blood loss was 30 mL (range, 8-130 mL) The recurrent laryngeal
nerves were clearly identified and preserved in all cases. Two patients experienced a transient hoarseness which was
resolved within 2 months. One patient experienced a late postoperative hematoma, which was treated conservatively.
Nobody had mental nerve palsy. No abscess or infections were found. The patients were discharged on a median of 4
days (range, 2–7 days) after operation.
Conclusion: Transoral endoscopic thyroidectomy vestibular approach was found to be safe and feasible and results
in absolutely no visible scaring. This technique may provide a method for an ideal cosmetic result.
Disclosure of Interest: None Declared
179
112.02
SEPTUAGENARIANS ARE AT HIGHER RISK OF MORTALITY WITH ADRENAL METASTASECTOMY: AN
ANALYSIS OF THE HCUP_NIS DATABASE FROM 1992 TO 2011
J. H. Kuo1,*, M. Wingo1, J. Chabot1, J. A. Lee1
1
GI/Endocrine Surgery, Columbia University, New York, United States
Introduction: Small institutional studies have shown that adrenalectomy to remove solitary metastases to the adrenal
is safe and can improve overall survival. However, outcomes of adrenal metastasectomy have not been evaluated
using large, national databases.
Materials & Methods: All cases of adrenal metastasectomies from 1992-2011 were identified in the HCUP-NIS
database. Primary endpoint analyzed was death during the same hospitalization. Secondary outcomes included
length of stay (LOS), blood loss requiring transfusion, surgical infection, cardiac complications, and respiratory
complications. A sub-analysis of 408 patients stratified by primary tumor (where data was available) was also
performed. Statistical analysis was performed using student t-test, chi-square, ANOVA, and logistic regression using
Stata software, significance was set at p-value of 0.05.
Results: A total of 2,262 cases of adrenal metastasectomies were identified. Median age of the patients was 62±13.2
years (49.9% men, 69.7% Caucasian). Over the study period, there was a general increase in the number of cases
performed and number performed by minimally invasive approaches. There was also a decrease in LOS and number
of deaths. However, age >70 years predicted a significantly higher rate of mortality (OR 3.3, CI 1.1-10.0) when
controlled for race, procedure type, year of surgery, and primary tumor in multivariable analysis. This age group had a
higher number of cardiac complications (5.5%, p=0.016) that likely contributed to the higher mortality rate. In addition,
there was no difference in surgical outcomes when stratified by primary tumor type for the entire cohort of patients.
Conclusion: Adrenal metastasectomy is a safe procedure with decreasing same-hospitalization mortality from 1992
to 2011. However, age > 70 years is a significant risk factor for same-hospitalization mortality. This increased risk
should be considered when discussing adrenal metastasectomy in this age population.
Disclosure of Interest: None declared
180
112.03
PANCREATIC NEUROENDOCRINE TUMORS: A SINGLE INSTITUTION RETROSPECTIVE ASSESSMENT
UTILIZING THE CESQIP PNET MODULE
G. Fernandez Ranvier1,*, D. Labow1, D. Shouhed1, E. Bresnahan1, M. Schwartz1, U. Sarpel1, H. Zhu2, W. Inabnet III3
1
2
3
Surgery, Pathology, Mount Sinai Hospital, Surgery, Mount Sinai Beth Israel, New York, United States
Introduction: The Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) is a national quality
initiative designed to facilitate the analysis of endocrine surgery data to improve outcome. Pancreatic neuroendocrine
tumors (PNETs) are rare neoplasms, which represent a heterogeneous group of tumors with distinct functional and
biological behavior. The aim of this study was to assess the functionality and accuracy of the PNET CESQIP module.
Materials & Methods: A retrospective analysis of a prospectively maintained database was performed on all patients
who underwent surgery for a PNET from 2002-14. Information on patient demographics, biochemical tumor
characteristics, treatment modalities, and short-term outcomes were assessed. The selection of study variables was
based on variables from the PNET CESQIP module.
Results: We identified 52 patients diagnosed with PNETs with a median age of 54 years. 58% of patients were
female. Most tumors were non-functional (53.8%); the remainder included insulinomas (38.5%), glucagonomas
(3.8%), VIPoma’s (1.9%), and gastrinomas (1.9%). The operations performed included enucleation (21.2%), distal
pancreatectomy and splenectomy (42.3%), spleen-preserving distal pancreatectomy (19.2%) and Whipple procedure
(17.3%). Most (73.1%) operations were performed laparoscopically. Upon pathological review, 29 patients (55.8%)
had a Ki67 <3, 19 (36.5%) had Ki67 between 3 and 20, and no patients had Ki67 greater than 20%. Mitotic count was
<2 in 40 patients (76.9%), between 2 and 20 in 9 patients (36.5%), and not reported in 2 cases. The number of benign
(53.8%) and malignant (46.2%) tumors were nearly equal. Portal vein invasion was seen in 4.2% of patients. Intraoperative complications included incidental enterotomy in 2 cases. Complications within 30 days included 6 ED visits,
5 readmissions, 1 reoperation, 8 pancreatic fistulas, 5 intra-abdominal abscesses, 3 porto-mesenteric venous
thromboses and 2 cases of persistent hypoglycemia. There was no 30-day mortality.
Conclusion: Within this single institution series of 52 patients undergoing surgical resection for
PNET, a laparoscopic approach was feasible in the majority (73%) of cases with a low
complication rate and no peri-operative mortality. CESQIP allows for practitioners to improve
patient outcomes based on the analysis of prospective data collection and collaborative learning
within the realm of endocrine surgery.
Disclosure of Interest: None declared
181
112.04
ANALYSIS OF INFLUENCING FACTORS FOR CENTRAL NECK LYMPH NODE METASTASIS IN PATIENTS
WITH PAPILLARY THYROID MICROCARCINOMA
K. C. Kim1,*, Y. S. Kim1
1
Surgery, Chosun University College of Medicine, Gwangju, Korea, Republic Of
Introduction: Papillary microcarcinoma (PTMC) is a small papillary thyroid carcinoma measuring 1cm or less in
diameter. Recently, incidence of PTMC has been increased due to an increase in the detection of subclinical disease
such as small and low-risk carcinomas with ultrasonography and fine needle aspiration cytology. However, there is
central neck lymph node metastasis in patients with PTMC. We performed analysis to determine the influencing
factors for central lymph node metastasis in patients with PTMC.
Materials & Methods: We analyzed retrospectively 622 patients with PTMC underwent thyroid surgery at Chosun
University Hospital from January 2002 to December 2012. We reviewed medical records including clinical information,
pathologic report.
Results: Central lymph node metastasis was found in 119 patients (19.1%) among total 622 patients with PTMC.
Lymph node metastasis occurred frequently in patients with following factors; female (p=0.025), tumor in bilateral
thyroid lobe (p=0.016), more than two in number of tumor (p=0.035), more than 0.5cm in largest tumor size (p<0.001)
and lymphovascular invasion (p=0.024). There were no statistically significant differences in age and capsular
invasion. In multivariate analysis, we determined significant factors for lymph node metastasis follows as; age at
operation (p=0.045), gender (p=0.020), tumor size (p<0.001) and lymphovascular invasion (p=0.023).
Conclusion: We suggest that must perform surgery in spite of PTMC. Moreover, we must consider seriously
prophylactic central neck lymph node dissection during surgery in PTMC.
Disclosure of Interest: None declared
182
112.05
A DEMOGRAPHIC STUDY INTO THE INCIDENCE AND TRENDS OF THYROID CANCER IN SINGAPORE
J. S. Hu1,*, W. B. Tan 1, K. Y. Ngiam1, K. K. Chow2, A. Jin2, R. Parameswaran1
1
2
Endocrine surgery , National University Hospital, National Registry of Diseases Office, Health Promotion Board,
Singapore, Singapore
Introduction: Thyroid cancer is the most common endocrine malignancy. The annual incidence of thyroid cancer is
known to vary with geographic area, age and gender. In recent years, there has been reports of increasing incidence
of thyroid cancer worldwide, which has been attributed to increase in detection of micropapillary subtype. We sort to
investigate if this holds true in Singapore and whether incidence varies with ethnicity.
Materials & Methods: The study is a retrospective analysis of thyroid cancers treated in Singapore between the
years 1974 and 2013. The data was collected from the National Cancer Registry and included patients treated in
public hospitals. Demographic data on gender, age, ethnicity and mortality is available for the said period while
additional data on histology and treatment is only available from 2004 to 2013.
Results: The age-standardized incidence rate of thyroid cancer increased by 224% (2.5 per 100,000 in 1974 to 5.6
per 100,000 in 2013). This increased incidence was predominantly seen in women (3:1) compared to men; and
Chinese and Malays compared to Indians. Papillary adenocarcinoma is the most common type of thyroid cancer, of
which 20% were micropapillary subtype. More of the patients with micropapillary subtype (97.7%) underwent surgery
compared to the non-micro papillary cancer (89.9%). Although incidence of thyroid cancer has increased since 1974,
the mortality rate has remained stable.
Conclusion: The trend of increase in incidence of thyroid cancer noted in Singapore is similar to other parts of the
world, but it is not attributed to increase in diagnosis of micropapillary subtype. The increased incidence seemed to be
higher in the Chinese and Malay race for reasons unknown.
Disclosure of Interest: None declared
183
112.06
UTILITY OF A 20 MINUTE MEASUREMENT IN INTRAOPERATIVE PARATHORMONE MONITORING FOR
PARATHYROIDECTOMY
J. Farra1, Z. Khan, BA2, A. Marcadis1, J. Meizoso1, J. Lew 1,*
1
2
Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
Introduction: Intraoperative parathormone monitoring (IPM) guided parathyroidectomy (PTX) for sporadic primary
hyperparathyroidism (SPHPT) has been used for over 25 years. A >50% parathormone (PTH) drop at 10 minutes after
gland excision has been shown to be 98% successful in predicting operative success. However, an additional 20
minute PTH value may be useful when the 10 minute value has not dropped by >50%. This study evaluates the utility
of an intraoperative 20 minute PTH measurement in patients with SPHPT.
Materials & Methods: 785 patients with SPHPT confirmed by elevated serum calcium and PTH levels underwent IPM
guided PTX at a single institution. When a >50% drop of intraoperative PTH level from highest either pre-incision or
pre-excision level was achieved after 10 minutes, the operation was completed. If this criterion was not met, an
additional 20 minute PTH measurement was obtained. Operative success was defined as eucalcemia ≥6 months
whereas recurrence was defined as calcium and PTH levels above normal range >6 months after successful PTX.
Multiglandular disease (MGD) was defined as persistently elevated PTH levels despite removal of one hypersecreting
gland at the time of initial operation, or when removal of a single gland resulted in operative failure.
Results: Of 785 patients with a mean follow-up of 42 months, operative success was 98% and recurrence was 1.3%.
A 20 minute PTH measurement was drawn in 121 patients due to a <50% PTH drop at 10 minutes. Of these patients,
84% (102/121) had a >50% drop at 20 minutes whereas 16% (19/121) did not. Of this latter group, 13 had at least one
additional gland removed with a >50% PTH drop after further excision. Of the remaining 6 patients, 4 had pre-incision
PTH values initially within normal range and were operative successes, whereas the remaining 2 were operative
failures. MGD was found in 14% (17/121) of 20 minute patients compared with 5% (34/664) of 10 minute patients (p
<0.01). Bilateral neck exploration (BNE) was performed in 27% (33/121) of 20 minute patients compared to 11%
(70/664) of 10 minute patients (p<0.01).
Conclusion: A 20 minute value may be useful in identifying patients with MGD who will require BNE and may prevent
unnecessary BNE in the select subset of patients with a delayed PTH drop.
Disclosure of Interest: None declared
184
112.07
MULTIVARIATE COMPARISON BETWEEN TWO PREDICTIVE MODELS FOR HYPERTENSION RESOLUTION
AFTER ADRENALECTOMY IN MEXICAN PATIENTS WITH ALDOSTERONOMA
E. M. Barajas Fregoso1,*, A. Herrera González1, M. F. Herrera Hernández1, D. Velázquez Fernández1, J. P. Pantoja
1
1
Millán , M. Sierra Salazar
1
Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, City, Mexico
Introduction: The aldosterone-producing adenoma (APA) represent 2%>5% of the patients with hypertension. The
treatment consists in unilateral adrenalectomy, however after surgery, a considerable number of patients persist with
hypertension. The aldosteronoma resolution score (ARS) has been advocated for predicting the hypertension
resolution. Our aim was to validate the ARS in Mexican patients at 6 and 12 months of follow-up and to elucidate the
features of this ARS that might differ in our population
Materials & Methods: Patients with APA who underwent unilateral adrenalectomy were included. Patients were
categorized into two groups 1) patients with remission of the hypertension and, 2) patiets with persisting hypertension.
Clinical variables associated to the ARS and hypertension resolution at 6th and 12th months of postoperative followup were included. Univariate and bivariate analysis was performed. ROC curves were developed for significant
individual variables for predicting hypertension resolution. Multivariate logistic regression was employed, any p value
equal o lower than 0.05 or 5% was considered as statistically significant.
Results: 28 patients were included. At 6 and 12 month the blood pressure was normalized in 50% and 57%
respectively. Preoperative variables associated to remission were systolic blood pressure [SBP] (p=0.0001), evolution
time (p=0.007), number of antihypertensive drugs (p=0.017), and grade of hypertension (p=0.001). The use of alphablockers correlated with persistent high blood pressure (p=0.018). We validated the majority of the variables included
in the ARS such as the number of antihypertensive medications. However, others such as age and body mass index
did not result statistically significant in our cohort. When we included some other such as SBP, hypertension grades,
evolution time, alpha-blockage and the number of antihypertensive drugs the model became more statistically
significant than the ARS (p=0.0001 vs. 0.007 respectively).
Conclusion: The ARS proposed by Zarnegar et. al, is the score most commonly used for predicting hypertension
remission in patients with APA. In our study we were not able to demonstrate that age and BMI were statistically
relevant neither in the bivariate or multivariate analysis. Moreover, some variables such as alpha-blockage, SBP and
hypertension grade did show a better predictive value. Based on our results we propose to reconsider some other
variables with potential prognostic value to predict hypertension remission in APA patients.
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2. Rossi, G. P. Diagnosis and treatment of primary aldosteronism. Endocrinol. Metab. Clin. North Am. 40, 313–32, vii–
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(2003).
4. Moneva, M. H. & Gomez-Sanchez, C. E. Establishing a diagnosis of primary hyperaldosteronism. Curr. Opin.
Endocrinol. Diabetes 8, 124–129 (2001).
5. Weinberger, M. H. & Fineberg, N. S. The diagnosis of primary aldosteronism and separation of two major subtypes.
Arch. Intern. Med. 153, 2125–9 (1993).
6. Anderson, G. H., Blakeman, N. & Streeten, D. H. The effect of age on prevalence of secondary forms of
hypertension in 4429 consecutively referred patients. J. Hypertens. 12, 609–15 (1994).
7. Utsumi, T. et al. High predictive accuracy of Aldosteronoma Resolution Score in Japanese patients with
aldosterone-producing adenoma. Surgery 151, 437–43 (2012).
8. Amar, L., Plouin, P. & Steichen, O. Aldosterone-producing adenoma and other surgically correctable forms of
primary aldosteronism. 1–12 (2010).
9. Carter, Y., Roy, M., Sippel, R. S. & Chen, H. Persistent hypertension after adrenalectomy for an aldosteroneproducing adenoma: weight as a critical prognostic factor for aldosterone’s lasting effect on the cardiac and vascular
systems. J. Surg. Res. 177, 241–7 (2012).
10. Zarnegar, R. et al. The aldosteronoma resolution score: predicting complete resolution of hypertension after
adrenalectomy for aldosteronoma. Ann. Surg. 247, 511–8 (2008).
Disclosure of Interest: None declared
185
112.08
CLINICAL IMPLICATION OF THE EXTENT OF CENTRAL LYMPH NODE DISSECTION FOR RECURRENCE IN
PATIENTS WITH PATHOLOGICAL N0 CLASSICAL PAPILLARY THYROID CARCINOMA WHO UNDERWENT
TOTAL THYROIDECTOMY
T.-Y. Sung1,*, Y.-M. Lee1, K.-W. Chung1, S. J. Hong1, J. H. Yoon1
1
Endocrine Surgery, Asan Medical Center, Seoul, Korea, Republic Of
Introduction: Pathological central lymph node (LN) metastases in papillary thyroid carcinoma (PTC) have been seen
to be a well-known risk factor for recurrence. However, correlation of the extent of LN dissection with recurrence in
patients with pathological Nx (pNx) or N0 (pN0) PTC is not well established. This study was aimed to evaluate the
impact of the extent of central LN dissection upon the recurrence in pNx and pN0 PTC.
Materials & Methods: A total of 468 patients who underwent total thyroidectomy with central LN dissection for
classical PTC at Asan Medical Center, and were reported to have pNx or pN0 classifications, between 2000 and 2005,
were reviewed retrospectively. Mean follow up period was 134 months. Risk factors for recurrence were evaluated by
univariate and multivariate Cox regression analysis. Furthermore, the patients were divided into group 1 (Nx), group 2
(N0, 1-2), group 3 (N0, 3-9) and group 4 (N0, ≥10) according to the number of retrieved LNs, and the recurrence-free
survivals (RFS) between the groups were compared.
Results: Number of patients per groups were group 1; 28 (6.0%), group 2; 44 (9.4%), group 3; 244 (52.1%) and group
4; 152 (32.5%). Overall recurrence rate was 2.3 % (9/468). The number of retrieved LNs was the only independent
risk factor for recurrence (P < 0.001) and significance was detected when 3 or more LNs were retrieved. Group 3 and
4 showed significantly lower RFSs as compared with those of group 1 and 2 (P < 0.05).
Image:
Conclusion: Albeit overall recurrence rate was very low in patients with pNx and pN0 PTC, adequate and complete
central LN dissection might improve RFS in the long term.
Disclosure of Interest: None declared
186
112.09
INTRAOPERATIVE QUICK BIOACTIVE (1-84) PTH ASSAY TO PREDICT ADEQUATE REMOVAL OF THE
PARATHYROID DURING PARATHYROIDECTOMY FOR UREMIC SECONDARY HYPERPARATHYROIDISM
S.-M. Huang1,*
1
Department of Surgery, National Cheng-Kung University, Medical College, Tainan , Taiwan
Introduction: An intraoperative quick parathyroid hormone second-generation (QPTH-2G) assay is a poor predictor
of the adequate removal of multiple parathyroid lesions, especially for uremic secondary hyperparathyroidism (HPT).
An intraoperative third-generatiobioactive (1-84) PTH-3G assay has not been used for uremic HPT; therefore, we
tested using it in patients with uremic HPT, and we investigated why intraoperative QPTH-2G fails.
Materials & Methods: Thirty patients with uremic secondary HPT underwent a parathyroidectomy. The intended
routine procedure was a total parathyroidectomy and autoplantation to the forearm. QPTH-2G and QPTH-3G were
measured before the skin incision, at 0, 5, 10, 15, 20, 25, 30, 35, 40, 45 min, and 24 h after the last parathyroid lesion
had been removed. The level of inactive PTH was [PTH-2G – PTH-3G]. The cleansing half-life of PTH-3G and the
inactive PTH were calculated. Postoperatively, all patients were followed-up for 6 to 13 months.
Results: Of 4 patients with a 20-min QPTH (QPTH20)-3G > 50 pg/ml (normal: 10-48 pg/ml), 2 had residual
parathyroid lesions during surgery, and the other 2 patients had persistent hyperparathyroidism (69 and 130 pg/ml of
QPTH20-3G, respectively). The other 26 patients with 23.4 ± 10.1 pg/ml of QPTH20-3G showed no evidence of
persistent or recurrent disease during the follow-up. The ratio of PTH-3G/PTH-2G was 40 ± 19% before the skin
incision, the cleansing half-life of PTH-3G was 2.4 ± 1.7 min, but 53.1 ± 17.0 min for the inactive form of PTH.
Conclusion: The intraoperative 20-min bioactive (1-84) PTH20-3G assay accurately predicts the adequate removal of
parathyroid lesions for uremic secondary HPT. The inactive form of PTH in uremic patients has quite high portions
(mean: 60%, and even up to 80%) and has much longer half-life (53 min vs. 2.4 min) than the active form. Those two
factors cause PTH-2G to fail to predict a successful parathyroidectomy for uremic secondary HPT.
Disclosure of Interest: None declared
187
113.01
EVALUATION OF THE NORTHWESTERN TRAUMA AND SURGICAL INITIATIVE’S TRAUMA FIRST
RESPONDER COURSE IN POTOSI, BOLIVIA
M. Boeck1,*, S. Schuetz1, C. Miller1, I. Helenowski1, J. R. S. Gonzáles1, M. Cabrera Vargas1, L. W. Ruderman1, J. L.
1
1
1
1
1
Gallardo , J. M. P. Laguna Saavedra , N. Issa , M. B. Shapiro , M. Swaroop
1
Northwestern University Feinberg School of Medicine, Chicago, United States
Introduction: Low- and middle-income countries like Bolivia disproportionately shoulder over 90% of the annual 5.8
million traumatic injury deaths globally. Pre-hospital trauma care leads to improved survival and decreased morbidity,
yet Bolivia lacks a structured emergency response system, and accessible trauma first responder courses (TFRC).
Frequently emergencies occur in settings where medical supplies and personnel are unavailable, necessitating
innovative stabilizing interventions with existing materials. Identifying these features of a health system at a program’s
inception is essential in order to adapt training to optimize available resources. The Northwestern Trauma and
Surgical Initiative (NTSI) developed a TFRC focusing on the usage of on-scene materials in the initial stabilization of
an injured patient. This study sought to evaluate the program via participant feedback of a novel TFRC offered across
the Potosí district of Bolivia.
Materials & Methods: In April to May of 2013 an eight-hour TFRC was offered at ten medical and fire centers in
seven towns and cities across the Potosí district of Bolivia. The design was based on other TFRC models and the
WHO guidelines, with significant input from local stakeholders, and validation in La Paz, Bolivia. The training was
divided into thirteen didactic components and six practical sessions, incorporating the use of commonly available local
supplies for treatment. Participants completed a program evaluation at the conclusion of the course. Data were
assessed via the one-sample chi-squared test and the signed rank test for categorical and continuous variables.
Results: A total of 315 individuals completed evaluations for analysis, with 75.6% (p<0.0001) rating the course as
useful. A similar 74.9% (p<0.0001) foresaw applying the learned skills in the future, with most assessing the depth of
information as appropriate (n=207, p<0.0001). There was a trend towards wanting to add more topics to both the
didactic and practical sections, with negligible support for removal (p<0.0001). Across individual analyses of the 19
sessions, median grades were four or higher on a five-point scale, corresponding to good or great ratings. The triad of
Airway, Breathing, and Circulation lectures received high scores (mean rating 4.4-4.5, range 2-5), with helmet
removal, logrolling, and pelvic binding scoring favorably among practical breakout sessions (mean rating 4.4, range 15). There was a modest increase in participant skill confidence between baseline and post-course surveys (mean 3.8
vs. 4.4 out of 5, p<0.0001).
Conclusion: The program evaluation of NSTI’s TFRC in Bolivia’s Potosí district shows overall positive results. A
majority of participants found the material useful for future interventions. When considered in conjunction with
improved skill confidence, this suggests a greater propensity to assist in emergencies. We plan to perform a follow-up
survey to assess skill and knowledge retention, along with recent emergency experiences, to continue strengthening
the course. These initial sessions were largely marketed towards healthcare professionals, in an effort to garner
support and adoption within the medical community, with planned subsequent expansion to other populations as part
of a more comprehensive emergency response program. Since basic knowledge and skills form the foundation of the
TFRC, we feel an extension to laypersons is feasible. Bolivia can thereby foster the development of a widespread,
basic pre-hospital trauma system that maximizes the potential of its available resources, with the ultimate goal of
providing improved emergency care where it is currently lacking.
Disclosure of Interest: None declared
188
113.02
CONTROLLING HAEMORRHAGE IN EXSANGUINATING PELVIC FRACTURES – UTILITY OF
EXTRAPERITONEAL PELVIC PACKING AS A DAMAGE CONTROL PROCEDURE
J. Hsu1,*, S. Yadev1, S. Faraj1
1
Westmead Hospital, Sydney, Australia
Introduction: Exsanguinating pelvic fractures are still associated with a significant mortality rate of 28-60%.
Extraperitoneal pelvic packing (EPP) has been proposed as an optimal method of early haemorrhage control.
The aim of this study was to determine the effect of EPP compared with angioembolization as a primary intervention
for patients with exsanguinating pelvic fracture
Materials & Methods: A prospective observational trial was performed at Westmead Hospital between September
2011 and May 2014. Adult patients with exsanguinating pelvic fracture were allocated into one of two treatment
groups determined by the primary/initial haemorrhage control techinique: 1. EPP followed by angioembolization or 2.
Angioembolization alone. The intervention was determined by the on-call surgeon’s proficiency with EPP.
Demographic, clinical and laboratory data were collected. Univariate analysis of the two groups was performed with
Student’s t-test, Mann-Whitney-U test and Fisher’s exact test.
Results: 24 exsanguinating pelvic fracture cases were included. 14 underwent EPP while 10 underwent
angioembolization as the primary intervention. Although not statistically significant, the EPP group was more severely
injured (Injury Severity Score 32 vs. 23), more acidotic (base deficit 7.9 vs. 6.2), and more hypotensive (Systolic Blood
Pressure 74.2 vs. 84.3). Despite these differences, mortality was reduced (7.1% vs. 30%, not significant). Time to
EPP compared with angioembolization was reduced (67.6 vs. 130.2 minutes, p=0.017). Pre-angioembolization
transfusion requirement was also reduced with EPP (0.032 vs. 0.052 units/min, p=0.04). Arterial injury was found in
51% of the EPP group. There were no significant differences in complication rates between the groups.
Conclusion: EPP appears to be a safe and efficient technique for primary haemorrhage control in exsanguinating
pelvic fractures. Given the high rate of associated arterial injury, EPP should be considered as the first part of a
“damage control” approach for exsanguinating pelvic fractures.
Disclosure of Interest: None declared
189
113.03
POST TRAUMATIC STRESS DISORDER IN TRAUMA SURGEONS? AN INTERNATIONAL PERSPECTIVE
B. Joseph1,*, V. Pandit1, B. Zangbar1, N. Kulvatunyou1, M. Khalil1, T. O’Keeffe1, A. Tang1, G. Vercruysse1, R. S.
1
1
1
Friese , R. Latifi , P. Rhee
1
The University of Arizona, Tucson, United States
Introduction: The impact of managing critical trauma cases on the well being of trauma surgeons remains unknown.
The aim of our study was to compare the incidence of Post-Traumatic Stress Disorder (PTSD) among trauma
surgeons practicing in the United States (US) and those practicing internationally. We hypothesized that trauma
surgeons practicing in the US have lower prevalence of PTSD compared to their international colleagues.
Materials & Methods: We surveyed all members of the American Association for Surgery of Trauma (AAST), the
Eastern Association for Surgery of Trauma (EAST), Trauma Association of Canada (TAC), and Brazilian Trauma
Society (SBAIT) using an established PTSD screening test (PTSD Checklist Specific- PCL-C). Members with dual
membership were cross-checked. Members were stratified into two groups based on place of work: National (US) and
international. A PCL-C score of ≥ 35 identified the presence of PTSD symptoms and a PCL-S score ≥ 44 diagnosis of
PTSD.
Results: There were 553 respondents (453 national, 100 international) of which, 37.4% (n=207) had symptoms of
PTSD and 14.1% (n=78) had diagnosis of PTSD.
After controlling for all confounding factors, trauma surgeons practicing in the US were 1.2 (OR [95% CI]: 1.2 [1.1-9.2])
times more likely to develop PTSD symptoms in comparison to the trauma surgeons practicing internationally.
Image:
Conclusion: Post-Traumatic Stress Disorder is alarmingly prevalent among surgeons practicing trauma globally.
Trauma surgeons practicing in the US are at a higher risk for developing symptoms of PTSD in comparison to their
international colleagues. Reducing the workload among US trauma surgeons may help to decrease the incidence of
PTSD symptoms.
Disclosure of Interest: None declared
190
113.04
COAGULATION RESONANCE AMPLITUDE (CORA) TECHNOLOGY: A NOVEL VISCOELASTIC APPROACH TO
POINT OF CARE COAGULATION MANAGEMENT: INITIAL PILOT STUDY
J. Kashuk1,*, E. Cohen1, G. Raviv1
1
Assia Medical Group, Tel Aviv, Israel
Introduction: Improved understanding of the cell based model of hemostasis and current enthusiasm
for viscoelastic technology (VET) have advanced our ability to diagnose, monitor, and treat perturbations of postinjury
coagulation. Despite this progress, several challenges appear to have limited widespread adaption of VET. These
include environmental sensitivity to vibration/contact, labor intensive titration, inability to generate multiple,
simultaneous results, and difficult standardization of instrumentation. We theorized that the new CORA® VET would
provide equivalent results to the TEG 5000 system but with amelioration of the challenges described, resulting in a
simplified, more efficient and user friendly technology.
Materials & Methods: 300 whole blood samples from three sites were split and analyzed on both the TEG 5000 and
the new CORA instrument. The CORA system produces the same numeric results in the familiar TEG parameters and
units, but incorporates analysis of clot viscoelastics via a series of non-contact measurements of resonance frequency
in response to controlled external vibration, providing a direct measure of clot stiffness. (Figure1). The system uses a
disposable microfluidics cartridge, which automates sample preparation, provides electronic quality control, reduces
required blood sample volume, and enables simultaneous running of multiple separate assays on the same whole
blood sample.
Results: Correlation coefficient r values of the split sample analysis for the R and MA parameters
comparing CORA and TEG 5000 were 0.98 and 0.99, respectively (Fig 2), with CORA results being produced in four
simultaneous channels [citrated RapidTEG® (RT), Kaolin (K), Kaolin+Heparinase (KH), and Functional Fibrinogen
(FF) assays].
Image:
Conclusion: This initial pilot study suggests that the CORA VET generates comparable results to the TEG 5000
system, but with amelioration of many current challenges of VET. An important advantage is the added ability to run
simultaneous RT,K, KH, and FF assays. While further study is indicated, these results suggest that the CORA will
likely improve our ability to diagnose, monitor, and treat postinjury coagulation disorders.
Disclosure of Interest: None declared
191
113.05
HEMODYNAMICALLY UNSTABLE PELVIC TRAUMA: MORTALITY IMPROVEMENT AFTER INTRODUCTION OF
ATLS GUIDELINES, TRAUMA TEAM AND PREPERITONEAL PELVIC PACKING. A CASE-CONTROL STUDY.
S. Magnone1,*, F. Coccolini1, R. Manfredi1, D. Piazzalunga1, G. E. Nita1, L. Ansaloni1
1
Pope John XXIII Hospital, Bergamo, Italy
Introduction: Hemodynamically unstable pelvic trauma in multi-trauma patients represents a great challenge even in
most experienced Trauma centers. We present our experience after the introduction of the Trauma Team (TT) and
Preperitoneal Pelvic Packing (PPP).
Materials & Methods: Retrospective research in a existing database. Patients were divided into two groups: before
and after introduction of ATLS guidelines, Trauma Team and preperitoneal pelvic packing. A historical control group
was identified from 1/2007 to 8/2011 (Control Gorup CG) while study group (SG) comprises patients treated from
9/2011 to 10/2014. Data are expressed in median (and interquartile range) or mean (and standard deviation) as
appropriate. P<0.05 was assumed as significant (Mann-Withney test for non normally distributed variables and
Student t test for normally distributed). Percentage are compared with chi squared test (Person uncorrected).
Results: From 1/2007 to 10/2014 40 patients with a pelvic trauma and hemodynamic instability, (systolic blood
pressure (SBP) under 90 mmHg or need for ongoing resuscitation), were treated in our Center. In 4/2011 a TT was
established and in 9/2011 we started to use PPP as a salvage maneuver to control pelvic bleeding. According with
availability external fixation was sometimes implemented but not on a regular basis due to lack of orthopedic surgeon
with an experience in it. We consider patients from 1/2007 to 8/2011 (20 patients, control group) and from 9/2011 to
10/2014 (20 patients, study group). Mean age was not different between the groups (52.8 years for CG vs 45.2 for
SG, p=0.19), as well as median initial Systolic Blood Pressure SBP (90 mmHg (85-103) in the CG vs 95 mmHg (82122) in the SG, p=0.6) and heart rate (HR) (90 vs 112, p=0.12). Median Injury Severity Score was high as mauch as
41 in the CG and 42 in the SG. Time from arrival in the Emergency Department (ED) to intervention was better for the
study group (172 min (120-211) vs 65 min (41-121), p=0.025). Mortality was statistically significant: 60% (12/20) for
the CG and 19.0% for the SG (4/21), p=0.007, odds ratio 6.37 (95% Confidential Interval 1.30-34.08). In the CG only
12/20 underwent a surgical (angio or surgery) maneuver, while 8 patients died in the Emergency Department. All
patients in the SG underwent a surgical or radiological maneuver on the same day of admission and we did not
observe Emergency Department mortality.
Conclusion: ATLS guidelines, Trauma Team and Preperitoneal Pelvic Packing introduction changed our approach in
hemodynamically unstable multi-trauma patients, with a better trend in terms of mortality. We need further study to
confirm these first favorable data.
Disclosure of Interest: None declared
192
113.06
A NOVEL DIAGNOSTIC AND PROGNOSTIC TOOL IN CRITICALLY-ILL TRAUMA PATIENTS: METABOLOMIC
PROFILING REVEALS PERVASIVE CHANGES
B. Parent1,*, S. Aarabi1, D. Raftery1, G. O’Keefe1
1
University of Washington Medical Center, Seattle, United States
Introduction: Metabolomics is the study of metabolites within an organism and provides an elegant real-time
summary of physiologic state. The metabolic profile is the sum of several thousands of lipids, amino-acids, nitrates,
and sugars which represent the ultimate downstream products of the genome and its interaction with the environment.
By analyzing patients’ serum and urine samples, prior studies have identified biomarkers which have led to earlier
identification of common illnesses like sepsis, pneumonia, and cancer. Further research in metabolomics may be
especially relevant in trauma care, given that our current laboratory repertoire to identify and trend metabolic
derangement can be both overly simplistic and misleading. This is particularly true in both shock and malnutrition
states, where the utility of lactate, base deficit, and albumin has been repeatedly called into question. Metabolomics
represents a potential new diagnostic and predictive tool that would allow for a more personalized and nuanced
approach to trauma care.
Materials & Methods: Patients were included in the study if they were within 12 hours of blunt trauma and had either
a systolic blood pressure of <90mmHg or a base deficit >6 within the first hour of arrival. Serum and urine samples
were obtained on hospital day 1, 3, 7, and 9. Patient charts were reviewed for clinical data. Healthy age and gendermatched volunteers donated samples in a fasting state at two time points separated by 72 hours. Samples from
patients and controls were then analyzed using nuclear magnetic resonance (NMR) and mass spectrometry (MS).
Partial least-squares discriminant-analysis models were applied to samples for comparison. Univariate and
multivariate statistical analyses were used to select potential biomarkers of interest.
Results: Data from among 7 patients and 7 controls revealed pervasive differences in metabolic profiles. Specific and
significant changes in trauma patients seen on NMR (Fig 1a, b) include evidence of an impaired TCA cycle (elevated
acetate, lactate, decreased citrate), evidence of muscle catabolism (elevated tyrosine, phenylalanine, decreased
hippuric acid), and evidence of deranged lipid metabolism.
Image:
Conclusion: Critically-ill trauma patients have an underlying inflammatory and catabolic burden which is
demonstrable on metabolic profiling and is distinct from a control population metabolome. Profiling the metabolome of
a trauma patient and trending changes in specific metabolites over time allows for a more direct assessment of
disease severity and tracks treatment efficacy. This technique represents a novel, rapid, and personalized diagnostic
tool which has the potential to provide new therapeutic targets in trauma patients.
Disclosure of Interest: None declared
193
114.01
FTY720 DECREASES LEVELS OF LIPID MEDIATOR IN TUMOR MICROENVIRONMENT AND SUPPRESSES
BREAST CANCER PROGRESSION
M. Nagahashi1,*, K. Moro1, J. Tsuchida1, K. Tatsuda1, J. Sakata1, T. Kobayashi1, K. Takabe2, T. Wakai1
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
Niigata, Japan, 2Division of Surgical Oncology, Virginia Commonwealth University School of Medicine, Richmond,
United States
Introduction: The tumor microenvironment is a determining factor in cancer biology and progression. Sphingosine-1phosphate (S1P), produced by sphingosine kinases (SphKs), is a bioactive lipid mediator that regulates processes
important for cancer progression including cell proliferation, migration, angiogenesis and lymphangiogenesis. The
interstitial fluid that bathes the tumor and stromal cells is considered an important part of the tumor microenvironment
not only as the initial route of metastasis, but also as a supplier of factors that promote tumor metastasis. Despite its
critical roles, the level of S1P in interstitial fluid (IF) has been understudied due to a lack of efficient methods for
collecting and quantifying IF. Here we introduce a simple and reproducible method for measuring the levels of
sphingolipids including S1P in small volume tumor interstitial fluid using a modified centrifugation method combined
with liquid chromatography-electrospray ionization tandem mass spectrometry (LC-ESI-MS/MS).
Materials & Methods: We utilized SphK1-/- and SphK2-/- mice and a syngeneic orthotopic breast cancer mouse
model with 4T1-luc2 cells. IF was collected from breast tissue and tumors by our improved centrifugation method.
Sphingolipids in IF, blood, and tissue samples were measured by liquid chromatography-electrospray ionization
tandem mass spectrometry (LC-ESI-MS/MS).
Results: To examine whether collected IF contained cells or components of broken cells, the proteins from the same
amounts of lymph node tissue and IF were separated by SDS-PAGE and immunoblotted with an antibody to actin, the
major intracellular protein. Actin was barely detectable in IF, indicating minimal contamination of cells in the collected
IF. Repeated analyses of IF samples demonstrated minimal variation, also indicating low contamination. Deletion of
SphK1 greatly reduced levels of S1P in IF from the breast tissue. The amount of S1P in IF from breast tumor was 10
fold higher than that in normal breast tissue. Levels of S1P in IF from breast tumors were greatly reduced by treatment
with FTY720, a S1P receptor modulator that suppressed tumor growth.
Conclusion: This is the first report describing the measurement of S1P in tumor IF. Measurement of S1P in tumor IF
may illuminate new aspects of the regulation of cancer progression. M.N. is supported by the Uehara Memorial
Foundation.
Disclosure of Interest: None declared
194
114.02
USEFULNESS FOR A PROGNOSTIC FACTOR OF NEUTROPHIL-LYMPHOCYTE RATIO IN PRIMARY BREAST
CANCER
S. Noda1,*, N. Onoda1, T. Morisaki1, S. Kashiwagi1, H. Kawajiri1, T. Takashima1, K. Hirakawa1
1
Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan
Introduction: In many types of cancer, systemic inflammatory response has been reported to be closely associated
with its prognosis. Neutrophil-lymphocyte ratio (NLR) has attracted attention as a simple and inexpensive indicator of
inflammatory response. Here we investigated the usefulness of NLR as a prognostic factor in patients with operable
primary breast cancer.
Materials & Methods: Seven hundred patients of primary breast cancer who undergone surgery from 2006 to 2013
were retrospectively investigated. Survival of them was calculated using the Kaplan-Meier method, and subjected to
Log rank test. Prognostic factors were analyzed by multivariate analysis (Cox proportional hazard ratio model).
Results: The median age of the patients was 62-years-old, including 691 females and 525 post-menopausal women.
The median observation period was 31 months. Recurrences and mortality events were observed in 43 (6%) and 24
cases (3.4%), respectively. The threshold to determine high NLR was calculated as 3.29 by the analysis of ROC
curves for the presence or absence of recurrence. High NLR (3.29 or more) was observed in 70 patients (10%).
Recurrent free survival rate (RFS) and overall survival rate (OS) of 5 year were significantly lower at 78% and, 75% in
high NLR group, compared with these at 93% and 96% in low NLR group. Independent prognostic factor of poor DFS
and OS were determined as negative estrogen receptor and high NLR. In 515 Luminal breast cancer patients, a
significantly poor RFS was observed in high NLR group, although there was no difference in OS. Only high NLR was
defined as an independent factor to determine DFS of Luminal breast cancer patients. In the 114 triple-negative breast
cancer (TNBC) patients, high NLR group had significantly poorer RFS and OS than low NLR group had. Independent
prognostic factors in TNBC were high NLR and T stage for DFS, and high NLR only for OS. In 71 HER2-positive
breast cancer patients, no significant differences of RFS and OS were observed between high and low NLR group.
Conclusion: NLR of the patients with breast cancer was suggested to be a useful prognostic factor, particularly in
these with TNBC but not in these with HER2-positive breast cancer. The significance of NLR to determine prognosis
in breast cancer might differ by subtypes.
Disclosure of Interest: None declared
195
114.03
THE IMPACT OF TUMOUR BIOLOGY UPON SURGERY TYPE AND COMPLETE PATHOLOGICAL RESPONSE
AFTER NEOADJUVANT CHEMOTHERAPY IN BREAST CANCER PATIENTS WITH AXILLARY NODAL
METASTASES.
M. R. Boland1,*, D. Evoy1, J. Geraghty1, C. Quinn2, G. Gullo3, A. O'Doherty4, E. W. McDermott1, R. S. Prichard1
1
Breast and Endocrine Surgery, 2Pathology, 3Oncology, 4Radiology, St Vincents University Hospital, Dublin 4, Ireland
Introduction: Few studies have focussed on effects of tumour biology on extent of surgery and rates of pathological
complete response (pCR) in breast cancer patients with nodal metastases who undergo neoadjuvant chemotherapy
(NAC). The aim of this study was to examine the impact of different biological tumour characteristics on extent of
breast surgery, nodal burden and rates of axillary pCR in breast cancer patients with nodal metastases who undergo
NAC.
Materials & Methods: A retrospective review of a prospectively maintained database identified breast cancer patients
with positive axillary fine needle aspiration cytology between 2007- 2012. Patients who underwent NAC and
subsequent axillary lymph node dissection (ALND) were recorded and tumour characteristics analysed. Extent of
surgery and rates of pCR after NAC by biologic subtype were compared.
Results: 111 patients with breast cancer and nodal metastases underwent NAC and subsequent ALND. With regard
to tumour biology, 58 patients (52.3%) were [ER+HER2-], 31 patients (27.9%) were [ER+HER2+], 16 patients (14.4%)
were [ER-HER+] and 6 patients (5.4%) were [ER-HER-]. Axillary pCR was significantly higher in the [ER-HER+] group
compared to the [ER+HER2+] and [ER+HER2-] groups (87.5% vs 48.4% vs 12.1%; p<0.001). Tumour biology did not
affect extent of surgery. Nodal burden (Mean positive nodes) was significantly lower in the [ER-HER+] group
compared to the [ER+HER2-] group (0.19 vs 7.46; p <0.001) and [ER+HER2+] group (0.19 vs 1.96; p=0.01).
Conclusion: HER2 positivity is associated with increased rates of axillary pCR and reduced nodal burden after NAC.
Patients with HER positivity could be amenable to less aggressive axillary surgery post NAC.
Disclosure of Interest: None declared
196
114.04
TUMOR VASCULAR REMODELING AND EPITHELIAL-MESENCHYMAL TRANSITION IN ERIBULIN
CHEMOTHERAPY FOR BREAST CANCER
S. Kashiwagi1,*, Y. Asano1, T. Morisaki1, S. Noda1, H. Kawajiri1, T. Takashima1, N. Onoda1, K. Hirakawa1
1
Department of Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan
Introduction: Eribulin mesylate (eribulin) is a promising chemotherapeutic agent to treat locally advanced or
metastatic breast cancer (MBC). Not only its cytotoxic efficacy, but its unique mechanisms to suppress epithelialmesenchymal transition (EMT) of the cancer cells, or to promote tumor vascular remodeling attracted attention in
basic models. In this study, we investigated markers of EMT and hypoxia in sets of clinical specimens before and after
treatment of eribulin in an aim to verify its profound mechanisms.
Materials & Methods: A series of 20 sets of the tissue specimens of MBC obtained before and after chemotherapy
from patients treated either with eribulin (n=10), or with paclitaxel (n=10) were immunohistochemically investigated
with the expression of E-cadherin, N-cadherin, Vimentin, and CA9. The cut-off for E-cadherin positivity was >30%
positive tumor cells with membrane staining. The cut-off for N-cadherin and Vimentin positivity were >10% positive
tumor cells with cytoplasm staining. And, the cut-off for CA9 positivity was >10% positive tumor cells with membrane
staining.
Results: Looking at the relation between the transition in this protein expression and therapeutic effect, cases
observed with positive conversion in E-cadherin expression and cases observed with negative conversion in CA9
expression had significantly high response rate (RR) (p=0.004, p=0.024). Among high RR cases, E-cadherin
expression was remarkably increased, the N-cadherin, Vimentin and CA9 expression were reduced. A significant
prolongation of progression-free survival (PFS) was observed in patients with tumor showed E-cadherin positiveconversion (p=0.041, log-rank). Significantly longer periods of time to treatment-failure (TTF) were achieved in
patients with tumors showed E-cadherin positive-conversion (p=0.018, log-rank) or showed CA9 negative-conversion
(p=0.038, log-rank). There was no difference in over-all survival (OS) of the patients when stratified with the
expression of and change in EMT markers. No difference was observed either in PFS, TTF, or OS of the patients
according to the expressions of and change in N-cadherin and Vimentin.
Conclusion: Increased expression of E-cadherin was observed along with reduced expression of N-cadherin,
Vimentin, and CA9, EMT suppression was caused by eribulin chemotherapy, and further, it was suggested that
vascular remodeling may have been induced.
Disclosure of Interest: None declared
197
114.05
PATTERN OF LYMPH NODAL INVOLVEMENT IN LOCALLY ADVANCED BREAST CANCER: ANALYSIS OF
1293 PATIENTS FROM A TERTIARY CARE CANCER CENTRE IN INDIA
S. Deo1, N. K. Shukla1, D. K. Muduly1, A. Jakhetiya1,*, A. Gogia2, V. Sreenivas3, D. Sharma4, S. Mathur5
1
2
Department of Surgical Oncology, Department of Medical Oncology, Institute Rotary Cancer Hospital, All India
3
Institute of Medical Sciences, Department of Biostatistics, All India Institute of Medical Sciences, 4Department of
Radiotherapy, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, 5Department of Pathology, All
India Institute of Medical Sciences, New Delhi, India
Introduction: Locally advanced breast cancer (LABC) constitutes approximately 50 to 60 % of breast cancer burden
in Low and middle income countries (LMIC) . There is paucity of large scale data on the pattern of lymph nodal
involvement in LABC which can have therapeutic implications in the era of “conservatism” in the management of
axillary nodes. We present an analyses 1293 LABC patients pattern of lymph node involvement.
Materials & Methods: A retrospective analysis of computerized prospective clinical database of breast cancer
patients treated consecutively during January 1994 to December 2012, in the department of Surgical Oncology,
Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India was performed. The AJCC/
TNM (2010) staging system was referred for staging purpose. All patients with stage III were classified as LABC. All
patients were offered tri-modality therapy (Systemic therapy + Surgery +Radiotherapy) and a complete axillary
clearance (Level 1 to III) was performed as part of surgical management of LABC . An analysis of patterns of axillary
nodal involvement was performed in these patients.
Results: A total of 1293 patients with LABC were included for analysis. The breakup of stage IIIA, IIIB and IIIC were
263 (20.34%), 676 (52.28%) and 354 (27.38%) respectively. A total 1071 (82.3%) patients had histo-pathologically
proven nodal metastases and only 222 (17.7%) were node negative. Among node positive patients 301 (28.1%), 416
(38.8%) and 354 (33.05%) patients had pN1, pN2 and pN3 status respectively. Mean number of positive nodes was
7.40 (+/-5.9) in the whole cohort of node positive disease. The mean number of positive nodes in patients undergoing
upfront surgery was 7.9 (+/- 6) and in those receiving neo-adjuvant chemotherapy was 5.9 (+/- 5.22) . Extranodal
spread was present in 357 (27.61%) patients. At a median follow-up of 35 months regional relapse was documented
in only 12 (1%) patients.
Conclusion: Unlike the western experience, the incidence and burden of axillary lymph node involvement in LABC
patients is significantly high in LMIC. Our experience has shown that excellent regional control could be achieved in
these patients with a policy of complete ALND. In the era of axillary conservatism, surgeons in LMIC should take a
cautious approach before adopting a policy of conservative axillary dissections and sentinel node biopsy in breast
cancer patients.
Disclosure of Interest: None declared
198
114.06
A NOVEL SEGMENT CLASSIFICATION FOR MULTIFOCAL AND MULTICENTRIC BREAST CANCER TO
FACILITATE BREAST CONSERVATION TREATMENT
M. P. Tan1,*
1
Breast Surgery, MammoCare The Breast Clinic & Surgery, Singapore, Singapore, Singapore
Introduction: Breast Conservation Treatment(BCT) is an appropriate alternative to mastectomy for the treatment of
unifocal breast cancer. Multifocal and multicentric breast cancers(MFMCBC) challenge conventional indications for
BCT and are often treated with mastectomy. Following progress in treatment strategies for unifocal tumours,(1) there
was a movement to evaluate the use of BCT for MFMCBC. Now a growing body of evidence from retrospective data
has emerged, demonstrating acceptable local control and overall survival rates with BCT for MFMCBC.(2) Prospective
studies are needed to confirm these findings. One possible barrier to such trials is the absence of a standardised
classification and nomenclature for MFMCBC at present. A novel segment classification is presented in this article in
an endeavour to overcome this deficiency and allow future work on this issue.
Materials & Methods: A lexicon is used to describe the five elements of this segment classification. Categorisation is
intended for a common understanding of MFMCBC to promote the development of techniques for BCT in conformity
to present guidelines for further academic and clinical work on the subject. The five main elements to be described
are: the laterality of the involved breast, the number of malignant lesions, the number of involved segments, the
positions relative to each other, and the proximity of the nearest lesion to the NAC. These characteristics are
respectively denoted as R/L Breast - xLx, xSx/x, A/D, Zx. There are two further optional descriptors which describe
quadrant and hemispheric separation of the lesions, whether in a sagittal or transverse direction. These additional
descriptors may be included in parenthesis at the end of the essential details: R/L Breast - xLx, xSx/x, A/D, Zx (xQ,
Hxx).
Results: Figure 1 demonstrates the use of the lexicon with the nomenclature of this multicentric disease being: R
Breast: 2Li, 2S 11/2, A, Z1 (2Q, Hs). Surgical spatial planning would involve a dual segment tumour resection where
the eilliptical limbs meet centrally. Full thickness parenchymal flaps are then mobilised after clear margins are
achieved. The unique resultant tissue pattern allow the breast parenchymal pillars to dovetail and 'lock' into place. The
edges are apposed and sutured to prevent deformity.
Image:
Conclusion: This new classification and lexicon can potentially provide a way forward by enabling a consistent
approach to BCT for MFMCBC regardless of breast tissue volume, and pave the way for further work in the future.
References: 1. Agarwal S, Pappas L, Neumayer L, et al. Effect of Breast Conservation Therapy vs Mastectomy on
Disease-Specific Survival for Early-Stage Breast Cancer. JAMA Surg 2014doi:10.1001/jamasurg2013.3049.
2. Wolters R, Wockel A, Janni W et al. Comparing the outcome between multicentric and multifocal breast cancer:
what is the impact on survival, and is there a role for guideline-adherent adjuvant therapy? A retrospective multicentre
cohort study of 8,935 patients. Breast Cancer Res Treat 2013;142:579-590.
Disclosure of Interest: None declared
199
114.07
SURVEY ON KNOWLEDGE AND RISK PERCEPTION AMONG CLINICIANS TOWARDS GENETIC TESTING FOR
HEREDITARY BREAST AND OVARIAN CANCER
S. Y. Yoon1, G. H. Tan2,*, Y. L. Woo2, C. H. Yip3, S.-H. Teo1, N. A. Mohd Taib2
1
2
3
Cancer Research Initiatives Foundation, Subang Jaya, University Malaya Medical Centre, Kuala Lumpur, Sime
Darby Medical Centre, Subang Jaya, Malaysia
Introduction: BRCA testing and the associated risk management strategies to reduce the risk for BRCA carriers is
well established for the management of hereditary breast and ovarian cancer. However, few BRCA carriers have been
identified in Malaysia and one of the reasons is the lack of referrals from clinicians for BRCA testing. This study aims
to investigate the understanding of BRCA genetic testing for hereditary breast and ovarian cancer among clinicians
and healthcare providers
Materials & Methods: A survey with a focus on knowledge of risk factors for BRCA1 and BRCA2 including cancer
type, pathological features of breast and ovarian cancer, family history and risk of cancers which are associated with
BRCA mutations was carried out at the College of Surgeons (Malaysia) meeting in 2013 and 2014, and subsequently
the same survey was conducted in the College of Obstetricians and Gynaecologist in 2014. There were a total of 157
responders for the surveys, 72 ( 46%) were surgeons / medical officers, 23 (14%) gynaecologists and 62 (40%) were
nurses.
Results: In the past year, only 12% of responders have referred any cancer patients for BRCA genetic test. 50% of
the responders correctly associated breast, ovarian and prostate cancer to BRCA, 73% correctly associated BRCA to
triple negative breast cancer, However, 50% were not aware that pre-menopausal breast cancer was associated with
BRCA and 50% were not aware that serous subtype of ovarian cancer was associated with BRCA. 91% correctly
associated with breast cancer in mother or sister, but only 34 % associated breast or ovarian cancer in paternal
relatives. Majority of the responders overestimated the average risk for breast cancer (37% replied 25%, 14% replied
>50%) but recognised the increase risk to breast cancer for BRCA carriers (50% replied 80% risk). However, only
15% of the responders were able to associate the increase risk to pancreatic and prostate cancer.
Conclusion: Clinicians are aware of the co-relation between increased breast cancer risk and BRCA mutation, but
overestimate it. There is little awareness of prostate and pancreatic cancer association to BRCA. There was an
overestimation of breast cancer risk in the average female. There was little awareness of family history on the paternal
side and association with pathological features of breast and ovarian cancer. The outcome of this survey suggests
that BRCA genetics training may be beneficial to clinicians and other healthcare providers.
Disclosure of Interest: None declared
200
114.08
SENTINEL LYMPH NODE BIOPSY TECHNIQUE: HOW MANY SHOULD WE EXCISE?
K. K. Ma1,*, M. W. Chan1, F. Wong1, A. Kwong1
1
Department of Surgery, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
Introduction: Although sentinel lymph node (SLN) biopsy is the preferred method for the axillary lymph node staging
in node-negative early breast cancer, there is still no consensus on the number of radioactive SLNs that should be
removed. 4 common models with different cutoff for number of SLN removal have been proposed. We aim to validate
these 4 models in an independent dataset.
Materials & Methods: We retrospectively studied consecutive 240 clinically node-negative early breast cancer
patients who underwent SLN biopsy in the Queen Mary Hospital from January 2008 to December 2012. Dual tracers
(Technetium 99 sulphur colloid and blue dye) were employed. All radioactive hot spots and blue nodes were removed.
Ex vivo count and pathology of each SLNs were evaluated. False negative rates (FNRs) of the 4 models were
calculated based on different stopping threshold and were compared.
Results: A total of 932 SLNs were harvested, 59 of them were positive for malignancy (39 macrometastasis, 14
micrometastasis, 6 isolated tumor cells). In those 59 positive SLNs, 57.6% were the hottest SLN, 6.8% had ex-vivo
count less than 10% of the hottest node. The FNR of model 1 (removing only the hottest node), model 2 (removing all
hot nodes), model 3 (10% rule) and model 4 (10% rule and blue dye) were 24.4%, 0%, 2.2% and 0% respectively.
Although the FNR were the same for model 2 and 4, model 4 had 26.4% less lymph nodes removed, which
theoretically should have less procedure-associated morbidities.
Conclusion: It is not necessary to remove all radioactive nodes, especially using dual tracers technique. 10% rule
AND removing all blue nodes is the preferred method for sentinel lymph node mapping.
Disclosure of Interest: None declared
201
114.09
CLINICAL BEHAVIOUR AND OUTCOMES IN BENIGN, BORDERLINE MALIGNANT AND MALIGNANT
PHYLLODES TUMOR OF THE BREAST.
P. RAMAKANT1,*, S. CHAKRAVARTHY1, A. J. CHERIAN1, M. PAUL1
1
ENDOCRINE SURGERY, CHRISTIAN MEDICAL COLLEGE, VELLORE, VELLORE, India
Introduction: Phyllodes tumor (PT) of the breast present diagnostic challenges, need optimal surgery extent and
some need adjuvant treatment. The understanding regarding PT (benign, borderline malignant and malignant)
behaviour, pathology and outcomes improves with longer duration follow up studies done on a larger subset of
patients.Aim- To assess the differences in the outcomes and behaviour patterns of all subtypes of PT of the breast.
Materials & Methods: Retrospective data analysis of all patients with PT of the breast from Jan., 2003 to
Dec., 2014. All clinical and pathological details noted. Data analysed using SPPS (version 17).
Results: Out of total 171 patients with PTs of the breast, mean age was 39.6 years (range 15-70 years), mean tumor
size was 10.4cm (range 1-30 cm) and mean duration of symptoms was 35.3 months (1-300 months). 32% patients
presented with local recurrence post lumpectomy done elsewhere.
Characteristics
Benign PT (n=86, 50.3%)
Borderline Malignant PT
Malignant PT (n=52, 30.4%)
(n=33, 19.3%)
Mean age ( range) in years
37.8 (15-59)
42.8 (23-70)
40.6 (17-58)
Mean tumor size (range) in
cm.
8.35 (1-30)
12.20 (4.5-28)
12.69 (1-30)
Surgery
Local excision (%)
Wide local excision (%)
Mastectomy (%)
Reconstruction surgery (%)
Margins
Involved (%)
Close (%)
Free (%)
Adjuvant therapy
Radiation
Chemotherapy
Recurrences (%)
Distant metastases
39 (45.4)
31 (36.0)
16 (18.6)
8 (9.3)
10 (3.3)
7 (21.2)
16 (48.5)
4 (12.1)
15 (28.8)
8 (15.4)
29 (55.8)
16 (30.8)
10 (11.6)
12 (14)
64 (74.4 )
4 (12.2)
8 (24.2)
21 (63.6)
3 (5.8)
8 (15.4)
41 (78.8)
6
0
16 (18.6)
0
9
0
14 (42.4)
0
28
5
24 (46.1)
7
Axillary lymph node metastasis was found in only 1 patient who had infiltrating ductal carcinoma along with PT. Six
patients with distant metastases died within 6 months to 2 years of treatment.
Conclusion: Patients with Borderline malignant and Malignant PTs have larger tumor size, need mastectomy and
have more local recurrences compared to Benign PTs. Distant metastases were seen in malignant PT subtype only
and these patients had dismal outcome. Borderline malignant and Malignant PTs need more aggressive treatment
compared to Benign PTs.
Disclosure of Interest: None declared
202
114.10
THORACO-ABDOMINAL FLAP: A SIMPLE FLAP FOR COVERING LARGE POST MASTECTOMY SOFT TISSUE
DEFECTS IN LOCALLY ADVANCED BREAST CANCER
S. V. S. Deo1, N. K. shukla1, A. Jakhetiya1,1,*, D. K. muduly1
1
Surgical Oncology, All India Institute of medical sciences, New Delhi, India
Introduction: Locally advanced breast cancer (LABC), constitutes 40%>50% of breast cancer in developing
countries. Large soft tissue defects, after mastectomy often require some additional cover. The primary aim of
reconstruction in this group should be an expeditious and simple closure with good quality skin cover, early recovery
and short hospital stay so that the patients can receive early postoperative radio-chemotherapy. Thoraco-abdominal
(TA) flap is a Type-c fasciocutaneous flap and the skin and fat of the upper abdomen are used based on medial or
lateral perforating vessels. We present our experience of TA flap cover for large post-mastectomy defects.
Materials & Methods: A retrospective analysis of prospectively maintained breast cancer database in department of
surgical oncologyfrom January 1994 to December 2014 at AIIMS, Delhi was performed. The medical records of
patients undergoing TA flap cover were analyzed to assess operative duration, blood loss, postoperative morbidity,
hospital stay, adjuvant treatment, recurrence patterns, and survival outcome.
Results: A total 2585 breast cancer patients underwent surgery, of which 1423 were LABC and 65 patients (4.56%) of
LABC required flap cover for closure of mastectomy defect. TA flap was used in majority of these patients 51 /65
(78.5%) for cover. Majority were stage IIIB (38/51) andwe could achieveR0 resection in all patients. TA flap was done
following MRM in 44 patients and RM in 7 patients. Upfront primary surgery was performed in 24 patients and 27
underwent surgery after neoadjuvant chemotherapy. Most commonly laterally based flaps were done, except 3
medially based flaps. The mean operating time was 30 min and blood loss was 50 ml. Mean hospital stay was 5 days.
Superficial flap necrosis occurred in 3 and wound infection in 2 patients, all managed conservatively. Only 1 patient
had major flap loss and required debridement and skin grafting. Planned post operative radiation could be delivered in
most of the patients in time. At a mean follow-up of 21 months only 6 out of 51 (12%) patients had loco- regional
recurrence.
Conclusion: Results of our experience show that TA flap is a simple, cost-effective procedure for managing large
post mastectomy soft tissue defects in LABC. It has huge potential in developing countries dealing witha large number
LABC because of simplicity and short learning curve.
Disclosure of Interest: None declared
203
114.11
POST MASTECTOMY RADIOTHERAPY IN N1 DISEASE
S. E. L. Tang1,*, P. M. Y. Chan1, E. Y. Tan1
1
Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
Introduction: Post mastectomy radiotherapy (PMRT) has been shown to reduce locoregional recurrence and improve
overall survival in those with tumour size more than 5cm and 4 or more positive lymph nodes. However, the role of
PMRT in those with N1 (1 to 3 positive lymph nodes) stage disease is controversial. This study aims to investigate if
PMRT reduces locoregional recurrence and improves survival in N1 disease.
Materials & Methods: A retrospective review was performed 325 patients diagnosed with N1 breast cancer between
2004 and 2011. All had undergone mastectomy and axillary clearance. Outcome was measured in terms of
locoregional recurrence, disease free survival and overall survival.
Results: Of the 325 patients, 206 (63.4%) had received PMRT and 119 (36.6%) had not. After a median follow-up of
57.6 months (Range: 1.1 to 120.9 months), there were 45 deaths and 41 locoregional recurrences in both groups.
Outcome in terms of locoregional recurrence (P = 0.30) and overall survival (P = 0.62) was not statistically significant
different among those who received PMRT and those who did not.
However, subgroup analysis revealed that in patients who were at higher risk (lymphovascular invasion, and higher
grade of tumour), there was a trend to reduction in locoregional recurrence in those who had undergone PMRT as
compared to those who did not (P=0.05). There was no statistical difference in outcome in relation to the number of
lymph nodes involved (1 to 3).
Conclusion: Overall, PMRT was not associated with a significant improvement in outcome. However, PMRT
appeared to confer a benefit among those with high risk factors, such as lymphovascular invasion and grade of
tumour
References:
1. Mukesh MB, Duke S, Parashar D, Wishart G, Coles CE, Wilson C. The Cambridge postmastectomy radiotherapy (C-PMRT) index: a practical tool for patient selection. Radiother Oncol. 2014
Mar;110(3):461-6
2. Ragaz J, Olivotto IA, Spinelli JJ, Phillips N, Jackson SM, Wilson KS, et al. Locoregional radiation therapy in
patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia
randomized trial. J Natl Cancer Inst 2005; 97: 116-26.
3. Recht A, Edge SB, Solin LJ, Robinson DS, Estabrook A, Fine RE, et al. Postmastectomy radiotherapy: clinical
practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001; 19: 1539-69.
4. Nagao T, Kinoshita T, Tamura N, Hojo T, Morota M, Kagami Y. Locoregional recurrence risk factors in breast
cancer patients with positive axillary lymph nodes and the impact of postmastectomy radiotherapy. Int J Clin Oncol
2013; 18: 54-61
5. Yang PS, Chen CM, Liu MC, Jian JM, Horng CF, Liu MJ, et al. Radiotherapy can decrease locoregional
recurrence and increase survival in mastectomy patients with T1 to T2 breast cancer and one to three positive nodes
with negative estrogen receptor and positive lymphovascular invasion status. Int J Radiat Oncol Biol Phys 2010; 77:
516-22.
Disclosure of Interest: None declared
204
114.12
ROLE OF PET– CT SCAN IN THE STAGING OF LOCALLY ADVANCED / RECURRENT BREAST CANCER
AS A SINGLE MODALITY IN COMPARISON TO MULTIPLE ORGAN DIRECTED CONVENTIONAL
INVESTIGATIONS
P. K. Garg1,2,*, S. V. S. Deo1, R. Kumar3, S. Thulkar4, N. K. Shukla1, A. Gogia5, D. Sharma6, S. R. Mathur7
1
Surgical Oncology, Dr BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi,
2
Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, 3Nuclear
Medicine, All India Institute of Medical Sciences, 4Radiodiagnosis, 5Medical Oncology, 6Radiotherapy, Dr BRA Institute
7
Rotary Cancer Hospital, All India Institute of Medical Sciences, Pathology, All India Institute of Medical Sciences,
New Delhi, India
Introduction: Multiple organ based imaging has been the conventional way of assessing the distant metastasis in
locally advanced (Stage –III) breast cancer. Desire to have single accurate investigation, which can image multiple
organs simultaneously and precisely, cannot be overstressed because of the patient’s convenience. This study is
designed to evaluate the role of single 18 FDG Positron Emission Tomography and Computed Tomography (PET-CT)
scan in comparison to multiple organ directed conventional investigations as a staging tool in locally advanced breast
cancer to detect regional and distant metastasis.
Materials & Methods: A comparative prospective study which included fifty patients of locally advanced (Stage –III)
breast cancer was conducted in a breast cancer clinic of a tertiary care oncology centre in North India. All eligible
patients were subjected to conventional imaging investigations (mammography, chest roentgenography to assess
lung metastasis, abdominal sonography to assess liver metastasis, and bone scintigraphy to look for skeletal
metastasis) followed by a single FDG PET- CT scan. All FDG PET CT detected metastatic lesions were considered
positive if they were multiple with typical appearance of metastasis (multiple lung nodules or lytic lesions in the
skeleton) else they were confirmed by histopathology (MRI in case of equivocal skeletal lesions) or by clinical/ imaging
follow up.
Results: FDG PET-CT detected distant metastasis in 26 (52%) patients while conventional imaging could identify
distant metastasis in 14 (28%) patients only. FDG PET-CT detected N3 disease in 21 (42%) patients - supraclavicular
lymphadenopathy in 14 patients and internal mammary nodes in 19 patients; this regional lymphadenopathy is not
detected by conventional imaging. Overall, FDG PET-CT upstaged the disease in 27 (54%) patients (to stage IV in 12
patients and within stage III in 15 patients) as compared to conventional imaging which upstaged the disease in 14
(28%) patients only. Overall concordance between conventional imaging and FDG PET-CT was 80% (100% for
contralateral breast, 90% for lung metastasis, 86% for skeletal metastasis, and 84% for liver metastasis). Overall,
FDG PET-CT changed the management plan in 13 (26%) patients.
Conclusion: The present study shows the superiority of FDG PET-CT scan over multiple organ directed conventional
investigations in staging of locally advanced breast cancer patients and its potential to change the management plan.
Disclosure of Interest: None declared
205
114.13
CD24 AND CD44 EXPRESSION IN INDIAN BREAST CANCER PATIENTS AND THEIR EFFECT ON RESPONSE
TO CHEMOTHERAPY
K. R. Singh1,*, A. A. Sonkar2, J. L. Miller2, A. A. Agarwal2, N. Husain3, J. K. Kushwaha2
1
2
3
Surgrey, Surgery, King George's Medical University, Pathology, RML Institute of Medical Sciences, Lucknow, India
Introduction: Cancer Stem cells (CSC) are thought to have the characteristics of unlimited proliferation and
differentiation and therefore an aberration in the CSC’s could be responsible for tumor formation and progression, and
metastasis. CD44, CD24, CD133, CD166, EpCAM has proven its role as a cancer stem cell surface markers in breast
cancer.
CD44+/CD24- phenotype has been associated with stem cell-like characteristics with enhanced invasive properties,
radiation resistance and with distinct genetic profiles suggesting a correlation to adverse prognosis in western
literature. The aim of this study was to study CD443+/CD24- phenotype as a adverse prognostic marker in Indian
breast cancer patients.
Materials & Methods: 61 breast cancer patients presenting to Department of Surgery KGMU between August 2013
to July 2014 and consenting to participate in the study were included. Tru-cut biopsy specimen was subjected to
histopathological examination and receptor studies (ER, PR, Her2 NeU, CD44 & CD24). Response was determined
using WHO clinical criteria.Immunohistochemical stained sections were scored using Allred's scoring method. The
CD44+/CD24- phenotype was analysed vis a vis hormonal receptor status, molecular sub types and response to
standard Antracycline and Taxane based neo adjuvant chemotherapy.
Results: Mean age at presentation was 47.78+/- 10.04 years (Range: 25-75). Majority of patients, 70.6% presented in
Stage III and 39% belonged to the Her2 neu enriched subtype. Of the 39 patients with ER-ve status, 33 (84.6%) were
found to have CD44+/CD24- phenotype and 82.5% of all the CD 44+/CD24- patients were ER negative (p=0.001). 34
(75.5%) of the PR-ve patients showed the CD44+/CD24- phenotype and of all the CD 44+/CD24- patients, 85% of
were PR Negative (p=0.006). 36 (75%) of Her-2-Neu +ve were CD44+/CD24-. 92% of the Her 2 Neu patients
expressed CD44+/CD24- and 76.9% of all the triple negative patients were found to be CD44+/CD24- expression
(p=0.001).
57 patients completed NACT; 42/57 (73.68%)had a partial response, 9 (15.7%) had no change and 6 (10.52%) had
progressive disease. No statistically significant association was noted between CD44+/CD24- phenotype and
response to chemotherapy.
Conclusion: CD44+/CD24- had a significant association with adverse prognostic factors like stage of disease,
hormonal receptor status and molecular sub types. However there was no significant association with CD443+/CD24phenotype with response to standard neo adjuvant Anthracycline and Taxane based chemotherapy.
Disclosure of Interest: None declared
206
114.14
ASSESSMENT OF SURGICAL MARGINS BY SPECIMEN ULTRASOUND IN BREAST
CONSERVATION SURGERY
N. Kaur1,*, S. somasekar1, A. Tandon2, U. R. Singh3
1
Deaprtment of Surgery, 2Department of radiology, 3Department of Pathology, UCMS & GTB Hospital, Delhi, India
Introduction: The primary aim of breast conservation surgery ( BCS) is to achieve tumour-free resection margins,
since the involvement of the margins has been identified as an important risk factor for local recurrence. Various
methods used for margin assessment such as frozen section, cavity shave margins , imprint cytology etc. have some
technical or practical limitations. We planned this study to evaluate the role of specimen ultrasound (USG) as a tool
for assessment of surgical margins in BCS
Materials & Methods: Twenty four patients undergoing BCS for early breast cancer were enrolled in the study and
after excision of the tumor, a specimen ultrasound was carried out to assess the status of the margins. The length of
the surgical margins was also measured. The results were compared with histopathological assessment ( HPE) of the
margins to evaluate the accuracy of specimen ultrasound in predicting status of surgical margins.
Results: Most of the patients had T1 and T2 cancers with average tumor size of 3.2 cm. In 24 patients 144 surgical
margins ( six margins each) were assessed. Three of 24 patients had one or more positive margins on USG and 2
patients on HPE. Out of 144 margins assessed, 11 were positive and 133 were negative on USG. Of the 11 positive
margins, 7 were true positive and of the negative 133 margins, 130 were true negative. Two deep and 2 radial
margins were false positive and 3 radial margins were false negative. The predictive validity of USG for specimen
assessment was 95.8%. In terms of margin assessment, USG had sensitivity of 70%, specificity of 97%, positive
predictive value of 64% and negative predictive value of 98%. Three margins which were false negative on USG
showed extensive DCIS component. Length of margins assessed on USG had good correlation with that assessed on
HPE and USG usually tended to have lower value than HPE ( mean length of radial margins on USG 1.12 cm vs 1.19
on HPE). Deep margin were twice as often positive on USG as on HPE ( 4 on USG and 2 on HPE) and average
length was 0.45 cm on USG and 0.8 cm on HPE
Table : Assessment of surgical margins on Specimen ultrasound
Tumor margins
+ HPE
- HPE
USG
+
7
(TP)
4
(FP)
11
USG
3 (FN)
130
(TN)
13 3
Total
10
13 4
144
Conclusion: Specimen USG can be used as a quick and economical tool for assessment of surgical margins in
patients undergoing BCS for clinically palpable tumors. It may give false positive margins for tumors close to chest
wall, due to compression effect. It may not be a reliable tool for tumors with DCIS
Disclosure of Interest: None declared
207
114.15
OPTIMISING BREAST CONSERVATION TREATMENT FOR MULTIFOCAL AND MULTICENTRIC BREAST
CANCER: A WORTHWHILE ENDEAVOUR?
M. P. Tan1,*, N. Y. Sitoh2, Y. Y. Sitoh2
1
2
Breast Surgery, MammoCare The Breast Clinic & Surgery, Singapore, Yong Loo Lin School of Medicine, National
University of Singapore, Singapore, Singapore
Introduction: Breast conservation treatment(BCT) is an accepted treatment modality for early breast cancer.(1)
However, multifocal and multicentric breast cancer(MFMCBC) is considered a relative contraindication to BCT.(2) Still,
BCT rates for MFMCBC averaging 44.0%(30.0-58.5%) with a median follow up of 36 months has been
reported.(3) This study was performed to evaluate BCT rates in MFMCBC, and to compare it with unifocal disease.
Materials & Methods: A retrospective analysis was performed for patients with breast malignancies who underwent
operative treatment between 2009 and 2011. Successful BCT was defined as the ability to obtain clear margins for all
tumour foci through a single incision with acceptable resultant cosmesis.(4)
Results: A total of 160 patients were analysed, of which 41 were MFMCBC. 35 of 41 patients with MFMCBC
underwent BCT(85.4%). After a mean follow up period of 54.4 months, there were no local recurrences in patients
with MFMCBC. Five-year overall survival was 97.1%. Patients with BCT for MFMCBC self-rated cosmesis as
‘satisfactory’ in 44.1%, ‘good’ or ‘excellent’ in 55.9%. None felt their aesthetic outcome was ‘fair’ or ‘poor’.
Table 1. Summary of clinicopathologic data for study population.
Clinicopathologic
All patients (n=160) Unifocal (n=119)
MFMCBC (n=41)
p value
Characteristic
(%)
(%)
(%)
Age in years
Median (Range)
48 (28-78)
0.04
Mean (SD)
48.8 (9.8)
49.7 (9.8)
46.13 (9.6)
Mean (SD)
Mode of Presentation
0.92
Symptomatic tumours
116
(72)
86
30
Screen detected lesions
44
(28)
33
11
Stage at diagnosis
0
I
II
III
IV
Histological Type
DCIS
Invasive Ductal
Invasive Lobular
Other invasive
Neoadjuvant medical therapy
Yes
No
Surgical Procedure
BCT
Mastectomy by need
Mastectomy by choice
Recurrence
Local Recurrence
Distant Disease/Death
Median Follow-up (months)
(range)
20
67
54
18
1
(12.4)
(41.6)
(34.2)
(11.2)
(0.6)
15
54
36
13
1
5
13
18
5
0
20
124
7
9
(12.4)
(77.6)
(4.4)
(5.6)
15
93
3
8
5
31
4
1
23
137
(14.3)
(85.7)
12
107
30
11
137
15
8
(85.7)
(9.3)
(5.0)
102
11
6
3
4
54
(27-72)
(1.9)
(2.5)
3
2
(85.7%)
(9.3%)
(5.0%)
35
4
2
0.48
0.53
0.008
(85.4%)
(9.7%)
(4.9%)
0.99
0.42
2
SD: standard deviation, *dimension of largest lesion
Conclusion: BCT was achieved in 85.4% of patients with MFMCBC in this cohort without evidence of poorer local
control. Further investigation is needed to confirm this finding for its potential contribution to improved survival
outcomes in the light of recent data.(5)
References: 1. NIH Consensus Conference. (No authors listed) JAMA 1991;265:391-5.
2. Goldhirsch A, Winer EP, Coates AS et al. Personalizing the treatment of women with early breast cancer:
highlights of the St Gallen International Expert Consensus on the primary therapy of early breast cancer 2013. Ann
Oncol 2013;24:2206-2223.
208
3. Ataseven B, Lederer B, Blohmer J.U. et al. Impact of multifocal of muliticentric disease on surgery and
locoregional. Distant and overall survival of 6.134 breast cancer patients treated with neoadjuvant chemotherapy. Ann
Surg Oncol 2014. doi:10.1245/s10434-014-4122-7
4. NCCN: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp
5. Agarwal S, Pappas L, Neumayer L, et al. Effect of Breast Conservation Therapy vs Mastectomy on DiseaseSpecific Survival for Early-Stage Breast Cancer. JAMA Surg 2014doi:10.1001/jamasurg2013.3049.
Disclosure of Interest: None declared
209
114.16
IMMEDIATE SURGICAL OUTCOMES OF ONCOPLASTIC BREAST CONSERVATION SURGERY FOR BREAST
CANCER
M. L.-B. Leong1,*, J. Hsu1, E. Elder1, J. French1
1
Breast Cancer Institute, Westmead Hospital, Sydney, Sydney, Australia
Introduction: Oncoplastic surgery is a change in paradigm for breast cancer surgery. It combines oncological with
aesthetic surgery. It is based on three principles; optimal oncology surgery, immediate reconstruction, and symmetry.
Oncoplastic techniques in breast cancer surgery have been shown to increase the volume resected, and also an
association with improved aesthetic outcomes. The aim of this study was to examine the immediate outcomes of
oncoplastic techniques for breast conservation surgery, and determine an atlas of techniques used based on location
and size of primary tumour.
Materials & Methods: A retrospective cohort review was performed for patients undergoing breast conservation
cancer surgery between 01/01/2013 - 31/12/2013 by three oncoplastic breast surgeons. Demographics, risk factors,
pre-operative planning, operation details and post-operative outcomes were recorded. Differences between patients
undergoing traditional versus oncoplastic techniques were compared with univariate and multivariate analysis.
Results: and 71 were traditional cases. The traditional cohort (mean age 62.93±10.81) was older than the oncoplastic
cohort (mean age 56.51±10.62) and there was higher prevalence of cardiovascular disease (50.7% vs. 29.73%
p=0.004) and NSAID use (12.68% vs. 0.9% p=0.0007). The mean tumour size excised in the oncoplastic cohort was
27.18±14.12mm, and 17.6±10.95mm for traditional cohort (p=0.00001). There was no statistical difference in receptor
status, Ki 67 and excision margins. There was no difference in the incidence of complications, management of
complications, readmissions, re-excisions, completion mastectomy rates and delay to adjuvant therapy. Round block
mastopexy and dual plane mobilisation appears most versatile and used in all quadrants. Grisotti and lateral
mammoplasty are mostly used in the lateral quadrants. Wise pattern reduction, vertical and batwing mammoplasty are
used in midline cancers in both upper and lower poles, and crescent flap mammoplasty is preferred for extreme lower
pole cancers.
Conclusion: Oncoplastic breast surgical techniques for breast conservation surgery results in acceptable immediate
outcomes. Oncoplastic techniques may allow breast conservation for larger tumours without any increased incidence
of complications, re-excision or mastectomy rates. The most versatile technique appears to be the round block
mastopexy technique.
Disclosure of Interest: None declared
210
114.17
DIFFICULTY IN DETECTION OF INVASIVE LOBULAR CARCINOMA, DOES IT STILL PERSIST?
W. Tangjatuporn1,*, P. Tanaanantarak2, S. Samphao1
1
2
Surgery, Radiology, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
Introduction: Invasive lobular carcinoma (ILC) is the second most common breast malignancy. Detection by imaging
is difficult due to diffuse infiltrative growth, low likelihood of producing calcification and no associated desmoplastic
reaction. However, advances in imaging techniques may improve the detection of ILC. We, therefore, retrospectively
reviewed the characteristics of ILC on mammography and/or ultrasound to see whether it could be detected easier.
We also identified the factors that may lead to further investigation, Magnetic Resonance Imaging (MRI), for accurate
diagnosis and proper management.
Materials & Methods: Records review identified 108 women diagnosed with ILC and those with mixed ILC and
invasive ductal carcinoma (IDC) from 1998-2012. Changing from film to digital mammography and imaging system in
our institute since 2005 causing some data lost. Only 29 breast ultrasounds and 10 mammograms could be reviewed.
Results: Median patient age was 49 (range 28-86). Most of the patients (94%) presented with palpable mass.
Mastectomy (82%) was a favor operative procedure. The tumor pathology included 62% of pure ILC and 38% of
mixed ILC and IDC. Seventy percent of the patients diagnosed with stage 2 and 3 diseases.
For mammographic findings (n=10), 50% had heterogeneous dense breast tissue; up to 40% had BIRADS 4 lesions;
30% had found no mass; 70% of those with masses had irregular shape and indistinct or spiculated margins; and only
50% found intermediate or suspicious malignant microcalcification.
For ultrasound findings (n=29), mass could be found in all patients; up to 40% had lobulated or oval shape masses;
62% found parallel orientation; 14% had circumscribed margin; 18% had shadowing posterior acoustic feature; and
only 2 patients had multifocal lesions.
The pathology showed multifocal disease in 15% (16/108) of patients. Of those with multifocal disease, 31% (5/16)
had received neoadjuvant chemotherapy. Among 11 patients with true multifocal disease, 3 had mammographic and 6
had ultrasound reviewed. None of mammographic and ultrasound findings showed mutifocal lesions. Patients younger
than 50 years (6/11) and those with mixed ILC and IDC (8/11) may benefit from further MRI in detection of multifocal
disease, effecting proper management.
Conclusion: Detection of ILC remains difficult in the era of advanced technologies. Combined imaging might help
increasing accuracy and early detection, resulting in further proper management.
References: Stivalet A. et al. Radiologica 2012
COMICE. Lancet 2010
Albayrak ZK, et al. Diagn Interv Radiol 2011
Disclosure of Interest: None declared
211
114.18
THE PREDICTIVE VALUE OF ULTRASOUND AXILLA IN OBVIATING SENTINEL LYMPH NODE BIOPSY
S. Jamaris1,*, S. Mee Hoong1, T. Gie Hooi1, N. Bhoo Pathy2, N. A. Taib1
1
2
Surgery, University Of Malaya, Kuala Lumpur, Petaling Jaya, Malaysia
Introduction: Axillary surgery is an important procedure for determinant of breast cancer staging. Axillary dissection
frequently associated with complications includes lymphoedema, seroma, sensory loss due to injury to intercostal
brachial nerve and motion impairment. However, Sentinel Lymph Node Biopsy less complications rate as compared to
axillary dissection. Generally, Ultrasound Axilla is a tool to predict the axillary lymph node involvement. Positive
ultrasound finding may proceed to sonography guided biopsy of the lymph node as this increase the sensitivity and
specificity of lymph node positivity. The objective of this study mainly to identify the sensitivity of Ultrasound Axilla in
patient underwent Axillary Dissection in predicting axillary lymph node involvement in our centre.
Materials & Methods: 992 patients diagnosed with breast cancer from January 2011 – December 2013 registered
into UMMC Breast Cancer Database. Of 992 only 374 patients who had underwent axillary dissection with Ultrasound
Axilla done in Univeristy of Malaya Medical Centre.
Results: Out of 992 cases diagnosed to have breast cancer in UMMC, 608 patients underwent axillary dissection.
Among them only 374 patients underwent Ultrasound Axilla. However 140 patients reported as having lymph node
involvement from Ultrasound Axilla, whereas 230 were negative results. 4 patients's result were missing. Table below
showing the histopathological examintation (HPE) results post axillary dissection.
Ultrasound Finding:
Lymph nodes Involved (HPE)
Axillary Lymph node
Positive
Negative
involvement
Positive
99
39
Negative
85
144
Sensitivity: 53.8% Specificity: 78.69%
Conclusion: In conclusion, our review shows that axillary sonography cannot be used in isolation as a method for
deciding whether to perform axillary lymph node dissection. Therefore, sonographic guided biopsy is suggest to be
performed in our centre when suspected positive axillary lymph node sonographically.
Disclosure of Interest: None declared
212
117.01
DIAGNOSTICS AND TREATMENT OF THE TUMOURS OF MEDIASTINUM
B. T. Madiyorov1,*, A. E. Rasulov1, B. Usmanov 1
1
thoracic surgery, National cancer research center, Ministry of health the Republic of Uzbekistan, Tashkent,
Uzbekistan
Introduction: to improve the results of diagnostics and treatment of the tumours of mediastinum with the use of
miniinvasive methods of treatment.
Materials & Methods: During the period from 2000 till 2013, in the hospital of ROSC 480 patients with the tumours of
mediastinum were treated, men - 280, women - 200. Patients were distributed due to age: till 19 years - 99, 19-44
years - 253, 45-59 years - 91, 60-75 years - 35, elder than 75 years - 2. For histological verification under the control
of ultrasound examination and CT in 328 patients the transthoracic section biopsy was done. In the cases of benign
tumours the removal of the tumour was done. In the cases of the localization of the great mass of the tumour behind
the breast bone when possibility of performance of removal of the tumour in 195 patients was not excluded were
performed miniinvasive interventions. From them: diagnostic thoracoscopy with the biopsy in 70 (35.8 %) cases, the
removal of the tumour by thorascopic way in 15 (7.6 %), VATS removal in 20 (10.2 %) patients. At the big sizes of a
tumour, intimate locating to vessels, tumour was removed by thoracotomic way in 62 (31.8 %) patients, by breast
bone access in 15 (7.6 %), by Koher's cut in the combination with the partial sternotomy in 11 (5.6 %), in two patients
(1.02 %) was made cytoreductive removal of the tumour.
Results: the use of miniinvasive methods in diagnostics and treatment of the tumours of mediastinum, in comparison
with open interventions, allowed to lower in 2 times time of the operation, from 160-180 to 80-90±20.5 minute, to
reduce the hemorrhage to 250-300±35.7 ml, after the removal of the tumour the relapse and lethal outcomes were not
noted. Results of morphological researches: the malignant thymoma was diagnosed in 169 (35.2 %) cases, noninvasive thymoma in 17 (3.5 %), thymoma with the clinical features of myasthenia in 12, benign tumours in 59 (12.3
%), lymphoma in 75 (15.6 %), various histological forms of sarcomas in 88 (18.3 %), neuroblastomas in 50 (10.4 %),
tuberculosis in 17 (3.5 %); sarcoidosis in 5 (1.04 %).
Conclusion: the use of miniinvasive methods in diagnostics and treatment of tumours of mediastinum, as for
differential diagnostics as for making the definitive diagnosis, allows to avoid diagnostic thoracotomies and to perfom
radical operations.
Disclosure of Interest: None declared
213
117.02
SLIDE TRACHEOPLASTY UNDER EXTRACORPOREAL MEMBRANE OXYGENATION IN CHILDREN
A. Razumovskiy1, V. Rachkov1, K. Bataev1, N. Stepanenko1,*
1
Thoracic Surgery Department, Filatov Children Hospital, Moscow, Russian Federation
Introduction: Until recently the prognosis for children with long-segment tracheal stenosis was extremely
unsatisfactory. Today this problem has been succesfully managed and proposed as preferable by method of slide
tracheoplasty.
Materials & Methods: From 2011 to 2014 in Filatov Pediatric Clinical Hospital №13 a total of 6 children (aged from 11
months to 7 years, weight ranged from 8 to 38 kg) underwent surgery with cardiopulmonary bypass for long-segment
congenital tracheal stenosis. The procedure was performed in different modifications: 4 patients underwent
sternotomy, 1 child underwent upper sternotomy through cervical approach, 1 child through the right thoracotomy.
Concomitant heart disease was present in 3 patients and a heart-lung machine was used during repair surgery, 3
children underwent the procedure under extracorporeal membrane oxygenation (ECMO) support.
Results: Mean operating time was 186 minutes. The average length of stay was 24 days. There was no intraoperative
complications. In early postoperative period there was deformation in the area of the anastomosis in 2 children which
required laser coagulation.
Conclusion: Management of congenital long-segment tracheal stenosis in childern by means of slide tracheoplasty
under ECMO despite the technical difficulty can be used as the treatment of choice, providing with increase in the
diameter of the trachea twice throughout by means of different approaches, eliminating the symptoms of respiratory
failure.
Disclosure of Interest: None declared
214
117.03
THE ROLE OF VIDEO THORACOSCOPIC OPERATIONS IN THE TREATMENT OF DRUG-RESISTANT FORMS
OF DESTRUCTIVE PULMONARY TB.
A. B. Sharipov1,*, M. Tillyashaykhov 1, O. Nematov1
1
Thoracic surgery, TB center of Uzbekistan, Tashkent, Uzbekistan
Introduction: Video-assisted thoracoscopic (VATS) anatomic pulmonary resection became widespread in the world.
The vast majority of operations in specialized centers with small peripheric lung lesions are performed only
thoracoscopic (VTS). The role of surgery in the treatment of DR forms of TB of the lungs has not been studied
enough.
Materials & Methods: In the Department of Thoracic surgery of TB center of UZB in 2013-2014 64 patients
underwent VATS and 11 patients with VTS anatomic pulmonary resection for destructive form TB. The age of patients
ranged from 18 to 67 years, mean age was 34+5. Male 52, female 23, male-female ratio was 2.3:1. In 47 cases the
operation is performed on the Fibrotic cavernous tuberculosis, tuberculoma in 14, in 6 cases was found cavernous TB,
3 cases occurred cirrhotic tuberculosis, 5 cases of infiltrative pulmonary TB. XDR process observed in 9 patients, 63
patients with MDR and PDR in 3 patients (DST determined by methods GeneXpert; HAIN test; BACTEC 360). 27
cases performed segmentectomy, 7 cases combined resection (lobectomy+segmentectomy), 23 lobectomy,
pneumonectomy 18. All operations were performed transthoracic access and adequate support considering drug DST.
Results: In all patients, the postoperative period was smooth. All patients were activated for 1 day after surgery and
noted subjective well-being. Narcotic analgesics, only the first day after surgery, the next 3-4 days, patients received
non-narcotic analgesics. Postoperative complications found in 6 patients, 2 patients without RC without BF detected in
2, postoperative bleeding in 1 wound healed by secondary intention, in 1 patients developed pneumonia after surgery.
After the operative mortality is not. Drains removed an average of 4 days after segmentectomy and lobectomy, and
after 27 days after pneumonectomy, which was carried out every day hemithorax sanation with solutions of antibiotics.
The mean duration of hospital stay was 19 days. In a short period of observation, all patients are alive, relapse and
reactivation registered.
Conclusion: DR TB to the main drugs is not a contraindication for VATS and VTS operation. To perform such
operation in DR MBT is a safe and reliable method in which accelerated psychological and medical rehabilitation of
patients, reducing the time interrupting patient hospital.
Disclosure of Interest: None declared
215
117.04
SURGICAL TREATMENT OF POSTOPERATIVE BRONCHOPLEURAL COMPLICATIONS IN PATIENTS WITH
PULMONARY TUBERCULOSIS.
A. B. Sharipov1, M. Tillyashaykhov 1, O. Nematov1,*
1
Thoracic surgery, TB center of Uzbekistan, Tashkent, Uzbekistan
Introduction: After resection of lung bronchial fistula occurs in 4-25% of cases. Residual pleural cavity (RPC) is
observed from 2-10%. After pneumonectomy incidence of bronchial fistulas(BF) can reach up to 19.2%. Mortality after
the failure of the main bronchus of the stump reaches 50-70%. Empyema with BF after PE occur in 2-17% without
fistula-in 3-13% of cases.
Materials & Methods: In2013-2014 operated 18 patients over the postoperative bronchopleural complications. Male
13, 5 female 5. XDR in 4, MDR in 10, PDR in 1, & sensitivity forms-3. Before admission in 2 patients-4 times
performed various operations on the management of complications in 4 patients–3 times, 3 patients–2 times & 9
patients-one time. In 8 of patients developed complications after PE, the remaining 10 after lung resection. RPC+BF+
thoracostomy (TS) in 6, RC+BF in 6 patients, RC 6 patients. With empyema in 11, without in 7.
Results: 4 patients underwent surgery stage oparestion single-stage surgery to deal with complications. When macro
fistula (fistula d>0,4cm) after PE or multiple fistulas with irreversible changes in the parenchyma of the remaining lung
is performed trans sternal occlusion of the main bronchus in 4 patients, which after 1.5-2.5 months was performed in 2
PE, & 2 distal stump removal of the main bronchus. Efficiency was 100%. Thoracomyoplasty was carried out with
micro fistula (fistula d<0,4cm) after PE in 5, with the main bronchus of the stump reamputation in 2. Efficiency was
80%, postoperative complications-2. VTS (Video thoracoscopy) thoracoplasty in 7, with RC in 6, RC+BF in 1.
Efficiency of 100%. 1 patient operation is performed transthoracic reamputation main the stump of bronchus,
eliminating thoracostomy in 1, lower lobectomy with resection of the left S4-5 segments, eliminating TS with plastic
local tissues. 100% efficiency. The overall efficiency was 94,4%, postoperative complications are 11%, postoperative
mortality-0%.
Conclusion: The efficacy of surgical treatment depends on many factors, such as: drug resistant, the type of surgical
intervention, the severity of complications, common status of the patient. Active surgical tactics is justified and should
be selected individually. Effectiveness of the developed our operations such as trans sternum occlusion main
bronchus & plastic with thymus and VTS thoracoplasty, high and wide practical application is recommended not only
in surgery of lung TB, as well as in other branches of thoracic surgery
Disclosure of Interest: None declared
216
117.05
COMPARISON OF MINIATUREZED EXTRACORPOREAL CIRCULATION (MECC) VERSUS CONVENTIONAL
EXTRACORPOREAL CIRCULATION (CECC) IN THE PREVENTION OF ATRIAL FIBRILLATION (AF) AFTER
CARDIAC SURGERY.
J. Halonen1,*, S. Ellam2, O. Pitkänen3, P. Korvenoja3, A. Valtola4, J. Hartikainen5
1
Heart Center Kuopio University Hospital, 2Kuopio University Hospital and University of Eastern Finland, 3Kuopio
University Hospital, Department of anesthesiology, 4Kuopio University Hospital, 5Kuopio University Hospital and
University of Eastern Finland, Heart Center Kuopio University Hospital, 70211 Kuopio, Finland
Introduction: Postoperative Atrial Fibrillation (AF) is the most common arrhythmia to occur after cardiac surgery with
an incidence between 20-45%. It is associated with increased morbidity, including increased risk of stroke and need of
additional treatment.The pathophysiology of AF is not fully understood. Cardiac surgery with extracorporeal circulation
is known to be associated with a systemic inflammatory response,which may be in part responsible for postoperative
AF. We hypothesized that miniaturized extracorporeal circulation (MECC) may have a lower systemic inflammatory
response (SIRS) than a conventional extracorporeal circulation (CECC).
Materials & Methods: In this prospective,randomzed,open labelled clinical study, 240 cardiac surgery patients were
randomized either Miniaturized extracorporeal circulation (MECC) group or Conventional extracorporeal circulation
(CECC) group before the surgery.The main outcome measure was the incidence of postoperative atrial fibrillation
during the hospital stay after Cardiac surgery.AF episodes lasting at least 30 minutes were recognized.
Results: The incidence of postoperative atrial fibrillation was (43/120, 35.8%) in the Conventional extracorporeal
circulation group (CECC) compared with (42/120, 35.0%) in yhe Miniaturized extracorporeal group, (p=0.893).
Conclusion: There was no difference between the groups related to postoperative atrial fibrillation after cardiac
surgery.
Disclosure of Interest: None declared
217
117.06
DEVELOPING A CELLULITIS SEVERITY SCORING SYSTEM – A NOVEL TOOL TO DETERMINE NECESSITY
FOR SURGICAL INTERVENTION
N. Subramaniam1,*, B. Hiremath1
1
General Surgery, MS Ramaiah Medical College, Bangalore, India
Introduction: Cellulitis is a very common problem encountered all over the world, representing a major cause of
morbidity and occasionally even mortality. However standard plan of care and treatment guidelines are far from
uniform and are a cause of confusion as these patients may be seen by a variety of doctors –general practitioners,
physicians, surgeons, paediatricians or dermatologists. Determining surgical intervention is also a common difficulty.
Our study was done to determine, the most likely clinical and pathological indicators suggesting requirement of
surgical intervention, and hence severity. Although not absolute, it may help decide when to attempt surgical
decompression as opposed to allowing conservative non-operative management.
Materials & Methods: The study was a cross-sectional prospective observational study including 148 patients
diagnosed to have cellulitis, presenting to M.S. Ramaiah Hospitals between Jan. 2013 and Jan. 2014. Thess patients
are from diverse ethnic and socio-economic backgrounds. Patients with necrotizing fasciitis were excluded. Patients
will be evaluated and various clinical and pathological parameters were collected. Based on these parameters and the
severity of cellulitis, those clinical and laboratory findings that had highest correlation with surgical intervention
were noted. The relative risk ratio for surgical intervention of each was taken as a component of the final scoring
system to determine probability of requiring surgical intervention and a risk stratification, first through a multivariate
and then univariate analysis.
Results: The following physical and biochemical parameters were found to have a statistically significant correlation
with surgical intervention – percentage of area involved (p<0.001), presence of skin necrosis (p<0.001), presence of
stretch pain (p<0.001), presence of chronic kidney disease (p<0.002), presence of diabetes mellitus (p<0.002),
presence of hyponatremia (p<0.006) and degree of elevation in total count (p<0.001). These were used to derive the
scoring system. Low risk was less than 5 points and high risk more than 10 points.
Image:
Conclusion: This scoring system may be helpful to determine requirement and timing of surgical intervention in
cellulitits, especially when to end a trial of conservative management. Additionally it may provide risk stratification for
prognostic value.
Disclosure of Interest: None declared
218
117.07
CORRELATIONS BETWEEN ROUTINE URINALYSIS AND CYSTOSCOPY IN THE DIAGNOSIS OF URINARY
BLADDER INVASION IN PATIENTS WITH CERVICAL CANCERS
W. Ratanalert1,*, J. Hanpresertpong2, S. Sangkhathat1, W. Karnjanawanichkul1, M. Tanthanuch1, C. Pripatnanont1 on
behalf of Tumor Biology Research Unit, Faculty of Medicine, Prince of Songkla University
1
Department of Surgery, 2Department of Obstetric and Gynecology, Faculty of Medicine, Prince of Songkla University,
Hat Yai, Thailand
Introduction: Cystoscopy is a study recommended in patients with cancer of cervix uteri (CC) in order to screen for
urinary bladder invasion (BI). However, yield of the study in early stages CC is very low, leading to a question if there
is any less invasive test that help selecting patients in higher priority to undergo a cystoscopy. This study aimed to
evaluate clinical correlations between the screening urinalysis and the cystoscopy for the diagnosis of BI in patients
with CC.
Materials & Methods: Medical records from the electronic database of CC patients who were treated in our Institute
from 2004 to 2013 were reviewed. In our institute, all newly diagnosed CCs were scheduled for a cystoscopy to
evaluate for BI. Those who had urinalysis sent within 100 days before or after cystoscopy were included. Data
including the patients’ age, stage at diagnosis, types of treatment received and urinalysis profiles were analyzed for
their correlation with cystoscopy results.
Results: A total of 875 cases were included in the analysis. Mean duration from diagnosis of CC to cystoscopy was
166 days. Cystoscopy was performed before treatment initiation in 238 cases (27.2%). The cystoscopy reported
negative study in 791 cases (90.4%). Among cases with positive findings, 23 cases (2.6%) had BI when the majority
of others had chronic cystitis. Tumor stages (III-IV) and timing of cystoscopy (those performed before treatment
initiation) were associated with higher BI positivity rate. When BI positivity was less than 1% in stage I/II, the incidence
increased to 4.3% in stage III and 32.1% in stage IV. UA parameters that were significantly associated with BI
included proteinuria, bilirubinuria, nitrisuria, microscopic hematuria, and positive urine leukocytes. On multiple logistic
regressions, proteinuria and nitrisuria were 2 parameters independently associated with BI at the OR 6.49 (95%CI
1.81-23.22) and 3.77 (95%CI 1.17-12.07), respectively. When the 2 independent parameters were considered
together with the pre-cystoscopy stage, the analysis showed that UA parameters increased the incidence of BI from
5% to 20-30% in stage III and from 30% to 60-100% in stage IV.
Conclusion: Routine practice of cystoscopy in CC should be re-considered. As the yield was very low, the study
might be avoided in the early stages. Priority should be given to those in stage III/IV, especially when protein and
nitrite were positive in a urinalysis.
Disclosure of Interest: None declared
219
117.08
OSTOID OSTEOMAS OF THE UPPER LIMB IN SCOTLAND
A. H. K. Riemen1,*, D. E. Boddie2
1
2
Orthopaedics, University of Aberdeen, Orthopaedics, Woodend Hospital, Aberdeen, United Kingdom
Introduction: Osteoid Osteomas are painful lesions most commonly presenting in the femur or tibia. Though benign, they are
reported to present with pain, most commonly in the second decade of life. We present data from the Scottish Sarcoma Database
after an interesting case of a 20-year-old student presenting with a two year history of index finger pain which we diagnosed with an
osteoid osteoma.
Materials & Methods: After Caldicott guardian approval, we investigated the Scottish Sarcoma Database, which to date holds
2446 benign bone and soft tissue tumours. We investigated the record held for each of the 38 cases of osteoid osteomas of the
upper limb to identify trends in history, initial management, formal treatment, complications and recurrence.
Results: There were only thirty-eight cases of osteoid osteomas of the upper extremity in Scotland in more than 60 years. In
Scotland 42% of cases presented in the children and teenagers. The majority present with pain. Only one third had a swelling or
deformity with pain. Half of the patients suffered for more than a year before they were seen by a specialist and diagnosed. On
examination, swelling or a deformity were appreciated in 60% of cases.
80% of patients had surgical treatment with excision and curettage. Only 2 patients had radiofrequency ablation. There have been
seven cases of recurrence. Of the six cases that presented in the last ten years four had a recurrence including all treated with
radiofrequency ablation.
Recurrence was always hallmarked by incomplete resolution of pain following the initial surgery suggesting incomplete removal of
the lesion.
Conclusion:
In summary, osteoid osteomas should be considered in a patient under 40 presenting with pain without any immediate other
differential diagnosis. Incomplete relief of pain was linked with early recurrence and incomplete excision
Disclosure of Interest: None declared
220
117.09
STUDY OF ANTIOXIDANT ENZYME LEVELS IN PATIENTS OF BREAST CANCER RECEIVING
CHEMOTHERAPY – A STUDY FROM INDIA
V. Jain1,*, S. misra1, S. misra1, S. tiwari1, S. tiwari1, S. K. yadav1, A. K. mishra1, A. K. mishra1
1
Surgery, King Georges Medical University, Lucknow, India, Lucknow, India
Introduction: Breast cancer is the most common cancer in Indian females. Age shift has been observed in past six
years. The average age of developing breast cancer has shifted from 50-70 years to 30-50 years. In India, for every
two women newly diagnosed with breast cancer, one lady is dying of it. Incidence of death is much less in US & china.
One of the reasons for this gap may be due to reduced antioxidant enzyme levels. Chemotherapy too generates
reactive oxygen species (ROS), which diminish the antioxidant capacity and performance status of the patients.
However a small number of studies are available from Indian subcontinent on this issue. Hence a prospective cohort
study was planned to find the effect on antioxidant enzyme levels in patient of breast cancer receiving chemotherapy
with aims – 1. To estimate antioxidant enzymes superoxide dismutase, catalase, glutathione peroxidise and
glutathione reductase in patients of carcinoma breast receiving chemotherapy. 2. To evaluate the effect of
chemotherapy on antioxidant enzyme levels.
Materials & Methods: Three Serial serum samples of 35 female patients of breast carcinoma receiving
chemotherapy (Age – 30 to 64 years) were taken after informed consent – first before start of chemotherapy, 2nd after
st
rd
rd
1 cycle and 3 after 3 cycle of chemotherapy. Estimation of antioxidant enzymes levels done. Simultaneously,
performance status was noted on Karnofsky scale and ECOG grade. statistical analysis of data done.
Results: As compared to pre chemotherapy levels, all the four antioxidant enzymes were significantly decreased after
first and third cycle (p<.001) of chemotherapy. Patients with low performance status had more decreased antioxidant
enzyme levels.
Conclusion: Lowered levels of antioxidant enzymes during chemotherapy and corresponding low performance status
in present study warrants the need of clinical trial for additive antioxidant therapy to combat the drug induced oxidative
stress and improve the overall well being of the patient. A similar study is soon to be activated at our institution.
Disclosure of Interest: None declared
221
117.10
INCORPORATING BREAST CANCER SCREENING IN THE SURGICAL CURRICULUM AT CEBU INSTITUTE OF
MEDICINE – A PILOT STUDY
R. Kotake1,*, S. Siguan1, S. T. A. Baking1
1
Surgery, Cebu Institute of Medicine - Cebu Velez General Hospital, Cebu City, Philippines
Introduction: Formalized instruction in breast cancer screening during medical school may help improve early breast
cancer detection and survival. The objective of the study is to describe the incorporation of breast cancer screening in
the medical curriculum of Cebu Institute of Medicine.
Materials & Methods: In 2011, a 3-hour module on proficiency in CBE was incorporated into the junior clerkship
program. The students are directed to watch a video featuring an instruction in performing CBE, and a lecture on
breast cancer is given by a professor in surgery. After a demonstration and return-demonstration, the students were
subjected to an examination for proficiency in clinical breast exam. If the student was able to meet satisfactory marks
in the examination, they were awarded a certificate of proficiency in clinical breast examination, and were entitled to
join the actual community outreach program at CIM-CMSS or at a community hospital in Argao, Cebu. The outreach
program (BCAcop) was composed of: a) breast cancer lay forum, b) breast self-examination (BSE) classes, and c)
breast clinic. The lay forum and BSE classes aim to educate the women of the risks for developing breast cancer, on
the early warning signs of breast cancer and how to properly examine their breast in order to detect breast
abnormalities and early manifestations of breast cancer. The on-site breast clinics included clinical breast
examinations as well as the diagnostic work-ups such as fine needle aspiration biopsy, core needle biopsy or open
biopsy required whenever cancer was suspected.
Results: From 2011 to 2014, a total of 92 CIM students participated in the course and outreach program. Twenty-nine
were first year medical students, 19 were second years, and 44 were third years. A total of 298 patients attended the
outreach program. Six patients (2.1%) were suspected to have breast cancer, out of which 4 (66.7%) proceeded to
biopsy. Two patients refused further work-up. Four patients (100%) were diagnosed with breast cancer. Two patients
were surgically treated. The other 2 patients refused treatment.
Conclusion: Incorporating breast cancer control in the medical curriculum is feasible and encourages medical
students to participate in outreaches for breast cancer screening to improve early breast cancer detection and
survival.
References: 1. Madan AK, Colbert PM, Beech B, Beech DJ. Effect of a short structured session on medical student
breast cancer screening knowledge. Breast Journal. 2003 Jul-Aug; 9(4): 295-297
2. Kann E, Lane D. Breast Cancer Screening Knowledge and Skills of Students upon Entering and Exiting a Medical
School. Academic Medicine. 1998; 73:904-906
3. Merilles P, Siguan S, Salutan A, Inot A. An Eight-Year Experience of Implementing a Pro-active Approach to Early
Detection of Breast Cancer in a Community. 2010. PJSS Vol. 65 No. 3 pp.96-104
4. Ramon Aboitiz Foundation, Inc. Cancer in Metro Cebu 1998 – 2002. Eduardo J. Aboitiz Cancer Center. 2014.
5. Geller AC, Prout MN, Miller DR, Siegel B, Sun T, Ockene J, Koh HK. Evaluation of a cancer prevention and
detection curriculum for medical students. Preventive Medicine. 2002 Jul; 35(1): 78-86.
6. Barrett SV, Zapka JG, Mazor KM, Luckmann RS. Assessing third-year medical students’ breast cancer screening
skills. Academic Medicine. 2002 Sep; 77(9): 905-910
Disclosure of Interest: None declared
222
134.01
HIGH INFILTRATION OF MAST CELLS PREDICTS WORSE OUTCOME FOLLOWING RESECTION OF
COLORECTAL LIVER METASTASES
S. Suzuki1,*, Y. Ichikawa2, A. Ishibe1, T. Kumamoto1, R. Matsuyama1, K. Takeda1, M. Ota3, I. Endo1
1
2
3
Gastroenterological Surgery, Oncology, Yokohama City University School of Medicine, Gastroenterological Surgery,
Yokohama City University Medical Center , Yokohama, Japan
Introduction: Tumor infiltrating mast cells (MCs) are considered a primary host immune response against cancer.
From some reports, their roles are not determined yet and vary with the type of cancer. There was no report about
tumor infiltrating MCs in colorectal liver metastases (CRLM). Aim of this study is to determine whether peritumoral
MCs infiltration of CRLM become a predictive factor of survival after curative resection of CRLM.
Materials & Methods: A total of 135 patients who underwent potentially curative resection for CRLM between 2001
and 2010 were included in our retrospective study. Expression of tryptase which are markers for MCs was determined
via immunohistochemistry of resected tumor specimens. The different types of immune cells in the 3 most abundant
peritumoral areas were counted, and the each cell number was utilized to predict a good prognosis. The cut-off point
of each immune cell number was calculated to select a group of good prognosis after liver resection by using the
Youden index from the ROC curve. Using these cut-off points, 135 patients were classified into 2 groups and statistic
difference of prognosis was calculated by Kaplan-Meier analysis and the log rank test, and statistic difference of clinicpathological feature was calculated by chi square test and cox proportional hazard regression. This study was
approved by the Yokohama City University Ethics Committee.
Results: Cancer-specific survival (CSS) at 1, 3, and 5 years were 91.0%, 62.4%, and 37.4%, respectively. The cut-off
points were fixed 26 of MCs. The cut-off point of MCs classified 2 groups which showed significantly different
prognosis. 54% (73 of 135) of patients were classified in the high MC group. Five-year disease free survival (DFS) of
the high MC group and the low MC group was 1.6% and 42.6%, respectively (P<0.001) and CSS of the 2 was 38.1%
and 55.6%, respectively (P<0.01). In the clinicopathological feature, only the peritumoral vessel density showed
significant difference, significantly higher in the high MC group. Multivariate analyses indicated that hypoalbuminemia
and high peritumoral MC infiltration were significant predictors of unfavorable CSS.
Conclusion: High peritumoral MC infiltration predicts poor prognosis in patients after resection of liver metastases of
colorectal cancer. High MC infiltration might be related with peritumoral neovascularization.
Disclosure of Interest: None declared
223
134.02
SURGEON´S COGNITIVE ASSESSMENT DURING SURGICAL PROCEDURES. INFLUENCE OF TIME AND
INTRAOPERATIVE COMPLICATIONS.
J. Beneduzzi1, F. Herbella1,*, R. R. Benassi1, P. Nascimento1, M. G. Patti2
1
2
Department of Surgery, Federal University of São Paulo, São Paulo, Brazil, Department of Surgery, University of
Chicago, Chicago, United States
Introduction: Surgeon´s performance may be influenced by several factors, such as sleep deprivation. The impact of
long duration procedures and intraoperative complications has not been fully studied. Cognition is the set of all mental
abilities and processes related to knowledge, especially attention, memory, problem solving and decision making. The
evaluation of cognition may be an adequate tool to measure surgeon´s performance. This report aims to evaluate
preliminary data from a prospective study designed to measure the effect of time and operative complications on
surgeon´s cognition.
Materials & Methods: 25 surgeons (mean age 30 years, 74% males, mean 2 years after board certification, all
surgical specialties) assigned to an operation expected to last for at least 2 hours volunteered for the study. All
participants underwent 3 cognitive tests. Concentration (Serial sevens, counting down from 100 by sevens), visual
(fast counting, counting the number of circles with the same color among a series of circles), and motor (trail making,
connecting a set of numbered dots). The time for each test was recorded. All tests were applied at the beginning of
the operation and hourly to the end of the procedure. Intraoperative complications (hemorrhage, organ lesions, severe
hemodynamic changes) were recorded.
Results: The mean time for the concentration test was 54, 41, 31, 28, 28, 24s for the 0, 1st, 2nd, 3rd, 4th, and 5th hour,
respectively, with a trend to be performed faster along time (r2=0.97). The mean time for the visual test was 17, 16, 10,
9, 10, and 14s for the 0, 1st, 2nd, 3rd, 4th, and 5th hour, respectively, with a trend to be performed faster until the 4th hour
and increase in time afterwards. The mean time for the motor test was 53, 48, 45, 50, 40, and 38s for the 1st, 2nd, 3rd,
4th, 5th and 6th hour, respectively with a trend to be performed faster along time (r2=0.7). Intraoperative complications
occurred in 4 (16%) cases (3 hemorrhage, 1 pleural lesion). The small numbers prevented mathematical analysis.
One surgeon performed badly after the complication during the concentration test, one during the visual test and two
during the motor test; in neither case the test subsequent to the complications was the individual worst result.
Conclusion: Our preliminary results showed that: (1) time does not jeopardize surgeon´s cognition, oppositely, they
learned to perform the tests faster, and (2) complications also does not jeopardize surgeon´s cognition.
Disclosure of Interest: None declared
224
134.03
SOLID ORGAN HYBRID SIMULATION TRAINING SYSTEM FOR HEPATO-INTERVENTIONAL SURGERY
J. LI1,*, W. LIU1, J. LU1, X. XU1, H. YANG1, F. MA1, Y. LV1
1
Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi’an Jiaotong University, XI'AN, China
Introduction: Currently, interventional therapies like transjugular intrahepatic portosystemic shunt (TIPS) and
transcatheter arterial chemoembolization (TACE) are effective procedures widely used to deal with portal
hypertension, carcinoma etc. which severely impair humanity health. However, interventional operations require
skilled and experienced physicians, but the practical experience for junior staffs is limited. The training systems
available have drawbacks, which are expensive, imperfect realism simulation. We describe a solid organ hybrid
simulation training system for hepato-interventional surgery．
Materials & Methods: The simulated training model consists of 6 parts: anthropomorphic dummy, main vessel
structures, animal liver, pump feedback system, radiology and visual system. The anthropomorphic dummy cover with
silica gel has the outlook and texture of human body. The related vessels for TIPS (jugular vein, vena cava, portal
vein), and TACE (femoral artery, abdominal aorta, celiac trunk, hepatic artery, superior mesenteric artery, splenic
artery) are settled as normal anatomical relations. Animal liver is acquired with integrity and proper processed with
perfusate. The vessels of animal liver can be connected with the designed vessel tubes and pump feedback system
provides the suitable circulation and real-time pressure display. Radiology and visual system provide operation
guidance.
Results: Based on this system, users can successfully revive the interventional procedures as a full-scale exercise to
improve the operating skills．Also, whether the operation is effective, the change of the portal vein pressure and
embolism images can be used as an assessment.
Conclusion: Solid organ hybrid simulation training system for hepato-interventional surgery is a feasible, effective,
and practical training and test system for inexperienced doctors to master hepato-interventional surgery.
Disclosure of Interest: None declared
225
134.04
ATTITUDES OF SURGEONS TOWARDS SURGICAL COMPLICATIONS
S. Y. W. Liu1,*, E. K. W. Ng1, H. T. Lok1, P. W. Y. Chiu1, P. B. S. Lai1
1
Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
Introduction: In surgical practice, most malpractice claims are directed against complications.
Surgeons can be seriously affected when they are involved in surgical complications. While most
surgical audits emphasize on outcome analysis, this study aims to evaluate the attitudes of
surgeons towards surgical complications and the impact of surgical complications on surgeons.
Materials & Methods: This was a cross-sectional anonymous questionnaire survey on surgeons from
all surgical subspecialties in 10 public surgical units in Hong Kong. Using a Likert scale, 42
questions were asked covering 4 domains on causative factors of complications (surgeon
attributes, operation nature, operative environment and operative timing) and 2 domains on impact
of complications on surgeons (surgeons’ responses and future reactions).
Results: A total of 135 surgeons (88 males) completed the survey (response rate 33.6%). These
include 80 (59.3%) surgical residents, 33 (24.4%) associate consultants and 22 (16.3%)
consultants. There were 38.5% of respondents aged ≥35 years, 67.4% being general surgeons,
and 38.5% working in academic hospitals. For surgeons’ attributes and operation nature, most
respondents disagreed that complications were due to surgeons’ weakness (63.7%), carelessness
(65.2%), inferior operative skills (62.2%) and poor decision making (59.3%). Instead, they
perceived inadequate experience (92.6%), poor preoperative preparation (88.9%), complex
disease condition (87.4%), complex operation (85.9%) and need of subspecialized skills (75.6%)
as causative factors for complications. Regarding operative environment, poor staff
communication (79.3%), suboptimal equipment (72.6%) and insufficient assistants (63.7%) were
perceived as attributing factors to complications. In terms of operative timing, many respondents
rated operation after midnight (80.7%), during non-office hours (74.1%) and at weekends (67.4%)
as leading causes of complications. In response to complication, 60.0% of respondents regarded
complications as their own faults. While 72.6% of respondents experienced psychological burden
from complications, only 40.0% developed negative physical responses. Up to 60.7% of
respondents reacted to complications by changing their usual ways of practising similar future
operations.
Conclusion: Surgeons did not perceive complications as their incompetence but rather as a
reflection of inadequate experience and suboptimal environment. Psychological burden was
common among surgeons after they were involved in complications.
Disclosure of Interest: None declared
226
134.05
THE TRAUMA ORIENTATION PROGRAM- A MULTIDISCIPLINARY INTER-PROFESSIONAL EDUCATIONAL
FRAMEWORK TO ENHANCE SYSTEMS-BASED PRACTICE AND TEAMWORK IN TRAUMA CARE
A. Vijayan1,*, T. J. Han2, M. O. Weijie3
1
2
General Surgery, Tan Tock Seng Hospital, Yong Loo LIn School of Medicine, National University of Singapore,
3
General Surgery Residency Program, National Healthcare Group, Singapore, Singapore
Introduction: Systems knowledge and multidisciplinary, inter-professional (MD-IP), and time-sensitive teamwork, in
addition to medical knowledge and skills is crucial to trauma management. Traditional trauma training does not
address these capabilities. Time taken in the emergency department (ED) by the MD-IP team to manage a trauma
patient from initial resuscitation to final disposition to either the Operating Room (OR) or wards (WD) is a function of
the effective teamwork and systems-based practice. Failure of such practice leads to treatment delay. To improve this
MD-IP teamwork, our institution introduced Trauma Orientation Program (TOP) in 2008. Conducted twice a year, the
TOP employs a mixed pedagogy approach including didactics, problem-based small group discussions and
simulations in a MD-IP learning environment, focusing on initial trauma management, systems-based skills and
teamwork concepts. The target participants are newly posted junior residents and nurses from the various clinical
departments who participate in trauma resuscitation and management.
Materials & Methods: This study’s objective was to examine the effectiveness of the TOP as an educational tool to
enhance systems-based practice and teamwork. Two measures were used. A qualitative measure of the participants’
pre-TOP and post-TOP knowledge of trauma systems and the patient’s length of stay, in minutes, in the ED (ED-LOS)
from resuscitation to final disposition to OR or WD, taken as a surrogate measure of systems-based practice and MDIP teamwork. ED-LOS was stratified by Injury Severity Score (ISS) groupings ( Grp 1: ISS 1-8, Grp 2: 9-15 Grp 3: 1624, Grp 4: 25-40, Grp 5: 41-49, Grp 6 >50) was compared for resuscitations before (2007) and after the introduction
of the TOP (2008 onwards).
Results: From 2008 to 2013, 24 TOP sessions were conducted with 376 doctors and nurses participants. For the
same period 941 trauma resuscitations were found suitable for the ED LOS analysis. The data was analysed using
SPSS Statistics 22. The participants’ improvement in knowledge in trauma systems (Fair to Good: 64 % to 85%) and
team dynamics (Fair to Good: 63% to 92%) was significant. Post TOP ED LOS especially in the ISS Groups 3 to 6
was reduced by an average of 20 minutes.
Conclusion: The TOP is an effective educational program in developing the competencies of systems-based practice
and team work in a multidisciplinary inter-professional work environment.
Disclosure of Interest: None declared
227
134.06
COMPARISON OF MODIFIED LIMBERG FLAP TRANSPOSITION AND LATERAL ADVANCEMENT FLAP
TRANSPOSITION WITH BUROW'S TRIANGLE IN THE TREATMENT OF PILONIDAL SINUS DISEASE
M. SAYDAM1,*, H. SINAN2, B. OZTURK1, P. DEMIR3, A. Z. BALTA4, M. T. OZER5, S. DEMIRBAS5
1
2
3
Surgery, Ankara Mevki Military Hospital, Ankara, Surgery, Van Military Hospital, Van, Medical Biostatistics, Yildirim
4
5
Beyazıt University, Ankara, Surgery, GATA Haydarpasa Military Hospital, Istanbul, Surgery, GATA Military Hospital,
Ankara, Turkey
Introduction: Although many options exist for surgical treatment of pilonidal sinus disease (PSD), consensus has not
yet been achieved, as all surgical methods have various rates of complications, postoperative infection, and
recurrence.This study compared two surgical treatments for PSD: modified Limberg flap transposition and lateral
advancement flap transposition with Burow's triangle.
Materials & Methods: Prospective, randomized, clinical trial. Consecutive 100 patients admitted to hospital for
treatment of PSD from May 2013 to August 2013. The patients received surgical treatment with either modified
Limberg flap (n=50) or lateral advancement flap with Burow’s triangle (n=50). We followed and enrolled the data of the
patients’ length of hospital stay; operative time; postoperative complications, wound dehiscence, surgical site
infection; Visual Analog Scale (VAS) for 12 months.
Results: The mean follow-up period was 12 months. No significant differences were observed between the two
groups in length of hospital stay (p=0.515), operative time (p=0.175), wound dehiscence (p=0.645), and VAS pain
scores (p=0.112). The mean operative times were 42.5 minutes in the modified Limberg group and 40.0 minutes in
the lateral advancement group.
Conclusion: Although, we could not determine a parameter that was statistically different such as operative time,
postoperative complication or the length of hospital stay, the lateral advancement flap is as viable an option as other
more preferable techniques in the treatment of PSD which particularly settled on the upper segment without a deep
natal cleft.
References: 1. Harlak A, Mentes O, Kilic S, Coskun K, Duman K, Yilmaz F. Sacrococcygeal pilonidal disease:
analysis of previously proposed risk factors. Clinics (Sao Paulo). 2010;65:125–131.
2. Arumugam PJ, Chandrasekaran TV, Morgan AR, Beynon J, Carr ND. The rhomboid flap for pilonidal disease.
Colorectal Dis. 2003;5:218–221.
3. Yilmaz S, Kirimlioglu V, Katz D. Role of simple V-Y advancement flap in the treatment of complicated pilonidal
sinus. Eur J Surg. 2000;166:269–272.
4. Unalp HR, Derici H, Kamer E, Nazli O, Onal MA. Lower recurrence rate for Limberg vs. V-Y flap for pilonidal sinus.
Dis Colon Rectum. 2007;50:1436–1444.
5. Menteş B, Leventoğlu S, Cihan A, Tatlicioglu E, Akin M, Oguz M. Modified Limberg transposition flap for
sacrococcygeal pilonidal sinus. Surg Today. 2004;34:419–423.
Disclosure of Interest: None declared
228
134.07
A RANDOMIZED MULTI-CENTRE STUDY COMPARING MESH FIXATION WITH CYANOACRYLATE GLUE VS.
SELF-GRIPPING MESH TO CONVENTIONAL LICHTENSTEIN HERNIOPLASTY (FINNMESH STUDY)
H. Paajanen1,*, K. Rönkä1, J. Vironen2, J. Kössi3, T. Hulmi4, I. Ilves5
1
2
3
Surgery, University Hospital of Kuopio, Kuopio, Surgery, Helsinki University Hospital, Helsinki, Surgery, Päijät4
5
Häme Central Hospital, Lahti, Surgery, North Karelia Central Hospital, Joensuu, Surgery, Mikkeli Central Hospital,
Mikkeli, Finland
Introduction: Mesh fixation may influence on chronic pain syndrome in Lichtenstein hernioplasty. Our study
compares 3 different methods of mesh fixation aiming to answer how to perform safe, less painful, cheap and simple
Lichtenstein hernioplasty in day-case surgery.
Materials & Methods: Altogether 605 adult patients with inguinal hernias were randomized into three fixation groups
using local anesthesia: lightweight mesh with tissue glue (n=202, Optilene™ + Histoacryl), self-adhesive mesh
(n=201, Parietex Progrip™) or non-absorbable suture fixation (n=202, Ultrapro™). Patient’s pain scores, operative
outcome, quality of life scores and costs of operation were recorded. The data was asked preoperatively, during
operation, 1, 7, 30 days, and 1 year after operation (Figure 1).
ClinicalTrials.gov Identifier: NCT01592942.
Results: There were no significant differences in pain response or operative parameters between the study groups.
Six wound hematomas, one infection, one recurrent hernia and four patients with chronic pain were recorded. Glue
fixation mesh and self-adhesive mesh were simple to introduce, but the former was cheaper.
Image:
Conclusion: This randomized study indicated that new fixation methods are safe, simple and cheap compared to
conventional method in Lichtenstein hernioplasty (1).
References: 1. Paajanen H, Kössi J, Silvasti S, Hulmi T, Hakala T. Randomized clinical trial
of tissue glue versus absorbable sutures for mesh fixation in local anaesthetic
Lichtenstein hernia repair. Br J Surg. 2011 Sep;98(9):1245-51.
Disclosure of Interest: None declared
229
135.01
A RANDOMIZED STUDY COMPARING PARATHYROIDECTOMY VERSUS CINACALCET TO TREAT
HYPERCALCEMIA IN KIDNEY ALLOGRAFT RECIPIENTS WITH PERSISTENT HYPERPARATHYROIDISM
P. Moreno1,*, J. M. Francos1, A. García-Barrasa1, E. Fernández Alsina1, R. Mast2, V. Torregrosa3, O. Bestard4, J. M.
Cruzado5
1
Endocrine Surgery Unit, 2Radiology, Hospital Universitari de Bellvitge, L'Hospitalet, 3Nephrology, Hospital Clínic,
Barcelona, 4Rheumatology, Hospital Universitari de Bellvitge, 5Nephrology, Hospital Universitari de Bellvite,
L'Hospitalet, Spain
Introduction: Cinacalcet corrects hypercalcemia and hypophosphatemia in patients with persistent
hyperparathyroidism (HPT) after kidney transplantation (KT). This study (NCT011178450) was designed to evaluate
whether subtotal parathyroidectomy (PTX, standard of care) was superior to cinacalcet (CIN) to control HPT after KT.
Materials & Methods: This is a 12-M, prospective, multicenter, randomized study. Kidney allograft recipients were
included if time after transplantation is > 6 m, eGFR > 30 ml/min, iPTH> 15 pmol/L, serum calcium (sCa) > 2.63
mmol/L, serum phosphate (sP) <1.2 mmol/L. The primary end point was achievement of normocalcemia. Secondary
end points were iPTH, sP, eGFR, bone mineral density and vascular calcification.
Results: A total of 30 patients were randomized (PTX, N=15; CIN, N=15). Baseline characteristics were similar
between groups, including serum calcidiol level (44±26 in CIN vs 41±15 in PTX) and eGFR (57±11 in CIN, 56±15 in
PTX). By ITT analysis both treatments were able to correct hypercalcemia although only PTX induced iPTH and sP
normalization.
Serum calcium, phosphate and iPTH
CIN, N=15 PTX, N=15 P
value
iPTH Baseline
2512
3738
0.22
iPTH 3m
187
910
0.02
iPTH 6m
209
76
0.001
iPTH 12 m
2211
65
0.001
sCa Baseline
2.720.1
2.780.2
0.3
sCa 3m
2.420.2
2.280.2
0.07
sCa 6m
2.420.2
2.260.2
0.04
sCa 12m
2.370.2
2.220.2
0.06
sP Baseline
0.920.2
0.930.2
0.9
sP 3m
1.10.1
1.30.2
0.01
sP 6m
1.00.2
1.30.2
0.001
sP 12m
1.10.1
1.30.3
0.01
Moreover, PTX was associated with better preservation of renal function (12-M ∆ eGFR was -9 ml/min in CIN vs -4
ml/min in PTX). Safety data was similar between groups.
Conclusion: Subtotal parathyroidectomy was superior to cinacalcet to control HPT after KT
Disclosure of Interest: None declared
230
135.02
REVISITING LOW-RISK PAPILLARY THYROID MICROCARCINOMAS RESECTED WITHOUT OBSERVATION:
DID THEY REQUIRE IMMEDIATE SURGERY?
Y. Ito1,*, A. Miyauchi1, H. Oda1, H. Masuoka1, M. Fukushima1, K. Kobayashi1, M. Kihara1, A. Miya1
1
Department of Surgery, KUMA HOSPITAL, Kobe, Japan
Introduction: Low-risk papillary thyroid microcarcinoma (PMC) without clinical evidence of node or distant metastasis
and invasion to adjacent organs such as vocal cord paralysis does not or only slowly grows. We proposed and
initiated an observation trial without immediate surgery for these patients in 1993. The revised ATA guidelines adopted
the observation policy without performing aspiration biopsy for suspicious tumors ≤ 1 cm unless high-risk features
described above are detected. However, we have recommended surgery for tumors touching the trachea (TR) or
locating in the course of the recurrent laryngeal nerve (RN), because these tumors may or will invade them. In this
study, we revisited low-risk PMC who underwent immediate surgery and investigated the relationship of tumors with
TR and RN.
Materials & Methods: We enrolled 1,143 low-risk PMC patients who underwent immediate surgery without
observation between 2006 and 2014. No patients had vocal cord paralysis by a preoperative fiberscope. Of these, 437
touched to TR on imaging studies and 270, 104, and 63 were graded as low, intermediate, and high-risk based on the
angle (sharp, unclear, and obtuse) between the surface of tumor and TR. Tumor was located in the course of RN in
144 patients and 35 and 109 were graded as low and high-risk based on the presence of normal thyroid capsule (clear
and obscure or lacking) in the direction of RN.
Results: The invasion to the TR cartilage was exclusively observed in high-risk patients (12 patients [20%]). Only
peritracheal connective tissue was resected in 21 (33%), 15 (14%), and 6 (2%) of high, intermediate and low-risk
patients, respectively. Significant invasion to the RN requiring complete resection with reconstruction or partial layer
resection was also exclusively observed in 9 (8%) of high-risk patients. The incidence of TR invasion in high- and
intermediate risk patients and that of RN invasion in high-risk patients was significantly higher (p=0.0000 and
p=0.0243) than in low-risk patients. Tumors < 7mm did not show significant TR or RN invasion in our series regardless
of their risk.
Conclusion: The angles formed by tumor and TR and the presence of normal thyroid capsule between tumor and the
course of RN are important to predict tumor invasion to these organs. Since PMC does not or very slowly grows, close
evaluation of tumor size and the positional relation of the tumor with the TR and RN on imaging studies could narrow
the indication of immediate surgical treatment of low-risk PMC patients.
Disclosure of Interest: None declared
231
135.03
LONG-TERM OUTCOME OF FOLLICULAR THYROID CARCINOMA (FTC) IN PATIENTS UNDERGOING
SURGICAL INTERVENTION FOR SKELETAL METASTASES (SM)
A. Mishra1,*, C. Kumar1, G. Chand1, G. Agarwal1, A. Agarwal1, A. K. Verma1, S. K. Mishra1
1
Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
Introduction: A significant proportion of Follicular Thyroid Carcinoma (FTC) patients in developing countries present
with overt skeletal metastases (SM). Surgical intervention is often required to prevent morbidity, palliate symptoms
and facilitate Radioiodine therapy (RAIT) in such patients. Scarce literature is available regarding long-term outcome
these patients. The aim of this study was to know the long-term outcome of FTC patients undergoing surgical
intervention for SM.
Materials & Methods: This retrospective study consists of FTC patients who had undergone any surgical intervention
for SM between January 1990 and December 2011. Clinico-pathologic profile and follow-up findings were noted.
Overall Survival (OS) was calculated with Kaplan-Meier curve.
Results: Out of 192 patients of FTC managed in the study period 95 patients (49.5%) had distant metastases and 31
of them had some form of surgical intervention for SM. The mean age of this cohort was 47.4 + 10 years and 32%
patients were < 45 years of age (M: F=1:2). Mean duration of disease was 62 months. Mean tumor size was 5.2 + 2.9
cm and 67% patients had tumors measuring > 4 cm. Local Invasion and cervical lymphadenopathy were noted in 19
and 13% patients respectively. 93.5% patients presented with synchronous and remaining with metachronous
metastases. All except two had multiple metastases. The surgeries performed for SM were- laminectomy in 51.6,
resection of skull metastases in 19.3, resection of Manubrium sterni in 16.2, partial clavicle excision in 9.7 and partial
mandiblectomy in 3.2% patients. The main indication of laminectomy was to prevent compressive myelopathy
whereas facilitation of RAI therapy was the main intent in remaining patients who had a single dominant overt skeletal
metastasis. All patients who were bed-ridden became ambulatory after laminectomy. There was no operative mortality
and morbidity. All patients had surgeries directed at primary thyroid tumor, 84% received RAIT (421+ 261 mCi) and
26% received external beam radiotherapy. 5 year OS was 42% and mean survival 67 + 11 months and didn’t differ
significantly from those who didn’t undergo surgery for metastases. The longest surviving patient was still alive at 121
months since primary surgery.
Conclusion: Surgical interventions for SM in FTC might not improve OS in presence of multiple metastases.
However, considering reasonable long-term OS of these patients, interventions should be considered for desired
palliation and preservation of body function.
Disclosure of Interest: None declared
232
135.04
FIBROSIS FROM SMALL INTESTINAL NEUROENDOCRINE TUMORS, AS A CAUSE OF OBSTRUCTIVE
UROPATHY AND INTESTINAL ISCHEMIA
K. Daskalakis1, A. Karakatsanis1, P. Stålberg1, O. Norlen1, P. Hellman1,*
1
Dept of Surgery, University Hospital of Uppsala, Endocrine Section, Uppsala, Sweden
Introduction: A subgroup of patients with small intestinal neuroendocrine tumours (SI-NET) have an extensive
fibrotic reaction predominantly in the mesenteric root and retroperitoneally. Some of these develop hydronephrosis or
occlusion of mesenteric vessels. We have studied a subgroup of patients regarding symptoms, treatment and
outcome among all patients referred to a tertiary referral center.
Materials & Methods: We included SI-NET patients (n = 860), who were diagnosed between 1985 and 2014. Clinical
data, outcome, radiological findings and surgical/radiological interventions were reviewed and presented.
Results: Among all patients a subgroup with retroperitoneal fibrosis were associated with obstructive uropathy and
hydronephrosis (n=16; median survival 7.7 years), or critically symptomatic obstruction of mesenteric vessels due to
non surgically- resectable bulky mesenteric nodal metastases and associated fibrosis in the mesenteric root (n=10).
The remaining patient group without these severe complications had a mean survival of 11.1 years. Extensive fibrosis,
causing hydronephrosis or obstruction of mesenteric vessels were more often associated with symptomatic and
advanced disease encompassing distant lymphnode metastases, liver metastases and peritonial carcinomatosis.
Intervention in terms of palliation, (percutanous nephrostomy, J-stent treatment and transhepatic portomesenteric
stent) was beneficial in the majority of the patients.
Conclusion: Extensive fibrosis from SI-NETs is associated with advanced disease, severe symptoms and poor
survival. Prompt recognition and intervention is essential for disease palliation and preservation of renal and intestinal
function
Disclosure of Interest: None declared
233
135.05
IMPROVING MINIMALLY INVASIVE ADRENALECTOMY: ROBOT-ASSISTED POSTERIOR
RETROPERITONEOSCOPIC APPROACH AND IMPACT OF THE INTRODUCTION OF MORE ADVANCED
SURGICAL SYSTEMS TECHNOLOGY
T. C. Lairmore1,*, J. Folek1, S. K. Snyder1, C. M. Govednik2
1
General Surgery, Surgical Oncology, Baylor Scott & White, Texas A&M Health Science Center, Temple, 2General
Surgery, Baylor Scott & White, Texas A&M Health Science Center, Waco, United States
Introduction: Minimally invasive adrenalectomy is the operation of choice for small adrenal tumors, and may be
performed by a transperitoneal laparoscopic (TLA), or posterior retroperitoneoscopic (PRA) approach. Our group first
reported robot-assisted PRA (RAPRA) in 2010. Introduction of newer surgical technology provides potential benefits to
the surgeon, but is associated with increased complexity and cost without current evidence for improved outcomes.
We reviewed our experience and results for minimally invasive adrenalectomy operations.
Materials & Methods: Between 2005 and 2014, 131 minimally invasive adrenalectomies were performed. A stepwise
introduction of new technology was incorporated, within the context of general surgical residency and endocrine
fellowship training programs. Operative time, blood loss, length of hospital stay and patient outcomes were
retrospectively evaluated.
Results: 50 TLA, 65 PRA, and 16 RAPRA were performed. Sex, age, tumor diameter, operating time, blood loss, and
hospital stay for the procedures are depicted in the TABLE. Adrenalectomy was performed for 39 benign nonfunctional adenomas, 27 pheochromocytomas, 36 aldosteronomas, 8 cortisol-producing adenomas, 4 ACTHdependent, 8 metastases, and 9 unusual tumors. Postoperative complications were minor and similar between
operative approaches.
Image:
Conclusion: Laparoscopic adrenalectomy is associated with excellent outcomes. Operating times for RAPRA are
increased in comparison to TLA/PRA, with significantly less EBL and comparable patient outcomes. Robotic system
technology provides potential advantages of greater instrument flexibility in a small operating field, and improved 3D
visualization and magnification. Although increasingly specialized and complex technology may facilitate the
performance of the operative procedure for the surgeon, further study is required to show improved patient outcomes.
Disclosure of Interest: None declared
234
135.06
RECURRENT LARYNGEAL NERVE DELIBERATIONS AND RECONSTRUCTIONS – A SINGLE INSTITUTION
EXPERIENCE
R. Dzodic1,2,*, I. Markovic1,2, N. Santrac1, I. Djurisic1, M. Buta1, M. Oruci1, S. Lukic3
1
2
Institute for Oncology and Radiology of Serbia, Surgical Oncology Clinic, Univeristy of Belgrade, School of Medicine,
3
Institute for Oncology and Radiology of Serbia, Department of Pathology, Belgrade, Serbia
Introduction: Recurrent laryngeal nerve (RLN) palsy is a major obstacle in thyroid surgery, with a reported rate of 0.5
to 10% in the relevant literature data. RLN injuries are more frequent during operations and reoperations of thyroid
cancer and recurrent goiter. Reconstruction of injured RLN can provide voice recovery to a certain extent. Aim of this
paper was to present our experience with deliberations and reconstructions of RLN after various mechanisms of
injury.
Materials & Methods: Two groups of patients were operated in our institution from year 2000 to 2015. First group (27
patients) had large benign goiters (toxic and non-toxic), locally advanced thyroid/parathyroid carcinomas or incomplete
previous surgery of malignant thyroid disease, with or without RLN paresis/paralysis. Second group (5 patients) had
operations due to RLN paralysis on direct laryngoscopy and severe dysphonic problems. Depending on the injury
mechanism, we performed deliberation or reconstruction of the RLN.
Results: As a part of surgical procedure, complete central compartment was explored, both RLNs were identified, as
well as the injury mechanism – misplaced ligation, resection, tumor infiltration or adhesions. Deliberations were
performed in 11 patients, 2 months to 16 years after RLN injury, by removing misplaced ligations or adhesions.
Immediate or delayed (18 months to 23 years) RLN reconstructions were performed in 21 patient, by direct suture of
resected RLN ends or anastomosis of ansa cervicalis and distal RLN stump (ARA) by Miyauchi. RLN deliberation
provided complete voice recovery within three weeks in all patients. Patients with direct sutures had better phonation
one month after reconstruction, while improved phonation was observed 2 to 6 months after ARA in 43% of patients.
Conclusion: Nerve reconstruction, either by direct suture or ARA, is a procedure that depends on surgeon’s skills and
experience. Although vocal cords don`t regain normal movement once being paralyzed, they can restore tension
during phonation by reconstruction, thus reinnervation of vocal cords, using one of the mentioned techniques, should
be the standard method in thyroid and parathyroid operations and reoperations with aim to improve patients’ quality of
life. Nerve deliberation, however, is a new method which enables patients with RLN paresis/paralysis a significant
improvement of phonation, even complete voice recovery.
Disclosure of Interest: None declared
235
139.01
THE RESULTS OF USING THE MINIMALLY INVASIVE LAPAROSCOPIC TECHNIQUES IN THE TREATMENT OF
GALLBLADDER DISEASE.
D. Puchkov1,*, K. Puchkov1
1
Clinical and Experimental Surgery, Swiss University Clinic, Moscow, Russian Federation
Introduction: Laparoscopic cholecystectomy (LCHE) has become the "gold" standard treatment of cholelithiasis, but
now there are new methods of performing cholecystectomy - minilaparoscopic (M-LCHE), SILS and hybrid NOTES
(HybNOTES) cholecystectomy.
Despite the obvious positive aspects of using all methods, the number of such kind of operations at the moment is still
very low.
Materials & Methods: From 2010 to 2014 were performed 517 laparoscopic cholecystectomies, using minimally
invasive technique. Patients were divided into 4 groups. Group A - 147 patients (LHCE), group B -138 patients (MLHCE), group C - 126 patients (SILS) and D group - 106 patients, (HybNOTES).
Body mass index in group A was 30.2 kg/m2, in group B - 28.4 kg/m2, group C - 24.7 kg/m2 and group D - 27.1
kg/m2.
Indications for operations were: chronic calculous cholecystitis, acalculous cholecystitis, polyps of GB.
Criteria for evaluating the effectiveness of operations were: total operation complications, pain intensity (NRS), a
cosmetic effect, the level of trauma tissue of the anterior abdominal wall, measured in conventional units (CU).
Results: Duration of operation was in group A - 37.5 minutes, in group B - 38.7 minutes, group C - 39.1 minutes, and
group D – 41.7 minute.
Patients in group A had the highest possible value - up to 2.8. Patients of groups B, C and D had similar level values
of postoperative pain, but in the group D, the level of pain was minimal and after 48 hours was only 0.2
For objectification the volume of trauma of anterior abdominal wall tissues were proposed a mathematical model.
Blinman T. found that the level of trauma after a linear incision depends on the tensile force exerted on it in the
postoperative period. Carvalho cylindrical geometric model used to calculate the amount of injury with trocars of
different diameters.
Maximum tension was created after the closure of abdominal wall defects after SILS operations - 655.36 CU, and the
smallest after HybNOTES - 28.09 CU. Similar data were obtained using the cylindrical geometry model calculation.
To evaluate the cosmetic effect after the operation in 2 weeks after surgery patients completed Body Image
Questionnaire and Cosmetic Questionnaire. The maximal cosmetic result was achieved in the group D - 97 patients
(91.5%) found the state of their body as "ideal".
Conclusion: Our results suggest that minimally invasive treatments of cholelithiasis have significant advantages in
comparison with traditional LHCE.
Disclosure of Interest: None declared
236
139.02
CAN LAPAROSCOPIC CHOLECYSTECTOMY PREVENT RECURRENT IDIOPATHIC ACUTE PANCREATITIS: A
PROSPECTIVE RANDOMIZED MULTICENTER STUDY
H. Paajanen1,*, S. Räty2, J. Pulkkinen1, I. Nordback2, J. Grönroos3
1
2
3
Surgery, University Hospital of Kuopio, Kuopio, Surgery, Tampere University Hospital, Tampere, Surgery, Turku
University Hospital, Turku, Finland
Introduction: Up to 75% of idiopathic acute pancreatitis (IAP) may be due to microlithiasis, which is undetectable by
conventional imaging methods (1). The aim of the present study was to ascertain whether laparoscopic
cholecystectomy (LCC) can prevent recurrent attacks of IAP.
Materials & Methods: This randomized, prospective study included 85 patients (39 in the LCC and 46 in the control
group) in 8 hospitals in Finland. The diagnosis of IAP was based on the exclusion of common etiological reasons for
acute pancreatitis (AP), whereafter the patients were randomized into conservative watchful waiting (controls) or LCC
group. During the follow-up all recurrent attacks of AP after an initial IAP episode were registered.
Results: During a median follow-up of 36 (5-58) months the recurrence of IAP was significantly higher in the control
group than in LCC group (14/46 vs 4/39, p=0.016), as was also the number of recurrences (23/46 vs 8/39, p=0.003).
In the subgroup of patients with at least 24 months` follow-up the recurrence was still higher among controls (14/37 vs
4/35, p=0.008). In patients with normal liver function, recurrence was also significantly higher in the control than in the
LCC group (13/46 vs 4/39, p=0.026). During surgery, 23/39 (59%) of the gallbladders were found to contain biliary
stones or sludge.
Image:
Conclusion: LCC can effectively prevent the recurrence of IAP when all other possible etiologies of pancreatitis are
carefully excluded. Five patients needed to be treated (NNT-value) to prevent one IAP.
References: 1. Garg P, Tandon R, Madan K. Is biliary microlithiasis a significant cause of idiopathic recurrent
pancreatitis? A long-term follow-up study. Clin Gastroenterol Hepatol 2007;5:75-79.
237
Disclosure of Interest: None declared
238
139.03
LONG-TERM OUTCOMES OF SURGICAL RESECTION FOR EARLY GALLBLADDER CARCINOMA
T. Wakai1,*, J. Sakata1, Y. Hirose1, N. Sudo1, T. Katada1, K. Takizawa1, M. Nagahashi1, T. Kobayashi1
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
Niigata, Japan
Introduction: No consensus regarding the performance of radical resection for gallbladder carcinoma invading the
muscle layer (pT1b) has been established. This study aimed to address whether pT1b gallbladder carcinoma is a local
disease and whether radical resection is necessary.
Materials & Methods: A retrospective analysis of 43 patients with pT1b gallbladder tumors, 25 of whom underwent
simple cholecystectomy and 18 underwent radical resection with regional lymph node dissection, was conducted. A
total of 168 regional lymph nodes were examined for metastasis. The median follow-up time was 127 months.
Results: Gallbladder carcinoma was diagnosed before operation in 16 of the 43 (37%) patients and preoperative
diagnosis of the depth of invasion was not possible. No patient had blood vessel or perineural invasion on histology.
Lymphatic vessel invasion was seen in one patient. Metastases were absent in all lymph nodes examined. Overall
cumulative 5- and 10-year survival rates were 84% and 69%, respectively. The outcome after simple cholecystectomy
(overall 5-year survival rate of 86%) was comparable to that after radical resection (that of 82%, P = 0.956; Fig. 1A).
Two patients who underwent radical resection died from tumor relapse in distant sites (liver and lung). Cumulative 5and 10-year disease-specific survival rates were 93% and 93%, respectively. The outcome after simple
cholecystectomy (5-year disease-specific survival rate of 100%) was comparable to that after radical resection (that of
94%, P = 0.956; Fig. 1B).
Image:
Conclusion: Most pT1b gallbladder carcinomas spread only locally. Preoperative diagnosis of pT1b gallbladder
carcinoma is rarely obtained and most pT1b tumors are first diagnosed by histopathologic examination of a resected
specimen. The performance of radical resection is justified, whereas additional radical resection is not necessary
when the depth of invasion of gallbladder carcinoma is limited to the muscle layer after simple cholecystectomy.
Disclosure of Interest: None declared
239
139.04
IMPACT OF SURGICAL RESECTION AND CHEMOTHERAPY ON LONG-TERM OUTCOMES IN PATIENTS WITH
LOCALLY ADVANCED GALLBLADDER CARCINOMA
T. Wakai1,*, J. Sakata1, Y. Hirose1, N. Sudo1, T. Katada1, K. Takizawa1, M. Nagahashi1, T. Kobayashi1
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
Niigata, Japan
Introduction: The aim of this study was to clarify long-term outcomes of radical resection and chemotherapy for
locally advanced gallbladder carcinoma.
Materials & Methods: A retrospective analysis was conducted of 159 patients with advanced gallbladder carcinoma.
Resection procedures included extended radical cholecystectomy (n = 92) and more extensive resection (performance
of hemihepatectomy and/or pancreaticoduodenectomy, n = 67). The primary tumor was classified as pathologic Stage
(pStage) II in 42 patients, pStage III in 60, and pStage IV in 57. Adjuvant chemotherapy was performed for 58 patients
(5FU in 48 patients and GEM in 10). The median follow-up time was 144 months.
Results: Cumulative 5-year survival rates were 91%, 49%, and 23% in patients with pStage II, III, and IV, respectively
(P < 0.001). Adjuvant chemotherapy (P = 0.001), residual tumor status (P = 0.004), and pStage (P = 0.024) were
independent prognostic factors after resection. The outcome after resection in 58 patients with adjuvant chemotherapy
(cumulative 5-year survival rate of 66%) was significantly better than in 101 patients without (cumulative 5-year
survival rate of 40%, P = 0.001). Cumulative 5-year survival rate was significantly worse in 23 patients with residual
tumor than in 136 patients without (57% versus 0%, P < 0.001).
Among patients with pStage II/III, cumulative 5-year survival rate was significantly better in 76 patients who underwent
extended radical cholecystectomy than in 26 patients who underwent more extensive resection (76% versus 39%, P <
0.001; Fig. 1A). Among patients with pStage III/IV, cumulative 5-year survival rate was significantly better in 40
patients with adjuvant chemotherapy than in 77 patients without (53% versus 27%, P = 0.004; Fig. 1B), whereas the
efficacy of adjuvant chemotherapy was not observed in patients with pStage II (P = 0.537).
Image:
Conclusion: Extended radical cholecystectomy provides survival benefit for patients with pStage II/III tumors only if
potentially curative (R0) resection is feasible. Patients with pStage III/IV tumors appear to be candidates for adjuvant
chemotherapy.
Disclosure of Interest: None declared
240
139.05
OUR EXPERIENCES OF MAJOR HEPATECTOMY FOR HEPATOBILIARY CARCINOMA IN EXTREMELY
ELDERLY PATIENTS
N. Koike1,*, Y. Ohshima1, T. Takeuchi1, S. Arita1
1
Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
Introduction: Incidences of hepato-biliary-pancreatic cancer in elderly patients have recently increased worldwide
because of the aging population. We evaluated the outcomes of major hepatectomy in elderly patients to clarify the
surgical indications and limitations.
Materials & Methods: For this study, patients ≥80 and <80 years were defined as extremely elderly and elderly,
respectively. Six extremely elderly patients (four males and two females; average: 80.5 years; range: 80–81 years)
underwent major hepatectomy (resection of >2 liver segments) for malignant hepatobiliary disease between March
2004 and December 2014 at our institute. Malignant hepatobiliary diseases were metastatic liver tumors in two
patients, hilar bile duct carcinoma in two patients, gallbladder carcinoma in one patient, and hepatocellular carcinoma
in one patient. Central bisegmentectomy was observed in one patient, left lobectomy in one patient, right lobectomy in
one patient, extended right lobectomy in one patient, and extended left lobectomy in two patients. No patient had
dementia and all were able to use the stairs without assistance. Forty-five elderly patients underwent major
hepatectomy during the same period at our institute. Postoperative outcomes were compared between the groups.
Results: No significant differences were observed in the duration of surgery, intraoperative blood loss, blood
transfusion volume, and postoperative hospitalization duration (35.5 ± 20.4 days in extremely elderly patients and 34.2
± 21.4 days in elderly patients) between the groups. Medium survival of extremely elderly patients after surgery was
28 months. Two patients died of primary diseases, one patient died of another disease after seven years, and one
patient died of sudden heart failure during hospitalization. One patient survived without recurrence for more than one
year. The morbidity rate of extremely elderly patients (83.3%) was significantly higher than that of elderly patients
(48.9%). Particularly, postoperative delirium was more frequent in extremely elderly patients.
Conclusion: High-risk hepato-biliary-pancreatic surgery was viable in extremely elderly patients; however,
unexpected fatal postoperative complications occurred in the patients. Indications for surgery in extremely elderly
patients should be carefully scrutinized, and postoperative management must be vigilantly performed.
Disclosure of Interest: None declared
241
139.06
PANCREATIC RESECTION FOR MALIGNANCY IN THE ELDERLY VERSUS THEIR YOUNGER
COUNTERPARTS: ANALYSIS OVER 14 YEARS AT A TERTIARY CARE CENTER
E. W. Gilbert1,*, C. Budde1, L. Merriman1, Y. Chen2, B. C. Sheppard1
1
2
Surgery, Public Health, Oregon Health & Science University, Portland, United States
Introduction: Pancreatic cancer is largely a disease of the elderly, yet the safety and efficacy of pancreatic resection
in elderly patients is still unclear. We sought to determine the morbidity and mortality of pancreatic resection for
malignancy in elderly patients when compared to their younger counterparts at a high-volume tertiary care center.
Materials & Methods: All patients who underwent curative pancreatic resection for pancreatic ductal adenocarcinoma
or ampullary cancer from 1996-2010 at our institution were identified. Elderly were defined as ≥ 70 years old at
resection. Patient characteristics, staging, and perioperative information were analyzed. Differences between the
cohorts were compared using chi-square test and two sample t-test. Kaplan-Meier method was used to estimate
survival. Multivariable models were fitted to compare outcomes after controlling for confounders.
Results: 295 patients met inclusion criteria (103 elderly, 192 younger). On multivariable analysis, younger patients
were less likely to have a post-operative complication (OR 0.52, 95% CI 0.32, 0.88, p = 0.004). Also, younger patients
were more likely to receive adjuvant treatment (OR 2.62, 95% CI 1.33, 5.16, p = 0.005). Overall median survival was
16.9 months (95% CI 14.7, 20.9). Overall one- and two-year survivals were 67.1% and 43.4%, respectively. There
was no difference in overall survival between the groups on Kaplan-Meier survival plots (p = 0.08).
Image:
Conclusion: Despite increased morbidity and decreased usage of multimodal therapy there is no difference in
survival between elderly and their younger counterparts undergoing pancreatic resection for malignancy. These
results suggest that pancreatic resection for cancer is beneficial for the elderly.
Disclosure of Interest: None declared
242
147.01
GENOTYPE-PHENOTYPE CORRELATION IN INDIAN PATIENTS WITH MEN2-ASSOCIATED
PHEOCHROMOCYTOMA AND COMPARISON OF CLINICO-PATHOLOGICAL ATTRIBUTES WITH SPORADIC
ADRENAL PHEOCHROMOCYTOMA
S. Rajan1,*, G. Zaidi2, E. Bhatia2, A. Mishra1, A. Agarwal1, A. K. Verma1, S. K. Mishra1, G. Agarwal1
1
Endocrine & Breast Surgery, 2Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS),
Lucknow, India
Introduction: Pheochromocytoma(PCC) manifests in upto 50% of MEN2 patients. We studied the correlation of
clinico-pathological features of PCC with RET mutations in MEN2 patients with PCC, & compared them with sporadic
adrenal PCCs.
Materials & Methods: In a retrospective single center PCC study (208 pts, 1997-2014), 17 MEN2–associated PCC
patients from 11 kindreds with a known mutation in exons 10/11/13/14/16 constituted the study cohort. 7 other MEN2
pts were excluded due to incomplete data. The sporadic PCC group had 132 pts with adrenal PCC, excluding extraadrenal (n=37) & VHL, NF1 or SDH (n=15) associated PCC pts. Mode of presentation, various MEN2 components,
biochemistry, surgical procedure, pathology & outcomes in the MEN-2 PCC group were correlated with the genotype,
and further compared with sporadic PCC group.
Results: In the 17 MEN2 patients (mean age 27.7 +12.2yrs, M:F::7:10), MTC was present in 13(76.5%); other
features seen were Marfanoid habitus in 2, & PHPT, cutaneous lichen amyloidosis(CLA) & mucosal neuromas in 1
patient each. In 11(64.7%), PCC was the first detected MEN2 component (Symptomatic:8, Incidentaloma:3). 4 were
normotensive. 8(47.1%)patients had bilateral PCC-7 synchronous & 1 metachronous.
All underwent PCC surgery, including laparoscopic adrenalectomy in 12. Cortical-sparing adrenalectomy was
performed in 2/8 patients of bilateral PCC. Mean PCC tumor size was 6.9+3.9 cm, none had malignant tumors, &
6(35%) had component of AMH in addition to PCC. 4 different types of genotype were encountered, & their correlation
with MEN2 phenotype is summarized in table-1.
Codon n Mea
MTC
pHP
Cutaneous
Marfano Mucos Normotens Adrenal
Bilatera
Mutati
n
T
lichen
id
al
ive
Medullary
l PCC
on
age
amyloidosis
habitus Neuro
Hyperplasia
at Dx
ma
C634R 4 22.5
4(100
0
0
1(25%)
2(50%)
2(50%)
2(50%)
%)
C634G 1 31.4
8(72.7 1(9.1 1(9.1%)
0%
2(18.1%)
4(36.4%)
6(54.5%
/F/S/W 1
%)
%)
)
V804M 1 42.0
0
0
0
0
0
0
0
M918T 1 18.0
1(100
0
0
1(100%) 1(100% 0
0
0
%)
)
A comparison between MEN2 & sporadic PCC groups is shown in image-1. MEN2 patients had significantly higher
urine metanephrines(p=0.004), bilateral disease(p<0.001), pediatric pts(p=0.007) and AMH(p<0.001), and significantly
lower age at presentation(p=0.018).
Image:
243
Conclusion: Results of this first Indian study on MEN2 associated PCC patients suggest that the most common
causative RET mutations are in codon 634. Compared to sporadic PCC, MEN2-associated PCC patients present at a
younger age and more commonly with bilateral disease. A higher fractionated urinary metanephrine values may be
predictive of MEN2-associated PCC.
Disclosure of Interest: None declared
244
147.02
THE NOVEL HISTONE DEACETYLASE INHIBITOR, N-HYDROXY-7-(2-NAPHTHYLTHIO) HEPATONOMIDE,
EXHIBITS POTENT ANTITUMOR ACTIVITY IN THYROID CANCER.
K. C. Park1, H. K. Kim1, S.-M. Kim1,*, H. Chang1, B.-W. Kim1, Y. S. Lee1, H.-S. Chang1, C. S. Park1
1
Departments of Surgery, Yonsei University College of Medicine, Seoul, Korea, Republic Of
Introduction: Epigenetic modifications play a crucial role in the regulation of all DNA-based processes, such as
transcription, repair, and replication. In relevant histone modifications can result in dysregulation of cell growth, leading
to neoplastic transformation and cell death. ATC (Anaplastic thyroid cancer) has been shown to have a higher global
methylation percentage and reduced histone acetylation. Recently, a novel HDAC inhibitor, N-hydroxy-7-(2naphthylthio) heptanomide (HNHA), has been introduced as an example of a new class of anti-cancer agents. The
anti-cancer activity of HNHA and the underlying mechanisms of action remain to be clarified.
Materials & Methods: The MTS assay using a panel of ATC was used to evaluate the anti-proliferative effects of
HNHA. The established HDAC inhibitors, SAHA and TSA, were used for comparison. Western blotting analysis was
performed to investigate the acetylation of histone H3 and the expression of apoptotic markers in vitro and in vivo.
Subcellular fractionation was performed to evaluate expression of Bax, Bak and cytochrome c in the cytosol and
mitochondria, and also translocation of cytochrome c from the cytoplasm to the nucleus. A confocal microscopic
evaluation was performed to confirm inhibition of cell proliferation, induction of apoptosis, and the nuclear
translocation of cytochrome c in ATC cells.
Results: In this study, we investigated the apoptosis-inducing activity of HNHA in cultured ATC cells. Apoptosis in the
HNHA-treated group was induced significantly, with marked caspase activation and Bcl-2 suppression in ATC cells in
vitro and in vivo. HNHA treatment caused cytochrome c release from mitochondria, which was mediated by increased
Bax, Bak expression and caspase activation. HNHA also induced nuclear translocation of cytochrome c, suggesting
that HNHA can induce caspase-independent nuclear apoptosis in ATC cells. An in vivo study showed that HNHA had
greater anti-tumor and pro-apoptotic effects on ATC xenografts than the established HDAC inhibitors.
Conclusion: HNHA has more potent anti-tumor activity than established HDAC inhibitors. Its activities are mediated
by caspase-dependent and cytochrome-c-mediated apoptosis in ATC cells. These results suggest that HNHA may
offer a new therapeutic approach to ATC.
Disclosure of Interest: None declared
245
147.03
SURGICAL THERAPY OF RETROPERITONEAL PARAGANGLIOMAS – IS THE MINIMALLY INVASIVE ACCESS
APPROPRIATE?
E. Karakas1,*, B. Seeliger1, P. F. Alesina1, M. K. Walz1
1
Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany
Introduction: Surgical removal is the treatment of choice in retroperitoneal paragangliomas (rPG) as these tumors
are potentially lethal by catecholamine excess. Up to now only very few and limited studies have demonstrated the
option of minimally invasive surgery (MIS) in these patients. In the following study we present our data in 65 patients
with rPGs treated during the last 15 years by minimally invasive access.
Materials & Methods: From 2000 until 2014 sixty-five patients (40M, 25F; age 34±17 years) underwent surgery for
rPG using MIS. During the same period an open approach was used only in 3 patients (3M) with metastatic or
recurrent malignant rPGs. These patients were excluded from the study. Underlying genetic diseases were found in
44 patients (von-Hippel-Lindau 25, SDHD 11, SDHB 7, SDHA 1), 21 patients suffered from sporadic rPGs. Seven
patients had multiple paragangliomas, 5 other patients recurrent paragangliomas. Altogether 89 rPGs were removed
by MIS. The laparoscopic approach was used in 31 tumors, the retroperitoneoscopic access in 58 lesions. All data
were prospectively documented and retrospectively evaluated.
Results: Mortality was zero. Conversions to open surgery was necessary in 2 cases (1 bleeding, 1 difficult
dissection). Mean operating time was 65 minutes (range 20- 530 minutes). Mean blood loss was 120 ml (range 02500 ml), blood transfusions were given in one patient. Median hospital stay was 3 days. After a mean follow-up of 57
months, one patient died from multiple metastases. Two other patients developed distant metastasis. Altogether, 5%
of the patients had malignant rPGs.
Conclusion: Minimally invasive surgery for rPG is safe and should be recommended in the majority of cases. The
laparoscopic approach is indicated in tumors caudally the renal vessels, the retroperitonesocopic access above this
level.
Disclosure of Interest: None declared
246
149.01
A BIOACTIVE LIPID MEDIATOR, SPHINGOSINE-1-PHOSPHATE LINKS INCREASED METASTATIC NICHES
AND LUNG METASTASIS OF BREAST CANCER
M. Nagahashi1,*, K. Moro1, J. Tsuchida1, K. Tatsuda1, J. Sakata1, T. Kobayashi1, K. Takabe2, T. Wakai1
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
Niigata, Japan, 2Division of Surgical Oncology, Virginia Commonwealth University School of Medicine, Richmond,
United States
Introduction: Sphingosine-1-phosphate (S1P) is a pleiotropic bioactive lipid mediator produced by sphingosine
kinases (SphKs) that plays critical roles in inflammation and cancer progression. Previous clinical studies have shown
that SphK1 is overexpressed in breast cancer and its expression is associated with poor patient outcomes. We
explored the role of S1P in formation of “metastatic niches”, specialized microenvironments in distant organs primed
by factors from cancer cells. In this study, we tested the hypothesis that S1P secreted from the primary tumor into the
tumor microenvironment could affect not only the primary tumor microenvironment, but also promote formation of a
“metastatic niche” in distant sites, such as the lung, that assists circulating cancer cells to form metastatic lesions at
that location.
Materials & Methods: A mouse model utilizing tail vein injection of E0771 syngeneic breast cancer cells was used.
Prior to tail vein injections of naive E0771 cells, mice were treated with conditioned media from E0771 breast cancer
cells overexpressing SphK1 (K1-CM) or that from E0771 cells cultured with the vector control (CT-CM). Histological
analysis, RT-qPCR, and western blot were used to examine the metastatic niche and metastatic lesions in the lung.
Results: Histological analysis after HE staining revealed that more inflammatory cells infiltrated the lungs from mice
treated with K1-CM than with CT-CM 7 days after E0771 cancer cell challenge. Strikingly, the lungs after K1-CM
treatment demonstrated much more infiltration of macrophages with greater IL-6 secretion than lungs from CT-CM
mice in areas without metastasis. Furthermore, SphK1, S1PR1 and IL-6 expression were all significantly higher in the
lungs of mice treated with K1-CM than with CT-CM. Oncogenic survival signaling, such as phosphorylated-ERK and
phosphorylated-AKT, was increased in the lungs of mice treated with K1-CM. Treatment with K1-CM also increased
levels of both Stat3 and NF-kB p65 subunits in the lung, which are considered to be pivotal inflammatory factors in
cancer progression and have previously been shown to be activated by S1P.
Image:
247
Conclusion: Our results suggest that S1P secreted from the primary tumor promotes formation of a metastatic niche
in the lung that assists circulating cancer cells to form metastasis. S1P will be a promising target for treatment of
breast cancer metastasis. M.N. is supported by the Uehara Memorial Foundation.
Disclosure of Interest: None declared
248
149.02
PREDICTORS FOR SURGICAL OPTIONS IN CHINESE PATIENTS WITH EARLY INVASIVE BREAST CANCER:
DATA FROM HONG KONG BREAST CANCER REGISTRY
S. W. W. Chan1,* on behalf of Hong Kong Brast Cancer Foundation, C. Cheung2 on behalf of Hong Kong Breast
2
2
Cancer Foundation, A. Chan on behalf of Hong Kong Breast Cancer Foundation, P. S. Y. Cheung on behalf of Hong
Kong Breast Cancer Foundation
1
Kowloon East Cluster Breast Centre, Surgery, United Christian Hospital, 2Hong Kong Breast Cancer Foundation,
Hong Kong, China
Introduction: There are different surgical options for early breast cancer patients. We aim to study the choice of
surgical options and their predictors among Hong Kong breast cancer patients.
Materials & Methods: The Hong Kong Breast Cancer Registry (HKBCR), was established in 2007 by the Hong Kong
Breast Cancer Foundation as the most comprehensive breast cancer registry in Hong Kong. During the period from
2007 to 2013, 4519 breast cancer patients with 4620 breast cancer cases diagnosed of invasive breast cancer stage
I-II who had surgical treatments for breast cancer were included in this retrospective observation study. Data on
patient factors were extracted from the HKBCR and analyzed retrospectively. Associations of surgical treatments for
different factors were examined by univariate analysis. Final multivariate regression model included significant
explanatory variables to predict surgical treatments. All statistical analyses were performed by SPSS (SPSS 18.0). P
value of <0.05 were considered as statistically significant.
Results: Among 4620 tumours, 40.5% of them underwent breast conserving surgery (BCS), 51.5% underwent
mastectomy alone (MTX), and 8.0% underwent mastectomy with either immediate or delayed reconstruction
(MTX+R).
Factors Associated with BCS vs.MTX In multivariate logistic regression, significant predictive factors for BCS
included younger age (age<40 OR1.5, age 40-49 OR 1.6), higher education level (undergraduate OR 2.8);never
marry (OR 1.5), minor significant past health (OR1.2), regular screening mammography (occasional screening
mammography; regular screening mammography (OR1.5), method of first detection (screen-detected OR 1.3), smaller
tumour size (<=2m OR 13.4, 2-5cm OR 6.2); tumour site (central OR0.43)and private medical service facility (OR1.8).
Factors Associated with MTX+R vs MTX Significant explanatory factors for MTX+R in the multivariate logistic
regression model included younger age (<40 OR 15.9, age 40-49 OR 9.3), higher education level (undergraduate
26.8), divorced (OR1.9), major significant past health (OR0.22), regular screening mammography (OR1.6), method of
first detection (screen detected OR2.1), smaller tumour size (<=2cm OR 0.39) and tumour at central region (OR2.2).
Conclusion: More work could be done on patient education and surgical trainings on advanced medical technology.
By promoting these aspects, we believe surgeons and patients themselves could make better surgical decision for
their surgical treatment of breast cancer.
Disclosure of Interest: None declared
249
149.03
HIGHER ORDER GENE- GENE INTERACTION OF DRUG METABOLIZING ENZYMES POLYMORPHISMS MAY
PREDICT TREATMENT OUTCOMES AND TOXICITY IN NORTH INDIAN BREAST CANCER PATIENTS
G. Agarwal1,*, S. Tulsyan2, P. Lal3, B. Mittal2
1
2
3
Endocrine & Breast Surgery, Genetics, Radiation Oncology, Sanjay Gandhi Postgraduate Institute of Medical
Sciences, Lucknow, India
Introduction: Cytotoxic chemotherapy is one of main-stays of multimodal breast cancer treatment. The response to
treatment and side-effects vary from patient to patient. In this pharmacogenomics study, we attempted to determine
the influence of variations in genes encoding phase 0 (SLC22A16); phase I (CYP450, NQO1); phase II (GSTs,
MTHFR, UGT2B15) and phase III (ABCB1) drug metabolizing enzymes (DMEs) on toxicity of chemotherapeutic drugs
in breast cancer treatment, and response to neo-adjuvant chemotherapy (NACT), using a multi-analytical approach.
Materials & Methods: North Indian female breast cancer patients (n=234) were genotyped for 19 polymorphisms,
namely- SLC22A16 146A>G, SLC22A16 1226T>C, CYP3A4*1B, CYP3A5*3, CYP2B6*5, CYP2B6*9, CYP2C8*3,
CYP2C9*2, CYP2C9*3, CYP2C19*2, NQO1 609C>T, GSTM1, GSTTI, GSTP1 313A>G, MTHFR 677C>T, UGT2B15
253A>C, ABCB1 1236C>T, ABCB1 2677G>T/A and ABCB13435C>T by PCR or PCR-RFLP or Taqman allelic
discrimination assay. Grade 2–4 chemo-toxicity was recorded in 234 patients according to NCI-CTCAE criteria, while
the tumor response to NACT was recorded in 111 patients as per RECIST system. Binary logistic regression and
GMDR analysis were performed. All statistical analysis was adjusted for potential confounding factors like age,
clinical stage, grade, lymph node status, hormone receptor and Her2-neu expression. Bonferroni test for multiple
comparisons was applied and p-value was considered to be significant at <0.025.
Results: On applying logistic regression, CT genotype of ABCB1 1236C>T polymorphism was found to have a
statistically significant correlation with response to NACT [p=0.013]. However, none of the polymorphisms reached
statistical significance with grade 2-4 toxicity. On GMDR analysis, interaction of CYP3A5*3, NQO1 609C>T, ABCB1
1236C>T polymorphisms yielded the highest testing accuracy for correlation with response to NACT (CVT=0.62). The
CYP2C19*2, ABCB1 3435C>T combination of polymorphisms yielded the best interaction model (CVT=0.57) for
grade 2-4 toxicity.
Conclusion: Higher order gene-gene interactions may provide a better pharmacogenomic based prediction of
associations of various polymorphisms in genes encoding DMEs with the treatment outcomes in North Indian breast
cancer patients.
Disclosure of Interest: None declared
250
149.04
DIAGNOSTIC ACCURACY OF LYMPHEDEMA MEASURED BY BIOIMPEDANCE SPECTROSCOPY IN POSTSURGERY BREAST CANCER PATIENTS.
S. W. W. Chan1,*, S. K. Law1, T. C. F. Lau1, K. Y. Wong1, Y. Lam2, R. Lam2, T. L. Chow1
1
Kowloon East Cluster Breast Centre, Surgery, 2Physiotherapy, United Christian Hospital, Hong Kong, China
Introduction: Early detection and management of lymphedema prevents the progression of lymphedema in patients
at risk.We aim to evaluate the sensitivity and specificity of Bioimpedance Spectroscopy (BIS) in detecting lymphedema
in post breast cancer surgery patients and to compare it with traditional methods. And to investigate whether BIS can
diagnose lymphedema in earlier stage.
Materials & Methods: We included patients with aged <=80 with unilateral breast cancer and underwent breast
surgery at Kowloon East Breast Centre.Patient had questionnaire done within 2 months before surgery and clinical
assessment within 1 week before surgery. FU questionnaire and assessment were performed at 1, 2,3,4,5,6,10,14,18
months after surgery.Lymphedema in our study is defined as at least 2cm difference between affected and unaffected
limbs at any point in time.We compared diagnostic accuracy of BIS with traditional methods by tape measurement.
Results: We reported our result at 18 months after surgery. 150 patients were included in the study. The mean age
was 55.5. The incidence of lymphedema ranged between 0% and 43.3% (table 1), depending on the definition to
classify lymphedema cases as well as the timing of measurement.The overall incidence of lymphedema at 18 months
after operation was 9.3% when lymphedema is defined as at least 2cm difference between affected and unaffected
limbs.The sensitivity of BIS was 100% at any point of the study. The specificity of BIS at 4 month was 91.9%. The
specificity of BIS was 87.5% at 18 months. When BIS measure was used, 4 out of 14 patients were diagnosed
lymphedema at 2 to 4 months earlier when compared with traditional limb measurement by tape method .
Cumulative incidence
2
4mon 6mon 8mon 12mont 18mont
mont
th
th
th
h
h
h
Circumference Tape >=2cm
0%
0.67
6.7%
7.3%
7.3%
9.3%
%
TLV >=200ml
0.67
1.3%
3.3%
4%
4%
6%
%
Self-reported swelling
11.3
21.3
29.3
34%
38.7%
43.3%
%
%
%
BIS
3.3%
8.7%
16.7
20.7
20.7%
20.7%
%
%
Conclusion: Conclusion:BIS is the most sensitive diagnostic method in detecting lymphedema. BIS is specific at
4month and is comparable to other study., But it has moderate specificity at 18 month. Longer follow-up is useful to
demonstrate the actual specificity of BIS test. It is because the peak incidence of lymphedema occurs 2-3 years after
surgery.BIS test allows earlier detection of lymphedema. As early detection of lymphedema can improve treatment
outcomes of patients, the clinical application of BIS is promising.
Disclosure of Interest: None declared
251
149.05
BREAST CONSERVING SURGERY: A COMPARATIVE ANALYSIS BETWEEN STANDARD AND ONCOPLASTIC
EXCISION.
L. P. Doreen Lee1,* on behalf of Ma JJ, Liew KW, Teng WW, Siti ZS, Chuah JA
1
Breast Surgery Unit, General Surgery, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
Introduction: The approach to standard BCS (breast conserving surgery) is excision of tumor with adequate margins.
Aesthetic results can be compromised in most standard lumpectomies. Oncoplastic BCS entails a more complex
approach and technique. There is paucity of information on the oncologic safety of the latter procedure.
Materials & Methods: The purpose of this review is to to determine and compare standard and oncoplastic excision
outcomes in a single center. This is a retrospective study with 136 breast conserving surgeries performed between 01
January 2013 and 31 Dec 2014 at a tertiary hospital in East Malaysia.
Comparison of the results was performed by statistical methods with SPSS version 19.
Results: Group 1 comprised of 64 patients who underwent standard wide local excision. 5 general surgeons
performed the procedure. 72 patients of Group 2 received oncoplastic excision of the malignant lesion by one surgeon
who was trained in the procedure.
Oncoplastic lumpectomy saw a larger mean tumor size of 32.5mm and larger mean specimen dimension of 95mm as
opposed to a mean 20.8mm and 34.3mm respectively in the standard excision group.
30 of 64 (46.8%) standard excision patients in Group 1 had involved margins which required salvage mastectomy in
27 (42.2%). Re-excision and salvage mastectomy rates were statistically lower in Group 2 (p<0.05).
Duration of primary surgery was notably longer in the oncoplastic group (p<0.05). The two groups did not differ
significantly in age and complication rates. Complications unique to the oncoplastic technique will be discussed. There
were no significant delays to adjuvant therapy in both BCS groups. Tumor location in Group 1 was almost always in
the upper outer quadrant (53.1%) and lower outer quadrant (26.5%) as opposed to larger tumor size in cosmetically
sensitive areas in Group 2 (70.8% spared of mastectomy).
Conclusion: Oncoplastic breast-conserving surgery yields better oncological results in managing larger tumors in
cosmetically sensitive areas of the breast. The application of oncoplastic procedures in our unit is associated with
lower re-operative surgery rates to address positive margins, specifically, mastectomy.
Disclosure of Interest: None declared
252
149.06
MOLECULAR GENETIC PROFILING ALLOCATES CHEMOTHERAPY MORE APPROPRIATELY AND MORE
COST-EFFECTIVELY – EIGHT YEARS OF TRANSCRIPTIONAL PROFILING IN A RESOURCE RESTRICTED
COUNTRY
J. Apffelstaedt1,*, R. Pienaar2, M. Kotze3
1
Surgery, University of Stellenbosch, Tygerberg, 2Private Practice, 3Pathology, University of Stellenbosch, Cape Town,
South Africa
Introduction: Molecular prognostic profiling of breast tumors became available in our country in 2006. We here report
®
the experience of applying a 70-gene expression profile (MammaPrint {MP}) in the ocnttext of a developing country.
Materials & Methods: For hormone receptor positive TNM stage 0-II tumors in patients aged 35-75 tumor samples
were taken and gene expression profiled. Demographic data, tumor staging and detailed histopathology were
recorded. Adjuvant therapy was based on MP results and compared to St Gallen recommendations. Ten-year survival
data were projected with adjuvantonline and compared to data on MP survival and chemotherapy benefit at 5 years
after diagnosis. .
Results: The average age of the patients was 55 years. For 110 tumors, the clinical staging was 0 in 20, I in 57 and II
in 33. The average histopathologic tumor size was 16.5 mm, 76 were node-negative. Of 36 St Gallen low risk tumors
23 were concordantly reported as MP low risk and 13 discordantly as MP high risk; of 74 St Gallen high risk tumors 32
were concordantly reported as MP high risk and 42 discordantly as low risk. Chemotherapy recommendation for 74
patients according to St. Gallen was projected to lead to an average absolute reduction of recurrence of 7.8% and
mortality of 3.9% at 10 years contrasted to a MP prognostication based recommendation for chemotherapy for 45
patients to an absolute 13% reduction in recurrence and 6.0% for mortality at 5 years in these patients. One MP
returned a low-risk result in a FISH amplified tumor; in one patient with 2 separate tumors of the same histopathology
in one breast one tumor was reported a MP high risk, the other as MP low risk. Two MP high risk tumors have
recurred and one of these patients has died, both tumors were concordantly reported as high risk. Health economics
evaluation puts the chemotherapy treatment cost for the entire group for St Gallen based prognostication at 973 000
US$ compared to MP prognostication of 809 000 US$ including costs of the test. MP prognostication led to treatment
changes in 50% of cases with a reduction in chemotherapy recommendations by 26% for the entire group.
Conclusion: Discordant immunohistochemistry - molecular genetic profiling results pose a clinical management
dilemma. Multicentric tumors can have discordant molecular genetic profiling results. Molecular genetic profiling
allocates chemotherapy more appropriately than histopathologic parameters and optimizes clinical outcomes.
Disclosure of Interest: None declared
253
149.07
LONG-TERM FOLLOW UP OF INTRAOPERATIVE RADIOTHERAPY (IORT) FOR EARLY BREAST CANCER IN A
RESOURCE RESTRICTED COUNTRY
Z. Keyser1,*, J. Apffelstaedt2, K. Baatjes2
1
2
General surgery, Head neck and breast, Tygerberg hospital cape town, Cape town, South Africa
Introduction: Partial breast irradiation has become standard of care for selected early breast cancer patients in wellresourced environments despite a lack of long-term data on its safety and oncologic efficacy. We here present 12-year
outcome data of an initial series of definitive, single dosage IORT in a developing country.
Materials & Methods: From 2002-2005 patients with TNM stage 0-II breast cancer, qualifying for breast conservation,
had a tumour excision and same session locally designed low cost applicator inserted into the tumour bed and
afterloaded with an Ir192 source. A single dose of 21Gy was administered. Demographic, histopathologic, clinical and
oncologic outcome data were collected prospectively and analysed according to Kaplan-Meyer.
Results: Thirty-nine patients with a mean age of 54.7 (35-68) years were treated. Tumours were clinically staged T0
in 1, T1C in 18 and T2 in 20 patients and N1 in 6 patients. Mean histopathologic tumor diameter was 19 mm; 36
tumors were infiltrating ductal, 2 infiltrating lobular and one mucinous; 30 tumors were ER receptor positive, 4 patients
had nodal involvement. Sixty-seven percent of patients have survived and been followed up for more than 9 years; the
median follow-up of the entire group is 120 months. At last follow up, of American Society of Therapeutic Radiation
Oncology (ASTRO) guidelines on accelerated partial breast irradiation (APBI) suitable (n=3), cautionary (n=28) and
unsuitable (n=8) cases, 0, 3 and 1 cases respectively suffered an isolated local recurrence after 1, 3, 5 and 11 years.
Three of these were salvaged by mastectomy; 1 declined further treatment and progressed to distant recurrence; all
still alive. No single demographic/histopathologic parameter was associated with local recurrence. Seven other
patients suffered distant recurrence; 1 is still alive with disease; 3 died of unrelated causes and 3 lost to follow-up. At
12 years, the local recurrence, disease-specific and overall survival rates were 12, 72 and 68 %.
Conclusion: In this, the longest follow up of definitive IORT long-term recurrences were rare despite the majority of
the patients falling into ASTRO guidelines cautionary/unsuitable groups. Classification into these groups also predicts
compromised survival and IORT may be sufficient to provide local control. In all breast conservation therapy patients,
a cost effective applicator with existing afterloaders, may make IORT an effective option in a financially constrained
environment, irrespective of ASTRO classification.
Disclosure of Interest: None declared
254
151.01
EXTRAHEPATIC STEM CELLS MOBILIZED FROM THE BONE MARROW BY THE SUPPLEMENTATION OF
BCAA AMELIORATE LIVER REGENERATION IN AN ANIMAL MODEL
T. Okabayashi1,*, Y. Shima1, T. Sumiyoshi1, A. Kozuki1, T. Tokumaru1, Y. Saisaka1
1
Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, Japan
Introduction: In recent years, bone marrow (BM)-derived stem cell repopulation of injured organs has become an
increasingly observed, however, the extent to which it occurs and its clinical relevance remain unclear. Here, we
investigated on the potential of extrahepatic stem cells to become hepatocytes by using the treatment of the oral
supplementation of beanched-chain amino acids (BCAA).
Materials & Methods: In the first, Sprague-Dawley (SD) rats were administered BCAA to promote liver regeneration;
in the second, syngenic liver transplantations using wild-type SD rats that do not express green fluorescent protein
(GFP) as syngenic donors and GFP-transgenic SD rats as recipients to confirm that an extrahepatic source of cells
+
–
(GFP ) could repopulate the transplanted (GFP ) liver were performed.
Results: Treatment of the oral supplementation of BCAA for 2-3 weeks before transplantation to promote liver
regeneration resulted in greater than 7 days graft volume with extensive spotty conversion of a small wild type graft to
+
the recipient GFP genotype. Definitely, liver repopulation could be achieved with hepatocytes that bone marrow
derived from stem cells proliferated. The treatment by oral supplementation of BCAA resulted in higher levels of
CD34+SDF+c-kit+ stem cells in the blood and liver after liver transplantation. Liver repopulation could be achieved
with hepatocytes that bone marrow derived from stem cells proliferated.
Conclusion: We have identified extrahepatic stem cell migration from the BM to the injured liver as a mechanism
underlying liver regeneration that supports hepatocyte proliferation in diseased liver. Our results suggested that BCAA
is able to mobilize a population of BM derived cells that contribute to hepatic regeneration.
Disclosure of Interest: None declared
255
151.02
RELATION OF SERUM VITAMIN D LEVELS IN HETEROGENOUS GROUP OF CANCERS IN INDIA
A. Anand1,*, A. A. Sonkar1, N. Husain2, K. R. Singh1, J. K. Kushwaha1, S. Singh1
1
2
Surgery, King George's Medical University, Pathology, RML Institute of Medical Sciences, Lucknow, India
Introduction: Vitamin D deficiency is quite prevalent in both urban and rural settings and in various income levels in
India. Vitamin D deficiency plays an important role in the high prevalence of rickets, osteoporosis, cardiovascular
diseases, diabetes, infections such as tuberculosis and cancers. Besides these, calcitriol also has broad anti tumor
effects. Numerous epidemiological and preclinical studies support role of vitamin D compounds in cancer prevention
and treatment. Low levels of plasma 25(OH) D3 are associated with higher cancer incidence and mortality in men in
colorectal, breast, lung and prostate cancers. In the present work an attempt has been made to study the serum levels
of Vit D in heterogeneous patients of breast cancer, oral cancer and cancer gall bladder.
Materials & Methods: n=312 {oral cancer (n=110 cases; n=15 controls; M:F=19:1); gallbladder cancer (n=30 cases;
n=11 controls; M:F=1:3); carcinoma breast (n=82 cases; n=64 controls) were included after institutional Ethics
Committee clearance between April 2012 and October 2013. Normal healthy, age and sex matched and unrelated to
patients were recruited to serve as “controls”.
Mean age of presentation of cases oral cancer was 42.67±10.83 years, gallbladder cancer was 47.43±9.27 years and
breast cancer was 48.43±12.45 years. Serum Vitamin D levels were estimated both in cases and controls and WHO
criteria was used for determining deficient state.
Results: The mean value of serum vitamin D was lower in cases (n=222; 25.7ng/ml) as compared to controls (n=90;
40.8ng/ml) though not statistically significant.
In oral cancer patients the mean Vitamin D levels of cases was significantly lower as compared to controls (p=0.002).
Mean Serum Vit D level was lower (23.9%) in gallbladder cancer patients (24.89±10.81ng/ml) as compared to control
subjects (32.70±17.38ng/ml), but the difference was not statistical significance (p>0.05) between the two groups.
The prevalence of vitamin D deficiency in carcinoma breast patients at the time of presentation was 74.4% with a
mean serum vitamin D of 26.03 ng/ml in the total study patients compared to 41.48 ng/ml in the total control group.
Conclusion: In all cases serum vitamin D levels were statistically lower in oral cancer cases compared to controls.
Carcinoma breast and cancer gallbladder cases also showed lower values but with no statistical difference. This study
highlights the association of low levels of serum vitamin D with the heterogeneous group of cancers in India.
Disclosure of Interest: None declared
256
151.03
EFFECT OF DIETARY SUPPLEMENTATION IN BUERGER'S DISEASE.
A. Kumar1,*, A. A. Sonkar1, J. K. Kushwaha1, A. Agarwal1
1
General Surgery, KG Medical University, Lucknow, India
Introduction: Buerger’s disease or thromboangiitis obliterans (TAO) is a disease of small and medium sized vessels
of unknown etiology having inflammation and occlusion with weak peripheral pulses giving rise to pain of varying
severity with or without ulceration of the toe or foot of patients of poor socio economic strata who smoke heavily.
Hypo-vitaminosis, deranged homocysteine metabolism and genetic deficiencies are often blamed. Presently treatment
is surgical with poor results. In present study effect of supplementation of L-arginine 15g/day {to increase Nitric Oxide
(NO) production and decrease vasospasm}, folic acid (5 mg), vitamin B6 (100 mg) and vitamin B12 (2000 mcg) is
assessed.
Materials & Methods: Male patients (n=16) median age 30 were included in this prospective observational study.
Serum of patient’s pre and post nutritional supplementation were collected in cryogenic vial and stored at – 800C for
estimation of NO levels spectrophotometrically using colorometric assay kit
Results: In post treatment arm two groups were identified, group A (n=8) duration of disease less than one year
(mean 7.37 months) and group B (n=8) duration of disease more than one year (mean 20.5 months). Pre & post
supplementation mean serum NO levels were 14.25 and 16.6 µmol/l respectively in group A and 8.625 & 11.125
µmol/l respectively in group B. Both groups showed increased NO levels after supplementation with relief of clinical
symptoms like pain etc.
Conclusion: A non statistical increase in NO levels was observed across groups with consequential decrease in pain
and requirement of analgesics.
Disclosure of Interest: None declared
257
151.04
REDUCING THE RISK OF COMPLICATIONS IN COLORECTAL SURGERY WITH PERIOPERATIVE CARE
RECOMMENDED BY ACERTO PROJECT.
A. Bicudo-Salomao1,2,*, J. E. Aguilar-Nascimento1, R. D. F. Salomão3
1
2
3
Surgery Department, Medicine Faculty, Mato Grosso Federal University, Surgery Department, Public Health,
Medicine Faculty, Cuiabá University, Cuiabá, Brazil
Introduction: The application of perioperative care multimodal protocol have resulted in significant improvement in
surgery's results. However, there is a wide variety of conducts in multimodal protocols, with different times of
application, which generates a particular interest to investigate what the components of a multimodal protocol would
be the most responsible for positive results that have been observed. We investigate in patients submitted to large
elective colorectal operations, the impact of the conducts of a multimodal protocol (ACERTO Project) in the risk of
anastomotic fistula, pneumonia-atelectasis and mortality.
Materials & Methods: Cohort study including patients submitted to elective open surgery, with colon resection and/or
rectum, primary anastomosis or Hartmann's colostomy closure.
Results: Were analyzed 234 patients, submitted to 84 (35.9%) Hartmann's colostomy reconstructions, 39 (16.7%)
right colectomy, 39 (16.7%) left colectomy and 72 (30.8%) anterior rectum resection. Increased risk of anastomotic
fistula occurred for malnutrition (OR=2,87 IC95=1,36-6,05; p=0,006), rectal surgery (OR=8,23 IC95=3,12-21,74;
p<0,0001) and presence of NNIS risk factor (OR=6,14 OR=2,09-18,05; p=0,001). Time preoperative fasting ≤4h
(OR=0,11 IC95=0,05-0,25; p<0,0001) constituted a protective factor for the occurrence of fistulas. Factors
significantly associated with pneumonia-atelectasis were cancer diagnosis (OR = 4.82 OR = 2.03 -11.47, p <0.0001)
and rectal surgery (OR=3,07 IC95=1,18-7,74; p=0,022), while the time of preoperative fasting ≤4h (OR=0,10
IC95=0,04-0,24; p<0,0001) and intravenous volume of crystalloid infused ≤30ml/kg/day (OR=0,36 IC95=0,13-0,97,
p=0,044) shown to be a protective factors. Cancer diagnosis was associated with an increased risk of death 9x (OR=
9,04 IC95=1,60-50,89). The duration of preoperative fasting ≤4h (OR=0,05 IC95= 0,01-0,23) and intravenous volume
of crystalloid infused ≤30ml/kg/day (OR=0,14 IC95=0,02-0,97) constituted protective factors for mortality.
Conclusion: Malnutrition, rectal surgery, NNIS risk factor and time of preoperative fasting exceeding 4h were
independent risk factors for anastomotic fistula. Were risk factors for pneumonia-atelectasis: rectum surgeries, time of
preoperative fasting exceeding 4h and intravenous crystalloid fluidtherapy exceeding 30ml/kg/day and cancer
diagnosis. Cancer diagnosis, prolonged preoperative fasting and intravenous crystalloid fluidtherapy exceeding
30ml/kg/day represented independent risk factors for postoperative death.
Disclosure of Interest: None declared
258
151.05
EVALUATION OF PERIOPERATIVE PLASMA AND DRAIN FLUIDS ENDOTOXIN LEVELS AS A BIOMARKER OF
DIAGNOSIS, SEVERITY AND POSTOPERATIVE COMPLICATIONS IN PATIENTS UNDERGOING LEFT
COLONIC DIVERTICULITIS SURGERY
D. M. Smirnov1,*
1
Surgical Diseases, South Ural State Medical University, Chelyabinsk, Russian Federation
Introduction: Acute diverticulitis (AD) is the most usual complications of diverticular disease. Delay in diagnosis and
treatment of AD encompasses a variety of conditions, ranging from localized diverticular inflammation to fecal
peritonitis, results in an increased rate of postoperative morbidity, mortality and hospital length of stay. The Aim of this
study was to evaluate the clinical significance of perioperative monitoring of plasma and drain fluid endotoxin (LPS)
levels as a predictor of diagnosis and severity of AD in case of surgical treatment.
Materials & Methods: Retrospective study based on a prospectively updated database: 100 consecutive patients
who underwent laparoscopic surgery (colon resection, primary anastomosis, peritoneal lavage) in acute complicated
diverticulitis were investigated between September 1, 2010 and November 1, 2014. Blood samples was obtained at
the time of patients admission, during operations and daily (during 10 days) after surgery for measuring plasma LPS
levels using the LAL-endotoxin scattering photometry. Drain fluids was collected at the same time after surgery. The
systemic inflammatory response (PSIR) was classified on the basis of admission data according to the standard
methods.
Results: The sensitivity and specificity of preoperative LPS level measurement for AD diagnosis were 98% and 100%
respectively. After surgery, 17% patients developed a postoperative infectious complication (wound infections,
peritonitis), which was diagnosed on postoperative days 2-7. Multivariate analyses using factors including pre-, intraand postoperative serum and drain fluid LPS levels, operation time and expressiveness of PSIR revealed that PSIR
(odds ratio, 2.172; P = 0.0192), preoperative serum LPS levels (odds ratio, 2.467; P = 0.0327) and postoperative drain
fluid LPS levels (odds ratio, 2.568; P = 0.0271) were associated with a postoperative infection. Univariate analysis
revealed that the expressiveness of preoperative serum LPS levels was the most sensitive predictor of postoperative
infectious complication (odds ratio, 2.135; P = 0.0051). The value of drain fluid LPS increased with the severity of AD
and also with the presence of peritonitis and infection.
Conclusion: The PSIR and perioperative serum and drain fluid LPS levels may be an additional early diagnostic
factors of AD. Preoperative serum LPS level can be used as a prognostic marker and predictor of infectious
complications following surgery and it can help to carry out timely surgical intervention.
Disclosure of Interest: None declared
259
151.06
EARLY ENTERAL COMBINED WITH PARENTERAL NUTRITION VS TOTAL PARENTERAL NUTRITION: IMPACT
ON POSTOPERATIVE OUTCOME IN PATIENTS UNDERGOING STANDARD PANCREATICODUODENECTOMY
J.-W. Lu1,2,3,*, X.-F. Zhang1,2,3, Y. Lv1,2,3
1
2
Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi’an Jiaotong University, Regenerative Medicine and
3
Surgery Engineering Research Center of Shaanxi Province, XJTU Research Institute of Advanced Surgical
Technology and Engineering, Xi’an Jiaotong University, Xi'an, China
Introduction: To evaluate the clinical outcome between patients undergoing EEN+PN (EEN by placing a nasojejunal
feeding catheter combined with additional PN (parenteral nutrition))and TPN (total parenteral nutrition).
Materials & Methods: From January 2009 to January 2013, 340 consecutive patients undergoing standard PD with
Child reconstruction in First Affiliated Hospital of Xi'an Jiaotong University were enrolled in this study, with 88 patients
in EEN+PN group and 252 in TPN group,respectively. Preoperative baseline characteristics,
histopathological types,intraoperative parameters and postoperative outcomes were recorded and analyzed between
the two groups.
Results: No significant difference was shown in preoperative baseline characteristics, histopathology of resected
lesions or intraoperative parameters. Patients undergoing EEN+PN had a significant higher delayed gastric emptying
(DGE)incidence (14/88, 15.9% vs 17/252, 6.7%,P=0.016), higher pneumonia morbidity rate (10.3% vs 3.6%,
P=0.024), prolonged nasogastric tube removal time (5.6±0.2days vs 3.9±0.1 days, P= 0.036) and higher
hospitalization expenses(10396.95±861.18 dollars vs 8663.86±239.21 dollars, P=0.008). Morbidity of other
postoperative complications, in-hospital mortality and unplanned reoperation occurrence within 30 days revealed no
statistical significance (all P> 0.05).
Conclusion: Our research suggests postoperative EEN+PN following standard PD is associated with increased
incidence of DGE and pneumonia, prolonged nasogastric tube removal time and more hospitalization expenses.
Hence, EN should only be performed scrupulously and selectively. A sequence of RCTs should be designed and
implemented to investigate the impact of EEN+PN on postoperative complication morbidity, the optimal timing and
dose corresponding to different postoperative recovery phases.
Disclosure of Interest: None declared
260
151.07
BODY COMPOSITION MEASURED BY DIRECT SEGMENTAL MULTIFREQUENCY BIOELECTRICAL
IMPEDANCE ANALYSIS IN THAI FEMALES
S. Denariyakoon1,*
1
Surgery, Chulalongkorn University, Bangkok, Thailand
Introduction: Body composition value is globally used as adjunct in nutritional status evaluation. Many instruments
were developed to present the body composition measurement. At present, bioelectrical impedance analysis is
reliable in estimating body composition data for evaluating nutritional status in clinic, especially fat mass index, fat free
mass index, visceral fat area and phase angle. Many studies showed gender effect in estimating the value. However,
there is lack of data in Thailand. The aim of this study is to present useful body composition value in Thai females.
Materials & Methods: Totally 402 Thai female healthy volunteers were included. The cross-sectional study in which
Direct segmental multifrequency bioelectrical impedance analysis(DSM-BIA) [5-1,000kHz] was use in order to
estimate FMI, FFMI, VFA, phase angle etc. in each age group including 23-84 years females
2
th
th
th
th
Results: FFMI was 13.13-18.55 kg/m (Percentile 5 -95 ) , FMI is 4.12-14.42 (Percentile 5 -95 ) Phase angle is
th
th
5.19-7.8 (Percentile 5 -95 ) of the Thai females (20-84 years). From young to elderly group, VFA and Percent body
fat are increased but phase angle and FFM tend to decline.
Conclusion: The measured value correlated to the previous western study, therefore the interval value should be
practically used. FFMI, FMI, VFA and phase angle showed effect of aging, and considered for additional use as
nutritional status evaluation in clinic.
Disclosure of Interest: None declared
261
170.01
EFFECT OF LOCAL ANESTHETICS PORT-SITE INFILTRATION AND SINGLE-DOSE PREOPERATIVE
INTRAVENOUS DEXAMETHASONE FOR POSTOPERATIVE PAIN AFTER LAPAROSCOPIC
CHOLECYSTECTOMY
V. Viriyaroj1,*, T. Boonsinsukh1, T. Rookkachart1, H. Yodying1, N. Yigsakmongkol1
1
surgery, HRH princess chakri Sirindorn medical center, Srinakharinwirot University, Nakhon-nayok, Thailand
Introduction: Laparoscopic cholecystectomy is one of the most common procedure in surgery. Post-operative pain
and post-operative nausea and vomiting (PONV) is a frequent event after laparoscopic cholecystectomy and an
unpleasant and distressed problem for patients. This study aimed to determine the effects of local anesthesia (1%
xylocaine with adrenaline) infiltrated at port-site and single-dose preoperative intravenous dexamethasone for
postoperative pain, post-operative nausea and vomiting after laparoscopic cholecystectomy.
Materials & Methods: One hundred twenty patients, who have indication for laparoscopic cholescystectomy at
MSMC hospital were randomly allocated into one of three groups. Group I received 20 ml of Normal saline at port-site
area and 2 ml of Normal saline intravenous 60-90 minutes before operation. Group II received 20 ml of 1% xylocaine
with adrenaline at port-site area and 2 ml of Normal saline intravenous 60-90 minutes before operation. Group III
received 20 ml of 1% xylocaine with adrenaline at port-site area and 8 mg of Dexamethasone intravenous 60-90
minutes before operation. All patients received a standardized anesthetic, surgery and multimodal analgesic
treatment. We measured visual analog pain scores, episode of nausea and vomiting at 1, 6, 24 hours postoperative
and discharge. Analgesic and antiemetic drug requirement included Erythrocyte sedimentation rate (ESR), C-reactive
protein (CRP) preoperative and postoperative, time of operation, hospital stay and complication were recorded.
Results: No significant difference existed between three groups regarding age, sex, previous operation, operation
time and hospital stay. The patients in group III significantly reduce visual analog pain score, episode of nausea and
vomiting at 1 and 6 hours postoperative, analgesic, antiemetic drug requirement and CRP postoperative. No
significant difference existed between group I and group II regarding visual analog pain score, episode of nausea and
vomiting, analgesic, antiemetic drug requirement, ESR, CRP preoperative and postoperative.
Conclusion: Single-dose dexamethasone 8 mg intravenous 60-90 minutes before operation can reduce pain score,
episode of nausea and vomiting at 1 and 6 hours postoperative and analgesic, antiemetic drug requirement but local
anesthesia (1% xylocaine with adrenaline) infiltrated at port-site can’t reduce pain score, episode of nausea and
vomiting postoperative laparoscopic cholecystectomy.
Disclosure of Interest: None declared
262
170.02
ACOUSTIC RADIATION FORCE IMPULSE ELASTOGRAPHY AS A PREDICTOR OF POSTOPERATIVE
COMPLICATIONS AFTER HEPATIC RESECTION
A. Miyoshi1,2,*, H. Koga1, T. Ide2, K. Kitahara1, H. Noshiro2
1
2
surgery, Saga-Ken Medical Centre Koseikan, surgery, Saga University, Saga, Japan
Introduction: Precise preoperative evaluation of functional liver reserve and the identification of sensitive predictors
of postoperative complications are necessary to reduce morbidity and mortality after hepatic resection for
hepatocellular carcinoma (HCC). This study assessed whether liver stiffness on acoustic radiation force impulse
(ARFI) elastography can evaluate hepatic reserve and predict postoperative complications.
Materials & Methods:
The study cohort consisted of 37 consecutive patients who underwent curative hepatic resection for HCC. Liver
stiffness on ARFI was compared with these other parameters in estimating hepatic reserve and in predicting patient
morbidity.
Results:
ARFI results correlated significantly with more than F3 fibrosis grade >F3 (p=0.001) and with histologically advanced
fibrosis (AUROC curve 0.84), with a cutoff value of 1.78 having a specificity of 88.9%. ARFI value also correlated with
markers of hepatic reserve, including platelet count (p=0.026) and serum albumin concentration (p=0.032). Patients
with ARFI ³1.7 m/s had a significantly higher morbidity rate (50.0%) than patients with ARFI <1.7 m/s (p=0.017).
Multivariate analysis showed that preoperative ARFI value was the only independent predictor of postoperative
complications (p=0.048).
Conclusion:
Preoperative ARFI value is a precise marker of liver fibrosis and hepatic reserve and could predict postoperative
complications after hepatic resection.
Disclosure of Interest: None declared
263
170.03
BALAD SCORE CAN PREDICT OUTCOME OF INITIAL HEPATOCELLULAR CARCINOMA AFTER
HEPATECTOMY
T. Kaida1,*, H. Nitta2, S. Nakagawa1, H. Hayashi1, H. Daisuke1, A. Chikamoto1, T. Beppu1, H. Baba1
1
2
Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto university, Kumamoto, Japan,
Kumamoto, Japan
Introduction: Tumor markers are one of prognostic factors for hepatocellular carcinoma (HCC). In addition, the
parameter of preoperative liver function such as albumin (Alb) or total-bilirubin (T-bil) greatly affects the therapeutic
strategies and the prognosis of patients with HCC. It was reported that BALAD score evaluated by five items including
the three HCC tumor markers (AFP, AFP-L3 and DCP), the level of preoperative Alb and preoperative T-bil was
greatly useful to predict the outcomes of patients with HCC (Toyoda et al, Clin Gastroenterol Hepatol, 2006).
However, It has not been reported about the usefulness of BALAD score in the patients with initial HCC who
underwent hepatectomy. Here, we analyzed the clinical usefulness of BALAD score in the HCC patients who
underwent initial hepatectomy.
Materials & Methods: Between January 2001 and April 2009, 393 patients were underwent hepatectomy for initial
HCC at the department of Gastroenterological Surgery, Kumamoto University Hospital. We classified in six groups
according to BALAD score (0 ~ 5) and analyzed the association between BALAD score and outcomes.
Results: The number of patients of BALAD score 0, 1, 2, 3, 4, 5 was 150, 138, 72, 31, 2, 0, respectively. There was
significantly difference in the level of AFP, AFP-L3 and DCP, the diameter of tumor, vascular invasion and Stage
between each group except score 5. Five-year recurrence-free survival (RFS) rate and overall survival rate (OS) of
each group was 31.3%, 26.2%, 24.9%, 21.7%, 0% (p=0.0003) and 78.6%, 61.7%, 62.8%, 29.4%, 0% (p<0.0001),
respectively. The RFS and OS of the patients with high BALAD score were significantly worse than those of patients
with low BALAD score. Univariate analysis demonstrated that the risk factors for poor RFS were age, the diameter of
tumor, the number of tumor and BALAD score. Multivariate analysis demonstrated that the number of tumor (HR
1.967, p<0.0001) and BALAD score (BALAD score 2: HR 1.531, p=0.026, BALAD score 3: HR 1.921, p=0.015) were
the independent risk factors for poor RFS.
Conclusion: BALAD score was useful to predict the RFS of initial HCC patients who underwent hepatectomy.
Disclosure of Interest: None declared
264
170.04
PERCUTANEOUS CHOLECYSTOSTOMY FOR DELAYED LAPAROSCOPIC CHOLECYSTECTOMY IN PATIENTS
WITH ACUTE CHOLECYSTITIS
E. Kamer1, F. Cengiz1, V. Çakır2, Ö. Ballı2, T. Acar1, M. Peşkersoy1, M. Hacıyanlı1,*
1
2
General Surgery, Interventional radiology, İzmir Katip Çelebi University Atatürk Training and Research Hospital,
İzmir, Turkey
Introduction: One of the most frequent emergency admissions to general surgical services is acut cholecystitis (AC).
Emergency cholecystectomy for AC is associated with high morbidity and mortality rates in patients with significant
comorbidities and high-risk surgery. The purpose of this retrospective study was to assess the effectiveness, possible
advantages, and complication of delayed laparoscopic cholecystectomy (LC) following percutaneous cholecystostomy
(PC) in patients with AC.
Materials & Methods: A total of 62 LC for AC were divided into 2 groups: the first group consisted of patients who
had PC followed by LC (PCLC group, n=12), and second group consisted of patients who had conservative treatment
followed by a delayed LC (non-PCLC group, n=40). The groups were statistically compared regarding their
demographic, comorbidity, hospital stay, conservation, and complication rates. PC was performed via the transhepatic
route under ultrasound guidance using local anesthesia. A specialized interventional radiologist team performed all
procedures.
Results: Fifty- two patients were considered to be at extremely high anesthetic or surgical risk because many of these
patients had underlying comorbid disease, as shown in Table 1. PC was technically successful in 12 patients with no
attributable mortality or major complications. Upon the regression of cholecystitis and the decrease in APACHE II
scores, the PC catheter was pluged out and elective LC was scheduled for after 8 weeks. All of patients in PCLC and
non-PCLC groups recovered well from cholecystectomy.
Conclusion: Result from this study suggests that PCLC would not significantly improve the outcome of outcome of
LC as assessed by conversion and morbidity rate and hospital stay compared with non-PCLC.
Disclosure of Interest: None declared
265
170.05
EFFICACY OF REPEATED LAPAROSCOPIC LIVER RESECTION.
K. Watanabe1,*, H. Uchida1, Y. Iwashita1, H. Takayama1, Y. Endo1, K. Yada1, M. Ohta1, M. Inomata1
1
Gastroenterological and Pediatric Surgery, Oita University, oita, Japan
Introduction: Repeated liver resection is the effective treatment for hepatocellular carcinoma and metastatic
carcinoma. However, it has remained unclear that laparoscopic liver resection (LLR) is effective for patients with prior
liver resection. The aim of this study was to evaluate surgical outcomes of LLR in patients with prior liver resection.
Materials & Methods: From January 2010 to October 2014, 21 patients underwent repeated partial liver resection in
our institute. They were divided into 2 groups according to the types of surgical approaches: open liver resection (OLR
group) and LLR group. Operative variables were retrospectively analyzed to identify differences between the 2 groups.
Results: Eleven patients and 10 patients were enrolled in the OLR group and LLR group, respectively. Patient
characteristics including age, tumor etiologies, intervals and so on were equivalent in the 2 groups. No conversion to
laparotomy was experienced in LLR group. There were no significant differences in operation time and postoperative
complications between the 2 groups (286 minutes in OLR group vs 187 minutes in LLR group, 2 cases (18%) in OLR
group vs 0 cases (0%) in LLR group). Significant differences between the 2 groups were observed in estimated
blood loss (444 ml in OLR group vs 68 ml in LLR group), postoperative hospital stay (19.4 days in OLR group vs 8.9
days in LLR group), postoperative maximum values of WBC (8090 /µl in OLR group vs 5210 /µl in LLR group) and
CRP (11.4 mg/dl in OLR group vs 4.9 mg/dl in LLR group).
Conclusion: Laparoscopic partial hepatectomy may be a good modality for patients with prior liver resection because
of its less invasiveness. These data should encourage surgeons to increase the offering of laparoscopy for repeated
liver resection.
Disclosure of Interest: None declared
266
170.06
THE C-REACTIVE PROTEIN TO ALBUMIN RATIO PREDICTS LONG-TERM OUTCOMES IN PATIENTS WITH
PANCREATIC DUCTAL ADENOCARCINOMA AFTER PANCREATIC RESECTION
K. Haruki1,*, H. Shiba1, T. Horiuchi1, Y. Shirai1, Y. Fujiwara1, K. Furukawa1, T. Misawa1, K. Yanaga1
1
Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
Introduction: The C-reactive protein to albumin (CRP/Alb) ratio, a novel inflammation based prognostic score, is
associated with outcomes in septic patients. The aim of this study is to evaluate the prognostic value of CRP/Alb ratio
in patients with pancreatic ductal adenocarcinoma after pancreatic resection.
Materials & Methods: The study comprised 113 patients who had undergone pancreatic resection for pancreatic
ductal adenocarcinoma between April 2001 and March 2011. We retrospectively investigated the relation between
CRP/Alb ratio and disease-free as well as overall survival.
Results: For disease-free survival, preoperative biliary drainage (p=0.011), advanced tumor-node-metastasis (TNM)
classification (p=0.002), and higher CRP/Alb ratio (p=0.049) were selected by univariate analysis, while advanced
TNM classification (p=0.003) by multivariate analysis was independent and significant predictor. For overall survival,
preoperative biliary drainage (p=0.012), advanced TNM classification (p=0.001), and higher CRP/Alb ratio (p=0.023)
were selected by univariate analysis, while advanced TNM classification (p=0.003) and higher CRP/Alb ratio
(p=0.035) were independent and significant predictors by multivariate analysis.
Conclusion: The CRP/Alb ratio seems to be an independent and significant indicator of poor long-term outcomes in
patients with pancreatic ductal adenocarcinoma after pancreatic resection.
Disclosure of Interest: None declared
267
170.07
INHIBITION OF NUCLEAR FACTOR KAPPA-B ENHANCES THE ANTITUMOR EFFECT OF COMBINATION
TREATMENT WITH GEMCITABINE AND NAB-PACLITAXEL FOR PANCREATIC CANCER CELLS.
Y. Shirai1,2,*, T. Uwagawa1, H. Shiba1, T. Horiuchi1, R. Iwase1, K. Haruki1, T. Ohashi2, K. Yanaga1
1
2
Surgery, Division of Gene Therapy, Research Center for Medical Sciences, The Jikei University School of Medicine,
Tokyo, Japan
Introduction: Nuclear factor κB (NF-κB) plays an important role in promoting growth, angiogenesis, and metastasis in
pancreatic cancer and serves as a mechanism underlying therapeutic resistance. Pomalidomide is investigational
immunomodulating drug (IMiDs) of thalidomide under development that also inhibits angiogenesis and induces
apotosis. We hypothesized that pomalidomide inhibits the anticancer agent-induced NF-κB activity and enhances the
antitumor effect of combination treatment with gemcitabine and nab-paclitaxel for pancreatic cancer cells.
Materials & Methods: We assessed NF-κB activity and cell viability of human pancreatic cancer cell lines (MIA PaCa
2) treated with gemcitabine alone , both gemcitabine and nab-paclitaxel, triple combination of gemcitabine, nabpaclitaxel and pomalidomide, or vehicle as control. NF-κB activation was evaluated by measuring nuclear localization
of p65 protein.
Results: NF-κB activity in anticancer agent groups were higher than that in control group (p<0.01, respectively).
Pomalidomide significantly inhibited anticancer agent-induced NF-κB activation (p<0.01, respectively). Triple
combination group revealed high apoptosis rates as compared with combination of gemcitabine and nab-paclitaxel
(p>0.01). Cell viability in triple combination group was lower than that in gemcitabine alone, or combination of
gemcitabine and nab-paclitaxel groups (p<0.05, respectively).
Conclusion: Inhibition of NF-κB by pomalidomide enhances the antitumor effect of combined gemcitabine and nabpaclitaxel for pancreatic cancer cells.
Disclosure of Interest: None declared
268
170.08
A NOVEL TECHNIQUE OF ENDOSCOPIC MAGNETIC COMPRESSION CHOLEDOCHODUODENOSTOMY
F. Xue1,2,3,*, F. Ren1,2,3, P. Liu1,2,3, J. Li1,2, X. Yan1,2,3, F. Ma1,2,3, Y. Lv1,2,3
1
2
Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi’an Jiaotong University, Shaanxi , Regenerative
3
Medicine and Surgery Engineering Research Center of Shaanxi Province, Shaanxi, XJTU Research Institute of
Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Shaanxi, Xi'an, China
Introduction: In patients with biliary stricture or tumor of lower bile duct, establishing a pathway between the common
bile duct and duodenum for biliary drainage is crucial for the development of diseases. Generally, PTCD, EST or
bilioenteric surgery are the most common methods, yet they may lead many complications including hemorrhage,
poor healing, anastomotic leakage and pancreatitis. The aim of this study is to introduce a novel technique of
endoscopic magnetic compression choledochoduodenostomy which is minimally invasive, simple, and practicable and
would cause minimal complication.
Materials & Methods: The magnets were made up of cylindrical nickel-plated neodymium-iron-boron (Nd-Fe-B)
material. The daughter magnet with basal diameter of 4mm and height of 6mm was fixed at the superior site of a 6French catheter by a long silk suture; the parent magnet was manufactured with basal diameter of 7mm and height of
6mm. Four dogs were selected randomly for the model of biliary obstruction; they underwent laparoscopic ligation of
lower bile duct before the experiment. Seven days after modeling, when the extrahepatic duct and ductus cysticus
were dilated completely, a guide wire was inserted through a 5mm incision in the bottom of the cholecyst of the
anesthetized dog under laparoscopy. The guide wire was pushed through the ductus cysticus to the upward side of
lower bile duct; then a 6-French catheter pushed the daughter magnet into designated spot in the common bile duct
via the guide wire. After that, we removed the fixing wire, catheter and guide wire and closed the fistula.
Simultaneously, the parent magnet was placed near the duodenal papilla under endoscopy; the two magnets were
attracted under the gravity.
Results: The magnets were fallen 3-, 4-, 4-, and 5 days after operation respectively. A 6mm fistula between the
common bile duct and duodenum can be observed under endoscopy and the bile flowed smoothly via the fistula. The
th
specimen taken on the 14 day showed that fistula kept patency, mild inflammation response can be observed
histopathologically and no leakage was observed in all dogs.
Conclusion: The magnets can only be placed through the ductus cysticus because of the anatomy characteristics of
dogs. According to other literature, the magnets can be placed by PTCD in human. The magnetic compression
anastomosis avoided a series of complications. This effective and simple operation would be a conventional method
for the treatment of biliary stricture and obstruction of common bile duct.
Disclosure of Interest: None declared
269
170.09
PROSPECTIVE OBSERVATIONAL UNICENTER STUDY ON EUS-GUIDED BILE DUCT DRAINAGE (EUS-BD), IN
PARTICULAR, FOR SPECIFIC BENIGN LESIONS IN A CONSECUTIVE PATIENT COHORT WITH CHOLESTASIS
& FRUSTRATING ERCP
U. Will1, F. Fueldner1, F. Meyer2,*
1
Dept. of Gastroenterology, Municipal Hospital (SRH Waldklinikum), Gera, 2Dept. of General, Abdominal and Vascular
Surgery, University Hospital at Magdeburg (Germany), Magdeburg, Germany
Introduction: Aim: To describe our experiences using this procedure established as alternative approach to ERCP
(gold standard) even in benign lesions.
Materials & Methods: From 2004-2014, EUS-BD was performed in 28 consecutive patients with exclusively benign
diseases & frustrating ERCP out of 160, the total number of patients who have undergone this procedure during this
time period. Indication profile comprised: chronic pancreatitis, n=5; former biliodigestive anstomosis/gastrectomy,
n=14 & n=1, resp.; atypical mouth of the bile duct at the duodenal transition point from the vertical to the horizontal
segment, n=1; papilla of Vater which cannot be cannulized, n=6; stump(s) of intrahepatic branches of the biliary tree
after former hemihepatectomy, n=1.
Results: There were various transluminal routes to approach the biliary tree: transgastric, n=19; -duodenal, n=7; jejunal, n=2. The technical success rate was 100% for cholangiography (n=28). However, while drainage was not
required in 2 subjects, balloon dilatation including stone extraction was sufficient in 3 individuals. Draining effect was
achieved in 74% (n=17/28) using placement of polyethylen (n=7) or metal stent (n=10). Techniques for stent insertion
& final EUS-BD sites included rendezvous technique (n=5/17), choledochointestinostomy (n=2/17), antegrade &
retrograde drainage (n=2/17) as well as hepaticointestinostomy: n=8. Complication spectrum (n=6; periinterventional
morbidity, 21%) was characterized by pancreatitis, bleeding; hemobilia, leckage of the biliary tree with operative
consequence (n=1 each) & stent migration (n=3; no death).
Conclusion: EUS-BD can be considered an elegant, suitable & safe alternative to drain necessarily biliary tree even
in cases with benign diseases. By consequently avoiding percutaneous cholangiodrainage & surgical intervention,
resp., an at least middle-term solution of cholestasis by an interventional EUS-based procedure & an improved quality
of life can be provided. Because of the frequently complex (pathological &/or postsurgical) anatomy, EUS-BD should
be only performed in centers of interventional EUS in experienced hands including developed expertise in abdominal
surgery in the background for the rare but serious & challenging cases of complications as well as unpredictable
events. It appears (urgently) required to perform larger studies with greater case numbers to objectify the approach &
its periinterventional management as well as to further develop the equipment, tools & devices.
Disclosure of Interest: None declared
270
176.01
RE-EXPLORATORY LAPAROTOMY IN MULTIPLE SHRAPNEL INJURIES OF THE ABDOMEN: A NOVEL
APPROACH IN WAR SURGERY
K. Somaratne1,*, T. Seneviratne2, K. Senanayaka3
1
2
General Surgery, Teaching Hospital Colombo South, Kalubowila, Pharmacology, University of Peradeniya,
3
Peradeniya, General Surgery, University of Rajarata, Mihintale, Sri Lanka
Introduction: In battle casualties multiple penetrations of the abdomen due to bullets or shrapnel is a common injury.
In exploratory loparotomy done for these injuries there is a possibility of missing out hollow organ penetrations due to
two reasons.
1. Shear multiplicity of penetrations
2. Under the pressure of heavy casualty influx the time that could be devoted for each loparotomy is limited
Thus we tested the viability of doing a re-exploratory laparotomy in 48-72 hrs. with the purpose of finding any missed
out penetrations of hallow organs.
Materials & Methods: In 84 cases of multiple shrapnel injuries of the abdomen received at the Army Base Hospital
Palaly from July, 2008 up to May, 2009 we performed re-exploratory loparotomy in 48-72 hrs with the purpose of
finding any missed out perforating at the primary exploratory loparotomy.
Results: In 09 patients out of total of 84 patients (10.7%) missed out perforations were found, and were
repaired/resected.
Conclusion: The fact that in 10.7% cases a missed out perforation was found in the 48 hrs exploratory laparotomy
implies that it may be a useful and a viable option in multiple shrapnel injuries of the abdomen.
Disclosure of Interest: None declared
271
176.02
EFFECTS OF THE SECOND GULF WAR ON MAN-MADE VASCULAR INJURIES
F. Abu-Zidan1,*, I. Zayyat2
1
2
Surgery, College of Medicine, UAE University, Al-Ain, United Arab Emirates, Surgery, Mubarak Al-Kabeer Teaching
Hospital, Jabirya, Kuwait
Introduction: Wars have long term effects in conflict areas. This includes the post-war change in the mechanism of
injury. We aimed to study the effects of Second Gulf War on the pattern of man-made vascular injuries in Kuwait.
Materials & Methods: Vascular injuries treated at Mubarak Al-Kabeer teaching Hospital, Kuwait, during the pre-war
period of 1984-1990 was compared with published data of vascular injures of the war period (1990-1991) [1] and post
war period [2] (1992-2000).
Results: There were 44 pre-war vascular injuries (7.3 cases/year) compared with 36 cases treated during the war (36
cases/ year) and 155 cases treated after the war (19.4 cases/year). The percentage of man-made vascular injuries
before the war was 4.6% (2/44), all were stab wounds, compared with 100% during the war, 94.4% due to firearms
and blast injuries, and 5.6% due to stab wounds. After the war, man-made vascular injuries were 43.2% of all vascular
injuries (67/155), 34.1% were due to stab wounds and 11.1% were due to firearms and blast injuries. This change was
highly significant (p < 0.0001, Fisher’s Exact test).
Conclusion: Wars have long term effects on behaviour of the population increasing the interpersonal violence.
Availability of weapons in the hands of civilians increases man-made penetrating trauma
References: 1. Jawas A, Abbas AK, Nazzal M, Albader M, Abu-Zidan FM. Management of war-related vascular
injuries: experience from the second gulf war. World J Emerg Surg. 2013;8:22.
2. Asfar S, Al-Ali J, Safar H, Al-Bader M, Farid E, Ali A, Kansou J: 155 vascular injuries: A retrospective study in
Kuwait. 1992-2000. Eur J Surg 2002, 168:626-630.
Disclosure of Interest: None declared
272
176.03
EFFICACY OF HAEMOSTATIC CHITOSAN GEL CONTAINING EXTRACTS OF EUPATORIUM ODORATUM LINN.
LEAVES.
S. Panichkul1,*, P. Hatthachote2, S. Wongkhan3
1
Phramongkutklao Military Medicine Center of Excellence, Phramongkutklao Hospital and College of Medicine,
2
Physiology, Phramongkutklao College of Medicine, 3Alternative Medicine, Rangsin University, Bangkok, Thailand
Introduction: Hemorrhage is a leading cause of death from trauma. An advanced hemostatic dressing could augment
available hemostatic methods. The purpose of this study is to develop a novel hemostatic chitosan gel contains the
crude extracted of Eupatorium odoratum Linn. with good gel properties and stability.
Materials & Methods: Many formulation of gel base use shrimps, crabs or squid chitosan dissolve in lactic acid
solution were developed. The formula of gel base compose of 3% chitosan from squid pen w/w in lactic acid
corporate with 1% of Eupatorium odoratum (EUO) extracted will give the gel right consistency, less bubble, static color
and best stability. The studies in animal were obtained to confirm hemorrhage stopping, while the irritation test confirm
safety and non toxic of the gels. Four type of the gels: chitosan gel base, chitosan with extract of EUO used water as
the solvent (EUO-H2O), chitosan with extract of EUO used ethanol as the solvent (EUO-EtOH) and chitosan with
extract of EUO used ethyl acetate as the solvent (EUO-Ethyl acetate) were selected to further clinical study in animal.
Results: The result of bleeding model showed that EUO-EtOH gel take least time (3.67 ± 0.67 min.) to stop bleeding
model in rats (P<0.05). While the result of acute dermal irritation (OECD Guidelines for Testing of Chemicals - 2002)
showed that there were minor rash in some rabbit and disappear afterward.
Conclusion: This study revealed that the formula of EUO-EtOH gel provided safety and best antihemorrhage
properties. It could be developed in further clinical human study.
References: 1. Pusateri, Anthony E. et al, " Effect of a Chitosan-Based Hemostatic Dressing on Blood Loss and
Survival in a Model of Severe Venous Hemorrhage and Hepatic Injury in Swine. " Journal of Trauma-Injury Infection &
Critical Care, 54(1): 177-182, January 2003
2. Peh K, Khan T, Ch'ng H., " Mechanical, bioadhesive strength and biological evaluations of chitosan films for wound
dressing. " J. Pharm. Sci., 2000 Sep-Dec; 3 (3): 303-11
3. Donald L Parsons “ The Layman’s Guide to Hemostatic Agents ” The Society of Army Physician Assistants, Vol.
19, No.1 ; February 2007
4. John G McManus, Ian Wedmore, “ Modern Hemostatic Agents for Hemorrhage Control – A Review and Discussion
of Use in Current Combat Operations ” Emergency Medicine Review 2005, reference section:
www.touchbriefings.com
5. Alec Belman, Mohamud Daya, Mark Stevens, Joseph Worley, “ From the Battlefield to the Street-Experience of
Suburban Fire/EMS Agency with Chitosan Dressing ” Hemostatic Management, Emergency Medicine & Critical Care
Review 2006, http://touchbriefing.com/pdf/2459/Belman.pdf
6. Lawrence E Heiskell et al, “ Blood Clotters ” SWAT medics report their findings on high-tech hemostatic dressing
used to stop bleeding when seconds count. , policemag.com; August 2004, 52-59
7. David Crane, “ Tactical Medicine: Revolutionary product stops major bleeding fast. ” Defense Review October
2006, www.defensereview.com
8. Hasan B Alam, “ Hemorrhage Control in the Battlefield: Role of New Hemostatic Agents ” Military Medicine,
Vol.170, 63-69; January 2005
9. Michael A Traver, Dean G Assimos, “ New Generation Tissue Sealants And Hemostatic Agents: Innovative Urologic
Applications ”, Reviews in Urology, Vol.8, No.3 : 104-111: 2006
10. Terdphong Triratana, Rachanee Suwannuraks, Waree Naengchomnong. Effect of
Eupatorium odoratum on Blood Coagulation. J Med Assoc Thai. 74(5), 1991 : 283-287
11. Suchitra Thongpraditchot, Wisuda Suvitayavat, Rungravi Temsiririrkkul. Effect of
Eupatorium odoratum Linn. on Vascular Tone and Primary Irritation Test. Mahidol J Pharm Sci. 21(2), 1994 : 44-49
12. Wongkrajang Y, Muangklum S, Peungvicha P et al. Eupatorium odoratum Linn. : An
enhancer of hemostasis. Mahidol J Pharm Sci. 17(1), 1990 : 9-13
Disclosure of Interest: S. Panichkul: None declared, P. Hatthachote Salary, Royalty or Honoraria from: 0, Receipt of
Intellectual Property Rights of: 0, Grant/Research Support from: 0, Consulting fees from: 0, Speaker’s Honorarium
from: 0, Ownership Interest of: 0, Other Financial/Material Support from: 0, S. Wongkhan Salary, Royalty or
Honoraria from: 0, Receipt of Intellectual Property Rights of: 0, Grant/Research Support from: 0, Consulting fees
from: 0, Speaker’s Honorarium from: 0, Ownership Interest of: 0, Other Financial/Material Support from: 0
273
176.04
TRIAGE OF WAR-RELATED INJURED PATIENTS: EXPERIENCE FROM THE SECOND GULF WAR
F. Abu-Zidan1,*, I. Ayyash2, S. Aman2
1
2
Surgery, College of Medicine, UAE University, Al-Ain, United Arab Emirates, Surgery, Mubarak Al-Kabeer Teaching
Hospital, Jabiryia, Kuwait
Introduction: Triage is an essential part of disaster management that affects its outcome. We aimed to compare two
triage methods and its effects on missed injuries during the Second Gulf War.
Materials & Methods: The triage system of Mubarak Al-Kabeer teaching Hospital in the first day of the Second Gulf
nd
war (2 August 1990) was different compared with its last day. It consisted in the first day of field triage in front of the
hospital and medical triage within the hospital. Three experienced general surgeons performed the field triage. The
man power became less with time. The triage at the last day of the war (26th February 1991) was only an in hospital
triage performed in the Emergency Department by a urologist who had previous experience in General surgery while
experienced surgeons were operating. Data regarding missed injuries were retrieved from the Gulf War Injury
Database which was retrospectively collected.
Results: Missed injuries in the triaged admitted patients on the last day of the war was significantly more than the
missed injuries of the triaged admitted patients on the first day of the war (1/80 compared with 5/30, p < 0.01, Fisher’s
Exact test).
Conclusion: Triage should be performed by the most expereinced surgeon. Adding a field triage in front of the
hospital is useful in improving the triage process.
References:
Disclosure of Interest: None declared
274
177.01
CLINICAL VALIDATION OF ROTATIONAL THROMBOELASTOMETRY (ROTEM) IN POST-OPERATIVE
ASSESSMENT OF COAGULOPATHY AFTER MAJOR PEDIATRIC SURGICAL PROCEDURES
S. Sangkhathat1,*, D. Suwannarat1, T. Boonpipattanapong1, B. Sangthong1
1
Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
Introduction: Rotational thromboeleatometry (ROTEM) is a point-of-care assessment of whole blood coagulation
widely used in transplantation and cardiothoracic surgeries. This study aimed to validate the diagnostic value of
ROTEM in diagnosing coagulopathy in major pediatric surgical operations.
Materials & Methods: Pediatric cases aged 1-14 years who underwent major pediatric surgical operations, from
September 2012 and December 2014, and met our high-risk criteria for post-operative coagulopathy were included.
The criteria included prior coagulopathy, diffuse bleeding in the operative field, oncologic operation, long operative
duration, massive intraoperative bleeding, sepsis and multisystem trauma. Immediate post-operatively, blood samples
were collected for platelet count, coagulograms and ROTEM study (INTEM and EXTEM). Cut-off values for all tests
used the hospital reference ranges.
Results: Sixty-five pediatric surgical operations (op) in 62 patients met the high coagulopathy risk criteria. Average
age of the patients was 5.6 years when average body weight was 18.0 Kg (2-57 Kg). The majority of operations were
tumor removal (39 ops), followed by splenectomy (3 ops) and biliary tract reconstructions (3 cases). The most
frequent positive item that led to inclusion was oncologic operation (44 ops), followed by long operative time (37 ops).
Post-operatively, clinical coagulopathy requiring transfusion occurred in 22 ops (33.9%). When coagulogram, platelet
counts and ROTEM profiles were analyzed against this clinical coagulopathy, their diagnostic values are shown in the
following Table.
Table: Diagnostic value of coagulation profiles and ROTEM parameters. LHR: likelihood ratio; PPV positive predictive
value; NPV: negative predictive value, Thrombocytopenia; Platelet count < 100,000 cells/cu.mm.
Parameters
LHR(95% confidence interval)
Sensitivity
Specificity
PPV NP
V
PTT
3.56 (1.10-11.51)
40.9
83.7
56.3 73.
5
PT-INR (>1.15)
2.77 (0.96-8.00)
54.6
69.8
48.0 75.
0
Thrombocytopenia
36.3
100.0
100. 75.
0
4
INTEM
17.00 (4.59-62.94)
81.8
79.1
66.7 89.
5
EXTEM
29.61 (5.66-154.84)
59.1
95.4
86.7 82.
0
Conclusion: Post-operative coagulopathy could be found in one-third of high coagulopathy risk pediatric surgical
operations. ROTEM study can be used in an assessment of coagulation in this setting.
Disclosure of Interest: None declared
275
177.02
PEDIATRIC FARM INJURIES – HIGH MORTALITY AND MORBIDITY IN INCREASINGLY MECHANIZED TIMES.
A. Fahy1,1,*, S. Polites1, C. Thiels2, M. Ishitani1, C. Moir1, D. Jenkins2, M. Zielinski2, S. Zietlow2
1
2
Department of Pediatric Surgery, Department of Trauma, Critical Care and General Surgery, Mayo Clinic,
Rochester, United States
Introduction: As the farming industry continues to mechanize, understanding of pediatric agricultural injuries is
required to drive safety prevention and standards. We hypothesize that pediatric farm-related injuries are more
severe than the injuries in the non-agriculture pediatric population and that prevention programs should focus on high
frequency mechanisms and times of year.
Materials & Methods: Pediatric trauma activations to our rural level I trauma center in the USA between 2002 and
2013 were reviewed to identify those children with farm-related injuries. Injury severity and outcomes were compared
between injured children with and without a farm-related etiology. Mechanisms and demographics were identified from
the prospectively maintained trauma database.
Results: Of 3957 pediatric trauma patients treated at our institution over 11 years, 93 presented with farm injuries
(2%). 79 patients were male, median age was 9.5 years (range 1.9 to 18 years). A higher proportion of farm injuries
than of non-farm injuries were sustained by children of schoolgoing age 6-14 (49.5% versus 37.8%, p =0.06). Injury
severity was greater in farm injuries as evidenced by injury severity score (ISS) (ISS >25; 12.9% vs 6.1%, p<0.05)
and this did not vary by age group. In-hospital mortality was significantly greater in farm injuries than non-farm injuries
(5.4% vs 1.6%, p<0.05). Children with farm injuries were more likely to be discharged to a rehabilitation facility or
swing bed (8% vs 4%, p=0.07).
Mechanized equipment was the most common cause of farm injuries (58%), followed by animals (21%) and falls
(13%). Specifically, equipment-related injuries involved augers (n=9), tractors (n=8), skid or pay loaders (n=6),
combines (n=3), silage spreaders (n=3), and hay cutters/baler (n=3). Non-mechanized wagons or carts caused 8
injuries. Farm injuries were more frequent in summer and fall than winter and spring (OR=1.56, 95% CI 1.4-1.8) and
on weekends than weekdays (1.5 OR, 95% CI 1.36-1.6).
Conclusion: The mortality and morbidity of pediatric farming trauma is markedly higher than other pediatric trauma.
Injury prevention programs should be tailored to local farming practices but in the rural USA, should focus particularly
on machinery safety in school age children and their parents, especially in the months leading up to summer.
Disclosure of Interest: None declared
276
177.03
LONG-TERM FUNCTIONAL OUTCOME OF PATIENTS WITH ANORECTAL MALFORMATIONS IN A TERTIARY
HOSPITAL IN THAILAND
M. Ngerncham1,*, N. Suksamanapun1, N. Tantemsapya1, M. Laohapensang1
1
Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Introduction: Anorectal malformation (ARM) is a common congenital anomalies with long-term impact to the patients.
The study determines to review functional outcomes of our ARM patients.
Materials & Methods: The database of the patients attending an anorectal clinic in a tertiary teaching hospital during
the year 2014 was reviewed to obtain demographics data, types, operations, and outcome according to Krickenbeck
classification. Those who had perineal or vestibular fistulas or blind end <1 cm. from the dimple were determined to be
“low” and underwent perineal procedures, i.e. anoplasty and anal transposition. Others so called “non-low” underwent
colostomy and posterosagittal anorectoplasty. After the operation, patients continued to attend the anorectal clinic for
monitoring of bowel movements and treatments by exercise, toilet training and diet adjustment.
Results: During the year 2014, there were 111 patients with ages ranged from 1 to 22 years old (median=5).
Functional outcomes could be evaluated in 57 patients who were older than 3 years old (36 M : 21F). The distribution
of the types of anomalies were 12 perineal fistulas, 9 vestibular fistula, 9 bulbous urethra fistulas, 8 cloacas, 7
prostatic urethral fistulas, 3 bladder neck fistulas, and 9 with no fistulas (1 patients were <1 cm. from the anal dimple).
Because of the relatively low patient numbers in each category, the functional outcomes were stratified by operative
procudures as in Table 1.
Table 1: Functional results of anorectal malformation patients
Perineal Procedures for “Low”
Posterosagittal anorectoplasty for “Nonanomalies (n=20)
low” anomalies (n=37)
Voluntary bowel movements
15
(75.0%)
24
(64.7%)
Soiling
3
(15.0%)
17
(45.9%)
Totally continent
14
(70%)
15
(40.5%)
Constipated
7
(35.0%)
12
(32.4%)
Conclusion: Functional outcomes of ARM patients depend on the complexity of the anomaly.
Intergrated management including meticulous surgery and long-term continuing care are required to help these
patients to achieve long-term voluntary bowel control.
Disclosure of Interest: None declared
277
177.04
MECONIUM PERITONITIS: EXPERIENCE OF A TERTIARY CARE IN THAILAND
N. Suksamanapun1,*, A. Mungnirandr1, R. Ruangtrakool1, M. Ngerncham1
1
Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Introduction: Meconium peritonitis is a rare congenital conditions afflicting newborn patients. Outcomes of the
condition have been improved over times. This study aims to review our experience of meconium peritonitis in a
tertiary hospital in Thailand.
Materials & Methods: Retrospective chart review of patients who were diagnosed with meconium peritonitis in our
institution from 2006 to 2011.
Results: Sixteen patients, ages ranged from 0 to 3 days, met our inclusion criteria. Birth weights ranged from 1.6 to
3.8 kg. All patients developed symptoms in the first day of life; among these, 5 were prenatally diagnosed.
Intraoperative findings were classified as pseudocyst (n=8), localize fibroadhesive (n=4), meconium ascites(n=3), and
generalized adhesive(n=1). Thirteen cases (81.3%) were related to congenital intestinal obstruction such as jejunal
atresia (n=6, 2 with volvulus), ileal atresia (n=6, 2 with volvulus), and total colonic aganglionosis (n=1). Single
perforation without distal intestinal obstruction was found in 3 cases including one with perforated Meckel’s
diverticulum. Primary repair could be achieved in 5 cases without postoperative complication. Postoperative
complications included intraabdominal collections in 2 cases and adhesive small bowel obstruction in 1 case. No
mortality was found in our series.
Conclusion: Currently, outcomes of meconium peritonitis in newborns are good. No mortality rate was reported in our
series. Eighty percent of cases were related to intestinal obstruction. It is necessary to rule out distal intestinal
obstruction before making decision of intestinal anastomosis.
Disclosure of Interest: None declared
278
177.05
PREDICTING UNPLANNED READMISSIONS IN PEDIATRIC SURGERY
S. F. Polites1,*, E. B. Habermann2, A. E. Wagie2, R. R. Cima3, A. E. Zarroug1, C. R. Moir1, M. B. Ishitani1
1
2
Division of Pediatric Surgery , Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery,
3
Department of Surgery, Mayo Clinic, Rochester, United States
Introduction: Unplanned readmissions after surgery are costly and decrease patient satisfaction. Using a large multiinstitutional pediatric surgery database, we determined if predictors for unplanned readmission specific to pediatric
surgical patients could be identified.
Materials & Methods: The 2011 American College of Surgeons National Surgical Quality Improvement Program
Pediatric Participant User File was utilized to identify unplanned readmissions within 30 days. Multivariable logistic
regression models determined predictors of ≥1 readmission for patients with length of stay (LOS) ≤14 days using
patient factors that were associated with readmission on univariate analysis. Postoperative complications were
included if they occurred prior to readmission.
Results: Readmission occurred in 2413 (5.1%) of 47,760 children and was most frequent following neurosurgery
(10.2%) and general/thoracic surgery (7.3%). Age <6, gastrointestinal and neurologic comorbidities, anemia,
emergent surgery, operative time, preoperative hospitalization >2 days, and postoperative LOS were associated with
increased risk of readmission on multivariable analysis of all patients (all p<.05). African American race (OR=0.86,
p=.04) and outpatient surgery (OR=0.54, p<.01) were protective. After stratifying by specialty, only childhood
malignancy, hematocrit <34, ASA class, operative time, and LOS remained consistently associated with readmission
(Table). Postoperative complications, except for incisional surgical site infection after neurosurgery (OR=3.1, p<.01),
did not predict readmission (all p>.05).
Image:
Conclusion: Children undergoing inpatient and general/thoracic or neurosurgery procedures are at the highest risk of
readmission. Predictors including ASA class and LOS can be used to identify at-risk patients and develop prevention
strategies. Unlike adults, postoperative complications do not appear to increase the risk of readmission.
Disclosure of Interest: None declared
279
177.06
THE 50 YEARS’ PROGRESS OF THE NEONATAL SURGERY IN JAPAN: WHAT THE MORTALITY CURVE OF
THE NEONATAL SURGERY CAN TELL US
A. Kubota1,*, Y. Mitani1, T. Watanabe1, H. Yamaue1
1
Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
Introduction: On the occasion of the 50th anniversary of Japan Society of Pediatric Surgeons (JSPS), we reviewed
the progress of neonatal surgery from the viewpoint of the mortality curve (MC) of neonatal surgical diseases. This
was based on the nationwide surveys conducted by the Committee on Academic Survey & Advanced Medical Science
of JSPS since 1964.
Materials & Methods: In the 1960's over the course of the first two surveys the mortality of major diseases was over
60%, over fifty years it decreased to less than 20%. The contributing factors of the drastic decrease must include:
improvement of neonatology, especially respiratory care and anesthesia; concentration of the cases; induction of
parenteral nutrition (PN); establishment of children's hospitals and training of pediatric surgeons at the children's
hospitals and medical colleges, antenatal diagnosis (AD).
Results: The MC of intestinal atresia rapidly declined after the first success of PN in USA in 1968 then followed by
Japan in early 70’s. The MC of congenital diaphragmatic hernia increased during the first 4 surveys. As more cases
were diagnosed earlier more severe cases were referred to pediatric surgeons, which must have died of respiratory
failure without diagnosis. After induction and rapid spread of AD, the MC declined steadily because of meticulous
therapeutic strategy based on AD. After a long steady decline the MC of intestinal perforation (IP) began to increase
around 1993. As more extremely-low-birth-weight infants (ELBWIs) were saved, the higher incidence and subsequent
higher mortality of IP characteristic of ELBWIs was noticed. Between 2003 to 2008 the MC of omphalocele increased,
which may be explained by changes in ethical considerations for the antenatal diagnosis of the most serious cases,
which must have been artificially aborted. Two cases of esophageal atresia (EA) were saved for the first time in Japan
in 1960. Until that point in time the mortality of EA was 100%. The MC decreased to 60% by 1964, and to 11% by
2008. Various factors contributed to the decline of MC of EA. One of the crucial factors was progress made in the area
of respiratory care, prevention of atelectasis and aspiration pneumonia in early days of lives.
Conclusion: Unfortunately the MC does not tell us the functional achievement, mental development and long-term
quality of life after neonatal surgery.
Disclosure of Interest: None declared
280
178.01
STUMP APPENDICITIS : DIAGNOSIS DILEMMA AND TECHNICAL CHALLENGE
M. M. Taher1,*, N. R. K. NIK MAHMOOD 1, A. A. WAHIDY 1, R. rajan 1
1
SURGERY, UNIVERSITY KEBANGSAAN MALAYSIA, Kuala Lumpur, Malaysia
Introduction: Appendicectomy is one of the most common operations performed by surgical personnel all over the
world. A rare complication that may occur post appendicectomy wether performed in open method or laparoscopically
is a stump appendicitis. Stump appendicitis was first described by Rose in 1945 is.Here we present a case of stump
appendicitis in a patient who had appendicectomy 5 years prior.
Materials & Methods: Case History :
15 years old boy presented with sudden onset sever lower abdominal pain associated with high grade fever and
generalised weakness. Clinically patient looks lethargic , dehydrated and ill looking. Temperature of 40 Celsius, BP
124/64 , HR 116. Abdomen distended and tender all over but precisely more in the right lower abdomen. Bowel
sounds still present but very sluggish. There was a Lans scar in the right iliac fossa for previous appendicectomy done
at age of 10 years old.
Ultrasound abdomen showed a minimal collection in the RIF but suboptimal study due to clamped bowel loops.
Proceeded with CT scan diffuse fluid collection,no evidence of abnormal growth,no extravasation of the contrast to
reveal any underlying perforation.
Results: Surgical Intervention
In spite of the complex picture from the radiological examination which cant tell the exact underlying pathology and in
view of clinical picture there was still a strong doubt of intra-abdominal pathology. Diagnostic laparoscopic
examination which showed a densely omental adhesions with clamped small bowel loops with underlying perforation
at the remnant appendicular stump very near to the cecal base fig (1) with wide appedicular stump and significantly
enlarged appendicular artery. we stapled the remnant appendicular stump below the perforation and reinforced with
intracorporeal interrupted absorbable suture. The Appendicular artery ligated with hemoclip and cut in between.
Patient went through normal recovery and sent home within three days post operatively.
Image:
Conclusion: Stump appendicitis is rare and difficult to diagnose.The timing of the presentation is not the key issue.
However, diagnosis of stump appendicitis is usually delayed as it is usually assumed that the diagnosis is not related
to the appendix.CT scan is best imaging modality.Laparoscopic surgery with good experienced surgeon have
advantages in these type of cases for better examination of the whole abdominal cavity and saved the patient from big
surgical scar and even may be limited right hemicolectomy.
References: 1) Rose, T. (1945). Recurrent Appendiceal Abscess. Med J Aust , 32, 659-662.
2) Kanona, H., Al Samaraee, A., Nice, C., & Bhattacharya, V. (2012). Stump appendicitis: A review. International
Journal of Surgery , 10, 425-428.
3) Bicknell , N. (2006). How time affects the risk of rupture in appendicitis. J Am Coll Surg , 202 (3), 401-406.
4) Truty, M., Stulak, J., Utter, P., Solberg, J., & Degnim, A. (2008). Appendicitis after appendectomy. Arch Surg , 143,
413-415.
Disclosure of Interest: None declared
281
178.02
COMPARISON OF INFECTED WOUND DRESSING USING THE TRADITIONAL DRESSING AND THE VACUUM
WOUND DRESSING
P. Leelachai1,*, S. Techapongsatorn1, W. Kasetsermwiriya1, A. Tansawet1, S. Lerdsirisopon1, S. Srimotayamas1, I.
1
1
Laopeamthong , P. Taewprasert
1
Surgery, Vajira Hospital, Navamindrahiraj University, Bangkok, Thailand
Introduction: This study aimed to evaluate the effectiveness of the traditional dressing and the vacuum wound dressing in cases
of infected wound care, in the terms of pain, limitation of patients movement, healing rate, re-infection rate and patient’’s
satisfaction.
Materials & Methods: Seventy patients who had debridement procedure for the necrotizing fasciitis were included in this study.
Patients were divided into two groups; 35 patients for each. Group A (the traditional dressing) and Group B (the vacuum wound
dressing). The pain score, limitation of patients movement, re-operative debridement and patient’s satisfaction were analzed
between the two groups.
Results: There is no difference between the two groups about the pain score, limitation of patient s movement. But re-operative
debridement rate in group A has slightly more than group B and the patient’s satisfaction in group B is better than group A.
Conclusion: Vacuum dressing is a modality that can apply for wound care in the infected wound cases.
Disclosure of Interest: None declared
282
178.03
THE MYOPECTINEAL ORIFICE: A STUDY IN THAI HUMAN CADAVERS
T. Rodsakan1,*, S. Techapongsatorn1, S. Lerdsirisopon1, A. Tansawet1, W. Kasetsermwiriya1, S. Srimotayamas2, I.
1
1
Laopeamthong , P. Taewprasert
1
2
Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindrahiraj University, Bangkok, Thailand
Introduction: The idea of the myopectineal orifice or the triple triangle of Fruachard is an anatomical
concept which is the cause of inguinal hernia. To prevent the hernia recurrent, mesh size should
be large enough to cover this area. The usually recommend mesh size is 10x15 cms. This study
aimed to determine the myopectineal orifice size by measuring in Thai human cadavers.
Materials & Methods: Thirty human cadavers (55 inguinal regions) were assessed. The myopectineal
orifices were measured.
Results: The myopectineal orifice size is the average of 6.7 + 1.2 cms in width and 7.2 + 1.5 cms in
length.
Conclusion: A mesh 10x15 cms is an appropriate size to coverage the myopectineal orifice in
Thais.
Disclosure of Interest: None declared
283
178.04
LAPAROSCOPIC REPAIR OF INCISIONAL AND VENTRAL HERNIAS WITH INTRAPERITONEAL MESH
PLACEMENT
G. F. Muslumov1,*, G. Aliyeva1, N. Zeynalov1, V. Behbudov 1
1
General Surgery, Scientific Center of Surgery, Baku, Azerbaijan
Introduction: Due to literature recurrence rates after repair of incisional hernias range from 18% to 55%.
Laparoscopic approach allows similar to the open Rives-Stoppa technique mesh placement with minimal dissection
and is a safe and effective alternative. Many studies shown that laparoscopic repair of incisional and ventral hernia is
preferred over open repair because of lower recurrence rates (less than 10%), less wound morbidity, less pain, and
early return to work.
Materials & Methods: To assess the safety and efficacy of laparoscopic ventral and incisional hernia repairs we
performed a prospective study including 45 patients (28 women and 17 men with a mean age of 56 years (range 2674 years) underwent laparoscopic repair in our institution between October 2010 and October 2014. Patient
demographic characteristics, operative details, and outcomes were recorded.The abdominal wall defect size ranged
from 2 to 25 cm. In 30 cases (I group) a polypropylene mesh, in other 15 cases (II group) intraabdominal composite
mesh was used.
Results: The mean operative time was 105 minutes (range 60-210 minutes). Mean estimated blood loss was 50 mL
(range 20 to 140 mL). Average hospital stay was 1.8 days (range 1 to 10 days). There was one open conversion, two
intraoperative complication and no deaths. In 25 patients was used stapling fixation method, in 14 patients stapling
device + suture and in 6 patients only suture fixation method.There were 6 complications (13.0%) recorded, including
1 prolonged suture pain, 2 persistent seroma, 1 hematoma, 1 prolonged ileus, 1 intraabdominal abscess. There were
no mesh infections requiring mesh removal. During a mean follow-up of 30 months, there were 3 (2 in I group, 1 in II
group) hernia recurrence (6,7%).There was no significant difference in the incidence of postoperative complications
such as chronic pain and seroma formation and among return to activity parameters over a mean follow-up period.
Cost of procedure was significantly less in group I (p < 0.001). Postoperative quality of life outcomes were similar in
the two groups.
Conclusion: Laparoscopic repair of incisional hernia and ventral hernia appears to be safe and effective.
Polypropylene mesh placement method is a cost-effective alternative to composite mesh placement in terms of early
postoperative pain, seroma formation and return to activity. The two procedures are equally effective regarding the
recurrence rates, complications and hospital stay.
Disclosure of Interest: None declared
284
178.05
LAPAROSCOPIC PARASTOMAL HERNIA REPAIR BY SUGARBAKER TECHNIQUE WITH DEFECT CLOSURE
COMPARE WITH NON-DEFECT CLOSURE
P. Vichajarn1,*, N. Boonyagard1, P. Chanswangphuvana 1, R. Tanompetsanga1, S. Udomsawaengsup1
1
Chulalongkorn university, Bangkok, Thailand
Introduction: Paraostomy hernia is one of the most complex complications after stoma formation. It has highly
recurrent rate after surgical correction. The concept of mesh re-inforcement was applied to its treatment as same as
other hernia repairs. Sugarbaker technique is popular and shows reducing of recurrence. With the defect closure adds
on to incisional hernia repair, many studies show reducing of seroma formation. Now we apply the defect closure to
Sugarbaker repair and compare the result to non-defect closure group.
Materials & Methods: We reviewed the medical record of patients who underwent laparoscopic parastomal hernia
repair from 2009-2014. The primary outcome was recurrence. The secondary outcomes were complications, seroma
formation and pain.
Results: Nine teen laparoscopic parastomal hernia repairs with Sugarbaker technique from 25 of all parastomal
hernia repairs were reviewed in last six years. Seven operations were done without defect closure and twelve
operations were added defect closure to Sugarbaker technique. Recurrence was occurred in one case of non-defect
closure group (14%). No recurrence was found in defect closure group. There was no difference in early post op pain
between both groups. The 2 seroma formations were founded in non-defect closure group and another one in defect
closure group (28% vs 8.3%). The serious complication occurred in one case of defect closure group (internal hernia
due to adhesion with mesh graft).
Conclusion: Laparoscopic parastomal hernia repair with defect closure is feasible for treatment parastomal hernia. It
reduces the incidence of seroma formation. The recurrent rate was lower in Sugarbaker with defect closure group.
Disclosure of Interest: None declared
285
178.06
THE ROLE OF ELISA IN SERODIAGNOSIS OF LIVER ECHINOCOCCOSIS
K. Anvarov1,*
1
Surgery, Republican Research Centre for Emergency medicine, Tashkent, Uzbekistan
Introduction: The diagnosis of echinococcosis is mainly supported by both serology and images of radiography or
ultrasound before surgery for proper and successful management. Various serological techniques were developed but
ELISA is cunently used for its diagnosis
Materials & Methods: For diagnosis, the fluid of Echinococcus granulosus hydatid cysts was collected from naturally
infected sheep in Uzbekistan. Also serum samples of infected patients who were surgically confirmed were collected
in a hospital in RRCEM, Tashkent. A total of 158 serum samples were collected and used in this study.
Among them, 59 were obtained from patients with echinococcosis who were confirmed by surgical
observation from 20012 to 2014 in RRCEM. The mean age of the patients was 38.5 ± 17.1 years
(age range; 15-75 years). Men were 46 and women were 13 of the 59 patients. For the analysis of
cross-reactions, 60 samples from patients with other parasite infections, which were retrieved from
the serum bank, were applied to EcAg. As negative controls, 39 serum samples of healthy
individuals with no evidence of helminth infections were used.The EcAg (150 pi of antigen at a
concentration of 1 pg/pl mixed with 150 pi of sample buffer composed of 50 mM Tris- HC1 at pH
6.8,2% SDS, 10% glycerol, 1% [3-mercaptoethanol, 12.5 mM ethylenediamine tetraacetic acid and
0.02% bromo- phenol blue)was boiled for 5 min and then separated on a 10% SDS-PAGE at a
constant current of 170 V for 1.5 hr. The individual antigen bands were then visualized by Brilliant
blue R250 protein staining solution
Results: The cut-off value for EcAg ELISA was defined as over the mean absorbance plus 3 SD
(0.063 ±0.054x3) of the values of 39 healthy controls. The absorbances of 59 echinococcosis
patients ranged from 0.112 to 0.974 (0.495 ± 0.199). When the absorbance at 450 nm was
blanked with the PBS, an absorbance of 0.270 was set as the optimum cut-off value to discriminate the positive and negative reactions. The ELISA for screening specific serum IgG
antibodies for EcAg gave 91.5% (54/59) sensitivity and 96% (95/99) specificity. The EcAg cross
reacted with serum samples of cysticercosis and clonorchiasis.
Conclusion: The EcAg of hydatid cysts fromsheep is a useful antigen for serodiagnosis of human
CE. The ELISA system will help differentiation of CE from other cystic diseases
References: Craig PS, McManus DP, Lightowlers MW, Chabalgoity JA, Garcia HH, Gavidia CM, Gilman RH,
Gonzalez AE, Lorca M, Naquira C, Nieto A, Schantz PM. Prevention and control of cystic echinococcosis. Lancet
Infect Dis 2007; 7: 385-394.
Disclosure of Interest: None declared
286
178.07
EMERGENCY CONSERVATIVE SURGERY FOR PATIENTS WITH BLEEDING EROSIONS AND ULCERS OF THE
UPPER GASTROINTESTINAL TRACT
S. Kharchenko1,*, V. Bratushka2, I. Duzhiy1
1
2
Department of General Surgery, Radiology and Phthisiology, Medical Institute of Sumy State University, Surgical
Unit (Gastrointestinal Bleeding Center), Sumy Regional Clinical Hospital, Sumy, Ukraine
Introduction: During the last five years near 11% of hospitalized patients with bleeding ulcers presented the absolute
indications to a surgical cure in Ukraine according to the Official Hospital Episodes Statistics. The operation of choice
in these patients, especially on a co-morbidity condition, remained in an intervention of minimal aggressivity as ligation
hemostasis of bleeding zone without organ resection or anastomotic performance. The work’s aim is to present clinical
characteristics and outcomes of the surgical treatment with ligation approach in patients with upper gastrointestinal
bleedings of ulcerogenic etiology.
Materials & Methods: We analyzed retrospectively 9 persons operated in the Operating Theatre of the Surgical Unit
of Sumy Regional Clinical Hospital affiliated with Sumy State University, Ukraine. The population of patients consisted
in 6 men and 3 women. The mean patient age was 46 (range 26-61). The indication for operative intervention was
uncontrolled bleeding. Considering patient’s clinical state, in all patients it was used upper midline laparotomy, gastroor duodenotomy with ligation of bleeding zones and one subhepatic drainage. In one patient the selective vagotomy
was indicated.
Results: The mean in-patient stay for the non-surgical treatment before operation depended from bleeding intensity
and varied from 0 to 15 days, in the mean 4 days. During the surgical revisions, we diagnosed gastric bleedings in 5
(56%) patients, the other bleeding sites were in 4 (44%) patients. Relaparotomy was done in 2 (22%) patients on the
postoperative period because of anastomotic leakage and recurrence development. The total in-patient stay was 14
days in the mean. The in-hospital mortality was 44% (4 patients), mainly caused by multiple organ failure. Five (56%)
patients discharged with satisfactory clinical results and under ambulatory surgeon’s observations.
Conclusion: The minimal volume of haemostatic intervention as laparotomy, gastro- or duodenotomy with ligation
approach and subhepatic drainage to the gastroduodenal bleeding of ulcerous origin should be reasonable, in
particular if it’s done on a co-morbidity base and by a dedicated gastrointestinal bleeding team. The main cause of the
in-hospital mortality is a multiple organ failure.
Disclosure of Interest: None declared
287
178.08
D-LEARNING, E-LEARNING, M-LEARNING AND GOOGLE GLASS IN EDUCATION OF MINIMALLY INVASIVE
SURGICAL TECHNIQUES
J. Sandor Md1,*, K. Kormos1, A. Ferencz1, G. Szabo1, D. Csukas1, T. Haidegger1,2, G. Weber1,2
1
Department of Surgical Research and Techniques, Semmelweis University Budapest, 2iBejczy iRobotics, Obuda
University, Budapest, Hungary
Introduction:
The fast spread of laparoscopic surgery in the surgical community required also introduction of
new methods of surgical education of the new techniques.
Materials & Methods:
25 years practice with training boxes applied for this reason meant a considerable help. It was useful also at the
Transatlantic Telementoring education process between Boston and Budapest (Harvard and Semmelweis
Universities).
The method of virtual reality by simulation represents also a new possibility in education. For the first time
in history of surgery we can measure medical students’ or residents’ dexterity and one can get acquited with a surgical
procedure in the form of …serious games”. By application of the up-to-date imaging methods we can practice the
movements of the surgeon’s hand even before the planned operation, and this can contribute to the safety of the real
procedure.
Information technology provides further opportunities in practical surgical education. iPad and its new forms
(Touch Surgery, iPad with overlay technique,etc.) represent intercative methods. Application of d (distant) – learnig by
records, tapes, discs, pendrives, etc. means audio and/or video education forms. By e-learning sitting at the
computer one can get acquinted with both the theoretical and practical surgery. m (mobile) – learning offers the same
possibilities, but by use of tablets, MP3-players, up-to-date mobile phones, etc, you are not fixed to a computer, but
can learn, practice anywhere and in any circumstances, or can perform …e-operations”.
…Goggle Glass surgeon” has a wearable computer by which he can be virtually in two placwes at the same
time providing significant advances fot the patient’s care.
Results: Introduction of the new methods of surgical education and training provides useful and safe way to
practice hand- work outside of OR.
Conclusion: Surgical residents can get significant contribution to improve their own dexterity provided by the
challenging new practical possibilities. Learning and practicing the new methods of surgical techniques at the
university the students can be influenced to be a surgeon.
References: J. Sándor, B. Lengyel, T. Haidegger, G. Saftics, G. Papp, Á. Nagy, G. Wéber:
Minimally invasive surgical technologies: Challenges in education and training Asian Journal of Endoscopic
Surgery 3: 101-108, 2010
Disclosure of Interest: None declared
288
178.09
PATIENT TRAVEL TIME BUT NOT DISTANCE IS ASSOCIATED WITH LOWER FOLLOW-UP AFTER
ENDOVASCULAR ANEURYSM REPAIR
J. E. Preiss1, S. Arya1, Y. Duwayri1, S. M. Shafii1, R. R. Rajani1, R. K. Veeraswamy1, T. F. Dodson1, L. P. Brewster1,*
1
Department of Surgery, Emory University, Atlanta, United States
Introduction: Patients receiving endovascular aortic aneurysm repair (EVAR) require lifelong post-operative
surveillance to detect problems. Despite established surveillance recommendations, reported compliance rates remain
low (33-65%). Determinants of poor follow-up are relatively understudied, and it is unclear whether these patients also
have poor follow-up with other physicians. This study aimed to determine if either patient travel time or distance were
associated with decreased post-EVAR follow-up compliance, and if so, were these patients captured by other services
during this period.
Materials & Methods: Under IRB approval, we identified patients that received EVAR for infrarenal AAA between
June 2009 and June 2013. Exclusion criteria included patients that died before one year, were treated for iliac artery
aneurysms, or received adjunctive renal or mesenteric artery stenting. Follow-up included 1, 6, and 12-month clinic
visits/imaging, with incomplete follow-up defined as missing ≥1 time-point. Vascular follow-up and alternate provider
contact were identified through institutional electronic medical records. Travel distance and time were calculated from
patients’ home addresses to the vascular clinic using Google Maps (2014). Variables were compared using t-test and
2
x test where appropriate, with P≤.05 considered significant.
Results: 203 patients were included for analysis. Compared to those with complete follow-up (n=62), patients with
incomplete follow-up (n=141) had greater travel time (90.3 minutes vs. 68.6 minutes, p=.049) and a trend towards
greater travel distance (83.6 miles vs. 60.6 miles, p=.068). 87/141 (61.7%) patients with incomplete follow-up had no
post-discharge surveillance or only a 1-month vascular follow-up. Of these patients, 31 (35.6%) visited a non-vascular
provider, and 14 (45.2%) of these patients saw a cardiologist.
Conclusion: Patient travel time, not distance, is associated with poorer follow-up after EVAR at our institution and
may be a more accurate measure of travel burden. Improved compliance may be facilitated through interdepartmental coordination, as at least 1/3 of patients without surveillance were seen by non-vascular providers.
Disclosure of Interest: None declared
289
178.10
LIMB SALVAGE RATE AFTER SURGICAL BYPASS IN PATIENTS WITH CRITICAL LIMB ISCHEMIA IN KING
CHULALONGKORN MEMORIAL HOSPITAL (KCMH) BETWEEN 2007-2012
R. Rayawa1,*
1
KCMH, bangkok, Thailand
Introduction: Critical limb ischemia (CLI) is an increasing morbid condition; without proper management, the patients
might lost their limbs or life. Also, this condition cause many health care problems.
Despite the increase in popularity of endovascular intervention, surgical bypass remain the standard management in
patients with CLI due to its effectiveness in patency and rate of limbs salvation, especially in developing countries,
where the technology and equipment for intervention are not ready.
Principles in surgical bypass has not changed in the last 30 years; e.g. adequate inflow, venous graft better than
prosthesis, and good surgical technique
Many studies had evaluated and show variable results of surgical bypass, but given the discrepancy in the resources
and data collection, its might not be true for every hospitals or centers.
So this study is to evaluate the outcome of surgical bypass in KCMH, which not before has been evaluated.
Materials & Methods: materials: the patients who were diagnosed with CLI and undergone surgical bypass from 1
JAN 2007 to 31 DEC 2012
method: the data were collected by charts review
due to poor compliance of many patients and inhomogenous data collection, the outcome of the study is limb salvage
rate only.
the data were sorted and characterized according to gender, comorbidities, investigation and method of surgery
the outcomes were access by chart review at 1st year to 5th year after surgery
Results: the majority of patients with CLI recieving surgical bypass at KCMH from 1 JAN 2007 to 31 DEC 2012 are
those with age above 65 years, male more than female. most common comorbid condition was hypertension. the most
frequence intervestigation before bypass was angiography. the most frequence operation was below knee bypass with
venous graft. in above knee bypass, the most frequence graft was prosthesis conduit (ePTFE)
primary outcome of the study reveal a 76% limb salvage rate and 71% limb salvage rate at 1st and 2nd year,
respectively
Conclusion: the limb salvage rate at 1st and 2nd year after surgical bypass for patients with CLI at KCMH from 1 JAN
2007 to 31 DEC 2012 are 76% and 71% respectively. CLI is a grave condition in which successful treatment required
both proper management and good complicance from the patients; and together with good medical record the reliable
result ensure. from this study, with poor compliance patients and inhomogenous medical records, the result might not
reflect the effectiveness of the management
References: 1.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society
Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007;45 Suppl S:S5-67.
2.
Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, et al. Bypass versus angioplasty in
severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 2005;366:1925-34.
3.
Antoniou GA, Chalmers N, Georgiadis GS, Lazarides MK, Antoniou SA, Serracino-Inglott F, et al. A metaanalysis of endovascular versus surgical reconstruction of femoropopliteal arterial disease. J Vasc Surg 2013;57:24253.
4.
Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et al. Recommended standards for
reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997;26:517-38.
5.
Ballotta E, Renon L, De Rossi A, Barbon B, Terranova O, Da Giau G. Prospective randomized study on
reversed saphenous vein infrapopliteal bypass to treat limb-threatening ischemia: common femoral artery versus
superficial femoral or popliteal and tibial arteries as inflow. J Vasc Surg 2004;40:732-40.
6.
Woratyla SP, Darling RC, 3rd, Chang BB, Paty PS, Kreienberg PB, Leather RP, et al. The performance of
femoropopliteal bypasses using polytetrafluoroethylene above the knee versus autogenous vein below the knee. Am J
Surg 1997;174:169-72.
7.
Conte MS, Bandyk DF, Clowes AW, Moneta GL, Seely L, Lorenz TJ, et al. Results of PREVENT III: a
multicenter, randomized trial of edifoligide for the prevention of vein graft failure in lower extremity bypass surgery. J
Vasc Surg 2006;43:742-51; discussion 51.
8.
Lawson JA, Tangelder MJ, Algra A, Eikelboom BC. The myth of the in situ graft: superiority in infrainguinal
bypass surgery? Eur J Vasc Endovasc Surg 1999;18:149-57.
9.
Whittaker L, Wijesinghe LD, Berridge DC, Scott DJ. Do patients with critical limb ischaemia undergo multiple
amputations after infrainguinal bypass surgery? Eur J Vasc Endovasc Surg 2001;21:427-31.
10.
Arvela E, Soderstrom M, Alback A, Aho PS, Venermo M, Lepantalo M. Arm vein conduit vs prosthetic graft in
infrainguinal revascularization for critical leg ischemia. J Vasc Surg 2010;52:616-23.
11.
Veith FJ, Gupta SK, Ascer E, White-Flores S, Samson RH, Scher LA, et al. Six-year prospective multicenter
randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal
arterial reconstructions. J Vasc Surg 1986;3:104-14.
290
Disclosure of Interest: None declared
291
194.01
MENOPAUSAL STATUS IN WOMEN IS AN INDEPENDENT PROGNOSTIC FACTOR FOR DISEASE-SPECIFIC
SURVIVAL IN PATIENTS WITH MALIGNANT GASTROINTESTINAL AND PANCREATIC NEUROENDOCRINE
TUMORS
N. Nilubol1,*, E. Kebebew1
1
Endocrine Oncology Branch, National Cancer Institute, NIH, Bethesda, United States
Introduction: In contrast to adenocarcinomas, high rates of immunohistochemical expression of estrogen and
progesterone receptors in gastrointestinal and pancreatic neuroendocrine tumors (GI-PNETs) have been observed.
GI-PNETs that expressed these receptors have been reported to be associated with lower tumor grades and less
advanced disease. These findings suggest that sex hormone status may influence the biology of GI-PNETs and
patient outcome. However, the role of menopausal status has never been studied in patients with GI-PNETs.
Materials & Methods: Data from patients with malignant GI-PNETs from the National Cancer Institute’s Surveillance,
Epidemiology and End Results 18 Registries Database (1973–2011) were used to compare characteristics and
outcome between pre and postmenopausal women (age 20-44, and > 55 years, respectively) and to men with
malignant GI-PNETs.
Results: Of 32,503 patients with malignant GI-PNETs, 4,556 (14%) had PNETs. Fifty-one percent were women
(n=16,577). Compared to premenopausal women, postmenopausal women with GI-PNETs had higher rates of poorly
differentiated tumors (10.9% vs. 20.3%, p<0.01), advanced T-stage (23.8% vs. 41.3%, p<0.01), lymph node (19.5%
vs. 30.8%, p<0.01) and distant metastases (26.7% vs. 37.5%, p<0.01), higher disease-related mortality (12.6% vs.
24.8%, p<0.01) and lower DSS (p<0.01). On univariate analysis, Caucasian (p<0.01), age ≥45 years (p<0.01), male
sex (p=0.01), postmenopausal women (p<0.01), PNET (p<0.01), poorly and undifferentiated tumors (p<0.01),
advanced T-stage (p<0.01), lymph node (p<0.01) and distant metastases (p<0.01) were associated with shorter DSS.
Multivariate analysis demonstrated that postmenopausal women was an independent prognostic factor associated
with shorter DSS (p<0.01, HR=2.3), while age and gender were not. Additional independent prognostic factors
included poorly and undifferentiated tumors (p<0.01, HR 6.9 and 9.1, respectively), advanced T-stage (p<0.01,
HR=1.31), stomach NET (p<0.01, HR=0.46), regional (p<0.01, HR=2.7) and distant metastases (p<0.01, HR=8.1).
Conclusion: Postmenopausal women with GI-PNETs have a shorter DSS. These findings have important
implications in the management of advanced GI-PNETs with hormonal therapy.
Disclosure of Interest: None declared
292
194.02
RISK FACTORS FOR CENTRAL NECK LYMPH NODE METASTASES IN FOLLICULAR VARIANT VS CLASSIC
PAPILLARY THYROID CARCINOMA
M. Raffaelli1, C. De Crea1, L. Sessa1, R. Bellantone1, C. P. Lombardi1,*
1
U.O. Chirurgia Endocrina e Metabolica, Università Cattoloca del Sacro Cuore, Rome, Italy
Introduction: Histological and clinical features have been advocated as possible clinical risk factors for central neck
nodal metastases in papillary thyroid carcinoma (PTC). Several studies showed a lower incidence of cervical lymph
node metastases and aggressive behavior in follicular variant of PTC (fvPTC) when compared with classic PTC
(cPTC). We aimed to compare risk factors for central neck nodal involvement in patients with fvPTC and cPTC.
Materials & Methods: The medical records of 1737 consecutive patients operated on between January 2008 and
September 2014 with a pathologic diagnosis of cPTC or fvPTC were reviewed. Demographic, clinical and pathological
findings were prospectively registered. Risk factors for central neck nodal metastases were evaluated by univariate
and multivariate analysis in cPTC Vs fvPTC patients.
Results: Six hundred and fifty-two patients (37.5%) had fvPTC and the remaining 1085 (62.5%) had a cPTC. The
diagnosis was incidental in 453 (69.5%) of the fvPTC and in 319 (29.4%) of the cPTC patients. Overall, 339 patients
(19.5%) showed central neck node metastases: 285/1085 cPTC (26.3%) and 54/652 fvPTC (8.3%) patients (p<0.001).
In both cPTC and fvPTC patients at univariate analysis age <45 years, non-incidental diagnosis, tumor size >5 mm,
multifocality, angioinvasion and extracapsular invasion were risk factors for central neck involvement. At multivariate
analysis independent risk factors for central neck metastases in cPTC patients were age < 45 years (p<0.01), nonincidental diagnosis (p<0.001), multifocality (p<0.001) and extracapsular invasion (p<0.001). Similarly, at multivariate
analysis independent risk factors for central neck metastases in fvPTC patients were age < 45 years (p<0.01), nonincidental diagnosis (p<0.001), multifocality (p<0.001) and extracapsular invasion (p<0.001).
Conclusion: In the present series, fvPTC represented 37.5% of the PTC cases, but about two third of the incidentally
diagnosed PTC. No differences were observed between cPTC and fvPTC with regard to risk factors of central neck
nodal metastases. However, fvPTC seems associated with a lower incidence of central neck nodal involvement,
presumably because of the higher rate of incidental diagnosis. With the exception of age, in patients with a
preoperative diagnosis of PTC, no preoperatively available clinical parameter is a reliable predictor of central neck
nodal disease.
Disclosure of Interest: None declared
293
194.03
THE MOTOR FIBERS OF THE RECURRENT LARYNGEAL NERVE CAN BE LOCATED ALSO IN THE
POSTERIOR EXTRALARYNGEAL BRANCH OF BIFID NERVES: RESULTS OF A PROSPECTIVE COHORT
STUDY WITH 2500 NERVES AT RISK.
M. Barczynski1,*, M. Stopa1, A. Konturek1, W. Nowak2
1
Department of Endocrine Surgery, Third Chair of General Surgery, 2Third Chair and Department of General Surgery,
Jagiellonian University Medical College, Krakow, Poland
Introduction: Recurrent laryngeal nerve (RLN) branching is common and was reported to be a risk factor for vocal
folds dysfunction after thyroidectomy. Few explanatory trials identified the motor fibers for both adduction and
abduction of the vocalis muscles to be located exclusively in the anterior branch of the bifid nerves. However, this
observation has not been confirmed in a large pragmatic trial. Hence, the aim of this study was to investigate the
location of the motor fibers to the intrinsic muscles of the larynx among the bifid RLNs utilizing intraoperative neural
monitoring (IONM), and assess the prevalence RLN injury with respect to nerve branching in a large cohort of
patients.
Materials & Methods: This was a prospective cohort study of 1250 patients (1130 females, 120 males, mean age
54.4±13.4 years) who underwent total thyroidectomy with IONM (2500 RLNs at risk). Primary outcome was the
position of motor fibers in bifid nerves. IONM was utilized to document the position of the motor fibers in all operations.
Adduction of the vocal folds was detected by the endotracheal tube electromyography and abduction by the finger
palpation of muscle contraction in the posterior cricoarytenoid. Secondary outcomes were the prevalence of RLN
branching and the prevalence of RLN injury in bifid vs. non-bifid nerves. Laryngoscopy was used to diagnose and
follow the RLN injury.
Results: Bifid RLNs were identified in 613/2500 (24.5%) nerves at risk, including 92 (7.4%) patients with bilateral
bifurcations. Motor fibers were present exclusively in the anterior branch in 605/613 (98.7%) bifid nerves, and in both
branches of the RLN in 8/613 (1.3%) bifid nerves. Median distance from ramification level to the entry point into the
larynx was 19 mm (95% CI: 17–21 mm) for nerves with motor fibers exclusively in the anterior branch vs . 9 mm (95%
CI: 7–11 mm) for nerves with motor component in both rami (p=0.001). Prevalence of RLN injury was 4.9% vs. 1.7%
for bifid vs. non-bifid nerves (p<0.001), OR 2.97 (95% CI: 1.78–4.92; p<0.001).
Conclusion: The motor fibers of the RLN for both adduction and abduction are located in the anterior extralaryngeal
branch in the vast majority but not all patients. In rare cases the motor fibers for abduction are located in the posterior
branch of the RLN. As bifid nerves are more prone to injury than non-branched nerves, meticulous dissection is
recommended to assure preservation of all branches of the RLN during thyroidectomy.
Disclosure of Interest: None declared
294
194.04
CHANGES OF LARYNGEAL MOBILITY AND SYMPTOMS FOLLOWING THYROID SURGERY – 6 MONTHS
FOLLOW-UP
A. E. Gohrbandt1, A. Aschoff 1, A. Keilmann2, H. Lang1, T. Musholt1,*
1
2
Visceral, General and Transplantation Surgery, Section Endocrine Surgery, Department of Otolaryngology, Head
and Neck Surgery, Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
Introduction: Swallowing disorders are frequent complains after thyroidectomy even in absence recurrent laryngeal
nerve pareses. The aim of this study was to assess the laryngeal movement following thyroidectomy in relation to
different symptoms.
Materials & Methods: 53 patients (mean age 52.4±12.5 yrs; 36 female) with benign pathologies and intact recurrent
nerve function were prospectively evaluated. Laryngeal movement was analyzed by ultrasound preoperatively and
1,3, and 6 months postoperatively. Additionally, a dysphagia and voice-specific quality of life questionnaire was
evaluated.
Results: Mean laryngeal movement differed between genders preoperatively and postoperatively resulting in a
recovery predominantly in women (differences preoperatively to 1, 3, and 6 months postoperatively in females 6.0,
3.7, and 1.5mm, in males 13.8, 11.7, and 10.3mm). Hoarseness (9 females) and cervical discomfort (7 females, 3
males) were mainly reported by women 1 month postoperatively. After 6 months, these complaints resolved (cervical
discomfort 1 female).
Conclusion: Laryngeal movement was postoperatively significantly impaired and only females revealed a recovery
nearly to baseline after 6 months. Though showing only a small grade of recovery of laryngeal movement, clinical
symptoms are rare in male patients.
Disclosure of Interest: None declared
295
194.05
DEBUNKING THE RISKS OF RECURRENT LARYNGEAL NERVE INJURY WITH CENTRAL NECK SURGERY
J. Folek1,*, S. K. Snyder1, T. Lairmore1
1
General Surgery, Baylor Scott & White, Texas A&M Health Science Center, Temple, United States
Introduction: Recurrent laryngeal nerve (RLN) injury is a dreaded complication of thyroidectomy, parathyroidectomy
and related central neck procedures. The literature reports increased risk of nerve injury with reoperative cases,
cancer, blood loss, large goiters, Graves’ disease and Hashimoto’s thyroiditis. The aim of this study was to analyze
risk factors for RLN injury at a single high volume academic endocrine surgery practice.
Materials & Methods: Between March 2004 and December 2013 a total of 2,726 patients underwent 2,733
procedures for thyroidectomy, parathyroidectomy, and/or neck dissection with a total of 4,650 nerves at risk. These
were performed by two surgeons at a single institution. Prospective data of these patients were collected with respect
to demographics, diagnosis, procedure, surgeon, and temporary versus permanent recurrent laryngeal nerve injury.
Nerve monitoring was utilized. The visualization and functional identification of the RLN was recorded as well as loss
of function. Preoperative and postoperative laryngoscopy was done according to surgeons practice. This data was
analyzed retrospectively for the influence of various factors on RLN injury.
Results: A total of 4650 nerves were at risk, 3834 for bilateral risk, 816 for unilateral risk. Overall incidence of RLN
injury is 2.5%. The incidence of permanent injury is .32%. A primary diagnosis of cancer was associated with
increased risk of RLN injury, p=.048. Previous surgery had a higher incidence of RLN injury, relative risk 1.2, but not
significant, p=0.6. Graves’ disease had increased risk, 19% vs. 15% but did not reach significance, p=0.3.
Hashimoto’s thyroiditis was not associated with increased injury, with incidence of 13% in non-injured and injured
RLN’s respectively. BMI was not associated with increased injury. Thyroid size by weight was not a risk factor, p=.52.
Blood loss was also not a significant factor, p=0.17. Central neck dissection had a higher incidence of injury, 23% vs
18.8%, but not significant, p=0.2. Excision for recurrent cancer had significantly increased risk of nerve injury, (n=3,
2.6%) p<0.001, with a relative risk of 10.5.
Conclusion: RLN injury is not associated with increased thyroid size, higher intraoperative blood loss or with a
diagnoses of Graves’ disease,or Hashimoto’s thyroiditis at our center. A primary diagnosis of cancer and excision of
recurrent cancer are both associated with significant increase in RLN injury.
Disclosure of Interest: None declared
296
194.06
DETERMINING THE LEARNING CURVE OF TRANSCUTANEOUS LARYNGEAL ULTRASOUND IN VOCAL CORD
ASSESSMENT BY CUSUM ANALYSIS OF EIGHT SURGICAL RESIDENTS – WHEN TO ABANDON
LARYNGOSCOPY?
K. P. Wong1,*, J. Y.-Y. Li1, J. Tsang1, S. Lam1, D. T.-Y. Chan1, N. C. Kotewall1, B. H.-H. Lang1
1
Department of Surgery, The University of Hong Kong, Hong Kong, China
Introduction: Transcutaneous laryngeal ultrasonography (TLUSG) is a non-invasive tool in vocal cord (VCs)
assessment before and after thyroidectomy. However, it remains unknown how many examinations are required
before one becomes proficient enough in performing TLUSG without laryngoscopic validation. We determined the
learning curve of TLUSG in a group of surgical residents (SRs) without prior ultrasound (USG) experience
Materials & Methods: Eight SRs without prior USG experience were recruited over a 2-year period. After a
standardized training program including clinical demonstrations and supervised examinations, each SR was asked to
perform TLUSG on consecutive 80 patients independently. Appropriate feedback was given after every 5-10 cases. All
TLUSG findings were confirmed by laryngoscopy afterwards. Performance of each SR was quantitatively evaluated by
a composite performance score comprised total examination time (in seconds), rate of VCs assessability and
assessment accuracy. Accuracy was determined by correlating between TLUSG and laryngoscopic findings.
Sensitivity, specificity and accuracy were compared between the 8 SRs. Cumulative sum (CUSUM) analysis was
applied to determine learning curve and assess performance over time.
Results: Eight different SRs performed 640 TLUSG examinations on 323 patients. Among these examinations, 43
(6.7%) were VC palsy (VCP) on laryngoscopy. In terms of VC assessability, sensitivity, specificity and accuracy, there
were no significant differences between the 8 SRs (p>0.05) but there was definite improvement in performance
(particularly less false negatives i.e. missing an actual VCP) over time.
The CUSUM curve showed a rising pattern (learning phase) until 7th TLUSG and then flattened. The curve declined
th
again from 28th TLUSG (after reaching a plateau). Sensitivity was improved after 40 case (55.6% vs 83.3%, p<
th
0.05). No further improvement in performance was observed after the 40 TLUSG examination. Beyond this point,
only two missed VCPs were found in the subsequent 320 cases.
Conclusion: Given appropriate training, the skills of TLUSG were readily learned by individuals with no prior USG
experience. From the CUSUM analysis, 7 cases were required in achieving acceptable level of performance while 40
cases were required in reaching proficiency. Upon attaining proficiency, it is reasonable to propose abandoning
laryngoscopy as the chance of missing a VCP was only 0.6%
Disclosure of Interest: None declared
297
198.01
MUCOSA-MUSCULAR SIGNALIZATION FOR BILE-INDUCED ESOPHAGEAL DYSMOTILITY.
R. C. Souza1, F. Herbella1,*, C. Tahan2, A. T. Ferreira2, M. G. Patti3
1
2
3
Department of Surgery, Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil, Department
of Surgery, University of Chicago, Chicago, United States
Introduction: Esophageal motor abnormalities are frequently found in patients with gastroesophageal reflux disease.
This may be caused by acid or bile reflux. In a previous experimental study, esophageal exposure to ursodeoxycholic
acid, a component of bile, decreased esophageal contraction amplitudes but not when the esophageal mucosa was
resected. These findings indicated that bile action in esophageal motility is directed towards mucosal signaling to the
muscular layer and not a trans mural process. This study aims to try to identify the exact nature of the mucosamuscular signaling path by receptors blockage in an experimental study.
Materials & Methods: Fifteen guinea pig esophagi were isolated, and its contractility assessed with force
transducers. Three-centimeter fragments were obtained from the distal esophagus and were mounted in the
chambers for isolated organ perfusion containing Krebs-Henseleit solution oxygenated by a mixture of 95% O2 and
5% CO2 (pH 7.4). The fragments were connected to force transducers attached to a micromanipulator to allow
variation of basal tension. The specimens were kept after assembly with a basal tension of 1 g for 1 hour to
stabilization. Developed force (contraction amplitude) was recorded. The esophagi were incubated in 100 µmL
ursodeoxycholic acid for 1 hour and 5 sequential contractions induced by 40 mm KCl spaced by 5 minutes were
measured. After 30 minutes, esophagi specimens were incubated in 3 different smooth-muscle contraction antagonist:
atropine (1mM) in 5, suramin (1mM) in 5 and genistein (1mM) in 5. The same protocol for contractions was repeated.
Values are expressed as mean ± standard deviation and encompass the mean of five stimuli. Experimental
procedures were approved by the University Institutional Review Board.
Results: Contraction amplitudes after bile incubation but before antagonists incubation were 1.5±0.8 g, 1.2±0.8 g, and
1.2±0.5 g for atropine, suramin and genistein, respectively. Mean contraction amplitudes after antagonists instillation
were 1.6±0.8 g, 1.4±0.5 g, 0.9±0.5 g, respectively. There was no different in contraction amplitude before and after
instillation of atropine (p=0.2), suramin (p=0.5) or genistein (p=0.1).
Conclusion: Our results show that blockage of cholinergic (atropine), purinergic (suramin) or tyrosine kinase
(genistein) paths do not change esophageal dysmotility induced by bile. Other molecular path may play the role in this
scenario.
Disclosure of Interest: None declared
298
198.02
DIFFERENTIAL MIR EXPRESSION REGULATING STEM CELL AND EMT TRAITS PREDICTS COLORECTAL
CANCER METASTASIS
N. Wieghard1,*, K. Chin2, M. Mori3, M. H. Wong4, V. L. Tsikitis5
1
2
3
4
General Surgery, Center for Spatial Systems Biomedicine, Knight Cancer Institute Biostatistics, Cancer, Cell and
5
Developmental Biology, Digestive Surgery, Oregon Health and Science University, Portland, United States
Introduction: microRNAs (miRs) are frequently dysregulated in colorectal cancer (CRC) and subsets are correlated
with advanced tumor stage and metastasis. Despite this, development of prognostic biomarkers that predict metastatic
potential remain elusive. Our study was designed to identify, validate and elucidate underlying biology imposed by a
miR signature that defines and predicts metastatic disease.
Materials & Methods: Genome-wide miR expression profiling was performed on patient-matched primary CRCs and
liver metastases then normalized to surrounding unaffected tissue. Validation of downstream target gene expression
of identified miRs (e.g. CD166, SNAIL, TWIST, and ECAD) were analyzed by qRT-PCR in CRC cell lines representing
early and late stage disease.
Results: A distinct nine member panel of miRs were identified as differentially expressed in both the primary CRC and
liver metastases (Table 1). These miRs were found to participate in a number of critical tumor pathways including
stem cell maintenance (CD166) and epithelial-to-mesenchyme transition (EMT: SNAIL, TWIST, ECAD). Late stage
CRC cell lines harbored increased CD166 expression (284.4 times), SNAIL (8.0 times), and TWIST (12.1 times) and
decreased ECAD expression (123.4 times) relative to early stage disease.
Image:
299
Conclusion: We identified a distinct miR signature shared between primary tumor and liver metastases that harbors
biology consistent with aggressive disease. This miR signature has potential to provide important prognostic
information for risk of progression to metastatic disease.
Disclosure of Interest: None declared
300
198.03
NQO1 EXPRESSION HAS PROGNOSTIC SIGNIFICANCE IN KRAS-WILD UNRESECTABLE COLORECTAL
CANCER
Y. Hirose1,*, H. Kameyama1, T. Ohashi1, K. Takizawa1, M. Nagahashi1, T. Kobayashi1, J. Sakata1, T. Wakai1
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
Niigata, Japan
Introduction: NAD (P) H: quinone oxidoreductase-1 (NQO1) is an obligate two-electron reductase which protects
cells from oxidative stress and detoxifies chemical stress. This study aimed to evaluate the immunohistochemical
expression of NQO1 in patients with unresectable colorectal cancer and to elucidate the prognostic value of NQO1
expression.
Materials & Methods: A retrospective analysis of 51 patients with unresectable colorectal cancer was conducted. The
definitions of unresectable colorectal cancer included far-advanced or recurrent unresectable colorectal cancer.
Immunohistochemistry of the tumor specimens was conducted using monoclonal anti-NQO1 antibody. KRAS
mutations in codon12, 13, and 61 were examined by direct sequencing. The correlation of NQO1 expression with
tumor characteristics, KRAS status and overall survival (OS) was analyzed.
Results: Of the 51 patients, KRAS mutation was found in 18 (35.3%) patients. Of the 51 patients, 40 were classified
as having tumors with NQO1-positive expression and 11 had tumors with loss of expression. NQO1 expression in
tumor specimen was not significantly correlated with any of the clinicopathological features of the unresectable
colorectal cancer. Both NQO1 expression and KRAS status were not associated with OS (P = 0.313 and 0.151,
respectively). However, among KRAS wild type patients, OS was significantly worse in patients with NQO1-positive
expression than in patients with loss of NQO1 expression (cumulative 5-year survival rate of 26.9% and 50%,
respectively; P = 0.043; Figure 1).
Image:
Conclusion: NQO1-positive expression indicates poor prognosis for patients with KRAS-wild unresectable colorectal
cancer.
Disclosure of Interest: None declared
301
198.04
EXPRESSION OF VITAMIN D RECEPTOR (VDR) IN GALLBLADDER CANCER (GBC), IMMUNOREACTIVITY
SCORING (IRS), SERUM VITAMIN D LEVELS (SVDL) AND EFFECT OF VITAMIN D SUPPLEMENTATION WITH
GEMCITABINE CHEMOTHERAPY.
A. A. Sonkar1,*, S. Mittal1, A. Anand1, K. R. Singh1, P. K. Srivastav 2, J. K. Kushwaha1, N. Husain3
1
Surgery, 2Radiotherapy, King George's Medical University, 3Pathology, RML Institute of Medical Sciences, Lucknow,
India
Introduction: GBC has a nonspecific clinical presentation and presents at an advanced stage leading to adverse
outcomes. VDR is involved in cell growth and differentiation in normal human tissue and via wide spectra of activities
is involved in anticancer defence mechanisms. The objective of this study is to see correlation between SVDL,
expression of VDR in GBC and its relation with stage of disease and possible role of oral vitamin D supplementation in
palliative chemotherapy group.
Materials & Methods: n=32 GBC between April 2012 and October 2013. Mean age 47.43±9.27 years; 73% females.
Besides operable group (n=2), in inoperable group (n=30) the USG guided FNAB was taken and sent for HPE and
VDR expression with IRS. n=11 cholecystectomy tissue control. n=19 inoperable GBC; supplemented with oral
vitamin D gemcitabine chemotherapy. Response was assessed using RECIST 1.1.
Results: Mean IRS score in cases 1.20±1.92 compared to 3.27±4.10 in controls. Mean intensity was 50.2% with
mean staining score significantly lower by 59.3% in GBC compared to controls.
On analysis of stage of the disease with IRS, patients with low VDR expression 61.9% patients T4 stage. No
significant association of IRS with age, sex, height, weight and SVDL but was significantly associated with lower BMI.
There was no statistical significant difference in tumor response post supplementation of vitamin D.
Conclusion: VDR expression was decreased in GBC compared to controls and patients with lower expression had
advanced disease compared with higher VDR expression. This study has been first of its kind relating VDR, SVDL
and GBC.
Disclosure of Interest: None declared
302
198.05
CLINICAL SIGNIFICANCE OF RIBONUCLEOTIDE REDUCTASE M1 EXPRESSION IN PATIENTS WITH
INTRAHEPATIC CHOLANGIOCARCINOMA
T. Katada1,*, N. Sudo1, Y. Hirose1, K. Takizawa1, M. Nagahashi1, T. Kobayashi1, J. Sakata1, T. Wakai1
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
Niigata, Japan
Introduction: Ribonucleotide reductase M1 (RRM1) is a key molecule for gemcitabine resistance. This study
evaluated the immunohistochemical expression of RRM1 in resected specimens of intrahepatic cholangiocarcinoma
(ICC), and investigated the efficacy of gemcitabine-based neoadjuvant chemotherapy in relation to RRM1 expression
in tumors.
Materials & Methods: A retrospective analysis was conducted on 43 consecutive Japanese patients who underwent
resection of ICC. Of the 43 patients, 4 were treated with neoadjuvant chemotherapy consisting of gemcitabine 800
2
mg/m every 2 weeks, to address extrahepatic tumor extension. Expression of RRM1 in tumor specimens was
assessed using immunohistochemistry and was classified as either positive or negative.
Results: RRM1-positive expression was detected in 27/43 (63%) tumor specimens. Four patients were treated with
gemcitabine-based neoadjuvant chemotherapy; 3 patients had tumor specimens showing RRM1-positive expression
and showed 11% (Figure 1A and B), 14% (Figure 1C and D), and 25% (Figure 1E and F) tumor reduction rate (stable
disease); another patient had a tumor showing RRM1-negative expression and showed a 68% (Figure 1G and H)
tumor reduction rate (partial response). Surgical procedures planned before administration of neoadjuvant
chemotherapy were performed in all 4 patients. RRM1-positive expression was more frequent in patients with pM0
disease (27/37; 73%) than in those with pM1 disease (0/6; 0%; P = 0.001). Survival after resection was comparable
between patients who had tumors showing RRM1-positive expression (median survival time, 35 months; cumulative 5year survival rate, 45%) and patients who had RRM1-negative tumors (median survival time, 19 months; cumulative 5year survival rate, 40%; P = 0.556).
Image:
Conclusion: Neoadjuvant chemotherapy with gemcitabine for locally advanced ICC was well tolerated and did not
impair planned surgical resections. Tumor expression of RRM1 may determine the efficacy of gemcitabine-based
chemotherapy for patients with ICC.
Disclosure of Interest: None declared
303
198.06
PROGNOSTIC SIGNIFICANCE OF NAD(P)H: QUINONE OXIDOREDUCTASE-1 EXPRESSION IN INTRAHEPATIC
CHOLANGIOCARCINOMA
N. Sudo1,*, T. Katada1, Y. Hirose1, K. Takizawa1, M. Nagahashi1, J. Sakata1, T. Kobayashi1, T. Wakai1
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
Niigata, Japan
Introduction: NAD(P)H:quinone oxidoreductase-1 (NQO1), also known as DT-diaphorase, menadione reductase, or
quinone reductase 1, is a flavoprotein that catalyses the two-electron reduction of quinones and related compounds.
Oxidative stress promotes nuclear accumulation of nuclear factor erythroid 2-related factor 2 (Nrf2) and activates
transcription of NQO1 This study aimed to evaluate the association between the immunohistochemical expression of
NQO1 and nuclear factor erythroid 2-related factor 2 (Nrf2) in resected specimens of intrahepatic cholangiocarcinoma
(ICC) and to elucidate the prognostic value of NQO1 and Nrf2 expression.
Materials & Methods: A retrospective analysis was conducted of 43 consecutive patients who underwent surgical
resection for ICC. Immunohistochemistry of the resected specimens was conducted using each of the following
primary monoclonal antibodies against NQO1 and Nrf2.
Results: Of the 43 patients, 28 were classified as having tumors with NQO1-positive expression and 15 had tumors
with loss of NQO1 expression, whereas 31 patients had tumors with Nrf2-positive expression and 12 had tumors with
loss of Nrf2 expression. NQO1 expression showed a positive association with Nrf2 expression (P = 0.012, Figure 1).
Loss of NQO1 expression was more frequent in tumor specimens that were moderately or poorly differentiated (14/33;
42%) than in well-differentiated tumors (1/10; 10%; P = 0.127). Post-resection survival was significantly worse in
patients with tumors with loss of NQO1 expression than in patients with NQO1-positive tumors (cumulative 3-year
survival rate of 13% and 60%, respectively; P = 0.009). Nrf2 expression was not associated with survival after
resection (P = 0.172). The Cox proportional hazards regression analysis revealed that loss of NQO1 expression (P <
0.001), lymph node metastasis (P = 0.003), distant metastasis (P = 0.007) had an independent adverse effect on
survival.
Image:
Conclusion: Loss of NQO1 expression may reflect the dedifferentiation of ICC tumor cells and thus indicates a poor
prognosis for patients undergoing surgical resection for ICC.
Disclosure of Interest: None declared
304
198.07
EX-VIVO CHARACTERIZATION OF LIVER AND PERITONEAL METASTASES BY CONFOCAL LASER
ENDOMICROSCOPY : THE PERSEE PROJECT
A. Pierangelo1, P. Validire1, A. Benali1, P. Dartigues2, D. Fuks3,*, B. Gayet3
1
2
Pathology department, Institut Mutualiste Montsouris, Paris, Department of Pathology, Gustave Roussy, Villejuif,
3
Department of Digestive diseases, Institut Mutualiste Montsouris, Paris, France
Introduction: In digestive oncology, a minimally invasive surgical exploration that evaluates the local and metastatic
extent of cancer is generally required before the tumor resection in order to determine the best therapeutic treatment.
Probe-based Confocal Laser Endomicroscopy (pCLE) is a new promising imaging technique enabling real time
microscopic analysis of tissues. This study aims at evaluating pCLE for the discrimination of benign or metastatic
nodules in liver and peritoneum.
Materials & Methods: Several fresh samples of liver and peritoneal nodules were analyzed ex vivo right after the
resection using a endomicroscopy system and a UHD confocal miniprobe. Healthy samples of the same tissues were
also analyzed for comparison. Indocyanine green (ICG) was topically applied on the specimens (2.5mg/ml). For each
sample, side by side comparison with histology was performed.
Results: We analyzed and correctly identified metastatic (n=5) and inflammatory (n=4) peritoneal nodules, and
metastatic liver nodules before (n=6) and after (n=2) treatment with chemotherapy. On healthy peritoneal CLE images
(acquired on 10 samples), the adipocytes, surrounded by the extra-cellular matrix (ECM) composed by a strongly and
uniformly fluorescent connective tissue, were clearly recognizable. On pCLE images of healthy liver (acquired on 7
samples), a compact line-structure of hepatocytes was observed. The irregular associations of cells forming tubular
structures typically found on adenocarcinoma histology and the strong inhomogeneity in the fluorescence signal of the
ECM compared to healthy tissue are two features that could also be seen in peritoneal cancerous nodules. At the
contrary, the connective tissue composing the ECM of inflammatory peritoneal nodules seemed to be more abundant
than in the healthy tissues. Lastly, after chemotherapy treatment, the liver metastatic nodule appeared to have a very
compact and fluorescent fibrotic tissue that replaces the tubular cell structures typical of the adenocarcinoma.
Image:
305
Conclusion: Our preliminary results suggest that pCLE is a promising tool for an immediate identification of
metastases both in liver and peritoneal tissues. This study reveals that the structure of the ECM may be an important
additional parameter to take into account in order to improve diagnosis. In vivo use of this innovative approach should
enable us to directly detect cancer without the need of more invasive and time-demanding biological sampling.
Disclosure of Interest: None declared
306
198.08
EVALUATION OF THE MARKERS FOR HEPATIC FIBROSIS IN HEPATOCELLULAR CARCINOMA
J. Ueda1,2,*, H. Yoshida1, N. Taniai2, M. Yoshioka2, Y. Mizuguchi2, T. Shimizu2, A. Hirakata1, H. Takata2
1
2
Surgery, Nippon Medical School Tama Nagayama Hospital, Surgery, Nippon Medical School , Tokyo, Japan
Introduction: Recent reports have revealed the relationship between hepatic fibrotic markers and the prognosis of
patients with hepatocellular carcinoma (HCC) post-hepatectomy. Our study evaluated the relationship between these
markers of hepatic fibrosis, clinicopathological findings and the patient’s prognosis.
Materials & Methods: The study targeted three hundred and sixty patients who underwent a hepatic resection for
HCC in Nippon Medical School Hospital between 1993 and 2013. These patients were divided these into two groups
(normal/abnormal) on the basis of their serum hyaluronic acid (HA) and type IV collagen levels.
Results: The overall survival rate and the recurrence-free survival rate of the normal group were significantly higher
than for the abnormal group. In the normal HA group, serum albumin and prothrombin time were significantly higher
than the abnormal group, while age, HCV-Ab positivity, Child-Pugh grade B incidence, liver cirrhosis incidence,
indocyanine green retention rate at 15 min (ICGR15), type IV collagen levels and type IV collagen 7s levels were all
significantly lower. In the normal type IV collagen group HCV-Ab positivity, liver cirrhosis incidence, ICGR15, HA
levels and type IV collagen 7s levels were significantly lower than the abnormal group. Multivariate analysis
independently revealed the significance of serum type IV collagen for overall survival and the significance of serum
HA for recurrence-free survival in these patients.
Image:
307
Conclusion: Preoperative examinations of serum HA and type IV collagen levels are imperative when performing a
hepatic resection to treat HCC, because these markers are significantly associated with liver function and patient
prognosis.
Disclosure of Interest: None declared
308
217.01
RISK FACTORS FOR RECCURENT ULCER BLEEEDING
Z. Lausevic1,*, M. S. Gvozdenovic2, V. Vukojevic3, D. B. Jovanovic3, S. Djuranovic4, A. Bajec3, M. Lausevic5
1
Center of Emergency Surgery, Clinical Center of Serbia , Medical Faculty, University of Belgrade, Belgrade, Serbia,
2
Center for emergency surgery, Clinical Center of Serbia, 3Center of Emergency Surgery, Clinical Center of Serbia ,
4
Medical Faculty, University of Belgrade, Clinic of Gastroenterology, Clinical Center of Serbia, 5Medical Faculty,
University of Belgrade, Clinic of Nephrology, Clinical Center of Serbia, Belgrade, Serbia
Introduction: Introduction: Bleeding peptic ulcers remained the commonest cause for emergency hospitalization
with significant mortality of about 10%. Despite advances in endoscopic treatment and other minimally invasive
procedures, surgery procedures are often appliead.
Moreover, patients tend to be older with multiple comorbidities keeping the mortality unchanged for the past 40 years.
Ulcer rebleeding is one of the important risk factors for mortality.
Aim of the study is to evaluate risk factors for persisting ulcer bleeding, ulcer reebleding and mortality.
Materials & Methods: Study included 3018 patients who presented at our institution with endoscopic diagnosis of
peptic ulcer bleeding over five years period (2010-2014). Data for risk factors were collected from database review:
age, multiple comorbidities, location and size of ulcer, hypotension on admission, endoscopic findings of recent
haemorrhage. Among laboratory features we analyzed hemoglobin levels, factors of coagulation and blood urea
nitrogen levels. Finally, we calculated Rocckal et AIMS score in all patients. Early surgery was considered an
operation within 24 hours post hospital admission.
Results: Rebleeding rate is 10.4% (314 patients). Overall mortality is 13.9% (419 pts), rebleeding mortality is 20.7%
(65 pts), while mortality in the group without rebleeding is 11.7%.The total number of patients who underwent surgery
is 379 (12.6%). Because of anastomotic leakage or recurrent haemorrhage 38 of 379 (10.2%) patients had one or
more reoperations. Number of patients who underwent early surgery because endoscopic failure and/or persistent
haemorrhage is significantly lower then number of patients who underwent surgery for rebleeding during period 48 72 hours after admission (124 and 255 respectively). Combination of any five risk factors predicts rebleeding with
probability of 95%, four factors of 78% and three factors of 46%. Hemodynamic instability on admission, ulcer
diameter > 2 cm and AIMS score ≥ 4 were the most significant predictors of rebleeding (93%) and mortality (79%).
Ulcer diameter > 2 cm and hypotension on admission were the most significant predictors of both persistent and
recurrent bleeding and need for surgery.
Conclusion: Many risk factors are valuable for rebleeding prediction in patients with ulcer, with ulcer size >2 cm,
hypotension at addmission and AIMS score being the most significant. Combination of risk factors brings additional
value to predictive models.
Disclosure of Interest: None declared
309
217.02
ANALYSES OF BLOOD PRODUCT UTILIZATION AND EFFECT OF TRANSFUSION STRATEGY IN ACUTE NONVARICEAL UPPER GASTROINTESTINAL BLEEDING - A NATIONWIDE STUDY OF 5861 HOSPITAL
ADMISSIONS IN DENMARK
P. Svenningsen1,*, R. Fabricius2, J. Hillingsøe1, L. B. Svendsen1, M. Sillesen1
1
Rigshospitalet, 2Hillerød Hospital, Copenhagen, Denmark
Introduction: Non-variceal upper gastro-intestinal bleeding (NVUGIB) is a major source of blood product utilization.
Studies have indicated that transfusing high ratios of Fresh Frozen Plasma (FFP) and Platelets (PLT) to packed red
blood cells (PRBC) is associated with favorable outcome in other patient groups. Whether this association is present
for NVUGIB is unknown. The aim of this study was to characterize the utilization of blood products transfused for
NVUGIB from 2011-2013 in Denmark. We hypothesized that transfusion strategies employing FFP and PLT would be
associated with a reduction in endoscopic failures, need for surgical hemorrhage control, in-hospital mortality as well
as a reduction in hospital length of stay (LOS).
Materials & Methods: The study design was retrospective. Data was retrieved from nationwide and well-validated
national databases: The Danish national patient registry and the Danish transfusion database.
All admissions where endoscopic hemostatic procedures had been employed in either the ventricle or the duodenum
were retrieved. Furthermore, information on diagnoses, comorbidities, length of stay, deaths, number and type of
surgical interventions as well as units of PRBC, FFP and PLT transfused were extracted. Data was analysed by
logistic and linear regression utilizing units of PRBC, FFP and PLT as predictors, respectively. Results were controlled
for confounders, including concurrent transfusion of other blood products (PRBC, FFP or PLT respectively), age and
comorbidities. These included the previous myocardial infarction, hypertension, heart failure, diabetes, atrial
fibrillation, renal and liver disease.
Results: 5107 patients received 10783 therapeutic endoscopic interventions during a total of 5681 admissions.
Accumulated blood products given were 48.255 (PRBC: 34327 units, FFP: 11069 units, PLT: 2698 units).
Associations between units transfused and outcome parameters are shown in the table.
Image:
310
Conclusion: NVUGIB is a major source of blood product utilization. Units of PRBC transfused were independently
associated with increased risk of repeated endoscopy, conversion to surgery, in-hospital mortality and LOS. FFP
transfusion was associated with increased risk of surgery and in-hospital mortality, but shorter LOS. PLT transfusion
was associated with a reduction in need for repeated endoscopic procedures as well as LOS. PLT transfusion may be
beneficial in this patient group.
Disclosure of Interest: None declared
311
217.03
IMPLEMENTATION OF A PREOPERATIVE CARE PATHWAY FOR PATIENTS WITH SUSPECTED
PERIAMPULLARY CANCER: HIGHER QUALITY OF CARE IN LESS TIME
M. Bakens1,2,*, M. Bongers1, J. Demelinne1, V. Lemmens2, I. de Hingh1
1
2
Surgery, Catharina Hospital Eindhoven, The Netherlands, Netherlands Cancer Registry, Comprehensive Cancer
Organisation Netherlands, Eindhoven, Netherlands
Introduction: The centralization of pancreatic surgery in The Netherlands led to improvement in surgical treatment for
pancreatic cancer. However, preoperative diagnosing and staging may be complex, time-consuming and demanding
for involved patients. To improve this process, specific preoperative care pathways are implemented. The aim of this
study was to evaluate the effect of the implementation of such pathway.
Materials & Methods: This study included all patients undergoing pancreatoduodenectomy for suspected
periampullary tumors from January 1 2009 to August 31 2014 in the Catharina Hospital Eindhoven, The Netherlands.
Patients’ characteristics, diagnostic procedures and time-schedules were extracted from the hospital records. Patients
were divided into groups; group A patients underwent surgery before the introduction of the care pathway and group B
patients underwent surgery after the implementation. Differences between the groups were analysed using MannWhitney U tests and Chi-Square tests.
Results: In total 155 consecutive patients were included: 49 patients prior to implementation (group A) and 106
thereafter (group B). The adequate procedure to assess surgical treatment is a combination of pancreas protocol
computed tomography and multidisciplinary team discussion. This was fulfilled in a higher percentage of group B
patients compared to group A patients (A:14.3%; B:72.6%, p=0.000). In group B patients more often a treatment plan
was made at the first day patients visited the outpatient clinic (A:63.3%; B:84.0%, p=0.004). Furthermore the time
between this visit and the surgical treatment was shortened (A: median 26 days; B: median 20 days, p=0.035). A
lower percentage in group B was referred after biliary drainage, however this was not statistically significant (A:37.5%;
B:29.7% p=0.398).
Conclusion: The preoperative care pathway in patients with a suspected periampullary malignancy is efficient since it
resulted in a higher percentage of patients receiving adequate diagnostic work-up and reduced the time to surgery
and amount of outpatient visits.
Disclosure of Interest: None declared
312
217.04
PROGNOSTIC SIGNIFICANCE OF P27 EXPRESSION IN NASH-RELATED HEPATOCELLULAR CARCINOMA
Y. Hirose1,*, K. Miura1, T. Ohashi1, K. Takizawa1, M. Nagahashi1, T. Kobayashi1, J. Sakata1, T. Wakai1
1
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences,
Niigata, Japan
Introduction: Non-alcoholic steatohepatitis (NASH) is a recently identified chronic liver disease, which progresses to
liver cirrhosis and hepatocellular carcinoma (HCC). Because the number of patients studied to date has been limited,
clinically useful prognostic biomarkers of NASH-related HCC have not been available. In this study, we investigated
the status of a cell-cycle regulator, p27, in NASH-related HCC. p27 has been regarded as a prognostic factor in
various types of cancer patients.
Materials & Methods: A retrospective analysis was conducted of 22 patients who underwent surgical resection for
NASH-related HCC, with a median follow-up period of 36.5 months. The status of p27, including the level of protein
expression, and phosphorylation at threonine 157 (T157) and serine 10 (S10) was assessed by immunohistochemical
analysis. Immunohistochemistry was conducted for proliferating cell nuclear antigen (PCNA) as a marker of cell
proliferation. The correlation of p27 with tumor characteristics, disease-free survival (DFS), and overall survival was
analyzed.
Results: p27 expression in tumor specimen was decreased in 13 patients (59%), and the low-p27 expressers was
significantly correlated with enlarged tumor size (P = 0.01). Phospho-p27 at T157 and S10 was detected in 4 (18%)
and 7 (32%) patients respectively. The presence of phospho-p27 (T157) in tumor specimen was significantly
correlated with advanced histological grade (P = 0.045), while the level of phospho-p27 (S10) in tumor specimen was
not significantly correlated with any of the clinicopathological features of HCC. The presence of phospho-p27 (S10) in
tumor specimen was significantly correlated with cell proliferation. Kaplan–Meier survival analysis showed that DFS
was 66.7% and 21.0% for the low- and high-p27 expressers respectively (log-rank; P = 0.042; Fig1A), and 61.1 % and
0% in the groups with negative and positive expression of phosho-p27 (S10) respectively (log-rank; P = 0.006; Fig1C).
Multivariate Cox regression model indicated that the levels of both p27 protein expression and phosphorylation at S10
failed to be independent predictors of cancer recurrence within 3 years. Intriguingly, however, univariate analysis
revealed that phospho-p27 (S10) was the only factor associated with increased cancer recurrence rates within 3 years
(hazard ratio 7.623 [1.457–39.882], P = 0.016)
Image:
Conclusion: The presence of phospho-p27 (S10) in tumor specimen may be useful as a biomarker for predicting
tumor recurrence in NASH patients.
Disclosure of Interest: None declared
313
217.05
THE STUDY OF THROMBOSIS OF PORTAL VEIN AND SUPERIOR MESENTERIC VEIN AFTER PORTAL VEIN
EMBOLIZATION
Y. Sawada1,*, R. Mori1, K. Mori1, G. Nakayama1, T. Kumamoto1, R. Matsuyama1, K. Takeda1, I. Endo1
1
Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama City,
Japan
Introduction: Portal vein embolization (PVE) before hepatectomy induces the hypertrophy of future liver remnant and
improves the safety of hepatectomy. Thrombosis of portal vein (PV) and superior mesenteric vein (SMV) was one of
the characteristic complications of PVE. We evaluated the treatment and risk factors of thrombosis of PV and SMV
after PVE.
Materials & Methods: We retrospectively analyzed the 120 consecutive patients who underwent PVE before
2
hepatectomy in our institution from 2010 to 2014. The independent t-test or χ test was used to compare patients with
thrombosis to those without thrombosis after PVE as clinical factors below (age, diagnosis, PT, APTT, D-dimer, PV
pressure, the site of procedure, volume of embolic material, operative time).
Results: The most common diagnoses were extrahepatic biliary cancer (45; 37.5%) and colorectal liver metastasis
(41; 34.2%). The most common procedure was right PVE (94; 78.3%). Thirty-seven patients underwent PVE with
hepatectomy or colorectal surgery. Thrombosis of PV or SMV occurred in 17 patients (14.1%, PV; 5 patients, SMV; 12
patients). Of the 17 patients with thrombosis, 13 patients were treated with anticoagulant therapy and 4 patients were
not treated. Thrombosis of PV or SMV were disappeared in these 17 patients. There were no significant differences
between patients with thrombosis and those without thrombosis as clinical factors below, age (68.9±8.3 year vs
66.5±11.0 year, p=0.401), PT(1.01±0.08vs 1.06±0.12, p=0.08), APTT (30.2 ±3.9 s vs 31.5±4.7 s, p=0.292), D-dimer
(2.8±2.6 µg/ml vs 2.3±2.3 µg/ml, p=0.401), procedure with colorectal or hepatic surgery (29.4 % vs 31.1 %, p=1.000),
PV pressure before PVE (10.3±4.9 mmHg vs 10.3±3.2 mmHg, p=0.969), PV pressure after PVE (13.4±4.7 mmHg vs
12.8±3.6 mmHg, p=0.577), volume of embolic material (16.0±6.3cc vs 15.8±5.2cc, p=0.860), operative time
(287.9±135.9 minutes vs 234.9±133.8 minutes, p=0.134). In 83 patients who underwent PVE only, 12 patients with
thrombosis significantly had longer operative time than 71 patients without thrombosis (212.8±68.0 minutes vs
163.0±36.6 minutes, p=0.029). These 12 patients with thrombosis tended to require more times of the embolization
than 71 patients without thrombosis (3.0±1.3 vs 2.3±0.7, p=0.125).
Conclusion: Operative time was the risk factor of thrombosis of PV and SMV after PVE. Especially for the patients
who require longer operative time and more times of the embolization, postoperative careful management for
thrombosis is required.
Disclosure of Interest: None declared
314
217.06
PERIOPERATIVE OUTCOMES FOLLOWING LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT AT A
SINGLE ACADEMIC CENTER
E. W. Gilbert1,*, E. Sohlberg1, M. Shapiro1, S. Garbus1, J. Dolan1, J. Hunter1
1
Surgery, Oregon Health & Science University, Portland, United States
Introduction: Laparoscopic jejunostomy tube (J-tube) placement has become a routine method to provide enteral
nutrition for patients who are otherwise unable to tolerate oral intake. The complication rate reported in the literature
varies dramatically from 5-25% and there is a lackof recent evidence that evaluate the morbidity of this procedure. Our
primary objective was to evaluate the morbidity rate of laparoscopic J-tube placement at our center and to identify risk
factors for morbidity in patients undergoing laparoscopic J-tube placement.
Materials & Methods: A retrospective review was performed of all patients who underwent recent laparoscopic J-tube
placement at a single academic center. Patients were identified in administrative data using the CPT code 44186.
Logistic regression models were used to estimate the association of J-tube complications with both demographic and
clinical variables. Multivariate analysis was performed to determine the combined effect of significant predictors on
outcomes and is expressed as the adjusted odds ratio (OR) with 95% confidence interval.
Results: 148 patients were identified between January 2010 and December 2013. The majority (73%) was male with
a median age of 63 (25-86). Most underwent laparoscopic J-tube placement in the setting of a cancer diagnosis
(85%). The procedure was either conducted alone (53%), or in combination with an elective procedure (43%) or an
urgent procedure (3%). The overall complication rate was 55.1% with 28.4% (n=42) of patients having one or more Jtube specific complications including dislodgement (81%), obstruction (21%) superficial infection (24%), bowel
perforation (2%) and bowel obstruction (2%). The overall reoperation rate was 27% and 32% in patients identified as
having a J-tube complication. Of the 23% with complication dislodgement, 6 patients subsequently underwent
operative revision. After controlling for age, indication, procedure category, BMI, smoking history and pre-operative
albumin only the diagnosis of DM2 was a significant predictor of J-tube complication [OR=3.5 (1.4-8.4)].
Conclusion: Although the benefits of J-tube placement for enteral nutrition are well established, the morbidity from
the procedure is less known. At our center, post-operative morbidity was high and was significantly associated with a
diagnosis of diabetes. Dislodgment is a frequent complication, which may be mitigated by a more secure fixation
technique.
Disclosure of Interest: None declared
315
217.07
LAPAROSCOPIC SURGERY OR CONSERVATIVE TREATMENT FOR APPENDICEAL ABSCESS IN ADULTS?
A RANDOMIZED CONTROLLED TRIAL
P. Mentula1,*, H. Sammalkorpi1, A. Leppäniemi1
1
Abdominal Surgery, Helsinki University Central Hospital, Helsinki, Finland
Introduction: Based on the retrospective studies, conservative management of appendiceal abscess is
recommended as a first line treatment, but some controversy exists. We hypothesized that immediate laparoscopic
surgery for appendiceal abscess would result in faster recovery than conservative treatment.
Materials & Methods: Sixty adult patients diagnosed with appendiceal abscess were randomly assigned to either
laparoscopic surgery (n=30) or conservative treatment (n=30). Hospital stay, recurrences, additional interventions and
complications within 60 days from randomization were recorded.
Results: There was no difference in hospital stay: 4 days (interquartile range 3-5 days) in the laparoscopy group
versus 5 days (3-8) in the conservative group, p=0.105. There were significantly fewer patients with unplanned
readmissions in the laparoscopy group: 1 (3%) versus 8 (27%), p=0.026. Additional interventions were required in 2
(7%) patients in the laparoscopy group (percutaneous drainage) and in 9 (30%) patients in the conservative group
(surgery), p=0.042. Recurrent abscesses and failure to respond to conservative treatment were the main reasons for
additional interventions. Open surgery was required in 3 (10%) in the laparoscopy group and in 4 (13%) patients in the
conservative group. Postoperative complications occurred in 3 patients in laparoscopic group versus 2 patients in the
conservative group. The rate of uneventful recovery was 90% in the laparoscopy group versus 50% in the
conservative group, p=0.002.
Table. Outcome within 60 days from randomization
Laparoscopy group
Conservative group
p-value
Attempted procedure failed†, n
4 (13%)
9 (30%)
0.209
Length of stay (primary), days
3 (3 – 5)
3 (2 – 4)
0.228
Length of stay (60 day)*, days
4 (3 – 5)
5 (3 – 8)
0.105
0.026
Re-admission, n
1 (3%)
8 (27%)
Recurrent or residual abscess between day 7 - 60
3 (10%)
8 (27%)
0.181
0.042
Additional intervention, n
2 (7%)
9 (30%)
0.002
Unplanned operation
0 (0%)
9 (30%)
0.007
Repeated CT-scan
3 (10%)
13 (43%)
0.002
Uneventful recovery
27 (90%)
15 (50%)
*t-test for normally distributed data used
†Appendectomy failed (no appendectomy or subtotal appendectomy performed) in the laparoscopy group or
attempted drainage of abscess failed in the conservative group
Conclusion: Laparoscopic surgery in experienced hands is safe and feasible first line treatment for appendiceal
abscess. It is associated with fewer readmissions and fewer additional interventions than conservative treatment with
comparable hospital stay.
References:
1. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and
meta-analysis. Ann Surg 2007;246:741–748.
2. Simillis C, Symeonides P, Shorthouse AJ, et al. A meta-analysis comparing conservative treatment versus acute
appendectomy for complicated appendicitis (abscess or phlegmon). Surgery 2010;147:818–829.
3. Deelder JD, Richir MC, Schoorl T, et al. How to Treat an Appendiceal Inflammatory Mass: Operatively or
Nonoperatively? J Gastrointest Surg 2014; 18:641-645.
Disclosure of Interest: None declared
316
217.08
CHEWING GUM AND POSTOPERATIVE ILEUS IN ADULTS: A SYSTEMATIC LITERATURE REVIEW AND METAANALYSIS
B. Su'a1,*, T. Pollock1, D. Lemanu1, A. MacCormick1, A. G. Hill1,2
1
South Auckland Clinical Campus, The University of Auckland, 2Department of General Surgery, Middlemore Hospital,
Auckland, New Zealand
Introduction: Post-operative ileus (POI) is a major problem following elective abdominal surgery. Several studies
have been published investigating the use of chewing gum to reduce POI. These studies however, have produced
variable results. Thus, there is currently no consensus on whether chewing gum should be widely instituted as a
means to help reduce POI.
Materials & Methods: We performed a systematic literature review to evaluate whether the use of chewing gum postoperatively improves POI in abdominal surgery. A comprehensive review of the literature was conducted according to
the guidelines in the PRISMA statement. The following databases were searched: MEDLINE, PUBMED, EMBASE,
SCOPUS, Science Direct, CINAHL and the Cochrane Central Register of Controlled Trials. Clinical outcomes were
extracted and meta-analysis was performed.
Results: There were 1019 patients from 12 randomised controlled studies included in this review. Only one study was
conducted in an Enhanced Recovery after Surgery (ERAS) environment. Seven of the twelve studies concluded that
chewing gum reduced post-operative ileus. The remaining five studies found no clinical improvement. Overall, there
was a small benefit in reducing time to flatus, and time to bowel motion, but no difference in the length of stay or
complications.
Conclusion: Chewing gum offers only a small benefit in reducing time to flatus and time to passage of bowel motion
following abdominal surgery. This benefit is of limited clinical significance. Further studies should be conducted in a
modern peri-operative care environment.
Disclosure of Interest: None declared
317
219.01
MISSED PARATHYROID GLANDS IN PATIENTS UNDERWENT REOPERATIVE PARATHYROIDECTOMY FOR
PERSISTENT OR RECURRENT SECONDARY HYPERPARATHYROIDISM
M. Okada1,*, T. Yamamoto1, T. Hiramitsu1, Y. Tominaga1
1
Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
Introduction: Some patients with secondary hyperparathyroidism (SHPT) require reoperative parathyroidectomy
(RPTX) due to missed parathyroid glands at the initial operation. We investigated the locations of missed
glands in those cases received RPTX for persistent or recurrent SHPT.
Materials & Methods: We retrospectively investigated the locations of missed glands in 165 patients who had
been received RPTX in our institution from August 1982 to July 2014. In our department, total parathyroidectomy
with forearm autograft is routine operative method in patients with SHPT. We routinely resect thymic tongues at
initial operation.
Results: Out of 165 patients, 82 patients underwent initial operation in our department (group A), and the others
underwent initial operation at other hospitals (group B). Totally 239 parathyroid glands were resected
(groupA;93, groupB;146). The most common sites of missed glands were in thymic regions in groupB (31/146).
On the other hand, in group A, missed glands most frequently existed in mediastinal regions (22/93), and only
seven glands were detected in remaining thymic tissue.
Conclusion: Transcervical thymectomy seems to be essential at the initial operations, because ectopic
parathyroid glands frequently exist in this region. And we should also give attention to ectopic glands in
mediastinum and it is necessary to perform preoperative image diagnosis to rule out presence of medeastinal
glands in patients with persistent or recurrent SHPT.
Disclosure of Interest: None declared
318
219.02
SECULAR TRENDS OF THE CLINICOPATHOLOGIC CHARACTERISTICS AND PROGNOSIS OF MEDULLARY
THYROID CANCER AND THE CHANGES OF THE PREDICTIVE FACTORS FOR THE RECURRENCE OVER THE
30 YEARS.
S.-M. Kim1,*, H. K. Kim1, H. Chang1, B.-W. Kim1, Y. S. Lee1, H.-S. Chang1, C. S. Park1
1
Departments of Surgery, Yonsei University College of Medicine, Seoul, Korea, Republic Of
Introduction: The increase in thyroid screening with ultrasound in general population may lead to the earlier detection
of medullary thyroid carcinoma (MTC) similar to papillary thyroid carcinoma in recent years. The aim of the study was
to evaluate the secular trends in the clinicopathologic characteristics, long term prognosis and its risk factors in MTC
patients
Materials & Methods: Total 331 patients with MTC were included from 1982 to 2012, and followed up for median 4.6
(0.2-30.8) years. Patients were grouped based on the year of diagnosis; 1982–2000, 2001–2005, 2006–2010 and
2011–2012 for the comparison of clinicopathological characteristics, 1982-2005 and 2006-2012 for the prognosis.
Results: The mean age had been increased over time, but the proportion of male was similar. The mean tumor size
(from 2.5cm to 1.7cm, p<0.001) and the proportion of extrathyroidal extension (from 52% to 26%, p=0.026) had been
decreased. In addition, the proportion achieved postoperative biochemical remission of serum calcitonin (BCR) had
been continuously increased with time (from 39% to 76%, p<0.001). The 5-year overall recurrence rate was
significantly decreased in 2006-2012 compared to 1982-2005 (10 % vs. 18% respectively, p=0.031), although 5-year
disease specific survival was not improved (8 % vs. 8%, p=0.929). On multivariate analysis, postoperative BCR was
the most strong predictive factor associated with recurrence (HR=50.26, 95% CI 6.24–405.09; p<0.001). The
increased BCR with periods was related with the improvements of surgical techniques as well as the decrement of
pathologic aggressiveness. For the mortality, male sex (HR=3.37, 95% CI 1.36–8.33; p=0.008), tumor size larger than
2cm (HR=10.83, 95% CI 2.42–48.54; p=0.002), or distant metastasis (HR=4.31, 95% CI 1.56–11.95; p=0.005) was
resulted as a significant prognostic factor.
Conclusion: The clinicopathlogic characteristics of MTC have been improved over the 3 decades, and the recurrence
was also decreased with times. The postoperative BCR was the most strong predictive factor for recurrence reflecting
both the pathological aggressiveness and surgical completeness. However, the proportion of distant metastasis and
the mortality remain unchanged over time and that suggest the necessity of earlier detection of tumors larger than
2cm.
Disclosure of Interest: S.-M. Kim Grant/Research Support from: Research Grant Number CB-2011-03-01 of Korea
Foundation for Cancer Research Fund, H. K. Kim: None declared, H. Chang: None declared, B.-W. Kim: None
declared, Y. S. Lee: None declared, H.-S. Chang: None declared, C. S. Park: None declared
319
219.03
TRENDS IN PREVALENCE OF THYROID CANCER OVER THREE DECADES: A RETROSPECTIVE COHORT
STUDY OF 17,526 SURGICAL PATIENTS.
A. Konturek1,*, M. Barczyński1, M. Stopa1, W. Nowak1
1
III rd Department of General Surgery, Jagiellonian University, Krakow, Poland
Introduction: Thyroid cancer (TC) incidence is increasing in recent years. Both improved detection and a real
increase have been debated as underlying reasons for this phenomenon. These changes affect surgical volume for
TC. The aim of this study was to investigate our institution-based estimates of operative volumes for TC over last
three decades.
Materials & Methods: This was a retrospective cohort study of patients undergoing thyroid surgery at our institution
between 1981 and 2012. Patients characteristics were reviewed in three subgroups: Group I (treated in 1981-1986),
Group II (treated in 1987-2002), and Group III (treated in 2003-2012). Primary outcome was prevalence of TC.
Secondary outcomes were pathological characteristics and staging of the disease.
Results: TC was diagnosed in 1578/17,526 (9.0%) thyroid operations, including 1548 (98.1%) primary TCs and 30
(1.9%) cases of metastases to thyroid gland. Incidence of TC increased from 3.7% in Group I, 7.9% in Group II, to
10.4% in Group III (p<0.001). This increase was significant in female patients below 40 years of age (p<0.001).
Incidence of papillary TC increased form 40.6% in Group I, 68.6% in Group II, and 81.3% in Group III (p<0.001). In the
latter group 23.5% of all papillary TCs were diagnosed in patients with Hashimoto’s disease. Meanwhile, incidence of
anaplastic TC decreased from 16.2% in Group I, 7.8% in Group II, to 2.1% in Group III (p<0.001). Incidence of
follicular TC decreased from 24.3% in Group I, to 9.6% in Group III (p=0.01). pT1 tumors were diagnosed in 8.1%
Group I, 37.6% Group II, and 54.8% Group III (p<0.001), whereas pT4 tumors were identified in 40.5% Group I, 2.4%
Group II, and 0.84% Group III (p<0.001). pT3 tumors were found in 51.6% Group I, whereas multifocal papillary TCs
were found in 15.7% Group III, the latter one with higher prevalence of pN1 stage (p<0.001). R2 operations were done
in 34.4% Group I vs. 0.42% Group III (p=0.02). Complete follow-up data were available for 84.1% patients at 5 years,
and 23.3% at 10 years.
Conclusion: The following trends in surgical volume for TC were identified throughout the study period: five-fold
increase of thyroid operations for TC, three-fold increase in incidence of papillary TC, and eight-fold decrease in
incidence of anaplastic TC. It is of interest that significant increase in incidence of multifocal papillary TC in young
female patients with Hashimoto’s disease was found over time.
Disclosure of Interest: None declared
320
219.04
MOLECULAR CHARACTERISTICS OF LARGE PARATHYROID ADENOMAS
R. pradhan1,*, A. Agarwal1, N. Kumari2, N. krishnani2, P. shukla2, S. Gupta3, G. Agarwal1, S. MISHRA1
1
2
3
Endocrine surgery, department of pathology, Department of endocrinology, sanjay gandhi post graduate institute of
medical sciences, LUCKNOW, India
Introduction: The clinical entity of LPTA (Large parathyroid adenomas) has not been well defined. It is speculated
that LPTAs would have biochemical, histological and molecular characteristics different from small adenomas. Our
study aimed to find out occurrence of atypia and carcinomas in large parathyroid lesions and presence of distinct
molecular abnormalities in LPTAs
Materials & Methods: We divided the parathyroid lesions into large (>2grams i.e LPTAs) and small (<2 grams)
adenomas. We performed parafibromin expression analysis by immunohistochemistry in atypical adenomas and
carcinomas and adenomas without atypia. Tumor specimens were immune stained with mouse monoclonal antibody
targeting exon 3 of human parafibromin (clone 2H1).
Results: Among 205 parathyroid tumors, 74 weighed < 2 g and 131 weighed >/= 2 g. Patients with large tumors had
higher parathyroid hormone levels. Atypia was found in 3 of 74 (4.05%) and 19 of 205 (14.5%) small and large tumors,
respectively (P < .05). Corresponding figures for carcinoma were 1 of 74(1.3%) and 9 of 131 (6.8%) (P <.05).
Loss of parafibromin expression was present in 7/9 carcinomas weighing more than 2 grams, whereas the only
carcinoma with weight <2 grams retained parafibromin expression. 2/3 (66.6) lesion (<2grams) with atypia retained PF
expression whereas 11/19 (57.9%) adenomas showed loss of PF expression (complete or focal).
Variable
>2
grams
< 2 grams
(LPTAs)
Number
131 (63.9%)
74 (36.1%)
Age
38yrs±14
44yrs±15
Male / female
42/89
32 %/68
25/49 34%/66
%
%
Peak calcium
12.66mg/dl±1.77
12.17mg/dl±1.79
PTH
975pg/ml± 869
406pg/ml±474
Alkaline phosphatase
1193±1336
395±653
Weight
7.6gms± 8.4
0.9gms±0.536
Atypical adenoma
19 (14.5%) *
3 (4.05%
)*
Carcinoma
9 (6.8%) *
1(1.3%)*
Image:
Conclusion: We conclude that there is higher incidence of atypical features in large parathyroid adenomas. Therefore
parafibromin staining helps us to risk categorise atypical adenomas which merit close follow up to pick up recurrences
and complements our histopathological diagnosis of parathyroid carcinomas
Disclosure of Interest: None declared
321
219.05
RISK OF RECURRENCE DURING A 15-YEAR FOLLOW-UP PROGRAM IN PATIENTS WITH PRIMARY
HYPERPARATHYROIDISM OPERATED WITH UNILATERAL NECK EXPLORATION
M. Thier1,*, E. Nordenström1, M. Almquist1, A. Bergenfelz1
1
department of surgery, Lund University hospital, Lund, Sweden
Introduction: Since the introduction of unilateral and focused surgery of pHPT it has been debated wherever this approach is
associated with an increased risk for long term recurrence compared to bilateral neck exploration. The aim of this study is
to evaluate the recurrence rate after unilateral or focused operation for primary hyperparathyroidism (pHPT).
Materials & Methods: Patients undergoing first time surgery for sporadic pHPT with unilateral or focused neck exploration
(UFNE) were included in a structured 15-year follow-up program.
Results: Some 292 patients operated with UFNE were analyzed. Median age was 66 years, interquartile range (i.q.r.) 57-75
years, 80.1% were female. Median, preoperative ionized calcium was 5.84 (i.q.r. 5.64-6.08) mg/dL and PTH was 94.3 (i.q.r. 69.8132.1) pg/ml. During the structured follow-up program (median 5 years, range 0-15 years), 275 patients (95.8%), were followed for
1 year (275 person-years, 5 patients deceased), 164 (76.3%) for 5 years (820 person-years, 31 patients deceased), 70 (77.8%) for
10 years (700 patient-years, 57 patients deceased) and 51 (83.6%) patients at 15 years after surgery (765 patient-years, 69
patients deceased). Three patients (1.1%) had persistent disease after the primary operation, of which none were re-operated.
Intraoperative parathyroid hormone measurement was false positive in all three patients. Histopathology revealed a single
parathyroid adenoma in two patients and one normal gland in one patient. During 15 years of follow up one patient had recurrent
disease which was diagnosed 5 years after primary surgery. Histopathology from the primary operation indicated a parathyroid
adenoma. This patient has been followed-up and has not been re-operated. None of the patients suffered from long term (> 6
months) postoperative hypocalcaemia.
Conclusion: Unilateral or focused neck exploration in patients with pHPT and apparent single-gland disease have a low risk for
long term recurrence with no patient suffering from long term hypocalcaemia.
Disclosure of Interest: None declared
322
219.06
DOES LYMPHADENECTOMY IMPROVE SURVIVAL IN PATIENTS WITH ADRENOCORTICAL CARCINOMA? A
POPULATION-BASED STUDY.
N. Nilubol1,*, E. Kebebew1
1
Endocrine Oncology Branch, National Cancer Institute, NIH, Bethesda, United States
Introduction: The survival of patients with adrenocortical carcinoma (ACC) has not improved in 6 decades. Surgical
resection remains the only curative treatment modality; however, the role of lymphadenectomy is not well-studied. A
recent study suggested a survival benefit in patients who had lymphadenectomy. The objective of this study was to
study the impact of lymphadenectomy on survival of patients with ACC.
Materials & Methods: Data from adult patients with histology-proven ACC from the National Cancer Institute’s
Surveillance, Epidemiology and End Results 18 Registries Database (1973-2011) were analyzed to assess the impact
of lymphadenectomy (≥4 lymph nodes removed) on disease-specific survival (DSS).
Results: Of 1,525 patients with ACC, 45% were male. Patients presented with localized, regional, and distant
metastatic disease in 36%, 20%, and 44%, respectively. Median tumor size was 10 cm. Forty-one percent of patients
had extra-adrenal extension. Only six percent of patients (n=69) underwent lymphadenectomy. We observed a higher
rate of lymphadenectomy performed in patients with regional disease (extraadrenal extension and/or lymph node
metastasis) than in those with localized tumor and distant metastasis (11.3% vs. 4.8% vs. 5.1%, respectively, p<0.01)
and in patients with ACC larger than 10 cm (10% vs. 3.2%, p<0.01). Lymph node metastasis was present in 12.8%.
Factors associated with lymph node metastasis included poorly and undifferentiated ACC (21.4% vs. 6.8%, p<0.01),
and extraadrenal extension (19.2% vs. 4.8%, p<0.01) but not tumor size (p=0.85).
Lymphadenectomy was not associated with improved DSS in univariate analysis (p=0.41) regardless of tumor size,
overall stage, status of extra-adrenal extension, or distant metastasis. Independent prognostic factors on multivariate
analysis were age ≥60 years (p<0.01, HR=1.70), regional disease (p<0.01, HR=2.5), distant metastasis (p<0.01,
HR=5.6), complete resection of tumor (p<0.01, HR=0.47), and debulking surgery (p<0.01, HR=0.49).
Conclusion: Lymphadenectomy is not commonly performed in patients with ACC. Although we did not demonstrate a
survival benefit in this cohort, lymphadenectomy should be considered in patients with extraadrenal extension due to a
higher rate of lymph node metastasis.
Disclosure of Interest: None declared
323
222.01
SURGICAL AND ANAESTHETIC SERVICES IN THE FAKO DIVISION OF THE SOUTH-WEST REGION OF
CAMEROON: AN URGENT CALL FOR ACTION.
A. Chichom-Mefire1,*, V. N. Mbome2, J. Atashili3
1
2
Faculty of Health Sciences, University of Buea and Regional Hospital Limbe, Cameroon, Regional Delegation of
3
Public Health, South-West Region, Cameroon, Department of Public Health and Hygiene, Faculty of Health Sciences,
University of Buea, Buea, Cameroon
Introduction: Conditions which can be potentially corrected by surgery represent a significant burden of diseases in
sub-Saharan Africa. It has been suggested that the quality and quantity of surgical and anaesthetic services offered in
this region are generally far below the real needs. Data on the delivery of surgical services remain however scarce
and policies are mainly based on national estimates. This study aimed at providing a comprehensive estimation of
surgical and anaesthetic services offered to the population of an entire division of the South-West Region of
Cameroon.
Materials & Methods: This study which was carried-out in the Fako Division of the South-West Region of Cameroon
st
st
analyzed surgical and anaesthetic activities between 01 January and 31 December 2013. All health institutions
which provided surgical services in 2013 were identified and visited. During the visit, we collected data regarding the
characteristics of the institution, human resources and nature and quantity of surgical and anaesthetic activities
delivered during the study period.
Results: A total of 18 health institutions were identified as involved in surgical activities and surveyed. They served a
total population of 527.525 inhabitants. Surgical services were delivered by 14 surgeons (2.65 surgeons/100.000
catchment population). A total of 12.232 surgical procedures (5.290 major and 6942 minor) were carried out over 1
year (2321 procedures /100.000 catchment population). These included 1195 caesarean sections (226/100.000). A
total of 8.985 anaesthetic procedures were administered (1704/100.000 catchment population). These included a
majority of local anaesthesia (45%). Most surgical procedures were performed on skin and soft tissue and on the
digestive system.
Conclusion: This comprehensive estimation of surgical and anaesthetic services in an entire division of the country is
the first of such in Cameroon and Central Africa. The caesarean section rate, when used as an overall indicator of
surgical services is dangerously low. The quality and availability of health care personnel providing surgical and
anaesthetic services is also alarming. These findings strongly suggest that unmet needs for surgical and anaesthetic
services are very high. It should be considered a call for a more comprehensive assessment of the surgical needs of
the populations of Fako division and of Cameroon as a whole.
Disclosure of Interest: None declared
324
222.02
EVALUATION OF A STRUCTURED HERNIA REPAIR COURSE FOR INTERN PHYSICIAN IN NORTHERN
UGANDA
E. Parvez1,*, T. R. Okello2, R. Lett3, M. D. Ogwang2, P. Mugabi4, G. Hwang5
1
2
Department of Surgery, McMaster University, Hamilton, Canada, Department of Surgery, St. Mary's Hospital Lacor,
3
Gulu, Uganda, Canadian Network for International Surgery, Vancouver, Canada, 4Department of Surgery, Gulu
Regional Referral Hospital, Gulu, Uganda, 5Department of Surgery, University of British Columbia, Vernon, Canada
Introduction: Due to the critical shortage of surgeons in Northern Uganda,1 inguinal hernia repair is often performed
by general physicians.2 Skills transfer workshops delivered with the assistance of international partnerships can help
3,4
provide adequate training in resource constrained environments. The purpose of this study was to evaluate the
knowledge and skills acquired by intern physicians in Northern Uganda after completing the Canadian Network for
International Surgery Structured Hernia Repair (SHR) course.
Materials & Methods: The 5-day SHR course was delivered at Gulu Regional Referral Hospital in October 2013 and
March 2014 by local faculty and visiting Canadian faculty. The course included didactic and simulation-based
instruction, as well as supervised operating. Students completed 3 inguinal hernia surgeries as the primary surgeon
under direct supervision. All patient participants provided informed consent. Students provided information on their
experience with inguinal hernia surgery before the course. Students’ knowledge was evaluated with a pre- and posttest. Various aspects of students’ operative skills were evaluated by supervising faculty using a 1-5 Likert scale.
Univariate analyses and descriptive statistics were used to analyze the data.
Results: Seventeen students participated in the course at GRRH. Only 41.2% of students had performed an average
of 1.86 groin hernia repairs/student before the course. Before the course, 38.5% of students felt they had enough
knowledge to perform an inguinal hernia repair vs. 100% after the course (p<0.05). Similarly, only 30.8% of students
felt they had adequate skill to complete a repair before the course vs. 100% after the course (p<0.05).The average
score on the pre-test was 40.6% vs. 81.6% on the post-test (p<0.05). The average rating on the 1-5 Likert scale by the
supervising surgeons on various aspects of the students’ operative performance was 4.3.
Conclusion: Prior to the course, students had limited knowledge of and experience with inguinal hernia surgery.
Following the course, all students felt they had the knowledge and skill necessary to complete a repair, and this was
reflected on their test scores and evaluations. This study demonstrates that the SHR course is an effective method of
teaching inguinal hernia repair surgery. Further research could assess the impact of the course on complication rates
after inguinal hernia repair.
References: 1. Hoyler M, Finlayson SRG., McClain CD et al. Shortage of doctors, shortage of data: a review of the
global surgery, obstetrics, and anesthesia workforce literature. World J. Surg. 38, 269–80 (2014).
2. Ozgediz D, Galukande M, Mabweijano J et al. The neglect of the global surgical workforce: experience and
evidence from Uganda. World J. Surg. 32, 1208–15 (2008).
3. Lipnick M, Mijumbi C, Dubowitz G et al. Surgery and anesthesia capacity-building in resource-poor settings:
description of an ongoing academic partnership in Uganda. World J. Surg. 37, 488–97 (2013).
4. Elobu AE, Kintu A, Galukande M et al. Evaluating international global health collaborations: perspectives from
surgery and anesthesia trainees in Uganda. Surgery 155, 585–92 (2014).
Disclosure of Interest: None declared
325
222.03
COST-EFFECTIVENESS OF MOBILE SURGERY IN LOW- AND MIDDLE-INCOME COUNTRIES: AN
ECUADORIAN CASE STUDY
H. T. Shalabi1,2,*, M. D. Price1,3, S. T. Shalabi1,2, E. B. Rodas1,4,5, B. Guzhñay1, A. Vicuña1, R. R. Price1,6, E. Rodas1,5
1
2
3
Cinterandes Foundation, Cuenca, Ecuador, East Midlands NHS Deanery, Nottingham, United Kingdom, Brigham
4
5
Young University, Provo, United States, Universidad del Azuay, Universidad de Cuenca, Cuenca, Ecuador, 6Centre
for Global Surgery, University of Utah, Salt Lake City, United States
Introduction: Four billion people lack access to surgery in low and middle-income countries (LMICs). Mobile surgery
tackles the challenges of access by bringing quality surgical care to local resource-limited areas. Cost-effectiveness
of mobile surgery in LMICs has not been fully investigated in the literature. Cinterandes Foundation has an
established Mobile Surgical Program in Ecuador, using a truck equipped as an operating theatre. It has conducted
7600 operations over the past 20 years in rural and remote areas. This research examines the cost-effectiveness of
mobile surgery in Ecuador.
Materials & Methods: A retrospective micro-cost analysis was conducted to assess the cost of mobile surgery
provided by Cinterandes Foundation in Ecuador between 01/01/13–01/01/14. The analysis followed standardised
WHO-CHOICE guidelines, exploring both provider and patient level costs, using the ingredients method. Two total
costs were examined: the cost incurred by this specific organisation taking into account donated and discounted items
and time (DI); and the total real market cost of mobile surgery (TR). The burden of surgical disease was estimated in
disability-adjusted life years (DALYs) averted, calculated based on the Global Burden of Disease data. Disability was
weighted according to the validated scoring system by Bickler et al. Calculations were adjusted for age-weighting and
discounting.
Results: Surgical care was delivered to 202 local patients in 10 different regions of Ecuador. The most commonly
performed operations were laparoscopic cholecystectomy, hernia repair, and orchidopexy. Total costs for delivering
mobile surgery were $121,356 (DI) or $212,135 (TR). Breakdown of cost includes truck facilities of $18,886 (DI) or
$24,791 (TR), equipment and materials of $23,334 (DI) or $38,208 (TR), personnel of $68,782 (DI) or $138,782 (TR),
and other costs for $10,352 (DI and TR). Total DALYs averted was 1,258. Cost effectiveness ratio was $96/DALY
(DI) or $169/DALY (TR).
Image:
Conclusion: These findings demonstrate that mobile surgery is cost-effective, and highly comparable to hospitalbased surgery in LMICs which typically costs $50-$300/DALY. Mobile surgery has many inherent advantages,
promoting equity and equality by reaching the secluded in rural and remote areas. Mobile surgery in Ecuador
compares favourably with other traditional public health interventions in LMICs: BCG vaccine for tuberculosis at $50$250/DALY, antiretroviral therapy for HIV at $500/DALY, and oral rehydration therapy at $1000/DALY.
Disclosure of Interest: None declared
326
222.04
TOWARDS A STANDARD APPROACH TO MONITORING OF PERI-OPERATIVE MORTALITY
R. Ariyaratnam1,2,*, D. Watters3, R. Gruen4 on behalf of Charlotta L Palmqvist, BaSc, Department of Clinical Sciences
in Lund, Paediatric Surgery and Global Paediatrics, Faculty of Medicine, Lund University, Children's Hospital, 22185
Lund, Sweden Phil Hider, MPH, Department of Population Health, University of
1
Surgery, Monash University, Melbourne, 2Surgery, Barwon Health, 3Surgery, Deakin University and Barwon Health,
Geelong, 4Surgery, National Trauma Research Institute and Monash Unviersity, Melbourne, Australia
Introduction: Peri-operative mortality rate is an indicator of safety & quality of surgical care. Its use as a metric, has
been limited by lack of a standardized approach to measurement, poor understanding of when it is best measured,
and need for risk adjustment. We examined these issues using datasets from high, middle and low-income countries
to enhance the value of POMR.
Materials & Methods: Datasets from Australia, New Zealand, South Africa & Papua New Guinea were used.
Characteristics thought to influence POMR such as age, admission type, ASA, & procedure type, were described. For
each site, POMR before discharge was calculated, for elective and emergency admissions, and for cholecystectomies
& hip fracture surgery, using procedures and, where possible, patients as denominator. Where post-discharge deaths
were recorded, true 30-day POMR was calculated as well as the difference between inpatient POMR & true 30-day
POMR. The independent effects of site, age, urgency and length of hospital stay on POMR were analysed using log
regression & effect of adjustment for covariates on odds ratio.
Results: 1,365,773 admissions & 1,514,242 procedures, with 8,655 deaths within 30 days were analysed. Overall inhospital POMR, ranged almost 8-fold, from 0·35% in the HIC data, to 2·75% in the SA & PNG data, varying by
admission urgency. In hospital 30-day POMR underestimated total 30-day POMR by a third. POMR based on
admissions was less than 10% higher than POMR based on procedures in the NZ and PNG data, but was 25% higher
and 70% higher in SA and Aus data respectively. In-hospital POMR varied largely when stratified by urgency & age.
Emergencies in patients over 65 had greater POMR. Emergency cases, length of hospital stay & age over 65 years
had significant independent associations with inpatient death. Adjusting for these factors affected the relative odds of
POMR between sites, but didn’t reduce the difference between HIC’s & LMICs.
Conclusion: Collection & reporting of data already exists, irrespective of income status of countries. Quality of data
collection & safety of surgery varied greatly. Risk adjustments based on casemix would be ideal but not essential for
monitoring performance. The effect of the denominator is still unclear as estimates vary from 10 to 70%.
Epidemiological principles suggest admission episodes are preferable however procedures can represent a usable
denominator. Standardized approaches to reporting will strengthen POMR as the principal indicator of safety of
surgery & anaesthesia.
References: 1.
Watters, D.A., et al., Perioperative Mortality Rate (POMR): A Global Indicator of Access to Safe
Surgery and Anaesthesia. World J Surg, 2014.
2.
Haynes, A.B., et al., A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl
J Med, 2009. 360(5): p. 491-9.
3.
van Schalkwyk, J.M. and D. Campbell, Mortality after surgery in Europe. Lancet, 2013. 381(9864): p. 370.
4.
Van Aken, H. and G. Brodner, [Perioperative mortality in Europe: intensive care saves lives]. Anasthesiol
Intensivmed Notfallmed Schmerzther, 2012. 47(11-12): p. 665-6.
5.
Pupelis, G. and I. Vanags, Mortality after surgery in Europe. Lancet, 2013. 381(9864): p. 369.
6.
Pearse, R.M., et al., Mortality after surgery in Europe: a 7 day cohort study. Lancet, 2012. 380(9847): p. 105965.
7.
Mikstacki, A., Mortality after surgery in Europe. Lancet, 2013. 381(9864): p. 369.
8.
Franek, E., et al., Mortality after surgery in Europe. Lancet, 2013. 381(9864): p. 369-70.
9.
Brodner, G. and H. Van Aken, Mortality after surgery in Europe. Lancet, 2013. 381(9864): p. 370.
10.
Ouro-Bang'na Maman, A.F., et al., Deaths associated with anaesthesia in Togo, West Africa. Trop Doct, 2005.
35(4): p. 220-2.
11.
Inbasegaran, K., P. Kandasami, and N. Sivalingam, A 2-year audit of perioperative mortality in Malaysian
hospitals. Med J Malaysia, 1998. 53(4): p. 334-42.
12.
Chu, K.M., N. Ford, and M. Trelles, Operative mortality in resource-limited settings: the experience of
Medecins Sans Frontieres in 13 countries. Arch Surg, 2010. 145(8): p. 721-5.
13.
Hansen, D., S.C. Gausi, and M. Merikebu, Anaesthesia in Malawi: complications and deaths. Trop Doct, 2000.
30(3): p. 146-9.
14.
Heywood, A.J., I.H. Wilson, and J.R. Sinclair, Perioperative mortality in Zambia. Ann R Coll Surg Engl, 1989.
71(6): p. 354-8.
15.
McKenzie, A.G., Mortality associated with anaesthesia at Zimbabwean teaching hospitals. S Afr Med J, 1996.
86(4): p. 338-42.
16.
Watters, D.A., et al., Audit of 'surgery in general' in an African teaching hospital. J R Coll Surg Edinb, 1991.
36(6): p. 402-4.
Disclosure of Interest: None declared
327
223.01
IMPLICATIONS OF RECOGNIZING SAPHENOUS FASCIAL ANATOMICAL VARIATION IN SOUTH ASIAN
CHINESE
M. Y. Tan1,*, H. Liu1, Q. T. Hong1, Y. F. Fong1, S. Narayanan1
1
General Surgery, TTSH, Singapore, Singapore
Introduction: Endothermal ablation of the great saphenous vein (GSV) is a very common procedure done for
varicose veins. The GSV is usually described as being enveloped within the saphenous fascia extending from the
inguinal venous confluence to the ankle. In South Asian Chinese, we describe our observations of anatomical
variations and it’s implication in our treatment technique.
Materials & Methods: Ultrasounds scans (USS) of the lower limbs are performed for 138 patients of South Asian
Chinese ethnicity for assessment of varicosities. This is performed both pre-operatively to confirm GSV reflux, and
intra-operatively to map the fascia from the groin to the ankle. Those with complete fascia is defined as the fascial
eye surrounding the GSV in its entire course. This finding is compared with the contralateral limb to assess for
anatomical symmetry.
Results: Fascia anatomy was recorded on USS in 138 South Asian Chinese patients with 95.7% incomplete fascia in
at least 1 limb and 97.5% of participants having incomplete fascia bilaterally. There were no patients with completely
absent GSV fascia. Recognizing this anatomical variation, do not assume any vein outside the saphenous fascia is a
tributary. It is important to map the GSV from the groin to the medial malleolus. Care is taken to provide adequate
tumescence to lift the skin away from the saphenous vein which may be outside and superficial to the saphenous
fascia to reduce risk of thermal injury.
Conclusion: The saphenous vein shows significant anatomical variation in South Asian Chinese as compared to the
Caucasian population. Additional precautions are therefore needed to reduce risks of thermal injury during
endovenous ablation.
Disclosure of Interest: None declared
328
223.02
A STUDY TO EVALUATE THE EFFICACY OF SUPERVISED EXERCISE TRAINING PROGRAMME IN PATIENTS
SUFFERING FROM PERIPHERAL ARTERIAL DISEASE OF THE LOWER LIMB ATTENDING A TERIARY CARE
CENTRE
T. A. Narain1, A. Dhar1,*, A. Srivastava1
1
Department of Surgical Disciplines, All India Institute Of Medical Sciences, New Delhi, India, New Delhi, India
Introduction: Peripheral arterial disease(PAD) has the potential to cause considerable impairment in the quality of life
(QOL), besides causing physical distress and loss of limbs. Disagreement exists between the quality of life as
perceived by the clinicians and the actual QOL of the patients. Patients with PAD have a poor QOL with intense pain
in the lower limbs which hampers their social and financial obligations. Supervised Exercise Therapy(SET) has been
proposed as a modality of treatment for PAD and entails graded exercise on a treadmill under expert guidance.
Exercise programs with risk factor modification offer the possibility of altering the clinical trajectory of PAD.
Materials & Methods: We determined the Intermittent Claudication Distance(ICD), the Maximum Walking
Distance(MWD), Ankle Brachial Index(ABI), pain on VAS scale and the Quality of Life, using the WHO QOL BREF
questionnaire, for patients of PAD at the beginning of the study. The subjects in the exercise group were then
subjected to supervised exercise training on a treadmill for ten sessions, two sessions in a week and each session
lasting for thirty minutes. There was graded increase in the intensity of the exercise with each session. These patients
were then evaluated at the end of 3 and 6 months and the same parameters were recorded. The control group, which
refused to undertake the exercise therapy had the above mentioned parameters recorded at 0, 3 and 6 months.
Results: Statistical evaluation showed significant improvement in the ICD,MWD and QOL in the exercise group, the
major improvements seen in the physical and psychological domains of the quality of life and limited improvements in
the social and environmental aspects of quality of life. The control group which was offered only medical therapy and
no exercise therapy had either static or progressively deteriorating disease.
Conclusion: SET should be offered to all patients of Peripheral Arterial Disease, not only to improve their functional
status, alleviate their sufferings and reduce the cardiovascular risk factors but also to improve their Quality of Life.
Measures should be taken to set up infrastructure and resources to provide this therapy to all patients of peripheral
vascular disease and in places where it is not possible, patients should be advised regarding walking exercises at
home with progressively increasing intensity. Our ultimate endeavor should be to improve the QOL of our patients and
not limit ourselves to providing symptomatic treatment for the disease.
Disclosure of Interest: None declared
329
223.03
OPEN VERSUS ENDOVASCULAR REPAIR OF NON-EMERGENCY ABDOMINAL AORTIC ANEURYSM: A TENYEAR SINGLE CENTER EXPERIENCE
J. Turtiainen1,*, E. Aro1, T. Hakala1
1
Surgery, North Karelia Central Hospital, Joensuu, Finland
Introduction: There are two available methods for abdominal aortic aneurysm (AAA) repair, an open aneurysm repair
(OPEN) and an endovascular aneurysm repair (EVAR). Whether EVAR reduces long-term morbidity and mortality,
compared to OPEN, remains uncertain. The study objective was to compare early and long-term outcomes of EVAR
versus OPEN.
st
Materials & Methods: A total of 165 patients undergoing non emergent AAA repair between January 1 2004 and
st
August 31 2014, were identified and included in this retrospective study. Open AAA repairs were performed in a
single secondary referral hospital. Patients receiving endovascular AAA procedure were referred to a single tertiary
referral hospital.
Results: Of the 165 patients with AAA, 100 (60%) underwent an OPEN and 65 (40%) an EVAR. The EVAR patients
were older (77 vs 70 years, p < 0.0001). Patients treated with the OPEN and the EVAR had similar comorbidities,
except that the EVAR patients suffered more often from a congestive heart failure (27% vs 6%< 0.0001). Thirty-day
mortality was 0% in both groups. The rate of short-term complications was 6% in the EVAR and 16% in the OPEN
group, p=0.06. Open repair showed longer hospitalization (12 vs 8 days, p=0.01). Re-intervention rates were similar in
both groups. A median follow-up was 47 months. At the end of the follow-up, 51% of the patients in the ENDO group
and 76%of the OPEN group were alive (p=0.001). The aneurysm related mortality was 8% in the ENDO group and 0%
in the OPEN group (p=0.005).
Conclusion: Patients in the ENDO group were older and suffered more often from a congestive heart failure. The
hospitalization time was longer in the OPEN group. There were no significant differences in short term morbidity or
mortality. Aneurysm related mortality was significantly higher in the ENDO group.
Long-term aneurysm related mortality seems to favor an open repair over an endovascular repair for non-emergency
abdominal aortic aneurysm.
Disclosure of Interest: None declared
330
223.04
SCREENING MEN WITH CORONARY HEART DISEASE FOR ABDOMINAL AORTIC ANEURYSM- A
PROSPECTIVE COHORT STUDY
T. Hakala1,*, V. Vänni1, J. Turtiainen1, J. Hernesniemi1
1
Surgery, North Karelia Central Hospital, Joensuu, Finland
Introduction: The prevalence of abdominal aortic aneurysm (AAA) is higher among patients with coronary heart
disease (CHD) compared with control population. The aim of this study was to assess and determine the prevalence
of non-diagnosed AAA in men with CHD.
Materials & Methods: A total 437 active male out-patients with CHD were screened for AAA by abdominal ultrasound
(US) examination. The largest infrarenal aortic dimension was registered. The patient was regarded to have AAA
when the aortic diameter was greater than 30 mm.
Results: We found altogether 25 AAAs. The incidence of AAA was 5.7%. One AAA patient was operated on, and the
other AAA patients are under surveillance. Independent predictors for AAA among CHD patients were increased age,
family history of AAA and current or previous smoking. The screening process took on average 5 minutes per patient,
and the cost of screening was 15€ ($18.50) per patient or €257 ($325) per found AAA.
Conclusion: Prevalence of AAA among patients with CHD remains high. Screening of AAA should be considered
among active patients with CHD. The most feasible and simplest option would be to perform the screening during any
routine or elective cardiac US by a cardiologist and we recommend to adopt it as a standard practice. Costeffectiveness for individual national screening programs requires further investigation.
Disclosure of Interest: None declared
331
223.05
NEGATIVE PRESSURE WOUND THERAPY TO PREVENT GROIN INFECTIONS AFTER VASCULAR SURGERY.
A RANDOMIZED CONTROLLED TRIAL
J. Hasselmann1,*, T. Kühme1, S. Acosta1
1
Vascular Center, Malmö - Lund, Skåne University Hospital, Malmö, Sweden
Introduction: Negative pressure wound therapy (NPWT) is increasingly being used in the treatment of infected
wounds but its role in the prevention of surgical site infections (SSI) and other wound complications is less explored.
Groin incisions are frequently used in endovascular and open vascular surgical procedures. The aim of this
randomized controlled trial (RCT) is to evaluate if prophylactic NPWT on primarily closed groin incisions may prevent
SSI in vascular surgical patients.
Materials & Methods: This prospective RCT registered at ClinicalTrials.gov (Identifier: NCT01913132) includes all
elective patients undergoing vascular surgical procedures with groin incisions at this vascular center. To prove that
PICO (Smith & Nephew, UK), a negative pressure wound therapy pad dressing, reduces the wound infection rate with
½ standard deviation, 90% power at the 5% significance level, requires the inclusion of 160 patients, 80 patients in
each group.
Randomized patients receive either the NPWT or the standard wound dressing (Vitri Pad, ViTri Medical, Sweden) at
the end of the procedure. In case of bilateral incisions, NPWT is applied to one, and the standard dressing to the
contralateral groin incision (Figure 1). While the standard dressing is routinely changed at day two postoperatively, the
NPWT-dressing is left in place for seven days according to the manufacturer’s instructions. The diagnosis SSI is made
according to the 1999 diagnostic criteria defined by the Centers for Disease Control and Prevention, USA.
Results: Eighty-one patients were included in this interim analysis, 64 groin incisions analyzed in the NPWT group
and 63 in the control group. The overall groin infection rate was 11.1% (9/81), which can be compared to the center´s
2013 groin SSI rate of 22.5% (p=0.085). The overall wound complication rate in the NPWT group and the control
group was 8/64 (12.5%) and 10/63 (15.6%), respectively (p=0.59). SSI in the NPWT group was observed in 4.7 %
compared to 11.1 % (p=0.18) in the control group, without differences between the groups regarding patient and
operative characteristics.
Image:
Conclusion: The overall groin SSI rate has been halved since the start of the study. The SSI rate in the NPWT was
also halved compared to the control group. In this interim analysis, however, no statistically significant difference in
SSI rate was observed between the groups.
Disclosure of Interest: None declared
332
223.06
ANTERIOR ACCESSORY SAPHENOUS VEIN REFLUX - A SIGNIFICANT RISK FACTOR FOR VARICOSE VEIN
RECURRENCE POST ENDOVENOUS LASER THERAPY
H. Liu1,*, M. Y. Tan1, Q. Hong1, Y. F. Fong1, S. Narayanan1
1
General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
Introduction: Anterior accessory saphenous vein (AASV) is present in approximately 40% of patients. AASV reflux
can be present concomitantly with great saphenous vein (GSV) reflux. We aim to analyse the role of AASV reflux as a
risk factor for varicose veins recurrence after endovenous laser therapy (EVLT) of GSV reflux.
Materials & Methods: A retrospective analysis of consecutive EVLT (Dornier 940 nm Laser) procedures performed at
a single centre between 2006 to 2011 for GSV reflux was done. All cases were traced for recurrence using National
Electronic Health record and paired duplex scans at original operation and at recurrence were compared.
Results: Of the 326 EVLTs performed between 2006 to 2011, paired duplex data was available for analysis in 307
patients. 101 patients (33%) had an AASV on the original duplex, of which 56 (55%) of AASV were incompetent on
the original duplex.
Recurrence was observed in 32 (10.3%) of all patients and median time to recurrence was 11.3 months.
Comparatively, 22 (39%) of patients with original AASV reflux experienced recurrence, and time to recurrence in this
group of patients was 6.2 months.
Conclusion: Untreated AASV reflux leads to a 4 fold increase in recurrence rates. Recurrence also occurs much
earlier in these patients post EVLT for GSV reflux. We recommend that AASV reflux should be treated at the same
setting as GSV reflux, to significantly improve recurrence rates post EVLT.
References: 1. Factors associated with recurrence of varicose veins after thermal ablation: Results of the REVATA
(Recurrent Veins After Thermal Ablation) Study. R.G. Bush et al
2. Treatment of the Great Saphenous Vein by catheter based thermoablation is associated with Anterior Accessory
Saphenous Vein treatment in almost a third of cases. M.S. Whiteley et al
Disclosure of Interest: None declared
333
223.07
SIDE-TO-SIDE VESSEL ANASTOMOSIS BY A NOVEL MAGNETIC RING
X. Yan1,2,3, X. Xu1,2,3,*, J. Ma4, D. Dong1,2,3, J. Li2,3,5, F. Ma2,3, H. Wang2,3, Y. Lv 1,2,3
1
2
Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi’an Jiaotong University, XJTU Research Institute of
3
Advanced Surgical Technology and Engineering, Regenerative Medicine and Surgery Engineering Research Center
of Shaanxi Province, Xi’an Jiaotong University, 4Department of Surgical Oncology, 5Department of Oncology Surgical,
Third Affiliated Hospital, Xi’an Jiaotong University (Shaanxi Provincial People’s Hospital), Xi’an, China
Introduction: Oboral introduced the idea of end-to-end nonsuture vascular anastomosis using magnet rings in 1978.
This study reported a new magnamosis method for side-to-side vein anastomosis in canine model.
Materials & Methods: In this study, the magnetic anastomosis device was composed with four magnetic rings. They
are all covered with a 4 to 5µm-thick layer of titanium nitride. Two rings (mother rings) are made of pure iron and
others (daughter rings) neodymium-ferrum-boron. The mother ring is stepladder-like and elliptic, and the daughter ring
is elliptic. The mother and daughter rings auto-assembled. We use the novel magnetic coupling device to complete
side-to-side portal vein and inferior vena cava anastomosis on 6 adult healthy mongrel dogs. We record the time of
the side-to-side vessel anastomosis and perform histological and electron microscopical analysis at 12 weeks
postoperatively.
Results: The time required to perform the vascular anastomosis was 5.1±0.7 min. We observed portal vein and
inferior vena cava anastomosing well. The re-endothelialization was smooth at the anastomotic site of the magnetic
device. The entire intravascular surface of the magnetic ring was covered with a monolayer of endothelial cells, and
endothelial cells were regularly aligned with blood flow and had a normal and uniform morphology. There was no
obvious inflammatory reaction in the tissue that covers the ring.
Image:
Conclusion: Using this novel magnetic device to anastomose vessel is effective, easy and reliable. This method
shortens operation time and maintains a high patency rate.
Disclosure of Interest: None declared
334
231.01
TRANSABDOMINAL LAPAROSCOPIC ADRENALECTOMY VS POSTERIOR RETROPERITONEOSCOPIC
ADRENALECTOMY IN PATIENTS WITH ADRENAL MALIGNANCIES
C. P. Lombardi1,*, C. De Crea1, S. Vanella1, L. Oragano1, P. Gallucci1, M. Raffaelli1, R. Bellantone1
1
U.O. Chirurgia Endocrina e Metabolica, Università Cattoloca del Sacro Cuore, Rome, Italy
Introduction: The role of endoscopic adrenalectomy (EA) for adrenal malignancies is still controversial, despite the
increasing number of unexpected adrenal malignancies endoscopically removed. The choice between the lateral
transabdominal laparoscopic (TLA) or the posterior retroperitoneoscopic (PRA) approaches is usually based on
surgeon preference: no study compared the two techniques in terms of oncologic results. We reviewed our series of
EA for adrenal malignancies comparing results of TLA and PRA.
Materials & Methods: All the patients with histological diagnosis of primary or secondary adrenal malignancy who
underwent EA were included and divided in 2 groups on the basis of the surgical approach: TLA-Group (TLA-G) and
PRA-Group (PRA-G).
Results: Thirty-one patients were included: 24 in TLA-G (7 malignant pheochromocytomas, 6 adrenocortical
carcinomas, 11 metastasis) and 7 in PRA-G (2 malignant pheochromocytomas, 1 adrenocortical carcinoma, 4
metastasis). No significant difference was found concerning demographics. Mean lesion size was significantly smaller
in PRA-G (37.9±15.7 mm vs 57.2±19.5 mm) (P<0.05). Mean operative time and postoperative complications were
similar between the two groups (P=NS). At a mean follow up of 43.1±40.3 months in the TLA-G, 4 loco-regional
recurrences (3 peritoneal) and 6 distant metastases were registered. All the distant metastases were observed in
patients with diagnosis of adrenal metastasis. Five patients died for the disease. In the PRA-G at a mean follow up of
65.2±42.5 months, one distant metastasis in a patient with adrenal metastasis from lung adenocarcinoma who died for
the disease was registered. No local recurrence was observed in the PRA-G. The recurrence rate between the two
groups was not significantly different (P=NS). In order to avoid the bias related to significantly different tumor sizes
between the two groups, comparison was conducted between the patients with tumor size ≤ 65 mm (maximum
diameter in PRA-G). No significant difference was found in this subgroup between TLA-G and PRA-G concerning
demographics, operative and pathologic findings, complications and oncologic outcome.
Conclusion: TLA and PRA showed an equivalent oncologic outcome. However, since most of the loco-regional
recurrences (75%) occurred intraperitoneally in the TLA-G, one could speculate that PRA could reduce the risk of
tumor cell seeding in the peritoneum.
Disclosure of Interest: None declared
335
231.02
PARTIAL THYROIDECTOMY FOR PAPILLARY THYROID MICROCARCINOMA – IS COMPLETION TOTAL
THYROIDECTOMY INDICATED?
G. Donatini1,*, M. Castagnet1, N. Rudolph1, D. Othman1, J. L. Kraimps1
1
General and Endocrine Surgery, CHU Poitiers, Poitiers, France
Introduction: Total thyroidectomy is a well-established surgical approach for the management of papillary thyroid
cancer (PTC). However, the best surgical approach for papillary microcarcinoma is nowadays still debated. Both total
thyroidectomy and simple lobectomy are used. We report the experience of a single University centre in the treatment
of thyroid microcarcinoma.
Materials & Methods: A retrospective analysis on all patients who underwent thyroid surgery at our institution over a
23-year period (1991 – 2014) was performed. Patients were grouped according to whether they received total
thyroidectomy (Group 1) or lobectomy (Group 2). Routine follow-up clinical and ultrasound examination was
performed. Specific outcomes as recurrence and need for reoperation as well as complications (transient vocal cord
paralysis and hypocalcemia) were analysed.
Results: During the study period 880 patients underwent surgery for PTC. Group 1 and 2 consisted respectively of
756 and 124 patients. A micro PTC (< 10 mm) was present respectively in 251 and 69 specimen of Group 1 and 2. No
evidence of disease recurrence in the follow-up was reported in Group 1 and in 57 patients of Group 2. In the
remaining 12 patients further surgery was carried out due to either suspicious ecographic findings of contralateral
nodules (10) or lymphadenopathy (1) and capsular invasion on initial pathological report (1). Five of these patients
presented a controlateral papillary carcinoma on definitive histopathologic examination. Thus recurrence rate for
patients of Group 2 was 7.25%. Morbidity rates were respectively for Group 1 and 2: transient nerve palsy 81 and 5
(11% vs 7.25%), transient hypoparathyroidism (Calcium < 2.10 mmol/L) 137 (18.6%) and 0. Three of the 12 patients
of Group 2 undergoing further surgery had a transient hypoparathyroidism
Conclusion: Thyroid lobectomy is an effective surgical strategy to manage papillary microcarcinomas with low
complications. Routine total thyroidectomy is not mandatory and completion thyroidectomy after simple lobectomy is
not always mandatory given the low aggressiveness of micro PTC. Appropriate selection excluding high-risk patients
is of paramount importance in order to achieve the best results.
Disclosure of Interest: None declared
336
231.03
USING TRANSCUTANEOUS LARYNGEAL ULTRASONOGRAPHY TO ASSESS POST-THYROIDECTOMY
PATIENTS’ VOCAL CORDS - WHICH MANEUVER BEST OPTIMIZES VISUALIZATION AND ASSESSMENT
ACCURACY?
K. P. Wong1,*, J.-W. Woo2,3, J. Y.-Y. Li1, K. E. Lee2,3, Y.-K. Youn2,3, B. H.-H. Lang1
1
Department of Surgery, The University of Hong Kong, Hong Kong, Hong Kong, 2Department of Surgery, 3Cancer
Research Institute, Seoul National University, Seoul, Korea, Republic Of
Introduction: Transcutaneous laryngeal ultrasound (TLUSG) is a non-invasive way of assessing vocal cord (VC)
movement. Three maneuvers, namely observing VC movements during quiet respiration (passive), phonation (active)
and breath-holding and bearing-down (Valsalva) have been commonly described. However, it is unclear which of the
three maneuvers allows better visualization and assessment accuracy of VCs. To address this, we prospectively
evaluated consecutive patients performed in two institutions.
Materials & Methods: A total of 342 post-thyroidectomy patients underwent TLUSG with direct laryngoscopic (DL)
validation afterwards. One assessor from each institution performed all TLUSG examinations. Consensus was made
on the definition of maneuvers between two institutions prior to the study. During each examination, patients were
instructed to perform all three maneuvers, namely passive, active and Valsalva. Assessor was required to identify VC
in each maneuver if possible and their findings were later validated by DL. VC palsy (VCP) was defined as decreased
or no movement in ≥1 VC on DL or TLUSG. VC visualization rate and accuracy between the three maneuvers were
compared.
Results: Nine (6.3%) and 10 (5.0%) suffered postoperative VCP from institutions 1 and 2, respectively. Although not
significant, visualization rate tended to be highest in Valsalva maneuver than other two maneuvers (92.1% vs.
passive: 91.5%; active: 89.8%). While test sensitivity was comparable between the three maneuvers (passive: 91.4%;
active: 75.0%; Valsalva: 81.3%, p>0.05), passive maneuver had significantly lower test specificity than active (94.3%
vs. 97.6%, p=0.01) and Valsalva maneuvers (94.3% vs. 97.4%, p=0.02) and higher false positivity than active (5.4%
vs. 2.3%, p<0.05) and Valsalva maneuvers (5.4% vs. 2.5%, p=0.02). Performing greater number of maneuvers did not
necessarily improve sensitivity or specificity (p>0.05). Assuming TLUSG was used as a screening tool for VCP,
Valsalva maneuver allowed more patients to undergo a successful examination without DL than passive maneuver
(85.96% vs. 81.87%, p=0.0125), while the chance of missing a VCP was 1% (3/342).
Conclusion: Valsalva was the preferred maneuver during TLUSG as it offered the best combination of high
visualization rate and assessment accuracy of the VCs after thyroidectomy.
Disclosure of Interest: None declared
337
231.04
BILATERAL AXILLO-BREAST APPROACH ROBOTIC THYROIDECTOMY FOR GRAVES’ DISEASE: MATCHED
COMPARISON WITH OPEN THYROIDECTOMY
H. Kwon1,*, J. Yi1, S.-J. Kim1, K. E. Lee1, Y.-K. Youn1
1
Surgery, Seoul National University Hospital, Seoul, Korea, Republic Of
Introduction: Bilateral axillo-breast approach robotic thyroidectomy (BABA RoT) has shown excellent cosmetic and
surgical outcomes for thyroid cancer. The aim of this study was to investigate the safety of BABA RoT in patients with
Graves’ disease, compared with open thyroidectomy (OT).
Materials & Methods: A total of 189 (44 BABA RoT and 145 OT) patients with Graves’ disease underwent
total thyroidectomy. Matched cohorts was selected by age, gender, body mass index, surgical indication, extent of
operation, excised thyroid weight, and follow up period.
Results: BABA robotic thyroidectomy was successful in all of 44 patients, and none required conversion to open
procedure. Patients in the BABA RoT group was younger (35.0 ± 10.7 years vs. 45.4 ± 14.8 years; p<0.001) and had
lower BMI (22.0 ± 2.2 kg/m2 vs. 23.5 ± 3.3 kg/m2; p=0.001) than those in the OT group. The weight of excised thyroid
gland was lower in the BABA RoT group than that in the OT group (35.2 ± 23.9 g vs. 64.5 ± 61.5 g; p<0.001). Most
common surgical indication was concomitant thyroid nodule in both groups.
After propensity score matching, total operation time was longer in the BABA RoT group than that in the OT group
(178.4 ± 52.0 min vs. 88.1 ± 26.1 min; p<0.001). However, hospital stay, intraoperative bleeding, and complication
rates showed no difference between BABA RoT, and OT groups, respectively (Table 1).
Table 1 comparison of surgical outcomes between robotic and open thyroidectomy after propensity score matching
P-value
Characteristics
BABA robotic thyroidectomy (n=44)
Open thyroidectomy (n=44)
Gender (male : female)
3 : 41 (93.2%)
5 : 39 (88.6%)
0.458
Age (years)
35.1 ± 10.8
36.4 ± 10.9
0.564
Body mass index (kg/m2)
22.0 ± 2.2
22.5 ± 3.0
0.412
Excised thyroid weight (g)
34.0 ± 24.0
35.7 ± 23.9
0.749
Median follow-up (days)
1,026.6 ± 724.8
1,103.3 ± 798.3
0.638
Operation time
Total operation time (min)
178.4 ± 52.0
89.3 ± 25.6
<0.001
Console time (min)
94.4 ± 54.5
Intraoperative blood loss (ml)
151.8 ± 165.4
134.5 ± 75.4
0.981
Hospital stay (days)
3.4 ± 0.7
3.3 ± 0.7
0.564
Complications
Transient RLN palsy
5 (11.4%)
5 (11.4%)
1.000
Transient hypoparathyroidism
8 (18.2%)
9 (20.5%)
0.787
Permanent RLN palsy
0 (0%)
1 (2.3%)
0.315
Permanent hypoparathyroidism
1 (2.3%)
1 (2.3%)
1.000
Postoperative bleeding
0 (0%)
0 (0%)
NA
Recurrence
0 (0%)
0 (0%)
NA
RLN recurrent laryngeal nerve
Conclusion: BABA robotic thyroidectomy is a feasible and safe procedure for the surgical treatment of Graves’
disease. It is recommended as an alternative for management of Graves’ disease.
References: 1. Bartalena L. Diagnosis and management of Graves disease: a global overview. Nat Rev Endocrinol.
2013;9(12):724-34.
2. Greenhill C. Robotic surgery shows promise for the treatment of PTMC. Nat Rev Endocrinol. 2011;7(7):374.
3. Sasaki A, Nitta H, Otsuka K, Obuchi T, Kurihara H, Wakabayashi G. Endoscopic subtotal thyroidectomy: the
procedure of choice for Graves' disease? World journal of surgery. 2009;33(1):67-71.
4. Lee J, Lee JH, Nah KY, Soh EY, Chung WY. Comparison of endoscopic and robotic thyroidectomy. Annals of
surgical oncology. 2011;18(5):1439-46.
5. Kwon H, Koo do H, Choi JY, Kim E, Lee KE, Youn YK. Bilateral axillo-breast approach robotic thyroidectomy for
Graves' disease: an initial experience in a single institute. World journal of surgery. 2013;37(7):1576-81.
6. Noureldine SI, Yao L, Wavekar RR, Mohamed S, Kandil E. Thyroidectomy for Graves' disease: a feasibility study of
the robotic transaxillary approach. ORL; journal for oto-rhino-laryngology and its related specialties. 2013;75(6):350-6.
7. Terris DJ, Duke WS. Robotic and remote access thyroidectomy: a time to pause. World journal of surgery.
2013;37(7):1582-3.
Disclosure of Interest: None declared
338
235.01
COMBINED OPEN AND LAPAROSCOPIC TECHNIQUE (COLT) FOR RECURRENT COMPLEX INCISIONAL
HERNIA REPAIRS
L. Toquero1,*, J. Ellul1
1
Colorectal Suregry, Kings College University, London, United Kingdom
Introduction: The aim of this study was to determine the suitability of a novel technique of a combined open and
laparoscopic technique (COLT Technique), in the repair of complex recurrent incisional hernias, where laparoscopic or
open techniques alone do not achieve optimal results. Immediate and late complication rates, and recurrence rates
are compared with that achieved with either laparoscopic or open (component separation) repair alone.
Materials & Methods: 19 consecutive patients with recurrent complex incisional hernia with significant morbidity were
enrolled, and all underwent the COLT Technique. Follow-up was at six, twelve and twenty four weeks, along with
subsequent telephone follow-up. The method involved
Results: Completion to follow-up was recorded in 100% of patients, with an overall healing rate of one hundred percent achieved, pain scores were found to be lower than those of the component separation technique. Infection and
seroma rates were relatively low (three per-cent), whilst only one recurrence was recorded (three per-cent).
Completion times achieved were within one and a half hours.
Conclusion: The COLT technique is an effective and safe treatment option in patients with complex recurrent
incisional hernias. Benefits of this procedure include ease of mesh placement, compared with open techniques
requiring using the introduction of sutures. Approximation of muscle layers repairing the defect without opening the
defect, its cost effectiveness negating the use of expensive biological meshes, early mobilization and quick recovery.
Disclosure of Interest: None declared
339
235.02
RELIABILITY AND VALIDITY OF THE THAI VERSION OF THE CAROLINAS COMFORT SCALE
P. Verasmith1,*, S. Techapongsatorn1, W. Kasetsermwiriya1, A. Tansawet1, S. Lerdsirisopon1, S. Srimotayamas1, I.
1
1
Laopeamthong , P. Taewprasert
1
Surgery, Vajira Hospital, Navamindrahiraj University, Bangkok, Thailand
Introduction: The study aimed to evaluate the reliability and the validity of the Thai version of the Carolinas Comfort Scale (CCS)
that use for measuring health-related quality of life in post hernia repaired patients.
Materials & Methods: Three hundred and twenty-eight patients whom underwent hernia repaired procedure from our institute
were recruited to the study. The Thai version of CCS was completely done by subjected and the test-retest reliability was
conducted at a 2 weeks interval.
Results: The internal consistency reliability of Thai version CCS was very good (Cronbach’s alpha = 0.89). The inter-rated
reliability was found to be in the substantial agreement with the intra-class correlation coefficient of 0.90. The test-retest reliability
over a period of 2 weeks was high, with an intra-class correlation coefficient of 0.92.
Conclusion: The Thai version of CCS had adequate reliability and validity. It could be used as an outcome for measuring of
HRQOL in the Thai patients whom underwent hernia repaired.
Disclosure of Interest: None declared
340
235.03
FEASIBILITY AND OUTCOMES OF HERNIA REPAIR IN PATIENTS OVER 80 YEARS OLD.
N. Wada1,*, T. Furukawa1, Y. Kitagawa1
1
Keio University, Shinjuku-ku, Japan
Introduction: We apply the same treatment strategy to all patients including elderly. In order to confirm the feasibility
of this idea, we retrospectively compare the outcomes of hernia repair in patients over 80 years old to those in
younger patients.
Materials & Methods: We reviewed 104 consecutive patients aged 80 and over (Group A) and 100 consecutive
patients aged between 70 and 72 (Group B) who were treated in our hospital from 2005 to 2014. Laparoscopic
surgery was indicated for bilateral hernia. All the patients were followed for at least 6 months after surgery.
Results: Patients in Group A had a mean age of 83.5 (range, 80-95) years, and 12.5 % were women. Mean age of
Group B was 71.0 and the rate of women was as low as 4.0 % (P=0.028). Emergency surgery was performed in 3
cases (2.9 %) in Group A and none in Group B. General anesthesia was chosen in 4 cases in Group A and 1 case in
Group B. The others are treated under local anesthesia. The rate of laparoscopic surgery was significantly lower in
Group A than in Group B (7.7 % vs 17.0 %, P=0.043). The mean +/- SD operation time of Group A and B was 102 +/38 and 116 +/- 67 minutes (P=0.063), respectively. When excluding the laparoscopically treated subjects, however,
the mean operation time of two groups becomes almost the same (96 minutes and 95 minutes, respectively). No
chronic pain and recurrence was not observed in both group.
Conclusion: More patients were treated laparoscopically in younger patients group. Very elderly patients tend to be
conservative in the management of minimally symptomatic or asymptomatic contralateral hernia, which may have
resulted in the lower rate of laparoscopy surgery. The similar clinical outcomes may support the hypothesis that very
elderly patients can be treated safely using same strategy as that of younger patients.
Disclosure of Interest: None declared
341
235.04
OPEN POSTERIOR(PREPERITONEAL) HERNIOPLASTY FOR MANAGEMENT OF COMPLEX GROIN HERNIA IN
PATIENTS UNFIT FOR ENDOSCOPIC HERNIOPLASTY: A PROSPECTIVE STUDY.
J. K. Kushwaha1,*, A. A. Sonkar1, K. Singh1, A. Kumar1, R. Gupta2
1
2
General Surgery, Anaesthesiology, KG Medical University, Lucknow, India
Introduction: Complex inguinal hernias (Recurrent/re recurrent, Giant unilateral or bilateral groin hernia) are
associated with a high recurrence rate. Laparoscopic hernioplasty is usually preferred for recurrent unilateral /bilateral
inguinal hernia, bilateral primary inguinal hernia. If patients is unfit for laparoscopic surgery due to comorbidity , open
posterior hernioplasty is only option for treatment of complex inguinal hernias. The various noninguinal approach like
Nyhus, stoppa/modified stoppa’s hernioplasty for complex inguinal hernia avoids distorting the inguinal anatomy,
markedly reduces the risk of damage to the nerves and testicular vessels as compared to transinguinal preperitoneal
hernioplasty (Rives) and permits inspection of all myopectineal orifices for groin hernia sites.
Materials & Methods: 100 patients were admitted in a year as complex inguinal Hernia from October 2011 to
September 2012. In 40 patients Endoscopic hernioplasty was done. Remaining 60 patients were unfit for laparoscopic
surgery due to co morbid conditions. In these 60 patients 40 patients had bilateral complete primary inguinal hernia
while 20 had unilateral recurrent inguinal hernia. In all 40 patients of bilateral inguinal hernia visceral sac was
reinforced by placement of giant mesh in preperitoneal space, based on stoppa’s technique through midline or
pfannenstiel incision .While in 20 patients of unilateral recurrent hernia, Nyhus hernioplasty was done. Mean age was
60 years (range 25 to 88) and 44.8% had one or more co-morbid conditions
Results: Mean hospital stay after surgery was 2.2 days (1-13 days). The mean operative time was 45 minutes (30-75
minutes).One patient developed seroma which managed by aspiration. Two patients had minor surgical sites infection.
One patient had inguinal abscess managed by incision and drainage. Neurological pain, numbness, testicular atrophy,
recurrence was absent in all patients in follow up of two years.
Conclusion: Preperitoneal hernioplasty is anatomic, tension-free and physiological .This is better alternative to
laparoscopic hernioplasy in patients who are unfit for laparoscopic surgery due to comorbidity as it can be performed
in regional anaestheia . Posterior hernioplasty through midline/pfannenstiell/suprainguinal approach avoids injury to
inguinal nerves, testicular vessel as compared to transinguinal preperitoneal approach.
References: 1.Muhammad S, Sajid L. Craciunas, K.K. Singh, P. Sains and M.K. Baig. Open transinguinal
preperitoneal mesh repair of inguinal hernia: a targeted systematic review and meta-analysis of
published randomized controlled trials. Gastroenterology Report (2013) 1–12.
2.Willaert W, De Bacquer D, Rogiers X et al. Open Preperitoneal Techniques vs Lichtenstein Repair for elective
Inguinal Hernias. Cochrane Database Syst Rev2012;7:CD008034
3.Arlt G, Schumpelick V. Transinguinal preperitoneal mesh-plasty (TIPP) in management of recurrent inguinal hernia,
Chirurg. 1997 Dec;68(12):1235-8
4.Franneby U, Sandblom G, Nordin P, Nyren O, Gunnarsson U: Risk factors for long-term pain after hernia surgery.
Ann Surg 2006, 244(2):212-219.
5.Wantz GE. Preperitoneal hernioplasty with unilateral giant prosthetic reinforcement of the visceral sac. Contemp
Surg 1994; 44:83–89.
Disclosure of Interest: None declared
342
235.05
ARE INGUINAL HERNIA REPAIR GUIDELINES TRANSLATED INTO CLINICAL PRACTICE? A NSQIP ANALYSIS
J. Bingener1,*, D. Ubl1, E. Haberman1
1
Mayo Clinic, Rochester, United States
Introduction: Laparoscopic inguinal hernia repair has been advocated for patients with bilateral or recurrent inguinal
hernia. Further, laparoscopic approaches have been recommended as preferable in women due to a larger proportion
of femoral hernias in women. We assessed the NSQIP database to evaluate whether this guideline recommendation
is translated into clinical practice.
Materials & Methods: We extracted data regarding the performance of inguinal hernia repair in participating centers
of the American College of Surgeons National Surgical Quality improvement project (NSQIP) from 2005 – 2012. Data
are captured by trained nurse abstractors in an 8 day cycle and up to 3 inguinal hernia repairs per cycle are entered.
We compared operative approaches by diagnosis (unilateral vs bilateral) and by gender. Recurrent diagnosis could
not be reliably extracted.
Results: A total of 110,381 inguinal hernia repairs were captured in the NSQIP database from 2005 to 2012; of those
17, 384 procedures (16%) were performed under local anesthesia with sedation and 5,080 (4.6%) were performed
emergently. With the increasing numbers of participating centers over time, the number of captured hernia repairs
increased from < 2000/year in 2005 to > 20,000 hernia repairs/year in 2012. Overall, 28,958 (26%) of the procedures
were performed with a laparoscopic approach. The distribution of operative approaches by laterality is depicted in
table 1.
Unilateral
bilateral
Other
(undesignated)
Laparoscopic
13,369
12,017
3,572
Open
60,562
8,121
21,592
Number of
73,931
20,138
25,164
Procedures
Number of
72,964
13,253
24,164
Patients
Of the 94,069 procedures with known laterality, 20,138 (21%) were bilateral hernia procedures, 60% of which were
performed laparoscopically. During the study period 13,146 inguinal hernia repairs in women (12%) were captured;
11,221 (85%) open repairs and 1, 925 (15%) laparoscopic repairs. Women underwent 13% of all open repairs and 8%
of all laparoscopic repairs, (p<0.001).
Conclusion: Although 95% of all inguinal hernia repairs were performed electively and 80% were performed under
general anesthesia, only 60% of bilateral hernia procedures and 15% of procedures in women were performed
laparoscopically. Translation of guidelines into clinical practice is incomplete.
Disclosure of Interest: J. Bingener Grant/Research Support from: NIDDK, Consulting fees from: Titan Medical,
Other Financial/Material Support from: Nestle Inc, D. Ubl: None declared, E. Haberman: None declared
343
POSTER EXHIBITION PRESENTATIONS
PE001
PROGNOSTIC IMPACT OF KRAS COPY NUMBER AMPLIFICATION IN ESOPHAGOGASTRIC JUNCTION
ADENOCARCINOMA
1,*
1
1
1
1
2
2
1
K. Nakamura , Y. Imamura , R. Tokunaga , S. Iwagami , N. Yoshida , E. Oki , Y. Maehara , H. Baba
1
2
Kumamoto University, Kumamoto, Kyushu University, Fukuoka, Japan
Introduction: The incidence of esophageal adenocarcinoma (EAC) or esophagogastric junction adenocarcinoma
(EGJA) has been dramatically increasing. KRAS oncogenic alterations activate multiple pathways in various types of
cancer. A recent comprehensive genetic study has reported that around 20% of EAC harbor KRAS copy number gain
(Dulak AM et al, 2012, Nat Genet). However, the prognostic role KRAS amplification has not been well examined in
EAC/EGJA.
Materials & Methods: DNA was extracted from formalin-fixed paraffin-embedded tissue of 150 EGJA (Siewert types
I-III). KRAS copy number was detected by real-time quantitative PCR, and KRAS copy number gain was defined as
KRAS/RNase P (as a reference) ratio ≥ 2.5. The impact of KRAS amplification was analyzed in relation to
clinicopathological factors, and patient outcomes [disease free survival (DFS), and overall survival (OS)]. Multivariate
cox proportional hazards model was performed adjusting clinicopathological factors.
Results: KRAS amplification was observed in 49 (32.7%) cases. KRAS amplification was significantly associated with
the depth of tumor invasion (P=0.045), and the lymph node metastasis (P=0.012), and was significantly associated
with poorer patient outcome [P=0.0227 in overall survival (OS), P=0.0014 in cancer specific survival (CSS), and
P=0.0193 in disease free survival (DFS)]. In multivariate analysis, KRAS amplification was an independent prognostic
factor for OS [multivatiate hazard ratio (HR)=2.24; 95% confidence interval (CI), 1.11-4.48, P=0.0256], CSS
[multivatiate HR=3.00; 95% CI, 1.11-8.39, P=0.0315], and DFS [multivatiate HR=2.58; 95% CI, 1.21-5.44, P=0.0146].
Conclusion: KRAS copy number amplificaion may be a useful prognostic marker in EGJA.
Disclosure of Interest: None declared
344
PE002
INFLUENCE OF PNEUMOPERITONEUM (INTRAABDOMINAL HYPERTENSION) ON BLOOD COAGULATION
SYSTEM.
D. Matyushko1, Y. Turgunov 1,*, N. Abatov1, M. Mugazov1, Z. Koishibayev1, A. Zlotnik2
1
2
Karaganda state medical institute, Karaganda, Kazakhstan, Soroka University Medical Center, Beer Sheva, Israel
Introduction: To create a space for any laparoscopic surgery we use a pneumoperitoneum (intraabdominal pressure12-15 mm Hg), which is pathological condition - intraabdominal hypertension. There is evidence of the negative effect
of pneumoperitoneum and the risk of complications (myocardial infarction, organs ischemia, phlebothrombosis,
pulmonary embolism), which is due to the change in blood coagulation.
Materials & Methods: Objects of the study - 50 male laboratory rats with the same age, size and weight. The main
group - 30 rats, which were created intraabdominal pressure 15 mm Hg by pneumoperitoneum (recommended level of
intraabdominal pressure in laparoscopy-12-15 mm Hg). Exposure of pneumoperitoneum - 2 hours (the average
duration of laparoscopic surgery-1-3 hours). The control group consisted of 20 intact rats. In both groups we
investigated the main indicators of blood coagulation (fibrinogen, prothrombin index (PTI), activated partial
thromboplastin time (APTT).
Results: The results of laboratory research of blood coagulation indicators rats are shown in Table 1.
Table 1 - Comparative analysis of blood coagulatiom in rats of two groups.
Blood coagulation
Averages indicators of the control group
Averages indicators of the main group
indicators
(n=20)
(n=30)
Fibrinogen, g/l
2,16±0,37
2,72±0,63
APTT, sec
34,5±4,2
31±5,35
PTI, %
99,75±4,5
107,3±4,04
Comparative analysis of the study showed higher levels in the main group compared with the control of the following
indicators blood coagulation: fibrinogen – in 1.25 times, PTI – in 1.07 times. Also we found lower rates of APTT in the
main group – in 1.11 times compared with the control.
These numerals demonstrate the laboratory signs of hypercoagulation (increased levels of fibrinogen and PTI,
reducing APTT) in the group of animals with 2 hours pneumoperitoneum (intraabdominal pressure - 15 mm Hg).
However, it should be noted that the statistical significance of differences between the two groups (p<0,05) was not
founded, фтв despite the changes in laboratory parameters of blood coagulation toward hypercoagulation, these
changes are in permissible values.
Conclusion: Pneumoperitoneum (intraabdiminal pressure - 15 mm Hg, duration of the operation - 2 hours) causes
laboratory signs of the hypercoagulation. However, these changes are in the range of acceptable values, which
proves the possibility of pneumoperitoneum in everyday endovideosurgical practice (but before the operation blood
coagulation parameters are in the normal range.
Disclosure of Interest: None declared
345
PE003
MDSCS ACCUMULATE INVASION FRONT OF PRIMARY COLORECTAL CANCER THROUGH CCL15-CCR1
CHEMOKINE AXIS, AND PROMOTE TUMOR PROGRESSION
S. Inamoto1,*, K. Kawada1, Y. Itatani1, T. Yamamoto1, S. Minamiguchi2, M. M. Taketo3, Y. Sakai1
1
2
3
Kyoto-University, Kyoto, Japan., Surgery, Kyoto-University, Kyoto, Japan., Diagnostic pathology, Kyoto-University,
Kyoto, Japan., Pharmacology, Kyoto, Japan
Introduction: Loss of the tumor suppressor SMAD4 in colorectal cancer (CRC) is associated with tumor progression
and metastasis. We previously reported that loss of SMAD4 in CRC cells promotes chemokine CCL15 expression to
recruit CCR1-positive myeloid cells via CCL15-CCR1 chemokine axis, which facilitates liver metastasis (Itatani et al.
Gastroenterology.2013). The aim of this study was to find out whether essentially the same mechanism worked in
tumor invasion of the primary CRC.
Materials & Methods: We analyzed CRC specimens of 333 patients who underwent resection of their primary tumors
at Kyoto University Hospital between 2005 and 2008. We detected expressions of SMAD4, CCL15, and CCR1 by an
immunohistochemical analysis. In order to characterize the CCR1-positive cells, we also employed a double
immunofluorescence staining with α-smooth muscle actin, Arginase1, CD3, CD8, CD11b, CD14, CD15, CD31, CD33,
CD68, HLA-DR, iNOS, MMP2, MMP9, and MPO. Finally, we measured serum CCL15 concentration of 132 CRC
patients by Enzyme-Linked Immunosorbent Assay.
Results: Loss of SMAD4 in primary CRC was significantly associated with CCL15 expression (P < 0.01). CCL15positive primary CRC recruited significantly higher numbers of CCR1-positive myeloid cells at their invasion front (P <
0.01). Patients with CCL15-positive primary CRC tended to have a shorter relapse-free survival (P = 0. 15). We
observed that CCR1-positive cells expressed CD11b, MPO, CD33 and CD15, but not CD3, CD8, a-smooth muscle
actin, or HLA-DR, which indicated that they are of granulocyte-myeloid derived suppressor cell (G-MDSC) phenotype.
These CCR1-positive cells also expressed MMP2, MMP9, Arginase1 and iNOS. Serum CCL15 concentration of
preoperative CRC patients was significantly higher than that of non-tumor control patients (P < 0.01).
Conclusion: In the primary CRC, loss of SMAD4 promotes up-regulation of CCL15 expression and successively
recruits CCR1-positive G-MDSC, which leads to worse relapse-free survival. Therapeutic strategy that blocks the
recruitment of CCR1-positive myeloid cells into CRC may improve prognosis. Serum CCL15 concentration may be a
novel biomarker of tumor progression or recurrence in CRC.
References: Weinberg RA. Multi-step tumorigenesis. The biology of cancer (Garland Science) 2007;11:399-462.
Salovaara R, Roth S, Loukola A, et al. Frequent loss of SMAD4/DPC4 protein in colorectal cancers. Gut 2002;51:56–
59.
Roth AD, Delorenzi M, Tejpar S, et al. Integrated analysis of molecular and clinical prognostic factors in stage II/III
colon cancer. J Natl Cancer Inst 2012;104:1635-46.
Alazzouzi H, Alhopuro P, Salovaara R, et al. SMAD4 as a prognostic marker in colorectal cancer. Clin Cancer Res
2005;11:2606-2611.
Takaku K, Oshima M, Miyoshi H, et al. Intestinal tumorigenesis in compound mutant mice of both Dpc4 (Smad4) and
Apc genes. Cell 1998;92:645–656.
Kitamura T, Kometani K, Hashida H, et al. SMAD4-deficient intestinal tumors recruit CCR1+ myeloid cells that
promote invasion. Nat Genet 2007;39:467–475.
Kitamura T, Fujishita T, Loetscher P, et al. Inactivation of chemokine (C-C motif) receptor 1 (CCR1) suppresses colon
cancer liver metastasis by blocking accumulation of immature myeloid cells in a mouse model. Proc Natl Acad Sci
USA 2010;107:13063–13068.
Hirai H, Fujishita T, Kurimoto K, et al. CCR1-mediated accumulation of myeloid cells in the liver microenvironment
promoting mouse colon cancer metastasis. Clin Exp Metastasis 2014;31:977-989.
Itatani Y, Kawada K, Fujishita T, et al. Loss of SMAD4 from colorectal cancer cells promotes CCL15 expression to
recruit CCR1+ myeloid cells and facilitate liver metastasis. Gastroenterology 2013;145:1064-1075.
Murdoch C, Muthana M, Coffelt SB, et al. The role of myeloid cells in the promotion of tumor angiogenesis. Nat Rev
Cancer 2008;8:618-631.
Joyce JA, Pollard JW. Microenvironmental regulation of metastasis. Nat Rev Cancer 2009;9:239-252.
Talmadge JE, Gabrilovich DI. History of myeloid-derived suppressor cells. Nat Rev Cancer 2013;13:739-52.
Gabrilovich DI, Ostrand-Rosenberg S, Bronte V. Coordinated regulation of myeloid cells by tumours. Nat Rev
Immunol. 2012;12:253-68.
Lesokhin AM, Hohl TM, Kitano S, et al. Monocytic CCR2(+) myeloid-derived suppressor cells promote immune escape
by limiting activated CD8 T-cell infiltration into the tumor microenvironment. Cancer Res 2012;72:876-886.
Li Y, Wu J, Zhang W, et al. Identification of serum CCL15 in hepatocellular carcinoma. Br J Cancer. 2013;108:99-106.
Bodelon C, Polley MY, Kemp TJ, et al. Circulating levels of immune and inflammatory markers and long versus short
survival in early-stage lung cancer. Ann Oncol. 2013;24:2073-9.
Massagué J. TGFbeta in Cancer. Cell. 2008;134:215-30.
Zhang B, Halder SK, Kashikar ND, et al. Antimetastatic role of Smad4 signaling in colorectal cancer.
Gastroenterology. 2010;138:969-80.
Voorneveld PW, Kodach LL, Jacobs RJ, et al. Loss of SMAD4 alters BMP signaling to promote colorectal cancer cell
metastasis via activation of Rho and ROCK. Gastroenterology. 2014;147:196-208.
346
Calon A, Espinet E, Palomo-Ponce S, et al. Dependency of colorectal cancer on a TGF-β-driven program in stromal
cells for metastasis initiation. Cancer Cell. 2012;22:571-84.
Katoh H, Wang D, Daikoku T, et al. CXCR2-expressing myeloid-derived suppressor cells are essential to promote
colitis-associated tumorigenesis. Cancer Cell. 2013;24:631-44.
Forssmann U, Magert HJ, Adermann K, et al. Hemofiltrate CC chemokines with unique biochemical proterties: HCC1/CCL14a and HCC2/CCL15. J Leukoc Biol 2001;70;357-366.
Pardigol A, Forssmann U, Zucht HD, et al. HCC-2, a human chemokine: gene structure, expression pattern, and
biological activity. Proc Natl Acad Sci U S A.1998;95:6308-13.
Starr AE, Dufour A, Maier J, et al. Biochemical analysis of matrix metalloproteinase activation of chemokines CCL15
and CCL23 and increased glycosaminoglycan binding of CCL16.J Biol Chem. 2012;287:5848-60.
Gladue RP, Brown MF, Zwillich SH. CCR1 antagonists: what have we learned from clinical trials. Curr Top Med Chem
2010;10:1268-77.
Disclosure of Interest: None declared
347
PE004
ESTABLISHMENT AND CHARACTERIZATION OF TWO NOVEL HUMAN PANCREATIC CARCINOMA CELL
LINES
K. Hirano1,*, Y. Shimada1, O. Tomoyuki1, T. Watanabe1, T. Yamaguchi1, N. Takuya1, K. Tsukada1
1
Department of Surgery and Science, University of Toyama, Toyama city, Japan
Introduction: Pancreatic carcinoma (PC) has been one of the most lethal carcinoma worldwide. Chemoresistance of
PC plays the role in its poor prognosis.
Materials & Methods: Two PC cell lines were established from different PC patients. TYPK-1 was established from
the metastatic lymph node of locally advanced PC and TYPK-2 from the ascites of multi-chemoresistance and multiple
metastatic PC. We demonstrated the characteristics including the mutation of K-ras and p53, sensitivities of
gemcitabine, 5-fluorouracil, cisplatin, and oxaliplatin and the mRNA expression of the rate-limiting enzyme of them.
Results: Both TYPK-1 and TYPK-2 could transplant to nude mouse. TYPK-1 was demonstrated wild type of p53 and
K-ras genes. TYPK-1 was more resistant to gemcitabine than TYPK-2. TYPK-1 was more sensitive to oxaliplatin than
TYPK-2.
Conclusion: The difference of two cell line may contribute to the research for growth and metastasis of PC. TYPK-2
may contribute to the research for the resistant to chemotherapies.
Disclosure of Interest: None declared
348
PE005
INFRA RED COAGULATION AS A MODALITY OF TREATMENT FOR PILES
S. Chitra1,*, K. Mayilvaganan1
1
Department of surgery, JJ hospital, Madurai, India
Introduction: Introduction:
Haemorrhoids is one of the commonest colo-rectal conditions.
Most of patients suffer from bleeding PR.
IRC is one of the safest out patient procedure which arrests bleeding in symptomatic patients.
Materials & Methods:
Study Period:
From 1998 to August 2014
Prospectively entered data in a database analysed
Total Number of Patients - 321
Results: Results:
Age Mal Femal
e
e
<20
12
4
2155
12
30
3168
19
40
4155
8
50
5134
5
60
>61
46
3
Total 270
51
Total
16
67
87
63
39
49
321
In our study 154 (47.97%) patients with piles were between
21-40 years of age group.
Piles I
51
II
203
III
67
---Total
321
---Symptoms - Bleeding PR (100%> 321cases)
Mass descending per Rectum 20.87% (67 cases)
Piles with Medical Problems treated with IRC:
Heart diseases
20
Polymyositis
1
Asthmatic Bronchitis
3
COPD
2
Anaemia with failure
11
Pleural effusion
1
Psychiatric Illness
1
Renal disease
14
Pregnancy
–
12
Repeat IRC:
Eighteen patients
Three patients after 3months
Five patients after 6months
One had two sitting to 3months & 1year
Three patients after 1 year
349
Three patients after 2 years
One patient after 5 years
One patient after 7 years
One patient after 10 years
Complications:
Five Patients had bleeding between V & IX day after IRC which was treated conservatively with bed rest, laxatives
and sedations.
Conclusion: Conclusion:
Patient acceptance is good. No notable complications. Recurrence very low.
Disclosure of Interest: None declared
350
PE006
PREOPERATIVE DEMENTIA IS A RISK OF POSTOPERATIVE DELIRIUM IN ADULT OPERATIVE PATIENTS
Y. Kitagawa1,*, S. Fukata1, Y. Kawabata1, K. Fujishiro1, K. Kuroiwa2, H. Akiyama3, Y. Terabe4, M. Ando5
1
2
Department of Surgery, NATIONAL CENTER FOR GERIATRICS AND GERONTOLOGY, Obu, Department of
3
Surgery, Tokyo Metropolitan Geriatric Hospital, Tokyo, Department of Gastroenterological Surgery, Yokohama City
University Graduate School of Medicine, Yokohama, 4Department of Restorative Medicine, National Center for
Geriatrics and Gerontology, Obu, 5Center for Advanced Medicine and Clinical Research, Nagoya University Graduate
School of Medicine, Nagoya, Japan
Introduction: Delirium is one of the most important inducements to the postoperative complications such as difficulty
of rest, troubles on procedures, mis-swallowing, aspiration pneumonia and self-removal of drains and catheters.
However, the mechanism of delirium is still unclear.
Materials & Methods: We performed prevention of postoperative delirium using haloperidol as prospective
randomized control study for aged surgical patients (Research Grant for Longevity Sciences (17C-3, 21-13) from the
Ministry of Health, Labor and Welfare and The Research Funding for Longevity Sciences (23-28) from National Center
for Geriatrics and Gerontology) This report is subgroup analysis of the studies, and explore the occurrence of
postoperative delirium in patients with preoperative dementia. 121 operative patients were included in this report. 59
patients were registered as the intervention group and 62 patients were registered as the control group. Preoperative
dementia was diagnosed using Mini-mental State Examination (MMSE). Their age, gender, disease treated with
surgery, activities of daily living (ADL; Barthel Index), and NEECHAM confusion scale (NEECHAM) were evaluated.
Patients with a NEECHAM score 19 or lower were considered to be delirium, in postoperative day 0 to 7.
Results: In 59 patients with intervention, 36 patients had dementia, preoperatively. In these patients, 19 patients
developed delirium. In 23 patients without dementia, 6 patients developed delirium. In 62 patients as control, 39
patients had dementia, preoperatively. In these patients, 18 patients developed delirium. In 23 patients without
dementia, 4 patients developed delirium. In both group, postoperative delirium was accrue to the patients with
preoperative dementia (P=0.039 and 0.020）.
Conclusion: The patients with preoperative dementia tend to develop the postoperative delirium in patient
with/without prophylaxis intervention. The patient with preoperative dementia is high risk of delirium.
Disclosure of Interest: None declared
351
PE007
COMPARISON OF THE RECURRENCE RATE AND POSTOPERATIVE QOL IN ADULT INGUINAL HERNIA
REPAIR BETWEEN ANTERIOR AND POSTERIOR APPROACH BY KUGEL PATCH.
T. Kishimoto1,*, Y. Okada1, E. Hayashi1, J. Nagata1, S. Ohira1, H. Kubota1
1
General Surgery, Handa City Hospital, Handa City, Japan
Introduction: The aim of this study is to compare the recurrence rate and postoperative quality of life (QOL) including
postoperative chronic pain and foreign-body sensation in the long-term follow-up between anterior and posterior
approach by Kugel patch repair.
Materials & Methods: Data about the recurrence was retrieved from clinical records. In addition, a questionnaire was
mailed to all the patients who had undergone inguinal hernia repair from January 2006 to August 2014 in order to
assess their postoperative QOL (chronic pain, foreign-body sensation). In the questionnaire, regarding how long
postoperative pain and foreign-body sensation of a mesh continued, patients were asked to choose one from five
options: within one month, within two months, within three months, three months and more, and until now. Since
chronic pain is defined as the pain lasting for three months or more according to the International Association for the
Study of Pain (IASP), we regard the pain or sensation lasting longer than three months (‘three months and more’ and
‘until now’) as positive for postoperative complications.
Results: Among 1133 patients who underwent surgical intervention for inguinal hernia, 836 patients had posterior
approach and 297 patients had anterior. Nineteen out of 343 patients with posterior approach (2.27%) and 3 out of
836 patients with anterior approach (1.01%) have experienced recurrent hernia. Therefore, there was no statistical
difference in the recurrence rate between two groups (p = 0.176). In postoperative QOL investigation, 553 patients
including 403 with posterior approach repair and 150 with anterior approach repair responded to postal
questionnaires. 17 patients with posterior approach repair (4.22%) and 8 with anterior approach repair (5.33%) had
chronic pain. In terms of chronic pain, there are no statistical difference between anterior and posterior approach (p =
0.741). Fifty-one patients with posterior approach repair (12.7%) and 43 patients with anterior approach repair (28.7%)
had foreign-body sensation of the mesh. Also in terms of foreign-body sensation, no statistical difference was proven t
between anterior and posterior approach (p = 0.553).
Conclusion: In Kugel patch repair, there might be no significant differences in the recurrence rate and the
postoperative QOL between between anterior and posterior approach.
Disclosure of Interest: T. Kishimoto Salary, Royalty or Honoraria from: none, Receipt of Intellectual Property Rights
of: none, Grant/Research Support from: none, Consulting fees from: none, Speaker’s Honorarium from: none,
Ownership Interest of: none, Other Financial/Material Support from: none, Y. Okada: None declared, E. Hayashi:
None declared, J. Nagata: None declared, S. Ohira: None declared, H. Kubota: None declared
352
PE008
RECTUS SHEATH HAEMATOMA IN THE ERA OF ANTICOAGULATION
F. Asomah1,*, S. P. Pillay2,3, S. Naidu3, J. Fenwick4
1
2
3
4
Surgery, LCCH, University of Queensland, Surgery, QE II Jubilee Hospital, Radiology, Queensland X-Ray,
Brisbane, Australia
Introduction: Rectus Sheath Haematoma (RSH) is a rare cause of acute abdominal pain but is becoming more
common with the increasing use of various anticoagulant preparations. It manifests as an acute painful lump confined
to a part of the rectus sheath. If there is no obvious cause for the haematoma, it is commonly referred to as
spontaneous rectus sheath haematoma (SRSH).
Materials & Methods: We carried out a retrospective study of eleven patients with RSH at our centre from June 2007
to May 2014 to identify potential causes, outcomes, and to suggest a management strategy based on current
literature.
Results: Nine of eleven patients with RSH were on anticoagulants and two were spontaneous. All patients with
anticoagulation-related RSH were female (n=9). The mean age was 72.9 years. Table 1 demonstrates our patient
population, type of and indications for anticoagulation, and patient outcome.
Table 1: Demographics
Patient Gend
A
Aetiology
Comorbidities
Hb (g/L)
Transfusion Outcome
er
g
(Units)
e
1
F
8
LMWH
AF, CCF
151 dropped
2
Resolved
7
to 98
2
F
8
LMWH and
CCF, HTN,
124 dropped
2
Died Day
5
clopidogrel
COPD
to 87
3
3
F
6
LMWH
SLE, HTN
114 dropped
4
Resolved
0
to 57
4
F
6
warfarin
PEs (multiple), COPD, HTN 115 dropped
3 and
Resolved
3
(INR 4.7)
to 80
4 FFP
5
M
7
spontaneous
dementia
155
Nil
Resolved
5
6
M
6
spontaneous
CCF
82
2
Resolved
9
7
F
6
clopidogrel
COPD, HTN
123
Nil
Resolved
2
8
F
8
warfarin
HTN, AF, IHD
112 dropped
2
Resolved
9
to 75
9
F
6
LMWH
COPD
147 dropped
2
Resolved
7
to 76
10
F
7
LMWH and
NSTEMI, CRF, APO
85 dropped
5
Resolved
5
clopidogrel
to 75
11
F
7
warfarin
AF, COPD,
77
2
Resolved
0
MVR,
LMWH: low molecular weight heparin, AF: atrial fibrillation, CCF: congestive cardiac failure, HTN: hypertension,
SLE: systemic lupus erythematosus, PE: pulmonary embolism, COPD: chronic obstructive pulmonary disease,
FFP: fresh frozen plasma, INR: international normalised ratio,
APO: acute pulmonary oedema, NSTEMI: non ST-elevation myocardial infarction, CRF: chronic renal failure,
MVR: mitral valve replacement
Conclusion: The mortality rate in patients with RSH is reported as 4%, but it can be significantly higher in patients
with serious comorbidities. RSH is most commonly managed conservatively. Surgery or radiological intervention is
only indicated for progressive uncontrolled bleeding. Anticoagulants need to be used with caution in the elderly,
especially those with borderline renal function and COPD. Rectus sheath haematoma, although rare, should be
considered in the differential diagnosis of abdominal complaints in the anticoagulated elderly patient
Disclosure of Interest: None declared
353
PE009
“A RANDOMIZED COMPARATIVE STUDY OF SUBFASCIAL ENDOSCOPIC PERFORATORS SURGERY (SEPS)
VERSUS MODIFIED LINTON PROCEDURE (MLP) IN PATIENTS OF CHRONIC VENOUS INSUFFICIENCY”
J. K. Kushwaha1,*, A. A. Sonkar1, K. Singh1, A. Kumar1
1
General Surgery, KG Medical University, Lucknow, India
Introduction: Perforating veins have an important role in the pathogenesis of chronic venous insufficiency (CVI).
Robert linton first described subfascial ligation of below knee perforatos by long vertical incision, but due to higher
wound complication now abandoned.
Modified Linton’s Procedure (MLP) which included the use of multiple short skin incisions and perforators are
ligated in subfascial space. In MLP due to short incisions on compromised skin , lack of visual control, perforators are
usually missed and wound complication is other problem.
Subfascial endoscopic perforator vein surgery (SEPS) because of the minimally invasive have lesser rate of
complications with encouraging results.
Materials & Methods: Patients having CVI (C4 and onwards) from December12-November 13 were included in this
study. Simple randomization was done for deciding procedure. Colour duplex scanning was done in all patients pre
and post operative follow up. In group 1 SEPS (n=25) and in group 2 MLP (n=25) were performed.
SEPS were performed by placing both ports below knee using conventional laparoscopic instruments. All perforators
were interrupted by bipolar cautery or ultrasonic scalpel or applying clip.
MLP were performed by giving short incision at sites of incompetent perforator ,which was already marked by colour
Doppler USG.
All patients were followed for 12 months. Student t test were used for statistical analysis.
Results: Table showing comparative results:
Duration of ulcer healing
Surgical sites infection
Group 1(SEPS)
n=25
04 months
04 (16%)
Group 2 (MLP)
n=25
08 months
08 (32%)
Calf cellulitis
01(4%)
02(8%)
Failure to interrupt all perforators
02 (8%)
04 (16%)
Recurrence
02 (8%)
04 (16%)
Hypertrophic Scar
1(4%)
2 (8%)
Sensory deficit
2 (8%)
04 (16%)
DVT
Gas embolism
Nil
Nil
nil
-
p
value
0.192
7
0.537
0
0.394
4
0.394
4
0.537
0
0.394
4
Image:
Conclusion: SEPS is feasible, safe ,effective, and superior to MLP and can be performed by conventional
laparoscopic instruments .Favorable ulcer healing rate, lesser wound complication and recurrence rate (statistically
insignificant) suggests that SEPS may have a considerable result in correcting the underlying pathology in CVI.
354
References: 1. Kianifard B, Holdstock J, Allen C, et al. Randomized clinical trial of the effect of adding subfascial
endoscopic perforator surgery to standard great saphenous vein stripping. Br J Surg 2007; 94: 1075-80.
2.Haruta N, Shinhara R. Subfascial endoscopic perforating vein surgery (SEPS): Two port system subfascial
endoscopic perforating vein surgery (TPS-SEPS) with the use of EndoTIP® cannula. Jpn J Phlebol 2011; 22: 63-7.
3.Luebke T, Brunkwall J.Meta-analysis of subfascial endoscopic perforator vein surgery (SEPS) for chronic venous
insufficiency.Phlebology February 2009; 24: 8-16.
4.Tenbrook JA Jr, Iafrati MD, O'donnell TF Jr, Wolf MP, Hoffman SN, Pauker SG, Lau J, Wong JB.Systematic review
of outcomes after surgical management of venous disease incorporating subfascial endoscopic perforator surgery. J
Vasc Surg. 2004;39(3):583-9.
5.Wiesław P, Waldemar K, Marek K, Rafał S, Magdalena Ł, Anna Ż, Radosław G.The place of subfascial endoscopic
perforator vein surgery (SEPS) in advanced chronic venous insufficiency treatment.Videosurgery and Other
Miniinvasive Techniques 2011; 6 (4): 181-189
Disclosure of Interest: None declared
355
PE010
THE TOLERABILITY OF S-1 IN POSTOPERATIVE ADJUVANT CHEMOTHERAPY FOR GASTRIC CANCER
Y. Asai1,*, K. Kurimoto1, M. Nakamura1, S. Ryo1, Y. Kato1, H. Matsushita1, K. Yamamura1, K. Ishigure1
1
Surgery, Konan Kosei Hospital, Konan city Aichi, Japan
Introduction: The results of the Adjuvant Chemotherapy Trial of S-1 for Gastric Cancer (ACTS-GC) demonstrated
that postoperative chemotherapy using S-1 is a standard treatment in Japan. But some patients discontinued planed
adjuvant S-1 chemotherapy because digestive adverse events of not only S-1 but also gastric surgery that results in
decreasing digestive function. We evaluated the tolerability of S-1 therapy in postoperative adjuvant chemotherapy for
gastric cancer, retrospectively.
Materials & Methods: We investigated 58 patients who received S-1 therapy after curative resection of gastric cancer
from Jan 2011 through Dec 2013. We examined background, completion rate and reasons of discontinuation.
Results: 39 men and 19 women were received S-1 adjuvant chemotherapy. The median age of the patients was 68
years (range, 46-83). 30 patients (51.7%) completed planned S-1 therapy for one year after surgery. There was no
difference in patient characteristics between completed group and non-completed group. In non-completed group, the
median treatment period was 9 weeks. 12 patients (42.9%) discontinued because of anorexia or diarrhea, 4 patients
(14.3%) did because of grade 3/4 hematological toxicities and 3 patients (10.7%) did because of recurrence.
Conclusion: The completion rate of S-1 in postoperative adjuvant chemotherapy for gastric cancer was low in this
study. For the completion rate improvement, it is necessary to care for digestive adverse events within the early
course.
Disclosure of Interest: None declared
356
PE011
THE GOOD IDEA USING THE GLISSONEAN SHEATH CODE TRANSECTION FOR ANATOMIC RESECTION OF
LAP-HEPATECTOMY
N. Taniai1,*, J. Ueda1, H. Takata1, H. Yoshida1, E. Ｕｃｈｉｄａ1
1
Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
Introduction: Laparoscopic liver resection has been reported as a safe and effective approach to the management of
liver cancer. The aim of this study was to analyze the good idea using the glissonean sheath code transection for
anatomic resection of lap-hepatectomy.
Materials & Methods: Between 1999 and 2014, 113 patients underwent laparoscopic liver resection. Fifty-two
patients at the first period (1999~2011) are compared to 61 patients at the second period (2012~2014) on operational
procedures.
Results: The numbers of anatomic resection at the second period was significantly increased those at the first period.
At the first period, nine patients underwent lateral segmentectomy and 1patient underwent posterior segmentectomy.
At the second period, nine patients underwent lateral segmentectomy, 2 patients right lobectomy, 3 patients left
lobectomy, 6 patients posterior segmentectomy and 2 patients underwent S6 subsegmnetectomy. By the good idea
using the glissonean sheath code transection, we usually used ENDO MINI-RETRCT with shortcut nelathon not only
to right or left branch but also to anterior or posterior sub-branches. And we think the understanding of a blood vessel
run by a 3-D picture by Synapse VINCENT is also important in diagnostic imaging before operation.
Conclusion: The good ideas for spreading the anatomic resection of laparoscopic hepatectomy are the operational
procedures, surgical device, and diagnostic imaging.
Disclosure of Interest: None declared
357
PE012
THE STRATEGIES FOR LAPAROSCOPIC SURGERY IN LARGE-SIZE INCISIONAL HERNIA
T. Tsuruma1,*, M. Nagayama1
1
Department of Surgery, JR Sapporo Hospital, Sapporo, Japan
Introduction: Laparoscopic surgery in incisional hernia is a very beneficial operative method because of minor
abdominal destruction, visualization of hernia resion, etc. However, in case of large-size incisional hernia, we
sometimes have difficulty with handling of a large mesh. So, we demonste the strategies for laparoscopic surgery in
large-size incisional hernia.
Materials & Methods: We have carried out laparoscopic operations of 20 patients with incisional hernia from July
2011 to February 2015 at JR Sapporo Hospital, Japan. We used following meshes; Parietex Composite (PCO) Mesh
(case 1 – case 13), VENTRALIGHT ST MESH (case 14 – case 20).
Results: 20 patients with incisional hernia have underwent laparoscopic surgery. There is no recurrence until now. 4
patients had complications that were subcutaneous hemorrhage, mesh bulging, intestinal paralysis, and seroma. The
complications except for mesh bulging were improved by conservative management. Our strategies of laparoscopic
incisional hernia operation without recurrence is as below. The 5mm optiview trocar is used as the first trocar,
because the open technique might conduce to the destruction of abdomen wall, especially in obese patients. Ports
are inserted at each side of lateral region to make certain of tacking the large-size mesh. Hernia orifice is reefed and
then mesh was fixed in order to prevent mesh bulging. The large-size mesh is hoisted by three points on a long axis
in the appropriate position, so we can get working space by turning over the side of mesh. Mesh is fixed by usage of
tacking device and full-thickness ligation. In case of hernia close to the bladder, mesh is inserted to prevesical region.
Conclusion: Laparoscopic incisional hernia repair surgery is a very minimally invasive surgery. So, it might be an
ideal surgical treatment method. However, in the case with large size hernia, some techniques are required.
Disclosure of Interest: None declared
358
PE013
ENVIRONMENTAL SANITIZATION IN THE HOSPITAL WITH THE HYPOCHLOROUS ACID.
T. Suehiro1,*
1
Department of Surgery, ONGA-NAKAMA Medical Association Onga Hospital, Onga, Japan
Introduction: The Intensive care unit (ICU) is a high risk of the nosocomial infection and environmental maintenance
is important. The hypochlorous acid is strong in sterilizing property and is the disinfectant which it is acidulous though
it is effective for not only viruses such as bacteria and an influenza virus, the norovirus but also the sporule and is
harmless to the human body, and, besides, there is the deodorization effect, and is very useful. We investigated an air
cleanliness degree of ICU and examined the environmental sanitization effect by the hypochlorous acid dry mist.
Materials & Methods: The number of the fall bacteria in ICU and the levitation bacteria were measured. The fall
bacteria left an agar nutrient medium for 15 minutes and the floating bacteria gathered air of 1,000L in air sampler
(MERCK company) and measured colony count after culture. The hypochlorous acid dry mist were sprayed from the
entrance side of ICU with density 50ppm humidity 60%. We measured bacteria colony count in 1,000L with an air
sampler over time. In addition, We examined the deodorization effect of hypochlorous acid.
Results: The fall bacteria were hardly detected with a 0-3 colony. There were many floating bacteria with 105 colonies
at the entrance whereas a bed side were 44-69 colonies. The colonies decreased after hypochlorous acid dry mist use
to 2/3. In addition, deodorization effects such as the filth were enough, too.
Conclusion: The hypochlorous acid water was effective in environmental sterilization in ICU, and it was thought that it
was very useful for nosocomial infection defense. In addition, it was effective for the in-hospital smell including the
filth. The hypochlorous acid dry mist can prevent contact infection such as the Ebola hemorrhagic fever.
Disclosure of Interest: None declared
359
PE014
TREATMENT FOR THORACIC EMPYEMA IN LOCAL HOSPITAL IN JAPAN
M. Kimura1,*, N. Taura1
1
Surgery, JCHO Hitoyoshi Medical Center, Hitoyoshi, Japan
Introduction: The number of elderly patients with thoracic empyema has grown up so much larger in Japan that its
therapy seems to become very difficult because of their underlying serious diseases and atrophic deterioration of their
physical and mental status. Most patients with acute thoracic empyema are cured by the appropriate antibiotic
dosage, chest drainage and operation. However some patients are not able to receive operation because of several
problems such as age, performance status, dementia, and poor general condition. This study aimed to examine the
current status of the treatment for the empyema patient including many elderly people at the rural area in Japan.
Materials & Methods: Forty-seven patients（39 male, 8 female, age 29 - 92 yo）with empyema excluding injury and
operation were treated primarily by antibiotic medication with or without thoracic cavity puncture and thoracic cavity
drainage in our hospital from January 2010 to December 2014. The patients unimproved by conservative therapy
received thoracoscopic assisted operation under general anesthesia as secondary therapy. The patients’ factor such
as mental status and performance status were examined that influenced treatment for empyema.
Results: As primary therapy all the patients were administered antibiotics, one of 47 patients treated without
thoracentesis died two days after hospitalization, 7 were treated by thoracentesis and 39 were added by thoracic
drainage. Twenty-two of 47 patients (47%) were improved by primary therapy, otherwise the other 24 patients were
necessary secondary treatment. Six of 24 patients were not able to receive surgical operation because of dementia,
renal failure, cancer, COPD and high age, and then died in the hospital. On the other hand 18 patients received
operations, two patients of 18 died from lung cancer and COPD, otherwise the other 16 patients (34%) were improved
uneventfully. There were no operative complication and median hospital stay was 22 days in all patients. Finally 38 of
47 patients (81%) were improved by the treatment, although nine of 47 patients (19%) died in the hospital whose
average age was over 83 years old. Six of 47 patients (13%) recurred, and then needed thoracic drainage in hospital
without operation.
Conclusion: It is so difficult to treat elderly patients with empyema that we may have to examine a less invasive
therapeutic strategy.
Disclosure of Interest: None declared
360
PE015
A COMPARISON OF EFFICIENCY AND SAFETY BETWEEN DUAL AND TRIPLE IMMUNOSUPPRESSIVE
REGIMENS IN PEDIATRIC LIVING DONOR LIVER TRANSPLANTATION
AT KING CHULALONGKORN MEMORIAL HOSPITAL
A. Vorasittha1,*, B. Nontasuti1
1
Surgery, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
Introduction: There has been many randomized controlled trials (RCTs) showing that dual regimen of Tacrolimus
(Tac) and corticosteroid (S) was potent enough to use as primary immunosuppressant in liver transplant recipients.
1,2
However, only 2 RCTs had been done in pediatric patients and none included Asian population. This will be the first
study in Thailand to compare between dual (D) and triple (T) primary immunosuppressive regimens in terms of their
efficiency and safety.
Materials & Methods: This retrospective cohort study was done in King Chulalongkorn Memorial hospital (KCMH). All
pediatric patients aged under 15 who had living donor liver transplantation between January 2008 and November
2014 were included in our study. Primary outcome was to compare biopsy-proven acute cellular rejection (BPAR) free
rates at 3 months post-transplantation between patients who had D and T regimens. In our center, Tac was given in
form of solution made by dissolving power from capsule in water/syrup. Keplan-Meier method was used to compare
primary outcome. Postoperative complications, adverse events and infection rates were also compared between
groups.
Results: 24 cases of PLDLT have been performed in KCLM hospital. There were 14 patients in D group and 10
patients in T group (8 patients received S, CsA, and azathioprine (AZA), 1 received S, Tac and AZA, and 1 received
S, Tac and mycophenolate mofetil). BPAR-free rates were 70% in T group and 42.86% in D group as showed in
Graph 1 (p=0.182). There was only one graft loss from hepatic artery thrombosis occurring in T group. Estimated graft
survival rates at 3 months were 100% in D group and 90% in T group (p=0.237). No patient death occurred.
Postoperative complications were comparable in both groups except for Ebstein-Barr virus (EBV) infection rates
(42.85% in D group versus 0% in T group; p=0.024).
Image:
Conclusion: There was a trend toward higher BPAR rates in dual group, as well as, EBV infection rates. It might be
because Tac had variable pharmacokinetics so that it was difficult to adjust optimum dose resulting in frequent over or
361
under-immunosuppression. This study supports that new models for Tac monitoring are required. Furthermore,
bioavailability and stability of tacrolimus in the form of extemporaneously compounded oral solution used in our center
should be tested.
References: 1.McDiarmid SV, Busuttil RW, Ascher NL, Burdick J, D'Alessandro AM, Esquivel C, et al. FK506
(tacrolimus) compared with cyclosporine for primary immunosuppression after pediatric liver transplantation. Results
from the U.S. Multicenter Trial. Transplantation 1995;59:530-6.
2.Kelly D, Jara P, Rodeck B, Lykavieris P, Burdelski M, Becker M, et al. Tacrolimus and steroids versus ciclosporin
microemulsion, steroids, and azathioprine in children undergoing liver transplantation: randomised European
multicentre trial. Lancet 2004;364:1054-61.
Disclosure of Interest: None declared
362
PE016
THE ASSESSMENT OF PERIPHERAL PERFUSION FOR THE PATIENTS WITH ISOLATED INFRAPOPLITEAL
ARTERIAL LESIONS BY INDOCYANINE GREEN ANGIOGRAPHY
K. Igari1,*, T. Kudo1, T. Toyofuku1, Y. Inoue1
1
Division of Vascular and Endovascular Surgery, Department of Surgery, Tokyo Medical and Dental University, Tokyo,
Japan
Introduction: Peripheral arterial disease (PAD) can be diagnosed based on an ankle-brachial pressure index (ABI) of
≦ 0.90; however, the sensitivity of this parameter is relatively low, especially in patients with isolated infrapopliteal
lesions. In this study, we evaluated the degree of peripheral perfusion and the severity of PAD in patients with
infrapopliteal lesions using indocyanine green angiography (ICGA).
Materials & Methods: This study was undertaken from a retrospective review of PAD patients with isolated
infrapopliteal lesions who underwent ICGA between November 2012 and October 2013. We compared the following
ICGA parameters with the ABI: the magnitude of the intensity of indocyanine green (Imax), the time to maximum
intensity (Tmax), the time from fluorescence onset to half the maximum intensity (T1/2), the time elapsed from the
maximum intensity to 90% of the Imax and to 75% of the Imax (Td 90% and Td 75%, respectively) and the rate of
intensity measured 60 seconds after the Tmax to the Imax (IR 60 sec).
Results: Twenty-six limbs in 16 PAD patients with isolated infrapopliteal lesions were examined using the ABI and
ICGA. The Tmax, T1/2, Td 90%, Td 75% and IR 60 sec values were significantly correlated with the ABI (ρ = -0.404, 0.432, -0.585, -0.468, and -0.497, respectively). A cutoff value of Td 90% > 40 seconds was significantly correlated
with an ABI of ≦ 0.9 (sensitivity: 92.9 %, specificity 75%).
Conclusion: ICGA can be used to quantitatively assess the degree of peripheral perfusion, even in PAD patients with
isolated infrapopliteal lesions. The value of Td 90% on ICGA may be used to assess the severity of PAD.
Disclosure of Interest: None declared
363
PE017
A NOVEL TECHNIQUE TO INFRAINGUINAL ARTERIAL OCCLUSIONS USING THE CROSSER™ SYSTEM
M. Nishizawa1,*, K. Igari1, T. Toyofuku1, T. Kudo1, Y. Inoue1
1
Department of Surgery. Division of Vascular and Endovascular surgery, Tokyo Medical and Dental University, Tokyo,
Japan
Introduction: Endovascular treatment (EVT) for chronic total occlusion (CTO) is a technically challenging problem in
peripheral arterial disease (PAD). The Crosser™ system is a CTO device with high frequency vibrational energy to
cross the CTO, which has been adopted for coronary CTO. In our institution, we performed EVT procedure by this
device for PAD with CTO. Therefore, the purpose of this study was to evaluate the efficacy and safety of, the
Crosser™ system, in the EVT procedures for infrainguinal arterial occlusions.
Materials & Methods: From April 2014 to December 2014, 21 patients with 25 sites of infrainguinal arterial occlusions
underwent EVT with the Crosser™ system. CTO was defined as 100% occlusion of the vessel, and technical success
was defined as the device’s ability to facilitate the successful intraluminal delivery of the guidewire into the distal
vessel. In addition, we evaluated the postoperative complications, including device-related complications.
Results: We treated 21 patients (15 males; median age, 70 years) with a median lesion length of CTO of 100 mm
(range, 35 – 270 mm). CTO was detected in the superficial femoral artery in 10 patients, popliteal artery in 1 patient,
the anterior tibial artery in 4 patients, the posterior tibial artery in 3 patients and the peroneal artery in 7 patients. A
technical success rate of 80 % was achieved, and no device-related complications were observed, including
dissection and perforation. In five of technical failure lesions, all the patients suffered from chronic kidney dieses with
hemodialysis, and all their CTO lesions were in crural aretries with the length ranged from 50 mm to 250 mm. The
uncrossing CTO vessels had severe calcifications with continuous calcium on both sides of the vessel wall on
radiographics. Even though five lesions in four patients were categorized by Rutherford classification as category 5 –
6, three patients were performed by other revascularization procedures, which led to limb salvage.
Conclusion: The Crosser™ system is an effective, safe and alternative option for treating CTO in the infrainguinal
arteries.
Disclosure of Interest: None declared
364
PE018
LENGTH OF ABDOMINAL AORTIC ANEURYSM AND INCIDENCE OF ENDOLEAKS TYPE II AFTER
ENDOVASCULAR REPAIR
F. Meyer1,*, D. D. N. Phan1, A. Udelnow1, Z. Halloul1
1
Dept. of General, Abdominal and Vascular Surgery, University Hospital at Magdeburg (Germany), Magdeburg,
Germany
Introduction: Aim: To evaluate the predicting factors for the development of Endoleak type II, its
frequency and influencing factors after elective endovascular repair (EVAR) of infrarenal
abdomimal aortic aneurysms (AAA).
Materials & Methods: Data were prospectively collected in a unicenter observational study (tertiary
center of [endo-]vascular surgery) and retrospectively evaluated in patients who had undergone
elective EVAR of AAA. Vascular (lumbar arteries [LA] and inferior mesenteric artery, aneurysm)
and general patient (habits, medication, basic diseases) as well as procedural characteristics,
were analyzed for their association with the development of Endoleak type II. Pre- and
postinterventional computed tomography (CT) scans were evaluated for aneurysm anatomy, in
particular, postinterventional growth or shrinkage as well detection of an endoleak of each type.
Results: The study cohort included 82 patients (mean age, 72 [52-87] years; 77 men, 93.9 %) throughout 36 months.
The median follow-up period was 29.5 (range, 1-57) months. Overall, 51 Endoleaks type II (62.2 %) were identified at
any time during the postinterventional follow-up period. In the Cox regression, AAA length was the only significant
predictor (P=0.024; Hazard ratio [HR], 1.07; 95
Conclusion: The preoperative AAA length (correlating with the number of lumbar arteries) can be
considered a risk factor for postinterventional occurrence of Endoleak type II prompting at least
temporarily to greater attention.
Disclosure of Interest: None declared
365
PE019
DIFFERENTIAL VASCULARMEDICAL MANAGEMENT OF VISCERAL ARTERY ANEURYSMS IN A SINGLECENTER CONSECUTIVE PATIENT COHORT AS PART OF AN ONGOING DISEASE-SPECIFIC SYSTEMATIC
PROSPECTIVE OBSERVATIONAL STUDY
F. Meyer1,*, A. Udelnow2, V. Scholtz2, Z. Halloul2
1
Dept. of General, Abdominal and Vascular Surgery, 2University Hospital at Magdeburg (Germany), Magdeburg,
Germany
Introduction: Visceral artery aneurysma (VAA) is a rare condition bearing the danger of rupture and embolisation with
peripheral visceral ischemia. Visceral artery pseudoaneurysma (VAPA) occur predominantly after abdominal
inflammations or surgery and are complicated by rupture and bleeding. The aim of the present investigation was to
find out which patients would be better treated by an endovascular approach and which by open surgery or watchand-wait strategy.
Materials & Methods: From November 2000 till August 2014, n=81 patients with VAA and/or VAPA, hospitalised and
treated in the Magdeburg university hospital, Germany, were consecutively included in an observatory setting, 37 of
them in an elective and 44 in an emergency situation.
A watch-and-wait strategy was selected in 21 cases, an endovascular approach in 47 cases, open surgery in 12 cases
and initial diagnostics only in one case.
Results: Elective patients were treated exclusively for VAA, and the treatment strategy was selected based on the
size of the VAA. Therefore the outcome could not be compared between the treatment groups. In the emergency
group containing predominantly VAPA patients the outcome was seemingly better in the open surgery compared to
the endovascular group with less bleeding recidives (0 vs. 39%, p=0.046) and less reinterventions (22 vs. 61 %,
p=0.044. Nevertheless covariate analysis revealed that localisation ist also decisive for outcome, and the groups
differed in the localisation characteristics.
Conclusion: While no recommendation could be drawn from the results regarding treatment indications in the
emergency group, localisation, anatomy and pathophysiology are the key variables for individual treatment decisions.
Disclosure of Interest: None declared
366
PE020
SHOULD NORMOTENSIVE PHEOCHROMOCYTOMA PATIENTS BE PUT ON ALPHA-BLOCKADE BEFORE
SURGERY?
N. Tripathi1,*, A. Agarwal1, S. Gupta2, P. Goyal3, G. Agarwal1, S. K. Mishra1, A. K. Verma1, A. Mishra1
1
2
3
Department of Endocrine Surgery, Endocrinology, Anaesthesiology, Sanjay Gandhi Post Graduate Institute of
Medical Sciences, Lucknow, India, lucknow, India
Introduction: Pheochromocytoma patients are put on alpha blockers before surgery to blunt hemodynamic alterations
during surgery. However, there is no consensus regarding optimal pre-operative management of normotensive or
subclinical pheochromocytoma.
We performed this analysis to evaluate peri & intraoperative hemodynamics in normotensive pheochromocytoma.
Materials & Methods: Between 1990-2014, 204 pheochromocytoma patients were operated. 30 patients were found
to be having normotensive pheochromocytoma. Biochemical diagnosis of pheochromocytoma was made in 28 by
finding of elevated 24 hr urinary metanephrine/normetanephrine. Data regarding patient demographics, preoperative
alpha blockade and intraopertive hemodynamic instability in terms of extremely high(SBP>180mmHg) or
low(SBP<90mmHg) arterial pressure, tachycardic(HR>120/min) and bradycardic episodes(HR<60min), maximum and
minimum HR & BP , arrhythmias & need of treatment for hyper or hypotension.
Results: Incidence of normotensive pheochromocytoma in our series is 16.3% (n=30/184).26 patients presented as
adrenal incidentaloma, 2 cases were detected on screening for MEN2A and 2 were siblings of MEN2A & MEN2B
cases. 5 patients had extraadrenal pheochromocytomas. Mean tumour size was 6.3cm. Mean 24 hr urinary
metanephrine in 9 patients done by dual column method was 6.97(n=9). In remaining 20 patients mean 24 hr
metanephrine and normetanephrine done by ELISA enzyme immunoassay was 1353.78mcg/day & 2687.98mcg/day
respectively. Pure epinephrine/ metanephrine producing tumours were 4 (13.3%).
28 patients were operated after adequate alpha blockade (prazosin=27;phenoxybenzamine=1). Average dose of
prazosin was 10.5mg & duration being 9.7 days. 2 patients did not receive alpha blockade & pheochromocytoma was
discovered intra-operatively
Hemodynamic alterations were observed in 71.4% (20/28) patients who were alpha blocked. Average maximum BP
was 194mmHg & HR was 134/min. No arrythmias or mortality was observed.There was no significant corelation
between preoperative u. metanephrines and tumour size with introperative hemodynamic instability.
Conclusion: Intra-operative behaviour of normotensive pheochromocytoma was similar to hypertensive
pheochromocytoma. Since intra-operative hemodynamic alteration was present in more than 70% of normotensive
patients despite alpha blockade, we recommend alpha blockade even in normotensive patients for an average period
of 10 days in order to achieve a less explosive and more manageable intraoperative hemodynamic alterations.
Disclosure of Interest: None declared
367
PE021
ROLE OF PRE-OPERATIVE META-IODO BENZYL GUANIDINE (MIBG) SCINTIGRAPHY IN BIOCHEMICALLY
PROVEN AND ANATOMICALLY LOCALISED ADRENAL PHEOCHROMOCYTOMA
K. R. Singh1,*, A. Agarwal2, G. Agarwal2, G. Chand2, A. Mishra2, A. K. Varma2, P. K. Pradhan3, S. K. Mishra2
1
2
3
Surgery, King George's Medical University, Endocrine and Breast Surgery, Nuclear Medicine, Sanjay Gandhi Post
Graduate Institute of Medical Sciences, Lucknow, India
Introduction: Radio labelled metaiodobenzylguanidine scintigraphy (MIBG) is used for used to image
pheochromocytomas. While computed tomography (CT) or magnetic resonance imaging (MRI) usually localize the
tumor, MIBG is often obtained to rule out multifocal and metastatic disease and to corroborate anatomic imaging with
functional status. Since the utility of routine MIBG is questionable in the pre operative setting, the aim of this
retrospective analysis was to evaluate the role of pre operative MIBG in bio chemically proven and anatomically
localised pheochromocytoma.
Materials & Methods: All patients of pheochromocytoma who underwent pre operative MIBG scintigraphy at Sanjay
Gandhi Post Graduate Institute of Medical Sciences, Lucknow between September 1997 and June 2013 were
identified retrospectively. The findings of 64 slice CECT, MIBG scintigraphy , operative findings and histopathalogical
results were reviewed and compared.
Results: A total of 29 patients underwent MIBG scintigraphy for the pre operative evaluation of pheochromocytoma
for variable reasons. All patients had a raised 24 hr urinary fractionated metanephrine or nor-metanephrine. Four
patients with >5 cm tumors had negative MIBG uptake and 4 patients, with unilateral tumors showed bilateral uptake.
MIBG did not identify any additional foci of disease or alter the surgical management in any patient but added to the
confusion regarding optimum management in patients with bilateral uptake.
Conclusion: The routine use of pre-operative MIBG scintigraphy is not useful in patients with biochemically confirmed
and localized apparently sporadic adrenal pheochromocytoma. Its use should be limited to the subset of patients with
equivocal biochemical disease, familial disease, negative cross sectional imaging or those with recurrent or metastatic
disease.
Disclosure of Interest: None declared
368
PE022
HAEMODYNAMIC CONSEQUENSES DURING MINIMALLY INVASIVE ADRENALECTOMY FOR
PHEOCHROMOCYTOMA: ROBOT-ASSISTED VERSUS THE CONVENTIONAL LAPAROSCOPIC APPROACH
O. Makay1,*, E. Yuksel2, A. Sargin2, M. Ozdemir1, V. Erol3, O. Bozbiyik4, S. Ulukaya2, M. Akyildiz1
1
2
3
General Surgery, Div. Endocrine Surgery, Anaesthesiology, Ege University, General Surgery , Baskent University,
4
Izmir, General Surgery , Usak State Hospital, Usak, Turkey
Introduction: Minimal invasive surgery of the adrenal gland is accepted widespread. Although reports demonstrating
safety and feasibility of robot-assisted adrenalectomy, the objective benefits are still unclear, compared to those of
conventional laparoscopy. Recently, robot-assisted approach is also possible for pheochromocytoma resection. Since
cardiopulmonary changes during robot-assisted dissection of the pheochromocytoma patient has not been studied in
detail, we aimed to assess these concerns, compared to the routine laparoscopic technique.
Materials & Methods: In this case-control study, 19 consecutive robot-assisted adrenal resections were compared
with a control group consisting of 14 conventional laparoscopic adrenalectomy. Patient characteristics and
2
intraoperative haemodynamic and respiratory parameters were assessed. Groups were compared using the χ test for
categorical variables and Student's t-test for continuous variables. Significance was considered p<0.05.
Results: The robot-assisted procedure was performed successfully in all patients, except one. The duration of the
robot-assisted procedure, compared to the conventional laparoscopy group was significantly longer (p<0.05).
Intraoperative blood loss was significantly less in the robot-assisted group (p<0.05). Dissection of pheochromocytoma
showed a significant difference between the groups, according incidence of intraoperative blood pressure fluctuations
(p<0.05). Robot-assisted approach resulted in less incidents. Other haemodynamic and respiratory parameters did not
differ between groups significantly. There were no perioperative deaths. Complications rates and postoperative
hospital stays were not significanly different.
Conclusion: Robot-assisted adrenalectomy is a safe and technically feasible procedure for the pheochromocytoma
patient. Robot-assisted resection of pheochromocytoma minimized the occurence of intraoperative blood pressure
fluctuations and blood loss.
Disclosure of Interest: None declared
369
PE023
CLINICAL COURSE OF PHEOCHROMOCYTOMA / PARAGANGLIOMA IN PATIENTS WITH VON HIPPELLINDAU SYNDROME (VHL)
Y. Yoshida1,*, K. Horiuchi1, A. Sakamoto1, Y. Omi1, H. Tokumitsu1, E. Nagai1, K. Haniu1, T. Okamoto1
1
Endocrine Surgery, Tokyo Women's Medical University, Tokyo, Japan
Introduction: Proper management of hereditary pheochromocytoma (P) and paraganglioma (PGL) is a
challenging issue because the disease often involves bilateral adrenals and multiple locations in the paraganglia.
In particular, the extent of adrenalectomy (total vs partial) has been controversial. The purpose of the study was
to describe how the disease (P-PGL) behaved over time in patients with VHL.
Materials & Methods: Nine patients (male/female = 5/4) with VHL underwent surgery for P-PGL from 1992 to
2014. Seven patients underwent primary surgery while other 2 had their initial treatments elsewhere. A
retrospective chart review was conducted to examine P-PGL location, tumor size, surgical management,
pathological findings as well as prognosis.
Results: For the 7 patients with initial surgery, the median age was 19 (range 10 - 42) years old, median tumor
size was 3.9 (2.0 – 7.0) cm and median follow-up duration was 98 (33 – 206) months. Two patients with
unilateral P underwent unilateral total adrenalectomy. One patient with unilateral P and PGL received unilateral
total adrenalectomy along with PGL resection. Of 3 patients with bilateral Ps, 2 underwent bilateral total
adrenalectomy while one had unilateral total adrenalectomy and contralateral partial adrenalectomy. One patient
had PGL only and received tumor resection. During the follow-up, one patient developed P in the contralateral
adrenal at 76 months after unilateral total adrenalectomy. Another patient had recurrent tumor in the remnant
adrenal at 125 months following partial adrenalectomy. Salvage surgery has been so far successful in other 2
patients. None of the patients experienced Addisonian crisis.
Conclusion: Partial adrenalectomy can be an alternative to total resection of the adrenals in selected patients
with P-PGL from VHL.
Disclosure of Interest: None declared
370
PE024
NEED FOR CONTINUED ORAL ANTIHYPERTENSIVE MEDICATIONS IN MEN VERSUS WOMEN FOLLOWING
SURGICAL TREATMENT OF PRIMARY HYPERALDOSTERONISM
A. M. Laird1,*, N. Fleischer2, J. Del Rivero2, M. White1, M. Jagust3, S. K. Libutti1
1
2
3
Surgery, Endocrinology, Radiology, Montefiore Medical Center/Albert Einstein School of Medicine, New York,
United States
Introduction: Adrenalectomy is a therapeutic option for management of primary hyperaldosteronism. The goal of
treatment is resolution of hypertension or reduction in the number of medications. Women may be more likely than
men to achieve resolution of hypertension without additional medications, i.e., men may have mixed primary and
secondary hypertension. We evaluated the post-operative use of oral antihypertensives in men and women following
adrenalectomy for primary hyperaldosteronism.
Materials & Methods: Nineteen patients who underwent an adrenalectomy for the management of primary
hyperaldosteronism at a single academic institution were identified from July 2009 to December 2014. Records were
reviewed for demographic information, pre- and post-operative aldosterone and renin levels, preoperative blood
pressure measurements and outcomes of blood pressure and need for anti-hypertensive medications postoperatively. Outcomes of male and female patients are compared.
Results: Seven women and 12 men underwent laparoscopic adrenalectomy for treatment of primary
hyperaldosteronism. Median age was similar for the groups. Preoperative blood pressure in women (median 141/89,
range 126-159/76-100) and men (median 149.5/91.8, range (135-205/77-101.5) are similar. All patients had either CT
or MRI preoperatively; 15/19 patients had adrenal vein sampling (AVS). No patients had adrenocortical cancer (ACC).
Hypertension resolved in 4/7 women (57.1%) and 1/12 men (8.3%) without the need for continued oral
antihypertensives following surgery (p=0.0379, Fisher’s exact test). The remaining 14 patients continue to take a
range of 1-5 antihypertensives after a median of 16.5 months of follow up (range 1.3-54.3 months). Postoperative
systolic blood pressure in women (median 121.5, range 110-143) was significantly lower than in men (median 139.5,
range 119-165) (p=0.0299, Student's t-test), but there was no significant difference in diastolic blood pressure
between men (median 91, range 70-109) and women (median 74.5, range 70.5-103) following surgery.
Conclusion: In this small series, it appears female patients are more likely to resolve hypertension without the need
for any oral anti-hypertensives with surgery alone for aldosterone-secreting adenomas. This observation may assist in
preoperative discussions as well as risk assessment for surgery and warrants further exploration.
Disclosure of Interest: None declared
371
PE025
CYTOSTATIC EFFECT OF EVEROLIMUS ON A GEFITINIB-RESISTANT ANAPLASTIC THYROID CANCER CELL
LINE WITH PI3KCA MUTATION
N. Onoda1,*, M. Nakamura1, K. Kurata1, S. Noda1, S. Kashiwagi1, Y. Asano1, T. Takashima1, K. Hirakawa1
1
Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan
Introduction: Anaplastic thyroid cancer (ATC) is one of the most aggressive malignancies showing
resistance to conventional multimodal therapeutic efforts. Molecular-targeted therapy is a newly
developed therapeutic strategy against ATC. We have demonstrated the efficacy of gefitinib, a
tyrosine kinase inhibitor of epidermal growth factor receptor (EGFR), in regulating cell growth in an
ATC cell line, ACT-1 1). At the same time, another ACT cell line OCUT-2, harboring mutated
PI3KCA gene, showed resistance to gefitinib. We attempted to investigate the effect of everolimus,
an inhibitor of mTOR to overcome this resistance.
Materials & Methods: Cell viability and cell cycle were measured by MTT assay and flowcytometry,
respectively. Additional cytotoxic effect of everolimus on to the paclitaxel was evaluated.
Results: A significant growth inhibitory effect of everolimus was demonstrated in OCUT-2 (IC50= 5
nM) compared with that in ACT-1(IC50 not reached at 100nM). Cell cycle arrest in G2M phase
was found by exposure to everolimus (1nM) with the 19% increasing ratio of cells in G2M phase
(32 to 39%). An additive effect (a 32% decrease of cell viability) of everolimus on to the cytotoxic
effect of paclitaxel was demonstrated at the dose of 1 nM.
Conclusion: A significant growth inhibitory effect of everolimus on a gefitinib-resistant cell line was
demonstrated. Possible correlation with the efficacy of everolimus and PI3KCA gene mutation was
suggested.
References: 1) Nobuhara Y. BJC 2005,92(6):1110-6.
Disclosure of Interest: N. Onoda Grant/Research Support from: Noartis Pharma supplyed everolimus, M. Nakamura:
None declared, K. Kurata: None declared, S. Noda: None declared, S. Kashiwagi: None declared, Y. Asano: None
declared, T. Takashima: None declared, K. Hirakawa: None declared
372
PE026
PAY IT FORWARD: STRATEGIES FOR SUCCESSFUL IMPLEMENTATION OF SHORT-TERM ENDOCRINE
SURGICAL MISSIONS
K. Long1,*, M. Cohen2, N. Perrier3
1
2
3
General Surgery, University of Kentucky, Lexington, University of Michigan, Ann Arbor, Endocrine Surgery, MD
Anderson Cancer Center, Houston, United States
Introduction: With increasing interest in humanitarian surgical efforts, numerous opportunities for specialized mission
trips have developed. Extreme short-term surgical “blitzes” of specialist teams have offered much-needed surgical
care but lack efforts for patient continuity and local sustainability. We sought to define characteristics that aid in the
long-term success of short-term international surgical missions to better apply this insight toward future dedicated
humanitarian endocrine surgical efforts.
Materials & Methods: A broad search-engine review identified 1954 reports of medical and surgical missions. 166 of
these abstracts involved surgical missions from 2009-2014 with 24 articles including details of specific mission trips.
We identified factors deemed essential for improving patient care and affecting local infrastructure for long-term
sustainability and included our prospective experience with an endocrine surgery-specific mission trip for comparison.
Results: Of the 24 articles reviewed, missions went to Africa(9), North America(8), South America(5), and Asia(5).
67% of these brought surgical trainees, 42% were plastic surgery-focused, and 37% were general/orthopedic surgeryfocused. None were specific to endocrine surgery. Factors for mission sustainability and success included (1)ability to
educate local physicians and trainees, (2)multiple return trips to the same location, and (3)formal pre-mission planning
and site visits. Emerging interest is on optimizing patient outcomes and cost-effectiveness. A recent dedicated
endocrine mission trip to Tanzania by one of our authors (MC) included 19 subtotal thyroidectomies performed over 5
days for symptomatic goiters. All patients were evaluated by the operating surgeon prior to surgical intervention and
were followed until discharge. Pathology was confirmed benign in all specimens and no postoperative complications
(bleeding, recurrent laryngeal nerve injury or hypocalcemia) were observed. Again all three factors noted above were
essential for success.
Conclusion: Short-term surgical missions require a local infrastructure for optimal patient outcomes. Sustainability
hinges on education and involvement of local physicians and surgical trainees, pre-mission planning, and return trips
to the same location. For endocrine surgical missions as noted by our experience, preoperative evaluation and
postoperative follow-up by the operating surgeon is important for optimizing performance and outcomes.
Disclosure of Interest: None declared
373
PE027
D631Y RET MUTATION IN THREE KOREAN FAMILIES WITH MULTIPLE ENDOCRINE NEOPLASIA 2A
H. W. Yu1,*, B. H.-H. Lang2, H. Kang1, S.-J. Kim1, J. H. Kim3, J. Y. Choi1, K. E. Lee1, Y.-K. Youn1
1
2
Surgery, Seoul National University Hospital, Seoul, Korea, Republic Of, Surgery, University of Hong Kong, Hong
3
Kong, SAR, Hong Kong, Internal medicine, Seoul National University Hospital, Seoul, Korea, Republic Of
Introduction: Multiple endocrine neoplasia 2A (MEN 2A) results from a germline mutation in the RET proto-oncogene
and appears two or more endocrine tumors such as pheochromocytoma, medullary thyroid carcinoma (MTC) and
Hyperparathyroidism is accompanied by several members of one family. A mutation in codon 631 of the RET protooncogene with MEN 2A is classified as ‘Risk B’ on ATA guidelines and is recommended prophylactic thyroidectomy.
Because this gene mutation is very uncommon, the report of a family with RET mutation D631Y was rare worldwide.
Materials & Methods: This study was a retrospective review of 8 patients who were diagnosed with MEN 2A at the
Seoul National University Hospital by RET mutation test.
Results: Eight individuals including proband from three unrelated families were found to have D631Y germline RET
mutation. Pheochromocytoma was detected in six patients. The mean age of Pheochromocytoma is 48.8-years-old at
the time of diagnosis. Two of pheochromocytoma patients had bilateral tumors. Five of six patients suffering with
pheochromocytoma had no clinical evidence of MTC at the time of diagnosis. One patient underwent total
thyroidectomy with elevated calcitonin and CEA at 42-years-old and received modified radical neck dissection at 582+
years-old. One patient had a clinical evidence of hyperparathyroidism with elevated PTH, serum Ca and 24-H urine
2+
Ca . This is the first report of family that have all three feature of MEN 2A, pheochromocytoma, MTC and strong
clinical evidence of hyperparathyroidism.
Conclusion: Pheochromocytoma might be the first manifestation in patients with the D631Y mutation. This genetic
profile might be related to the less dynamic clinical presentation and the late onset of MTC than reported with other
RET mutations. Prophylactic total thyroidectomy will be performing later than 5-years-old as described in current
guideline with close observation for D631Y carriers.
References: 1. Bae S J , Kim D J , Kim J Y , Park S Y , Choi S H , Song Y D , Ki C S , Chung J H . A rare
extracellular D631Y germline mutation of the RET proto-oncogene in two Korean families with multiple endocrine
neoplasia 2A . Thyroid 2006 ; 16 : 609 – 614
2. M. S. Elston , G. Y. Meyer-Rochow. Holdaway , J. V. Conaglen. Patients with RET D631Y Mutations Most
Commonly Present with Pheochromocytoma and not Medullary Thyroid Carcinoma. Humans, Clinical. 2012, 339-342
Disclosure of Interest: None declared
374
PE028
THE IMPACT OF INTRAOPERATIVE NEUROMONITORING ON RECURRENT LARYNGEAL NERVE
PRESERVATION DURING TOTAL PARATHYROIDECTOMY FOR SECONDARY HYPERPARATHYROIDISM
T. Hiramitsu1,*, M. Okada1, T. Yamamoto1, Y. Tominaga1
1
Transplant and Endocrine Surgery, Nagoya Second Red Cross Hospital, Nagoya , Japan
Introduction: During the thyroid and parathyroid surgery, not only anatomical but also functional nerve preservation is
essential. Recently for that purpose, intraoperative neuromonitoring (IONM) is widely used to confirm the preservation
of vagal nerve, recurrent laryngeal nerve (RLN) and external branch of superior laryngeal nerve during the operation.
And efficacy of IONM for thyroid surgery is well reported. But for parathyroid surgery, especially for secondary
hyperparathyroidism, the efficacy of IONM has not been investigated before. So we investigated the efficacy of IONM
during total parathyroidectomy for secondary hyperparathyroidism.
Materials & Methods: Between September 2010 and December 2014, 197 patients underwent total
parathyroidectomy with forearm autograft for refractory secondary hyperparathyroidism. 394 RLNs were investigated.
During the operation IONM responses were recorded and after the operation vocal cords were checked by ENT
doctors.
Results: The accuracy of IONM was 94.7%. In 15 RLNs, IONM was useful, because parathyroid glands were
severely adhered to RLNs. In 23 RLNs, vocal cord paralysis was identified. Except for one RLN injury, no RLN injury
was identified anatomically. During the follow up, improvement of vocal cord paralysis was identified in 9 RLN s
without any treatment.
Image:
Conclusion: IONM is very useful to confirm the preservation of RLN anatomically and functionally during total
parathyroidectomy for secondary hyperparathyroidism.
Disclosure of Interest: None declared
375
PE029
VALUE OF PROPHYLACTIC CERVICAL THYMECTOMY IN PARATHYROID HYPERPLASIA
M. Boltz1, N. Zhang1, C. Zhao1, A. Siperstein1,*, J. Jin1
1
Cleveland Clinic, Cleveland, United States
Introduction: In parathyroid hyperplasia, cervical thymic disease is a cause of recurrence. However, due to
differences in pathophysiology, variable practice patterns exist regarding performing bilateral cervical thymectomy
(BCT) in primary hyperplasia (PHPT) versus hyperplasia from renal failure (RHPT). The objective of this study was to
capture the proportion of patients where thymic tissue was found when undergoing subtotal (three and a half gland)
parathyroidectomy (STPTX) with intended BCT, to identify the number of thymic supernumerary glands (SNG), and to
determine the overall cure rate.
Materials & Methods: Retrospective review of patients from an endocrine surgery database who had four gland
exploration with intended BCT for parathyroid hyperplasia from 2000-2010 was performed. Identification of thymic
tissue and SNG were determined by operative and pathology reports. Univariate analysis was used to identify
differences in overall cure rate in patients undergoing STPTX with or without BCT. Cure for classic and
normohormonal PHPT, and post-transplant RHPT profiles were defined as final follow-up serum calcium <10.5mg/dL.
Cure for normocalcemic PHPT was defined as decline of 0.5mg/dL in follow-up serum calcium from the preoperative
value, and PTH<65pg/mL. Pre-transplant RHPT patients were cured if follow-up PTH was <500pg/mL.
Results: Thymic tissue was found in 55% of 163 PHPT patients (12% unilaterally, 43% bilaterally) and 74% of 85
RHPT patients (24% unilaterally, 50% bilaterally). 7% of PHPT and 16% of RHPT patients had SNG identified within
the thymectomy specimens (p=0.078). Cure rates of PHPT patients undergoing STPTX with BCT were 86%
compared to 75% in STPTX alone (p=0.098). RHPT cure rates were 97% with BCT compared to 77% without BCT
(p=0.004). Median follow-up times were 40 and 60 months for PHTP and RHPT, respectively.
Conclusion: Despite exploration, many patients have no identifiable cervical thymic tissue. The relative incidence of
intrathymic parathyroid glands in PHPT vs RHPT parallels the cure rate. Failure to remove the cervical thymus may
increase risk of recurrence, either due to supernumerary glands outside the dissection field, or anatomic variation of
thymic tissue. These data advocate that if thymic tissue is readily identified, then cervical thymectomy should be
performed in hyperparathyroidism due to parathyroid hyperplasia.
Disclosure of Interest: None declared
376
PE030
CAN PTH LEVEL MEASURED ON DAY 1 PREDICT MISSED PARATHYROID GLAND IN PATIENTS
UNDERWENT INITIAL PARATHYROIDECTOMY FOR SECONDARY HYPERPARATHYROIDISM?
Y. Tominaga1,*, T. Hiramitsu1, T. Yamamoto1, M. Okada1
1
Transplant and Endocrine Surgery, Nagoya 2nd Red Cross Hospital, Nagoya, Japan
Introduction: Secondary hyperparathyroidism (SHP) due to chronic kidney disease (CKD) is a typical multigland
disease and missed gland/glands could be a cause of persistent/recurrent HPT. To recognize missed gland/glands is
important to detect origin of PTH oversecretion. We investigated that PTH level after PTｘcan predict the missed
gland/glands
Materials & Methods: This is a retrospective observational study. The materials were 1666 patients (Female: Male
787: 879) who underwent total PTx with forearm autograft at the initial PTx in our department for advanced SHPT due
to CKD between 1999 and June 2013. Preoperative image diagnosis (MIBI, CT, US) were routinely performed and
thymic tongues were routinely resected. Intact (i) PTH level was routinely measured at the morning on day 1 after PTx
and was defined as min. PTH. Existence of missed gland/glands was confirmed by removal of gland/glands at
reoperation from neck or mediastinum.
Results: 1, In 101/1666 (6.1 %) patients fewer than 4 and in 327 / 1666 (19.6 %) patients more than 5,supernumeral
glands were removed at the initial PTx.
2, The relation between min PTH and the incidence of missed gland confirmed reoperation was as following. Min PTH
10 pg/mL>, 2/564 (0.33%), 10~30 pg/mL 6/838 (0.70%), 30~60pg/mL 7/134 (5.2%), 60~240 pg/mL 11/99 (11.1%),
240~500 pg/mL 5/23 (21.7%), >500 pg/mL 4/8 (50%). When cut off value was 60 pg/mL the specificity was 99.0%.to
Conclusion: Intact PTH 60 pg/mL measured on day 1 after PTx could be a useful predictor to recognize missed
gland/glands in patients with advanced SHPT.
Disclosure of Interest: None declared
377
PE031
IMMUNOHISTOCHEMICAL PANEL OF PARAFIBROMIN, GALECTIN-3, APC AND PGP9.5 FOR DIAGNOSIS OF
PARATHYROID CARCINOMA
A. Agarwal1,*, R. Pradhan1, P. Shukla2, S. Gupta3, N. Kumari2, N. Krishnani2, A. Mishra1, G. Agarwal1
1
2
3
ENDOCRINE SURGERY, pathology, endocrinology, SGPGIMS, LUCKNOW, India
Introduction: Most studies have investigated the accuracy of one or two markers. No study has studies a
combination of parafibromin, APC and PGP9.5. Our aim was to investigate the utility of a panel of markers that could
complement the histopathological diagnosis of parathyroid carcinoma.
Materials & Methods: Eleven cases of parathyroid carcinoma diagnosed according to WHO criteria were included in
the study. Representative sections were selected for immunohistochemistry (IHC) for parafibromin, APC, Galectin 3
and PGP9.5. Primary antibodies used were parafibromin (clone 2H1, dilution 1:20, Santa Crutz), APC (clone EP701Y,
dilution 1:50, AbCam), Galectin 3(clone B2C10, dilution 1:50, Santa Crutz) and PGP9.5 (Rabbit polyclonal, dilution
1:50, Dako). The staining pattern for parafibromin was classified in three categories: diffuse positive, partial loss and
complete loss. Positive staining of > 10% was taken as positive stain for parafibromin. Cytoplasmic positive staining
for APC, Galectin 3 and PGP9.5 were taken as > 10% tumor cells positive.
Results: All cases were diagnosed postoperatively and had capsular invasion in addition to other features of
malignancy. Chief cell type was the predominant cell type in 7 cases whereas oncocytic cells were predominant in 4
cases. All 11 cases had the full immunohistochemistry panel performed. All cases had atleast one
immunohistochemical result suggestive of parathyroid carcinoma (100% sensitivity).
Diagnostic accuracy of markers in parathyroid carcinoma
S.
Markers
Positive Negative Diagnostic Accuracy
No.
PF
1
3
8
72.7%
APC
2
3
8
72.7%
PGP9.5
3
9
2
81.8%
Galectin-3
4
6
5
54.5%
Conclusion: Morphological diagnosis of parathyroid carcinoma is difficult. Amongst the panel of
immunohistochemical markers, PGP9.5 has the highest accuracy. Combination of parafibromin and PGP9.5 gives
100% sensitivity
Disclosure of Interest: None declared
378
PE032
MINIMALLY-INVASIVE VIDEO-ASSISTED IDENTIFICATION OF BOTH IPSILATERAL PARATHYROIDS FOR
PRIMARY HYPERPARATHYROIDISM IS A FEASIBLE AND CLINICALLY RELEVANT STRATEGY.
C. Bendinelli1,*, H. Suradi1, A. Gray1, S. Acharya2, S. McGrath2
1
2
Surgery, Endocrinology, John Hunter Hospital, Newcastle, Australia
Introduction: Focused parathyroidectomy for primary hyperparathyroidism (PHPT) relies on preoperative localization
studies to predict single gland disease. The durability of this approach has been questioned, and some advocate a
return to bilateral neck exploration to minimize recurrent or persistent disease. The minimally-invasive video-assisted
(MIVA) technique offers a versatile approach to the neck, which we have employed to excise the preoperative
localized adenoma and then complete the ipsilateral neck exploration. We hypothesized that: a) MIVA would allow
identification of both the adenoma and the ipsilateral glands and b) this would be a clinically relevant strategy.
Materials & Methods: Prospective case series study conducted from August 2008 to November 2014 on all patients
with PHPT and preoperative diagnosis of single adenoma based on ultrasound and/or (99m) Tc-sestamibi scan (both
tests performed in all). The MIVA approach was utilized to excise the preoperative localized parathyroid adenoma and
to seek for ipsilateral parathyroid gland (which if enlarged, was excised,). Intraoperative parathyroid hormone (PTH)
was not available at our institution.
Results: Of 208 patients referred with PHPT, 132 were preoperatively diagnosed with single gland diseases and were
offered MIVA unilateral neck exploration (mean age: 63.1 (SD 11.2), females: 94 (71.1%), symptomatic: 89 (67.4%),
preoperative calcium: 2.7 (SD 0.2) mmol/L, preoperative PTH: 16.8 (11.9) pmol/L). A single pathologic gland was
identified by US in 114 (86.3%) and by Sestamibi in 119 (90.1%) patients. Imaging was concordant in 107 (81.1%).
Conversion to open procedure was required in 14 patients (excluded from subsequent analysis). The second
ipsilateral parathyroid was identified in 62 (52.5%). This appeared enlarged and was excised in 11 (9.3%) and was
confirmed pathologic in 4 (3.4%). Two patients experienced transitory recurrent laryngeal nerve palsy. Two others
(who did not have the second parathyroid identified) required reoperation (1 for hyperplasia and 1 for contralateral
adenoma). Mean follow up: 28.1 (SD 15.6) months.
Conclusion: The MIVA approach allowed identification of a second ipsilateral parathyroid in over 50% of patients.
This strategy was clinically relevant in 4 (3.4%) patients.
Disclosure of Interest: None declared
379
PE033
USE OF A CALCIUM-PTH NOMOGRAM FOR DIAGNOSIS AND CURE DETERMINATION OF PRIMARY
HYPERPARATHYROIDISM
O. A. Lavryk1,*, A. E. Siperstein1
1
Endocrine Surgery, Cleveland Clinic, Cleveland, United States
Introduction: Nomograms have been widely applied for the diagnosis of cryptic conditions, such as insulinoma, when
clinical presentation appears atypical. The establishment of primary hyperparathyroidism (PHPT) diagnosis remains
challenging in patients with borderline laboratory values and those with unusual PHPT presentation
Materials & Methods: The study analysis included 474 patients that were studied retrospectively. Four hundred
patients underwent neck surgery for primary hyperparathyroidism. A logistic regression analysis of 74 healthy patients
identified the upper and lower limits of calcium and PTH relationship. The reference range of calcium and PTH was
defined using 95% CI. A reference box was plotted on the graph and used as a new diagnostic tool to confirm the
diagnosis of PHPT. This plot was subsequently applied to determine the cured patients after parathyroidectomy at 6
and 12 months postoperatively.
Results: There was an inverse linear correlation between calcium and PTH among healthy patients (r = - 0.4,
p<0.03). Decrease of the PTH levels regarding the rise of calcium levels was seen. Using a mathemathical equation
of the calcium and PTH correlation we created a calcium-PTH nomogram, by calculating the upper and lower limits of
calcium-PTH correlation, representing 95% CI. This nomogram was applied to our study population to distinguish the
healthy and PHPT subjects. In contrast preoperative subjects with PHPT, There was a positive linear correlation
between calcium and PTH (r = 0.3, p<0.001). Mean preoperative calcium was 10.9+0.5 mg/dL, PTH – 121.6+59.4
pg/dL, respectively. At 6 months follow up after parathyredectomy, no correlation was seen between calcium and PTH
(r=0.03, p<0.04). The relationship between calcium and PTH among cured patients (n=388, 97%) was linearly
inversed (r = - 0.12, p<0.07), and looked similar to the control group. The plotted values of the cured patients
remained within the reference range of the control group. The sensitivity and the specificity of the nomogram were
98.5% (95% CI: 97.6-99.1%) and 97.4 % (95% CI: 91.0-99.6%) respectively.
Conclusion: In our study, there is an inverse linear correlation between calcium and PTH In normal subjects and
cured patients. This relationship was lost in PHPT patients. We propose a new diagnostic nomogram for PHPT. This
nomogram would be a useful tool for the diagnosis of atypical PHPT and may help to simplify the disease recurrence
criteria.
Disclosure of Interest: None declared
380
PE034
ABILITY OF ULTRASOUND AND SESTAMIBI TO IMAGE INDIVIDUAL GLANDS IN PRIMARY
HYPERPARATHYROIDISM: IMPACT OF GLAND VOLUME AND MULTIGLANDULAR DISEASE.
R. Chagpar1,*, A. Siperstein1
1
Endocrine Surgery, Cleveland Clinic, Cleveland, OH, United States
Introduction: In patients with primary hyperparathyroidism, the sensitivity of localizing studies is thought to decrease
in patients with multiglandular disease. It is unknown whether this is solely related to gland volume or whether this
may also be a function of the biology of the disease. We investigated whether the effect of gland volume on
localization by Ultrasound (US) or Sestamibi (MIBI) was dependent of the number of glands involved.
Materials & Methods: A prospectively maintained database of patients with primary hyperparathyroidism who
underwent a 4-gland exploration at our institution was queried to obtain information on preoperative US and MIBI
localization, number of glands excised and individual gland volumes. The effect of gland volume on localization on a
per gland basis was assessed using multivariate logistic regression models with an interaction term for number of
diseased glands and gland volume.
Results: A per gland analysis was performed using a total of 2301 glands from 1025 patients with single gland
disease, 544 patients with double adenomas, and 732 patients with hyperplasia. For US, the average volume of a
localized gland was 1258cc vs 483cc for a non-localized gland (p<0.001). For MIBI, these values were 1261cc and
663cc, respectively (p<0.001). In multivariate models for localization with US or MIBI, respectively, both gland volume
and number of glands involved were independent predictors of localization. To further investigate whether the number
of abnormal glands influenced the effect of gland volume on localization, an interaction term was added to the model.
For both US and MIBI, this interaction term was found to be significant (p<0.001). A stratified analysis was then
performed. For a gland size of 1000cc, the predicted probabilities for localization on US was 85.3% vs 80.5% vs
58.3% for single adenomas, double adenomas and hyperplasia, respectively. Similarly, for MIBI, these predicted
probabilities were 58.3% vs 27.3% vs 27.4%, respectively.
Conclusion: Gland localization by US and MIBI is effected by both gland volume and number of glands involved.
Controlling for gland size, single adenomas are best imaged by both US and MIBI; double adenomas are less well
imaged by MIBI, and hyperplastic glands are least well imaged by both modalities. This result may be explained by
both metabolic and structural factors.
Disclosure of Interest: None declared
381
PE035
STRICTER INTRAOPERATIVE PARATHORMONE MONITORING CRITERION DOES NOT IMPROVE OUTCOMES
AFTER PARATHYROIDECTOMY FOR SPORADIC PRIMARY HYPERPARATHYROIDISM
Z. Khan1, M. Rodriguez1, A. Marcadis1, J. Farra1, J. I. Lew1,*
1
The DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine,
Miami, United States
Introduction: Intraoperative parathormone monitoring (IPM) guided by parathyroidectomy (PTX) with the “classic”
criterion of >50% intraoperative parathormone (ioPTH) drop at 10 minutes after abnormal gland excision has
successfully treated patients with sporadic primary hyperparathyroidism (SPHPT) for almost 3 decades. Some argue,
however, a “stricter” criterion requiring >50% ioPTH drop to within normal range (WNR) improves surgical outcomes.
This study examines whether this “stricter” criterion corresponds to better operative outcomes compared to the
“classic” criterion.
Materials & Methods: 763 patients with SPHPT confirmed by elevated serum calcium and parathormone (PTH)
levels underwent IPM guided PTX at a single institution. Only patients after initial operation with at least 6 months
follow-up were included. When a >50% ioPTH drop from highest either pre-incision or pre-excision level was achieved
after 10 minutes, the operation was completed. There were 2 study groups: patients with >50% ioPTH drop only
(“classic” criterion) and patients with a >50% ioPTH drop to WNR defined as <65 pg/mL (“stricter” criterion). Operative
success was defined as eucalcemia ≥6 months whereas recurrent hyperparathyroidism was defined as calcium and
PTH levels above normal range >6 months after successful PTX. Multiglandular disease (MGD) was defined as
elevated ioPTH levels despite removal of one hypersecreting gland, or when removal of a single gland resulted in
operative failure. Patients with multiple endocrine neoplasia, 2° or 3° hyperparathyroidism, and parathyroid cancer
were excluded.
Results: Of 763 patients with a mean follow-up of 35 months, overall rate of operative success was 99.2% with a
recurrence rate of 0.8%. In 182 patients with >50% ioPTH drop only, operative success was 98.3% (176/179) with a
recurrence rate of 1.7% (3/176). In 584 patients with >50% ioPTH drop to WNR, operative success was 99.5%
(581/584) with a recurrence rate of 0.5% (3/581). Rates of MGD and bilateral neck exploration (BNE) were 6.1%
(11/179) and 8.4% (15/179) in the classic group compared to 9.1% (53/584) and 10.8% (63/584) in the stricter group.
Rates of operative success, recurrence, failure, MGD and BNE were not statistically significant between groups.
Conclusion: A stricter ioPTH criterion does not improve operative outcomes after PTX in patients with SPHPT. The
classic >50% ioPTH drop criterion remains clinically relevant for optimal surgical outcomes.
Disclosure of Interest: None declared
382
PE036
CHANGING PATTERN OF DIAGNOSING PRIMARY HYPERPARATHYROIDISM IN YOUNG PATIENTS
I. Lou1,*, D. F. Schneider1, R. Sippel1, H. Chen1, D. Elfenbein 1
1
Surgery, University of Wisconsin- Madison, Madison, United States
Introduction: The incidence of primary hyperparathyroidism (PHPT) is increasing in the adult population, due in part
from incidental diagnosis on screening labs. PHPT is rarely reported in children and young adults, where blood work is
obtained more judiciously. The aim of this study was to examine the trend of PHPT diagnosis in young patients, and to
assess characteristics and outcomes of PHPT in young people.
Materials & Methods: A retrospective analysis was performed on our surgical parathyroid database to include all
patients ≤ 25 years who underwent parathyroidectomy for PHPT from 2001-2014 with a minimum 6-months of followup. The patients were divided into two equal time periods for analysis: those who underwent surgery from 2001-2007
(A) and those who had surgery from 2008-2014 (B). To identify patients who were diagnosed incidentally, we looked
for patients who lacked strong symptoms of PHPT (kidney stones, bone pain, and crisis) and without a positive family
2
history. Categorical variables were analyzed using Chi tests, and independent t-tests were used to compare
continuous variables.
Results: 40 patients who underwent parathyroidectomy were identified with PHPT, 16 individuals in group A and 24 in
group B. Those in group A compared to group B had similar mean age, (18 versus 19, p=0.591), preoperative calcium
(11.8 versus 11.5, p=0.503) and parathyroid hormone (117.8 vs 186.5, p=0.182). Only 1 patient (2.5%) had a
permanent complication after surgery, and all 40 patients achieved cure with their operation, defined as
normocalcemia at 6-month follow-up. Overall, 12 (30%) patients had a positive family history, including MEN1 and
familial hyperparathyroidism. Patients with a positive family history were more likely to undergo a bilateral operation
(p=0.011), with a higher complication rate (p=0.017), and recurrence rate (p=0.022). An incidental diagnosis was
much more common in the later time period (46% vs 25%, p=0.001). All of these patients were diagnosed during
workup of non-specific symptoms or on labs drawn for another disease process.
Conclusion: Primary hyperparathyroidism in young patients is increasingly being found during the workup of nonspecific symptoms or another diagnosis. This trend may be attributed to the increasing use of labs in younger
patients.
Disclosure of Interest: None declared
383
PE037
PARATHYROID HORMONE ASSAY OF TISSUE ASPIRATE IS A RELIABLE FUNCTIONAL LOCALIZATION
STUDY IN RECURRENT OR PERSISTENT RENAL HYPERPARATHYROIDISM PATIENTS WITH SUSPICIOUS
NECK LESIONS.
C.-L. Hung1,*, S.-M. Huang1, C.-J. Hung1
1
Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine,
National Cheng Kung University, Tainan, Taiwan, R.O.C., Tainan, Taiwan
Introduction: Persistent and recurrent renal hyperparathyroidism still brings a big challenge to surgeon in term of
evaluation and management. Accurate pre-reoperative evaluations are considered as the cornerstone for successful
reoperation. However, there are sometimes conflict results between different localization studies. In addition, some
ectopic unusual neck lesions also cause the confusion of the nature. Parathyroid hormone (PTH) assay of tissue
aspirate was ever introduced to confirm the suspicious parathyroid lesion in patients with primary hyperparathyroidism
but not renal hyperparathyroidism. The purpose of this study is to inspect the role of parathyroid hormone assay of
tissue aspirate in the functional localization of persistent and recurrent renal hyperparathyroidism.
Materials & Methods: Between Sep. 1995 and Dec. 2014, 115 patients with recurrent or persistent renal
hyperparathyroidism received localization studies at our hospital. Localization studies included routine sonographies
(neck and graft site) and scintigraphies (neck, mediastinum, and graft site). Furthermore, echo-guiding tissue PTH
assays were performed for suspicious neck lesions if needed. Histories of prior operations, localization studies, tissue
PTH assay, reoperative findings and procedures, pathological findings, and post-reoperative courses were reviewed
and analyzed.
Results: Thirty-three tissue PTH assays were performed during the period. Neck exploration was performed and neck
parathyroid was removed in twenty-three patients with high tissue PTH level and one patient with low tissue PTH level
but positive localization studies. Among them, eleven cases were ectopic (4 undescended, 6 intrathyroid, 1 between
middle part of left CCA and IJV), 3 cases were parathyromatosis, and 1 case was intrathymic. Five cases (15.2%) with
suspicious neck lesion from parathyroid scan or neck sonography yielded low tissue PTH level and negative neck
exploration was avoided. Four cases (12.1%) with conflict result between parathyroid scan and neck sonography
showed high tissue PTH level and received neck parathyroidectomy. No complication was noted during all procedures
of tissue aspiration.
Conclusion: PTH assay of tissue aspirate is a reliable functional localization study for confirmation of parathyroid
nature. It should be considered and incorporated as part of the localization studies in recurrent or persistent renal
hyperparathyroidism patients with suspicious neck lesions.
Disclosure of Interest: None declared
384
PE038
NEGATIVE SESTAMIBI SCINTIGRAPHY SHOULD NOT BE A CONTRA-INDICATION TO
PARATHYROIDECTOMY IN PRIMARY HYPERPARATHYROIDISM
S. Graham1,*, A. Aniss1, S. Fraser1, S. Sidhu1, L. Delbridge1, M. Sywak1
1
Endocrine Surgical Unit, University of Sydney, Sydney, Australia
Introduction: Image-guided parathyroidectomy utilizing Sestamibi Scintigraphy (MIBI) is widely accepted as an
effective surgical strategy for the management of primary hyperparathyroidism (HPT). Pre-operative imaging in HPT is
now routine but physicians may be less likely to refer patients for surgery if pre-operative imaging is negative or nonlocalizing. This study aims to compare presenting symptoms and surgical outcomes between patients with negative
versus positive MIBI.
Materials & Methods: Data entered prospectively into a dedicated Parathyroid Surgery database were analyzed in a
retrospective cohort study. All patients undergoing surgery had the dominant symptom and indication for surgery
recorded prospectively. The primary outcome measure was a comparison between this and MIBI result. Secondary
outcome measures were preoperative biochemistry, surgical approach, complications, gland weight, biochemical cure
at 6 months.
Between January 1 2005 to February 28 2014, 1996 patients underwent parathyroidectomy who had a preoperative
MIBI recorded. Patients for whom a MIBI result was not available were excluded. 1905 cases remained for analysis.
Data were compared between patients with a negative preoperative MIBI (Group A) and those with a positive
preoperative MIBI (Group B).
Results: Of the 1905 patients, 18.6% had negative MIBI imaging (Study Group A). The remaining 81.4% had a
positive MIBI (Study Group B). The two groups were equivalent in terms of mean age (Group A: 63.8 years, Group B:
62.3 years, p=0.12) and gender. Group B patients had a higher pre-operative corrected serum calcium (2.80 versus
2.73mmol/L, p=0.006). There was no difference in preoperative PTH levels (36.9 versus 38.1pmol/L, p=0.87).
At presentation, Group A had a higher incidence of symptomatic renal calculi 10.7% versus 6.6%, p=0.007). Rates for
osteoporosis, normocalcaemic hyperparathyroidism, asymptomatic disease, abdominal and neuropsychiatric
symptoms were equivalent between groups.
Group B patients had a higher rate of single adenoma disease (86% versus 69% p<0.001) and mean weight of
removed glands was higher in this group (839 versus 538mg, p<0.001). The overall cure rate for the entire cohort was
97.6%.
Conclusion: In patients undergoing surgery for HPT, negative MIBI is associated with equivalent rates of
osteoporosis, neurocognitive and abdominal symptoms but higher rate of symptomatic renal calculi than patients with
positive MIBI. Negative preoperative imaging is not a contraindication to surgery in patients with HPT.
Disclosure of Interest: None declared
385
PE039
THYROID RFA CAN BE ONE OF THE ALTERNATIVES TO THE TREATMENT FOR PMTC ?
N. Fukunari1,*, M. Nakano1, T. Nishikawa1, M. Aida1
1
Surgery, Showa University Northern Yokohama Hospital, Yokohama, Japan
Introduction: The management of papillary thyroid microcarcinomas (PTMC) has been controversial, and
furthermore, only observation without surgery has been advocated for the patient with low-risk PTMC. Radiofrequency ablation（RFA）has been applied to thyroid nodule, which shows its safe and useful results for benign
thyroid nodules. In our institution, not only benign nodules, but also thyroid malignancies have been attempted to be
therapeutic objectives by RFA.
Materials & Methods: 170 cases were treated by RFA from 2007 in our institution, which consisted of 94 hyperplastic
nodules, 32 AFTNs, 11 local recurrences of papillary carcinomas, 11 metastatic LNs and 22 primary PMTCs. All of 22
patients with PTMC were initial cases without the history of previous thyroid surgery or irradiation, and refused the
surgery because of cosmetic and private reasons.
RFA has carried out under general or local anesthesia and under careful US imaging guidance. As an intra-operative
assessment for the estimation of extent of ablated area, gray-scale US, color-Doppler imaging, Elastography and
contrast enhanced US were applied to judge the satisfactory ablation.
Results: All cases showed no side effect or thermal damage, and discharged after one night observation. The efficacy
of RFA has been verified with both imaging diagnosis and repeated FNA. Post therapeutic FNA revealed no cancer
cells remained in 21 of 22 PTMC cases.
Image:
Conclusion: The efficacy of RFA has shown satisfactory results and a possibility to be one of alternative treatments
for PMTC. Long-time follow-up and careful attention for thermal damage to surrounding tissues are required.
Disclosure of Interest: None declared
386
PE040
MULTIFOCAL VS SOLITARY PAPILLARY THYROID CARCINOMA
A. KIRIAKOPOULOS1, D. LINOS2,*
1
2
Dpt of SURGERY, HYGEIA HOSPITAL, Dpt of SURGERY, UNIVERSITY OF ATHENS MEDICAL SCHOOL,
ATHENS, Greece
Introduction: PTC which accounts for over 85% of all thyroid cancers in iodine rich areas, appears either as a single
tumor or as two or more, anatomically separate, neoplastic foci within the thyroid gland. The latter entity defined as
Multifocal PTC), is associated with few controversial issues regarding its clinical characteristics. We present the
comparative results between these types focusing on the multifocal variant.
Materials & Methods: Demographics, tumor characteristics (size, laterality, number of foci and histologic subtype)
and TNM staging (AJCC) were compared to solitary PTC patients. Presence of lymphocytic or Hashimoto’s thyroditis
and Primary Hyperparathyroidism were also analyzed. Relations between categorical variables were examined
2
through the Chi-Square Test (Pearson χ ). Independent samples t-test and the non-parametric Mann-Whitney U test
was undertaken to compare mean values of two groups of patients. The assumption for normally distributed variables
was examined though Kolmogorov-Smirnov test. Statistical level of 5% was used to testify significant relations.
Results: From January 2008 to December 2012, among 647 patients with PTC, 241(37.2%) had MFPTC: 177
females (73.4%) and 64 males (26.6%), mean age 48.5 yrs (range: 12-87). Bilateral tumors were found in 147 patients
(60.1%). Mean number of tumor foci was 3.3 (range: 2-26), which were significantly higher among males than females
(p=0.014). MFPTC patients presented with more advanced T stage (28.2% vs 18.7%, p=0.01) and more LN
metastases (28.6% vs 13.8%, p<0.001) compared to the solitary tumor group respectively. Advanced local disease
(T3/4 status) was related with the size, but not with the number of foci. Central (N1a) or lateral (N1b) LN involvement
correlates strongly with male gender (p value=0.024) and younger age (p<0.001). Besides the classic PTC, the
follicular variant was the next most frequent histologic subtype associated with extremely rare LN metastases. Primary
hyperparathyroidism was found in 4.6% of pts with MFPTC which was statistically higher than those with solitary
tumors (p=0.018).
Conclusion: MFPTC comprises a more aggressive form of papillary thyroid cancer. Male gender and younger age
correlate with LN metastases, which were extremely rare in the follicular variant of PTC. A statistically significant
association of primary hyperparathyroidism with multifocal PTC was revealed.
Disclosure of Interest: None declared
387
PE041
COMPLICATIONS AND TREATMENT-REQUIRING EVENTS IN THE MANAGEMENTS OF LOW-RISK PAPILLARY
MICROCARCINOMA OF THE THYROID
H. Oda1,*, A. Miyauchi1, Y. Ito1, M. Fukushima1, T. Higashiyama1, K. Kobayashi1, M. Kihara1, A. Miya1
1
Surgery, Kuma hospital, Kobe, Japan
Introduction: Papillary carcinoma of the thyroid 1.0 cm or smaller in size is defined as papillary microcarcinoma
(PMC). Some of PMCs show aggressive features such as nodal or distant metastases or extrathyroidal extension,
which we call high-risk PMCs. We recommend surgical treatments for high-risk PMCs and also for PMCs without
these aggressive features that attached to the trachea or located on the course of the recurrent laryngeal nerve
(worrisome features). However, the majority of PMCs do not show these aggressive or worrisome features, which we
call low-risk PMC. In 1993, we proposed and initiated an observation trial for patients with low-risk PMCs diagnosed
with fine needle aspiration biopsy. We offered two options, immediate surgery or active surveillance. Patients chose
one of them. In this study, we compared the incidences of complications and treatment-requiring events in patients
who underwent these managements.
Materials & Methods: From February 2005 to August 2013, 2201 patients were diagnosed with low-risk PMC in our
hospital, excluding patients associated with Graves’ disease or primary hyperparathyroidism and patients with a short
follow-up period less than 1 year. Of them 1061 patients (Group A) chose the surgery and 1140 patients (Group B)
chose the active surveillance. The surgical treatment was hemithyroidectomy with paratracheal dissection in 631
patients and total thyroidectomy with central compartment dissection in 430 patients.
Results: The incidences of complications and treatment-requiring events in Group A and Group B were: transient
vocal cord paralysis, 5.6% and 0.0%, respectively (p < 0.0001), persistent vocal cord paralysis, 0.25% and 0.0%,
respectively (N.S.), transient hypoparathyroidism, 18.1% and 0.0%, respectively (p < 0.0001), persistent
hypoparathyroidism, 1.5% and 0.08%, respectively (p < 0.0005), and administration of L-thyroxine, 66.4% and 15.6%,
respectively (p < 0.0001). One of the patients in Group B had idiopathic hypoparathyroidism. L-thyroxine was
administered as supplemental or TSH suppressive treatment. All of the patients with total thyroidectomy and 43.5% of
the patients with hemithyroidectomy were administered with L-thyroxine. None of the patients died of the disease.
Conclusion: The active surveillance was associated with definitely less complications and treatment-requiring events
than the immediate surgery although the surgeries were performed in a high volume center.
Disclosure of Interest: None declared
388
PE042
NEXT DAY PTH AS A PREDICTOR OF POST-THYROIDECTOMY HYPOCALCEMIA
A. J. Cherian1,*, P. Ramakant1, T. V. Paul2, D. T. Abraham1, M. J. Paul1
1
2
Endocrine Surgery, Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India, Vellore, India
Introduction: Post-operative parathormone (PTH) lower than a value between 8-15pg/dl measured intra-operatively
or the same day has been shown to accurately predict the development of post-thyroidectomy hypocalcemia in
various studies. This aids in determining the safety of early discharge of patients and the appropriate calcium/vitamin
D supplementation. At our institution, we do not use intra-operative PTH (IOPTH) testing and the default discharge on
second/third post-operative day was restricting efficient patient turnover. In low/middle income countries like ours, the
majority of patients do not want to be discharged on the same day of operation because of perceptions of safety and
pain control. One additional day in hospital does not add a significant cost to the procedure. Additionally, postoperative haemorrhage usually occurs within the first 24 hours of surgery and warrants in-patient observation in the
absence of efficient return to hospital mechanisms. We found that the optimal time for safe discharge of our patients is
the day after surgery if the risk of hypocalcaemia can be predicted. This study aimed at evaluating the accuracy of
next day morning PTH as a marker for predicting the development of hypocalcemia and to obtain our institution’s cutoff value of PTH that predicts hypocalcemia.
Materials & Methods: A prospective observational study of fifty patients undergoing thyroidectomy was conducted.
Postoperatively blood samples were collected for PTH on the morning following surgery. Serum calcium was
monitored once daily in the postoperative period till discharge. Statistical analysis was performed using STATA I/C
10.1.
Results: 15/50 (30%) patients had biochemical post-operative hypocalcemia (S. Ca <8mg/dl). In twenty patients
(40%) postoperative PTH was low (<8pg/ml). There was a significant association between PTH <8pg/dl and the
presence of post-operative hypocalcemia (p= 0.029). 10/13 (77%) of the symptomatic hypocalcemia patients was
associated with PTH levels < 8pg/mL. The area under the Receiver Operating Characteristic (ROC) curve was 0.7 and
a PTH of 4.1- 6 showed the highest sensitivity and specificity (80% and 60% respectively).
Conclusion: PTH is an accurate test to predict post-thyroidectomy hypocalcemia. PTH < 6pg/ml can be used as our
institution’s cut-off value. Department protocols for calcium and vitamin D supplementation following total
thyroidectomy may be formulated based on the appropriately timed local postoperative PTH value to assist safe and
early discharge of patients.
Disclosure of Interest: None declared
389
PE043
CAN SHORT STAY THYROIDECTOMY BE SAFELY PERFORMED BY SURGICAL TRAINEES?
N. Bansal1,*, S. K. Mishra1, M. Sabaretnam1, G. Chand1, A. Mishra1, G. Agarwal1, A. Agarwal1, A. K. Verma1
1
Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sceinces, Lucknow, India
Introduction: Comprehensive hands-on experience in the operating room is not the sole yet vital component for a
surgical trainee. With more advancement in surgical techniques, more number of thyroid surgeries are being
performed as an outpatient or short stay procedures; further limiting the hands-on experience for a trainee. Inspite of
guidelines laid down by leadings thyroid associations, controversy still exists regarding the surgeon`s experience
before he/she can perform outpatient thyroid surgery with acceptable outcome and literature is silent on safety of short
stay thyroid surgery performed by trainees. So, we aim to study if trainee can perform short stay thyroidectomy safely?
Materials & Methods: The study was conducted prospectively from January 2013 to July 2014, at the department of
Endocrine surgery, SGPGIMS, Lucknow, India. Study group included trainee performed and matched control group
included consultant performed short stay hemithyroidectomy. Outcome in both the groups were compared in terms of
Operating time, Post-Anesthetic Discharge Score (PADS) and Complication rates. Short stay was defined as surgery
followed by overnight observation with discharge the following morning; typically stay duration 23 hours. Euthyroid
ASA grade I & II patients of all age groups, with thyroid nodule volume less than 80ml requiring hemithyroidectomy
and also satisfying social logistic parameters were included in this study. Results were analyzed using SPSS version
17.0. Independent T and Chi-square tests were used for statistical analysis.
Results: Total 58 short stay hemithyroidectomy (Study group n=39, Control group n=19) were performed during the
nd
rd
study period. In study group all surgeries were performed by Endocrine surgery trainees in their 2 and 3 year of
curriculum. Both groups were comparable in terms of Mean age (31.08±10.35 years vs. 32.84±9.89 years, p= 0.54)
thyroid volume (25.66±18.48ml vs. 20.05±15.79ml p= 0.26), ASA grade, and thyroid pathology. Procedure time was
more in trainee performed surgeries (124.89±24.64mins vs.108.77±30.79mins, p =0.05), however there was no
difference in terms of mean post anesthetic discharge score (9.79±0.41vs. 9.79±0.42, p =0.96) and complication rates
(p =0.69).
Conclusion: In our study, there was no significant difference in final outcome among two groups, affirming that short
stay thyroid surgery can be performed safely by an Endocrine surgery trainee.
Disclosure of Interest: None declared
390
PE044
FORGOTTEN GOITER (FO). LESSION LEARNED FROM A MULTICENTRIC EXPERIENCE.
T. Courvoisier1, G. Donatini1,*, L. De Calan2, E. Miralliè3, A. Hamy4, M. Castagnet1, J. L. Kraimps1
1
2
General and Endocrine Surgery, CHU Poitiers, Poitiers, General and Endocrine Surgery, CHRU Tours, Tours,
3
4
General and Endocrine Surgery, CHU Nantes, Nantes, General and Endocrine Surgery, CHU Angers, Angers,
France
Introduction: FO is a rare disease defined as a mediastinal thyroid mass discovered after “supposed” total
thyroidectomy. We report a multicentric experience of 4 University Centers.
Materials & Methods: Data of all patients diagnosed with FO between the years 2001 and 2014 were collected and
reviewed. Sex, age, patient’s characteristics, initial surgery, mean time between operations, radiological imaging and
surgical approaches were analyzed. Patients who underwent a previous intentional “less than total” thyroidectomy
were excluded.
Twelve patients (female to male ratio = 9:3) were found to have FO. Mean age was 56.8 years (range 34-71), mean
time between first operation and diagnosis of FO was 11.7 years (range 1 month – 25 years). Eight patients were
symptomatic: 6 had hyperthyroidism (3 with associated dyspnea), 1 progressively increasing dyspnea and 1 mild
dysphagia. Preoperative imaging modalities were as follows: cervico-mediastinal CT scan ± ultrasound in 7/12, CT
scan + scintigraphy in 3/12, ultrasound exam + scintigraphy in 2/12.
Results: Ten out of 12 patients underwent re-operation, while two did not (l waiting for treatment, 1 not operated for
contraindications due to overall morbidity). Cervicotomy alone was performed in 5 patients, direct thoracic approach in
4 other patients, cervicotomy + sternotomy in 1 patient. On definite pathological examination 2/10 patients presented
an invasive thyroid cancer. Definitive inferior laryngeal nerve palsy occurred in 4/10 patients. Two of these patients
had the invasive carcinoma. No definitive hypoparathyroidism reported. Figures 1 reports the specimen of a thyroid in
which a FO may be generate at time of initial surgery.
Image:
Conclusion: FO is often diagnosed in a picture of hyperthyroidism in patients who had a previous “supposed” total
thyroidectomy. Although scintigraphy may help confirmation of FO, CT scan is the gold standard to identify it and
helps the surgeon to decide the better surgical approach. Thoracic approach is often necessary and its use should be
considered in case of tran-scervical attempt for FO. Morbidity is quite high (4 nerve palsies, 2 in patients with thyroid
cancer). Accurate preoperative evaluation is always mandatory at the time of initial surgery and intraoperative findings
should always be compared with preoperative imaging, especially in case of cervico-mediastinal goiter, in order to
avoid further operations.
References: FO is often diagnosed in a picture of hyperthyroidism in patients who had a previous “supposed” total
thyroidectomy. Although scintigraphy may help confirmation of FO, CT scan is the gold standard to identify it and
helps the surgeon to decide the better surgical approach. Thoracic approach is often necessary and its use should be
considered in case of tran-scervical attempt for FO. Morbidity is quite high (4 nerve palsies, 2 in patients with thyroid
cancer) because both of anatomy and re-do surgery. Accurate preoperative evaluation is always mandatory at the
time of initial surgery and intraoperative findings should always be compared with preoperative imaging, especially in
case of cervico-mediastinal goiter, in order to avoid further operations.
Disclosure of Interest: None declared
391
PE045
COMPLETION THYROIDECTOMY AND RADIOACTIVE IODINE ABLATION: DOES ONE SIZE FIT ALL?
J. Yoo1, K. L. McCoy1, M. T. Stang1, R. L. Ferris2, C. Coyne3, Y. Nikiforov4, S. E. Carty1,*, L. Yip3
1
2
3
4
Endocrine Surgery, Otolaryngology, Endocrinology, Pathology, University of Pittsburgh, Pittsburgh, PA, United
States
Introduction: After initial thyroid lobectomy (TL) for histologic differentiated thyroid cancer (DTC), completion
thyroidectomy (CoT) and remnant ablation with radioactive iodine (RAI) are classically recommended to resect all
remaining foci of disease and to facilitate follow-up. Factors such as selective use of RAI and the sensitivity of tests
utilized for surveillance have led to recent treatment variability. In patients with DTC at initial TL, our study aim was to
determine if CoT followed by RAI remnant ablation is clinically necessary.
Materials & Methods: Retrospective record review was performed with QA/QI-IRB approval for all patients between
1/07-12/10 with histologic DTC who had initial TL. Thyroglobulin (Tg) levels were coded undetectable when the result
was below the threshold of the lower reference limit and Tg antibodies were negative.
Results: In total, 118/807 (15%) DTC patients had initial TL for histologic DTC, and 65% (77/118) had AJCC stage I
disease. CoT was performed in 106 (95%) patients and was more likely to be used for larger tumors (mean 2.7 v. 1.6
cm, p=0.02). After CoT, 29 (27%) patients had contralateral DTC. Contralateral disease after CoT was more likely in
patients with multifocal DTC than with single focus DTC after TL (50% v. 15%, p<.001). Baseline unstimulated-Tg
(uTg) levels were obtained after CoT in 65 patients, and were undetectable in 43% (28/65). After CoT+RAI, uTg levels
were available for 83 patients and were undetectable in 73%. As expected, an undetectable uTg level was more likely
following CoT+RAI than CoT alone (73% v. 43%, p<.001). With an overall mean followup of 46 months (0.9-89), 1
patient (0.8%) with AJCC stage II disease recurred in the central compartment 3 years following CoT+RAI.
Conclusion: Histologic DTC in the contralateral lobe was observed in 27% of patients after completion thyroidectomy
and was more common if multifocal disease was diagnosed after TL. Undetectable uTg levels were more likely
following RAI, however undetectable uTg levels were also achieved in 43% of patients after CoT alone. Therefore, in
patients who have undetectable uTg and who also have low risk DTC, completion thyroidectomy without RAI may be
sufficient to facilitate long-term DTC surveillance.
Disclosure of Interest: None declared
392
PE046
THE NEUTROPHIL TO LYMPHOCYTE RATIO CAN DISCRIMINATE ANAPLASTIC THYROID CANCER AGAINST
POORLY OR WELL DIFFERENTIATED CANCER
J. S. Cho1,*, Y. J. Ryu1, M. H. Park1, J. H. Yoon1
1
Department of Surgery, Chonnam National University College of Medicine, Gwangju, Korea, Republic Of
Introduction: We evaluated the capability of the Neutrophil to lymphocyte ratio (NLR) as a diagnostic tool to
discriminate between poorly differentiated thyroid cancer (PDTC) and anaplastic thyroid cancer (ATC) from welldifferentiated thyroid cancer (WDTC).
Materials & Methods: The NLR of 3,870 patients with benign and malignant thyroid tumors were analyzed. There
were 436 benign, 3,364 papillary, 15 medullary, 34 follicular or hurthle type, 14 PDTC, and 7 ATC type neoplasms.
Patients were divided into two groups: a high NLR group and a low NLR group.
Results: The NLR of all 3,870 patients was a normal distribution, and the median value was 1.57. Advanced stage
cancer, such as T3 or T4 was high (30.4 % vs. 26.5 %, p=0.027), and cancer-specific deaths were also high (1.2 %
vs. 0.4 %, p=0.018) in the high NLR group. The proportion of PDTC (0.6 % vs. 0.1 %) and ATC (0.3% vs. 0.1 %) was
higher in the high NLR group. The NLR can discriminate between PTC, PDTC, and ATC (p=0.035, 0.002, and 0.025,
respectively), and the cut-off value was 3.8 between PDTC versus ATC. None of the NLR of PDTC exceeded the cutoff value of 3.8.
Image:
Conclusion: We demonstrated that the NLR is significantly different and high in PDTC and ATC as compared to
WDTC, and represents a poor prognosis for those cancers. Therefore, NLR can play a relevant role as a
discriminating tool and may be considered as a new diagnostic criterion in discriminating these aggressive forms of
thyroid cancer.
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thyroid gland: a review of the clinicopathologic features of a series of 28 cases of a heterogeneous, clinically
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2)
Tallini G. Poorly differentiated thyroid carcinoma. Are we there yet? Endocr Pathol 2011;22:190-4.
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Volante M, Landolfi S, Chiusa L, Palestini N, Motta M, Codegone A, et al. Poorly differentiated carcinomas of the
thyroid with trabecular, insular, and solid patterns: a clinicopathologic study of 183 patients. Cancer 2004;100:950-7.
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Carcangiu ML, Zampi G, Rosai J. Poorly differentiated ("insular") thyroid carcinoma. A reinterpretation of
Langhans' "wuchernde Struma". Am J Surg Pathol 1984;8:655-68.
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resistance of cultured cells to chemotherapy. Oncogene 1999;18:477-85.
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Hosal SA, Apel RL, Freeman JL, Azadian A, Rosen IB, LiVolsi VA, et al. Immunohistochemical Localization of
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Balkwill F, Mantovani A. Inflammation and cancer: back to Virchow? Lancet 2001;357:539-45.
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Mantovani A, Marchesi F, Porta C, Sica A, Allavena P. Inflammation and cancer: breast cancer as a prototype.
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Queen MM, Ryan RE, Holzer RG, Keller-Peck CR, Jorcyk CL. Breast cancer cells stimulate neutrophils to
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10) Forrest LM, McMillan DC, McArdle CS, Angerson WJ, Dunlop DJ. Evaluation of cumulative prognostic scores
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11) Pierce BL, Ballard-Barbash R, Bernstein L, Baumgartner RN, Neuhouser ML, Wener MH, et al. Elevated
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2007;204:764-73; discussion 73-5.
14) Bradly DP, Reddy V, Prinz RA, Gattuso P. Incidental papillary carcinoma in patients treated surgically for benign
thyroid diseases. Surgery 2009;146:1099-104.
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tumor size in patients with differentiated thyroid cancer. J Surg Oncol 2013;107:493-7.
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carcinoma: the Turin proposal for the use of uniform diagnostic criteria and an algorithmic diagnostic approach. Am J
Surg Pathol 2007;31:1256-64.
18) Walsh SR, Cook EJ, Goulder F, Justin TA, Keeling NJ. Neutrophil-lymphocyte ratio as a prognostic factor in
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Disclosure of Interest: None declared
394
PE047
A DIFFUSE SCLEROSING VARIANT OF PAPILLARY THYROID CARCINOMA:CLINICAL AND PATHOLOGIC
FEATURES AND OUTCOMES OF 166 CASES
S.-M. Kim1,*, H. K. Kim1, H. Chang1, B.-W. Kim1, Y. S. Lee1, H.-S. Chang1, C. S. Park1
1
Departments of Surgery, Yonsei University College of Medicine, Seoul, Korea, Republic Of
Introduction: The diffuse sclerosing variant (DSV) is considered aggressive subtypes of papillary thyroid cancer
(PTC). The aim of this study was to analyze the clinicopathologic features and outcomes of patients with DSV.
Materials & Methods: Between January 2009 and October 2012, 166 patients with DSV of PTC were analyzed.
Clinical and histological features (sex, age, tumor size,multifocality, bilaterality, extrathyroid extension, and local and
distant metastases) were evaluated in all patients, as well as any persistent disease and the patients’ disease status
at last observation.
Results: The rate of central and lateral neck metastasis was 91.0% and 65.1%. The group of lateral neck metastases
was significantly related to these clinicopathologic features in multivariate analysis; the portion of age <45 (p = 0.022),
size > 1cm (p<0.002), extrathyroidal extension (p=0.043) and central node metastasis (p=0.020). The mean
stimulated thyroglobulin of patients underwent lateral neck dissection was similar with patients who did not undergo
(14.1 mg/dL vs. 10.5mg/dL, p = 0.675).
Conclusion: The DSV of PTC was associated with more aggressive disease at the time of surgery. However, the age
≥45 patients had primary tumor size ≤ 1cm, without extrathyroidal extention of primary tumor and no central node
metastasis may not be undergone prophylactic lateral neck dissection.
Disclosure of Interest: None declared
395
PE048
RECOVERY FROM PERMANENT HYPOPARATHYROIDISM AFTER TOTAL THYROIDECTOMY
S.-M. Kim1,*, H. K. Kim1, H. Chang1, B.-W. Kim1, Y. S. Lee1, H.-S. Chang1, C. S. Park1
1
Departments of Surgery, Yonsei University College of Medicine, Seoul, Korea, Republic Of
Introduction: Permanent hypoparathyroidism after total thyroidectomy is a rare but potentially serious iatrogenic
complication. The aim of this study was to investigate recovery from post-operative, long-term hypoparathyroidism in
patients who undergo thyroidectomy without parathyroid autotransplantation
Materials & Methods: This study was a prospective case series with a post-operative follow-up of up to 3 years. We
enrolled patients with thyroid cancer who underwent total thyroidectomy with central compartment dissection with or
without lateral neck dissection, and had postoperative hypoparathyroidism for 12 months. Hypoparathyroidism was
defined as serum levels of intact parathyroid hormone (PTH) <15 pg/mL. In the post-operative follow-up period, serum
levels of PTH and calcium were measured regularly. Recovery from hypoparathyroidism was defined as return to
normal serum levels of PTH (15–65 pg/mL) and calcium (8.5–10.1 mg/dL) without calcium supplementation.
Results: In the 1,467 patients who underwent total thyroidectomy, 22 presented with permanent postoperative
hypoparathyroidism. In 5 of these 22 patients, PTH levels increased steadily and returned to normal in 27.6 ± 2.9
months, after which supplementation of calcium and vitamin D could be discontinued
Conclusion: Although recovery from permanent hypoparathyroidism is rare, patients should be monitored for serum
PTH levels so that unnecessary treatments such as calcium and vitamin D supplementation can be avoided.
Disclosure of Interest: None declared
396
PE049
VALIDATION OF GENETIC MARKERS FOR DIFFERENTIAL DIAGNOSIS OF THYROID FOLLICULAR
NEOPLASMS
H. J. Sohn1,*, K. H. Kang1, S. J. Park1, Y. K. Park1, S. J. Cha1
1
General Surgery, Chungang University Hospital, Seoul, Korea, Republic Of
Introduction: Differential diagnosis of follicular neoplasms is a challenging problem, because fine needle aspirates
(FNA) and intraoperative frozen biopsy are rarely helpful for it. These lesions include benign (nodular hyperplasia and
follicular or Hurthle cell adenoma) and malignant (follicular or Hurthle cell carcinoma and follicular variant of papillary
carcinoma) lesion and the final diagnosis is most often determined after thorough examination of the lesion after
resection of involved thyroid lobe.
Materials & Methods: We validated 14 candidate genes (TERT, TFF3, DDIT3, ARG2, ITM1, C1orf24, PLAB,
CCND2, PCSK2, c-Met, EMMPRIN, Adrenomedullin, Autotaxin, and TGF β II receptor) that have been suggested as
indicators for differential diagnosis of FN in genome-wide expression profiling studies with quantifying mRNA
expression of each gene with RT-PCR and real time RT-PCR in our fresh frozen tissue specimens including 6 normal
thyroid tissues, 6 FA and 6 FTC. We also compared levels of mRNA expression of these genes according to the
pathologic diagnosis, histologic features and immunohistochemical staining results.
Results: The fold changes of TERT, TFF3, DDIT3, ITM1 and C1or24 gene expression showed statistical significance
when compared between three types of tissues and Clorf24 was the only gene whose expression was significantly
different between FA and FTA ( P = 0.041 ). The fold change of C1or24 gene expression showed positive correlation
with tumor size, number of capsular invasion and Ki67 labeling index. The fold change of ARG2 and PLAB gene
showed positive correlation with number vascular invasion.
Image:
397
Conclusion: Clorf24 was a genetic marker that expressed highly in FTC compared to FA and ARG2 and PLAB were
potential markers indicating vascular invasion in FN among 14 molecular markers selected from other genome-wide
methods.
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Kim SW, Lee JI, Kim JW, Ki CS, Oh YL, Choi YL, Shin JH, Kim HK, Jang HW, Chung JH.
BRAFV600E mutation analysis in fine-needle aspiration cytology specimens for evaluation of thyroid nodule: a large
series in a BRAFV600E-prevalent population. J Clin Endocrinol Metab; 95(8):3693-3700.
2.
Carling T, Udelsman R. Follicular neoplasms of the thyroid: what to recommend. Thyroid 2005; 15(6):583-587.
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Hegedus L. Clinical practice. The thyroid nodule. N Engl J Med 2004; 351(17):1764-1771.
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Mallick UK. The revised American Thyroid Association management guidelines 2009 for patients with
differentiated thyroid cancer: an evidence-based risk-adapted approach. Clin Oncol (R Coll Radiol); 22(6):472-474.
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Baloch ZW, LiVolsi VA, Asa SL, Rosai J, Merino MJ, Randolph G, Vielh P, DeMay RM, Sidawy MK, Frable WJ.
Diagnostic terminology and morphologic criteria for cytologic diagnosis of thyroid lesions: a synopsis of the National
Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference. Diagn Cytopathol 2008; 36(6):425437.
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Takano T, Yamada H. Trefoil factor 3 (TFF3): a promising indicator for diagnosing thyroid follicular carcinoma.
Endocr J 2009; 56(1):9-16.
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Nikiforov YE, Steward DL, Robinson-Smith TM, Haugen BR, Klopper JP, Zhu Z, Fagin JA, Falciglia M, Weber K,
Nikiforova MN. Molecular testing for mutations in improving the fine-needle aspiration diagnosis of thyroid nodules. J
Clin Endocrinol Metab 2009; 94(6):2092-2098.
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Guerra LN, Miler EA, Moiguer S, Karner M, Orlandi AM, Fideleff H, Burdman JA. Telomerase activity in fine
needle aspiration biopsy samples: application to diagnosis of human thyroid carcinoma. Clin Chim Acta 2006; 370(12):180-184.
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Bartolazzi A, Orlandi F, Saggiorato E, Volante M, Arecco F, Rossetto R, Palestini N, Ghigo E, Papotti M,
Bussolati G, Martegani MP, Pantellini F, Carpi A, Giovagnoli MR, Monti S, Toscano V, Sciacchitano S, Pennelli GM,
Mian C, Pelizzo MR, Rugge M, Troncone G, Palombini L, Chiappetta G, Botti G, Vecchione A, Bellocco R. Galectin-3expression analysis in the surgical selection of follicular thyroid nodules with indeterminate fine-needle aspiration
cytology: a prospective multicentre study. Lancet Oncol 2008; 9(6):543-549.
10. Weber F, Shen L, Aldred MA, Morrison CD, Frilling A, Saji M, Schuppert F, Broelsch CE, Ringel MD, Eng C.
Genetic classification of benign and malignant thyroid follicular neoplasia based on a three-gene combination. J Clin
Endocrinol Metab 2005; 90(5):2512-2521.
11. Cerutti JM, Delcelo R, Amadei MJ, Nakabashi C, Maciel RM, Peterson B, Shoemaker J, Riggins GJ. A
preoperative diagnostic test that distinguishes benign from malignant thyroid carcinoma based on gene expression. J
Clin Invest 2004; 113(8):1234-1242.
12. Barden CB, Shister KW, Zhu B, Guiter G, Greenblatt DY, Zeiger MA, Fahey TJ, 3rd. Classification of follicular
thyroid tumors by molecular signature: results of gene profiling. Clin Cancer Res 2003; 9(5):1792-1800.
13. Franc B, de la Salmoniere P, Lange F, Hoang C, Louvel A, de Roquancourt A, Vilde F, Hejblum G, Chevret S,
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Pathol 2003; 34(11):1092-1100.
14. Miyake Y, Aratake Y, Sakaguchi T, Kiyoya K, Kuribayashi T, Marutsuka K, Ohno E. Examination of
CD26/DPPIV, p53, and PTEN expression in thyroid follicular adenoma. Diagn Cytopathol; 40(12):1047-1053.
15. Schmittgen TD, Livak KJ. Analyzing real-time PCR data by the comparative C(T) method. Nat Protoc 2008;
3(6):1101-1108.
16. Cooper DS, Schneyer CR. Follicular and Hurthle cell carcinoma of the thyroid. Endocrinol Metab Clin North Am
1990; 19(3):577-591.
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18. Velculescu VE, Zhang L, Vogelstein B, Kinzler KW. Serial analysis of gene expression. Science 1995;
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19. Cerutti JM, Oler G, Michaluart P, Jr., Delcelo R, Beaty RM, Shoemaker J, Riggins GJ. Molecular profiling of
matched samples identifies biomarkers of papillary thyroid carcinoma lymph node metastasis. Cancer Res 2007;
67(16):7885-7892.
20. Kirkpatrick KL, Mokbel K. The significance of human telomerase reverse transcriptase (hTERT) in cancer. Eur J
Surg Oncol 2001; 27(8):754-760.
21. Saji M, Xydas S, Westra WH, Liang CK, Clark DP, Udelsman R, Umbricht CB, Sukumar S, Zeiger MA. Human
telomerase reverse transcriptase (hTERT) gene expression in thyroid neoplasms. Clin Cancer Res 1999; 5(6):14831489.
22. Takano T, Miyauchi A, Yoshida H, Kuma K, Amino N. High-throughput differential screening of mRNAs by serial
analysis of gene expression: decreased expression of trefoil factor 3 mRNA in thyroid follicular carcinomas. Br J
Cancer 2004; 90(8):1600-1605.
23. Finley DJ, Zhu B, Barden CB, Fahey TJ, 3rd. Discrimination of benign and malignant thyroid nodules by
molecular profiling. Ann Surg 2004; 240(3):425-436; discussion 436-427.
24. Foukakis T, Gusnanto A, Au AY, Hoog A, Lui WO, Larsson C, Wallin G, Zedenius J. A PCR-based expression
signature of malignancy in follicular thyroid tumors. Endocr Relat Cancer 2007; 14(2):381-391.
25. Jin K, Mao XO, Eshoo MW, del Rio G, Rao R, Chen D, Simon RP, Greenberg DA. cDNA microarray analysis of
changes in gene expression induced by neuronal hypoxia in vitro. Neurochem Res 2002; 27(10):1105-1112.
26. Talukder AH, Wang RA, Kumar R. Expression and transactivating functions of the bZIP transcription factor
GADD153 in mammary epithelial cells. Oncogene 2002; 21(27):4289-4300.
27. Hong G, Deleersnijder W, Kozak CA, Van Marck E, Tylzanowski P, Merregaert J. Molecular cloning of a highly
conserved mouse and human integral membrane protein (Itm1) and genetic mapping to mouse chromosome 9.
Genomics 1996; 31(3):295-300.
28. Majima S, Kajino K, Fukuda T, Otsuka F, Hino O. A novel gene "Niban" upregulated in renal carcinogenesis:
cloning by the cDNA-amplified fragment length polymorphism approach. Jpn J Cancer Res 2000; 91(9):869-874.
29. Lizardi PM, Forloni M, Wajapeyee N. Genome-wide approaches for cancer gene discovery. Trends Biotechnol;
29(11):558-568.
30. Fonseca E, Sobrinho-Simoes M. Diagnostic problems in differentiated carcinomas of the thyroid. Pathol Res
Pract 1995; 191(4):318-331.
31. Shaha AR, Loree TR, Shah JP. Prognostic factors and risk group analysis in follicular carcinoma of the thyroid.
Surgery 1995; 118(6):1131-1136; discussion 1136-1138.
Disclosure of Interest: None declared
399
PE050
SAFETY AND FEASIBILITY OF ROBOTIC ENDOSCOPIC THYROIDECTOMY WITHOUT DRAINGE PROCEDURE
J. Cho1, S. H. Kang1, Y. Kim1,*
1
Department of Surgery,, Keimyung University Dongsan Medical Center, Daegu, Korea, Republic Of
Introduction: Many studies have been reported that routine use of drain is not necessary after conventional open
thyroidectomy. However, many surgeons insert the drain after robotic endoscopic thyroidectomy. The aim of this study
is to evaluate the safety and feasibility of no use of drain after robotic endoscopic thyroidectomy.
Materials & Methods: A total 127 patients who underwent robotic endoscopic thyroidectomy with bilateral axillobreast approach (BABA) from June 2011 to April 2014 were enrolled in this study. The enrolled patients were divided
into two group, such as drainage group (55/127) and non-drainage group (72/127).
Basic clinical characteristics including hospital stay time, pain assessed by visual analogue scale (VAS) on
postoperative day(POD) 0 and POD 1, the incidence of complications were assessed and compared between the two
groups.
Results: Mean age of participants was 37.6 and 37.3 years in drainage and non-drainage group. Most participants
were female. Between the two groups, there was no difference in the operation range, percentage of central
compartment neck dissection (CCND), number of harvested lymph node. Mean duration of hospital stay was
significantly longer among the drainage group as compared with non-drainage group [4.89(±1.14) vs. 3.72(±0.92)
days (p=0.000)]. The pain relief between POD 0 and POD 1 in non-drainage group was significantly higher than those
in drainage group [2.75(±1.43) vs 1.83(±1.79) (p=0.002)]. There were no significant difference in postoperative
complication, such as hematoma and seroma between the two groups.
Conclusion: By this study, the routine use of drain after robotic endoscopic thyroidectomy with BABA is not
necessary. Not inserting a drain after robotic endoscopic thyroidectomy with BABA is thought to be able to reduce the
postoperative pain, hospital stay time without increase of complications.
Disclosure of Interest: None declared
400
PE051
THE ROLE OF STIMULATED THYROGLOBULIN IN PAPILLARY THYROID CANCER (PTC) PATIENTS WITH THE
UNDETERMINED SIGNIFICANCE OF RADIOACTIVE IODINE THERAPY
J. W. Choi1,*, J. Lee1
1
general surgery, Ajou university medical center, Gyeonggi-do, Korea, Republic Of
Introduction: : Effectiveness of radioactive remnant ablation (RRA) for intermediate to high risk
patients without tumor size >4cm, distant metastasis, or extrathyroidal extension, is inconclusive
and evidence-lacking, and post-RRA whole body scan (WBS) and stimulated Thyroglobulin (sTg)
are associated with declined quality of life in patients. Recently, treatment response of each
patient is considered to individualize treatment plan. Therefore, we investigated the role of postRRA WBS and sTg as modulators for individualized postoperative management.
Materials & Methods: We retrospectively reviewed 3334 patients with papillary thyroid carcinoma
who had undergone thyroidectomy at Ajou University Hospital. One thousand, two hundred and
sixty-five intermediate-risk patients (37.9%) with tumor size ≤ 4cm, no distant metastasis, no T4
disease, no intrathyroidal PTMC without lymph node metastasis were included in the study, and
they underwent RRA after total thyroidectomy. These patients were followed for 1-14years (mean:
44 months).
Results: There were 69 patients with recurrence (5.4%). On univariate analysis, prognostic factors
for recurrence were gender, extrathyroidal extension, N stage, number of metastatic LNs,
postoperative sTg and post-RRA sTg. On multivariate analysis, N stage, postoperative sTg and
post-RRA sTg were significant prognostic factors for recurrence. When compared with low-risk
patients, the recurrence rate of patients with postoperative sTg <2 ng/mL and post-RRA sTg
<2ng/mL was similar to that of low-risk patients. Post-RRA sTg increased above 2ng/mL in
nineteen patients (4.3%) among those with postoperative sTg <2ng/mL.
Conclusion: Both postoperative sTg and post-RRA sTg were significant prognostic factors together
with N stage. However, 95.7% patients with postoperative sTg <2ng/mL were low risk patients
because post-RRA sTg was also below 2ng/mL in these patients. Therefore, periodic neck
ultrasound and T4-on Tg may be considered without post-RRA sTg and I131 WBS in patients with
postoperative sTg < 2 ng/mL.
Disclosure of Interest: None declared
401
PE052
COMPLICATIONS OF PROPHYLACTIC THYROIDECTOMY IN YOUNG PATIENTS WITH HEREDITARY
MEDULLARY THYROID CANCER
Y.-J. Chen1,*, J. Pasternak1, I. Suh1, W. Shen1, O. Clark1, Q.-Y. Duh1, J. E. Gosnell1
1
Surgery, University of California, San Francisco Medical Center, San Francisco, United States
Introduction: Hereditary medullary thyroid carcinoma (MTC) may be observed with either multiple endocrine
neoplasia syndromes (MEN 2A and MEN 2B) or as familial MTC (FMTC). Prophylactic thyroidectomy is recommended
for patients with hereditary MTC. The risk of thyroidectomy complications in young patients remains unclear
Materials & Methods: A retrospective study carried out by reviewing patients undergoing prophylactic thyroidectomy
at a tertiary care endocrine surgery unit with hereditary MTC, between 1993 and 2011. Charts were reviewed for
demographics, tumor markers and intervention as well as evidence of post-operative complications including recurrent
laryngeal nerve (RLN) injury, hypocalcemia and hematoma. Hypocalcemia was defined as symptomatic or serum
calcium level less than 8 mg/dL. RLN injury was defined as patients who experienced hoarseness after surgery.
Patients were analyzed by age with 2 groups; those <8 years and those≧8 years
Results: Nineteen patients underwent prophylactic thyroidectomy. Temporary hypocalcemia occurred in 7 of 19
patients (36.8%) and temporary RLN injury occurred in 2 of 19 patients (10.5%). There were no cases of permanent
hypocalcemia or RLN injury. Young patients (<8 years) had a similar rate of complications compared with the older
group (≧8 years) (p = 1.00). Of note, the group of older patients had a higher rate of MTC in their thyroidectomy
specimen (p=0.001) as well as 634 codon mutation (9 patients vs 2 patients).
Table 1. Characteristics of MTC patients
Age ( years)
<8
P
≧8
value
7
Number of patients
12
Sex (M:F)
4:3
4:8
Median age (range)(years)
5.51 (417.08 (8-37)
7)
Hereditary MTC
MEN 2A
6
11
Familial MTC
1
1
RET mutation codon
609
2
1
618
1
0
634
2
9
768
1
1
804
0
1
Pre-operative calcitonin (pg/ml)(range)
5.8 (<220.84 (2.4-66)
8)
Operation
Total thyroidectomy
1
5
Total thyroidectomy+ unilateral central LN dissection
6
5
Total thyroidectomy+ bilateral central LN dissection
0
2
Complications
4
1.00
Transient hypocalcemia
2
1
1
1.00
Temporary RLN injury
Hematoma
0
0
Wound infection
0
0
1.28
1
Hospital stay (day)
Pathologic report
Normal thyroid tissue
7
2
10
0.001
MTC
0
Follow-up calcitonin
<2
<2
Conclusion: As they age, patients undergoing prophylactic thyroidectomy have increased rates of MTC at the time of
surgery but do not have lower complications rates. These data support the idea that within an experienced and highvolume endocrine surgery unit, delay in prophylactic thyroidectomy should be avoided in this patient population.
References: 1. Skinner MA, Moley JA, Dilley WG, Owzar K, Debenedetti MK, Wells SA Jr 2005 Prophylactic
thyroidectomy in multiple endocrine neoplasia type 2A. New Engl J Med 353:1105–1113
2. Telander RL, Zimmerman D, Sizemore GW, van Heerden JA, Grant CS 1989 Medullary carcinoma in children.
Results of early detection and surgery. Arch Surg 124:841–843.
3. Machens A, Ukkat J, Brauckhoff M, Gimm O, Dralle H 2005 Advances in the management of hereditary
medullarythyroid cancer. J Intern Med 257:50–59.
Disclosure of Interest: None declared
402
PE053
CANCER INCIDENCE IN THYROID NODULES ≥4CM WITH BENIGN CYTOLOGY.
H. K. Kim1,*, S.-M. Kim1, H. Chang1, B.-W. Kim1, Y. S. Lee1, H.-S. Chang1, C. S. Park1
1
Departments of Surgery, Yonsei University College of Medicine, Seoul, Korea, Republic Of
Introduction: Generally, FNAB has been shown to have a high diagnostic sensitivity and specificity. But, the
diagnostic accuracy seems to have limitation in large thyroid cancer(>4cm). The aim of this study is to evaluate the
incidence of cancer in thyroid nodule 4cm or larger and to verify the necessary for diagnostic lobectomy or carefully
observation.
Materials & Methods: Between January 2010 and August 2014. A retrospective analysis was performed on all
patients who underwent thyroid surgery for thyroid nodule 4cm or larger with benign cytology. . Of these patients,
67(65.0%) had a benign final pathology and 36(35.0%) had a malignancy pathology. Clinicophathologic feature, mass
size, thyroiditis, multiplicity and Suspicious U/S finding were compared in the two group s
Results: Thirty-six patients (35.0%) had a thyroid carcinoma within nodule on final pathologic finding. Final histology
subclassification of malignancy included follicular variant of papillary carcinoma 15 cases (66.2% in PTC), follicular
carcinoma 8 cases (22.2%), and hurthle cell carcinoma 5cases (13.9%). The two groups were not different with regard
to the sex, age, mass size (ultrasonography size), thyroiditis and multiplicity. Cancer pathologic group was significantly
more related to suspicious U/S finding (p<0.001) than benign pathology.
Conclusion: In patient with thyroid nodule 4cm or large, preoperative FNAB had high false-negative rates. Therefore,
thyroid nodule 4cm or large should be recommended diagnostic lobectomy or carefully observation.
Disclosure of Interest: None declared
403
PE054
BRAF MUTATION IN CERVICAL LYMPH NODE METASTASIS: HAS IT A ROLE IN THE METASTATIC
POTENTIAL OF PAPILLARY THYROID CANCER
N. Kurtulmus1, B. Ertas2, H. Kaya3, Y. Saglican4, S. Giray5, M. Algan6, P. S. Barut7, M. Duren8,*
1
2
Division of Internal Medicine,Department of Endocrinology, Acibadem University, Faculty of Medicine, Department of
3
Otorhinolaryngology, Acibadem Maslak Hospital, Department of surgery, , Acibadem Maslak Hospital,Thyroid Clinic,
4
Department of pathology, Acibadem University, Faculty of Medicine, 5Departmen of surgery, Acibadem Maslak
Hospital, Thyroid Clinic, 6Department od pathology, Acibedem Maslak Hospital, 7Department of pathology, Acibadem
8
Maslak Hospital, Department of surgery, Acibadem Maslak Hospital, Thyroid Clinic, Istanbul, Turkey
Introduction: Papillary thyroid cancer(PTC) constitutes more than 90% of the thyroid cancers.BRAF which is a
member of Raf-kinase family, activates MAP kinase/ERK pathway. BRAF gene activating mutations lead to neoplastic
transformation in thyroid follicle cells.The most common BRAF mutation is T1799(V600E).Neck lymph node
metastasis are more frequent when this mutation is present.We evaluated the prevalence of BRAF mutation, clinicopathological findings and the relation between BRAF mutation and lymph node metastasis of PTC.
Materials & Methods: We evaluated 43 patients with PTC in our thyroid clinic treated between 2012-2014.All patients
had undergone total thyroidectomy with lymph node dissection by the same surgeon.Tissue samples of primary
tumors and matched lymph nodes were reviewed by the same pathologist.BRAFV600Emutation was identified by a
quantitavive real-time PCR assay.
Results: 43 patients with PTC(34 female,9 male) were analyzed.While 37(86%) patients had the classical variant of
PTC, 6(14%) had other sub-types PTC.The prevalence of BRAFV600E mutation was found in 29 patients(67.5%).
15(51.7%) of these 29 patients had the same mutation in their primary tumor tissue as well as in the lymph nodes.Six
of 14 patients who had no mutation in lymph nodes had multiple foci of PTC in the thyroid gland.The remaining six
patients had solitary PTC.Four patients with BRAFV600E mutation in lymph nodes had no mutation in their primary
tumors.Three of these 4 cases had multipl foci of PTC in thyroid gland, while only one had a single focus.There was
no relation between BRAFV600E mutation in the primary tumor and the tumor size in the thyroid gland or lymph node,
whereas BRAFV600E mutation in lymph nodes was associated with increased tumor size in lymph nodes.Thirteen
patients(86.7%) with a positive mutation in lymph nodes had a tumor diameter larger than 1cm in metastasis.Whereas
tumors larger than 1 cm were found in three patients (21.4%) with negative BRAF mutation in lymph nodes.In our
patients,BRAF gene mutation of the primary tumor in thyroid gland and concomitant lymph node metastasis did not
correlate with age, sex, lymphocytic infiltration.
Conclusion: BRAFV600Emutation in PTC is associated with negative clinico-pathological characteristics.Our results
show a high prevalence of BRAF mutation in patients with lymph node metastasis.When lymph node metastasis of
PTC has BRAF mutation this may play an important role in progression and recurrence of PTC.
Disclosure of Interest: None declared
404
PE055
ENHANCER OF ZESTE HOMOLOG 2 EXPRESSION AND CORRELATION WITH KI-67 IN THYROID
CARCINOMA.
N. Suganuma1,2,*, A. Yoshida1, H. Iwasaki1, A. Yamanaka2, H. Inari2, Y. Rino2, M. Masuda2
1
2
Breast and Endocrine Surgery, Kanagawa Cancer Center, Surgery, Yokohama City University, Yokohama, Japan
Introduction: Enhancer of zeste homolog 2 (EZH2) is a member of the polycomb group of genes, which are key
factors in regulation of cell proliferation and differentiation through histone modification, chromatin remodeling, and
interaction with other transcription factors. EZH2 is overexpressed in many malignancies, and thus has been proposed
as a candidate prognostic factor and treatment target. In this study, we analyzed EZH2 expression levels in different
histological subtypes of thyroid cancer to examine the utility of EZH2 as a prognostic factor for thyroid cancer and its
correlation with Ki-67 expression.
Materials & Methods: Immunohistochemical analyses of EZH2 and Ki67 expressions were performed in tissue
samples from 67 cases of poorly differentiated thyroid cancer (PDTC) and 48 cases of undifferentiated (anaplastic)
thyroid cancer (UTC), and in samples from adjacent normal and differentiated thyroid cancer (DCT) tissue.
Results: Expression of EZH2 protein was found in 17.9% (12/67) of PDTC cases and 87.5% (42/48) of UTC cases,
but was not found in tissue samples from normal thyroid gland and DCT. Higher expression levels of EZH2 correlated
with poorer survival in PDTC (p=0.004, log-rank test) and a similar trend was observed in UTC (p=0.166, log-rank
test). In multivariate analysis, there was no difference in survival between cases with higher and lower EZH2
expression. Ki-67 expression was correlated with EZH2 expression.
Conclusion: Our results suggest that immunohistochemical analysis of EZH2 overexpression may be associated with
the malignant potential of thyroid cancer and tumor cell proliferation.
Disclosure of Interest: None declared
405
PE056
THYROID SURGERY WITHOUT OPTICAL LOUPE MAGNIFICATION: ARE WE MISSING THE BIG PICTURE?
G. Agarwal1,*, V. Aggarwal2, D. Sadacharan3, G. Nanda4, K. R. Singh5, S. Rajan1
1
2
Endocrine & Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Endocrine &
3
Breast Surgery, Sir Ganga Ram Hospital, New Delhi, Endocrine Surgery, Madras Medical College, Chennai,
4
Endocrine & Breast Surgery, Ajanta Hospital, 5Surgery, King Georges Medical University, Lucknow, India
Introduction: Capsular dissection technique with preservation of external branch of superior laryngeal (EBSLN) &
recurrent laryngeal (RLN) nerves, and parathyroid (PTG) & their vasculature is largely the reason for safety and
success of modern day thyroid surgery in expert hands. Use of optical loupe magnification (OLM) during thyroid
surgery is a matter of the surgeon’s personal preference, with no data supporting or refuting its need/ utility. In this
non-randomized comparative study of results of thyroid surgery with or without OLM in hands of a single endocrine
surgeon, we evaluated if indeed optical magnification contributes to the safety of thyroid surgery.
Materials & Methods: Operative, follow-up & outcome data of 100 consecutive patients who underwent total
thyroidectomy (TTx) for euthyroid benign multi-nodular goiter (BMNG)- 50 without OLM (Group A) & 50 with OLM
using a 2.5X loupe (Group B) were derived from a prospectively maintained data-base. All TTx in both groups were
performed by a single endocrine surgeon using a uniform "tie & cut" surgical technique with selective PTG autotransplantation policy. Outcome measures compared in two groups included operating time, blood loss, EBSLN &
RLN identification rates, number of PTGs identified, preserved in-situ, and auto-transplanted, inadvertent parathyroid
excision (IPE), post-op hemorrhage, transient hypocalcemia, permanent hypoparathyroidism and temporary &
permanent RLN palsy.
Results: Patients in the 2 groups had comparable mean age, gender distribution & goiter size/weight (214 vs 231
gm). Mean surgery duration, blood loss, EBSLN (88 vs 92%) & RLN (98 vs100%) identification rates, mean no. of
PTGs identified (3.76 vs. 3.88) & preserved in-situ (3.62 vs 3.82), post-op hemorrhage, & RLN palsy rates (temporary7 vs 6%; permanent 2 vs 2%) were not different (p>0.05) between groups. The IPE rate in group A (4 patients, 8%),
was significantly higher than group B (0%, p<0.001). In group A 17 (34%) pts (including 4 with IPE) had 1 PTG autotransplanted- significantly higher than group B (7 pts, 14%). Transient hypocalcemia (24% vs 18%, p=0.065) and
permanent hypoparathyroidism (2% vs 0%) rates were lower in OLM usage group, though did not reach statistical
significance.
Conclusion: Optical loupe magnification usage during TTx for BMNG allows an expert surgeon avoid inadvertent
PTG removal, preserve more well-vascularized PTGs in-situ, and can potentially reduce the RLN palsy, transient
hypocalcemia and permanent hypoparathyroidism rates.
Disclosure of Interest: None declared
406
PE057
RISK FACTORS RELATED TO RECURRENCE IN PAPILLARY THYROID CARCINOMA WITH LATERAL LYMPH
NODE METASTASIS
Y.-M. Lee1,*, T.-Y. Sung1, K.-W. Chung1, S. J. Hong1, J. H. Yoon1
1
Department of surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea, Republic Of
Introduction: Papillary thyroid carcinoma (PTC) having lateral node metastasis (pN1b) showed worse prognosis than
PTC having central node metastasis (pN1a). Although all patients with pN1b were classified as stage IV-A in the
UICC/AJCC TNM classification, we hypothesized that other lymph node (LN) related factors, such as retrieved LN
number, metastatic LN number or LN ratio (LNR) would be more associated to recurrence. This study aimed to
evaluate the impact of LN related factors upon the prognosis of PTC with pN1b.
Materials & Methods: From 1996 to 2010, 422 patients who underwent total thyroidecotmy with unilateral lateral LN
dissection for classical PTC at Asan Medical Center were enrolled in this study. We reviewed clinico-pathologic
features through medical report retrospectively and evaluated risk factors related to recurrence. To investigate the
association between LN related factors and recurrence, we classified into three subgroups according to LN area (total
LN group [central LN + lateral LN], central LN group and lateral LN group) in each LN related factor and performed
analysis in every subgroup.
Results: There were 324 female and 98 male patients with mean age of 45.6 years. The median follow-up was 71.5
months (range 12~220 months. 81 patients (25%) were detected recurrence during follow-up period and most of these
patients showed only loco-regional recurrence (62/81, 76.5%). Well-known risk factors like old age (≥45years; P=0.01,
odds ratio, 1.04 [95% confidence interval, 1.01~1.07]), tumor size (≥4.0cm; P=0.035, odds ratio, 1.17 [95% confidence
interval, 1.01~1.34]) and T classification (T4a; P=0.03, odds ratio, 1.74 [95% confidence interval, 1.22~5.52]) were the
independent risk factors for recurrence in multivariate analysis. Among LN related factors, metastasized central LN
number (P=0.009, odds ratio, 1.07 [95% confidence interval, 1.02~1.12]) and LNR of central LN (P=0.001, odds ratio,
6.22 [95% confidence interval, 2.44~15.81]) were the independent risk factors.
Conclusion: The number of central LN and LNR of central LN were the independent risk factors to the patients who
were diagnosed as PTC with pN1b. We are planning to perform additional analysis to investigate cut-off values and to
evaluate the risk factors according to recurrence patterns.
Disclosure of Interest: None declared
407
PE058
THE PRESENTATION OF MICROSATELLITE INSTABILITY IN THE PATHOGENESIS OF THYROID
MALIGNANCY
J. Y. Chen1,2,3,*, C.-H. Lee1,3, C.-W. Chi2,4, A.-H. Yang5, L.-M. Tseng3
1
2
Department of medicine, School of Medicine, Department and Institute of Pharmacology, School of Medicine,
3
National Yang-Ming University, Division of General Surgery, Department of Surgery, 4Department of Medical
Research, 5Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
Introduction: Thyroid cancer is the second most lethal endocrine tumors and accountsfor about 1% of all cancer
death.The major treatment for thyroid cancer is surgical interventionwith/without radioiodine therapy followed. It is
thought that thyroid tumors arise through a series of genetic mutationsfound in a variety of different genes. These
mutations, largely made up ofsomatic mutations, occur throughout the genome, in both intronic and exonicregions.
More specifically, somatic mutations that occur in the microsatelliteregions were shown to be linked to the
etiopathogenesis of several solid organtumors.Microsatellite instability (MSI), a recently discovered mechanism
thatreflects a defect in DNA replication or repair in damaged DNA and leads to theso-called replication error (RER)
phenotype, has been proposed as a possibleexplanation for tumor growth.
Materials & Methods: In this study, we collect 48 patients with thyroid neoplasm. The resected specimen were
analyzed for MSI, then interpret the difference in MSI frequency with thecriteria proposed from the National Cancer
Institute Workshop on MicrosatelliteInstability for Cancer Detection and Familial Predisposition.
Results: We found that there were most of MSI-stable and few MSI-low presentation in the resected specimen.
However, there were no significant difference compared with their clinicopathologic characteristics. Besides, the
incidence of BRAF mutation was up to 67.7% (21/31) in 31 PTC patients. The tumors with BRAFV600E mutation were
larger in size, and lymph node metastases were frequently noted.
Conclusion: Microsatellite instability is seldom in thyroid malignancy. BRAFV600E mutation remains important role in
aggressiveness of thyroid cancer.
Disclosure of Interest: None declared
408
PE059
LONG-TERM FOLLOW-UP STUDY OF ORAL VITAMIN B12 REPLACEMENT FOR PATIENTS AFTER TOTAL
GASTRECTOMY
H. Shimoji1,*, T. Nishimaki1, H. Karimata1, K. Hayasaka1
1
Digestive and General Surgery, University of the Ryukyus, Nishihara, Okinawa, Japan
Introduction: Vitamin B12 deficiency is a common long-term complication after total gastrectomy due to lack of
intrinsic factor. Therefore the standard treatment of post total gastrectomy vitamin B12 deficiency is intramuscular
injection of vitamin B12. Recently several studies reported that oral vitamin B12 replacement was an effective
treatment for vitamin B12 deficiency after total gastrectomy but the long-term follow-up study is few. Here we report
long-term follow-up study of oral Vitamin B12 replacement for patients after total gastrectomy.
Materials & Methods: We have treated 24 patients after total gastrectomy by oral vitamin B12 replacement. Of these,
9 patients who were followed up five years or more were analyzed in this study. Of the 9 patients, 7 were male and 2
were female. The mean age was 60.9 ± 14.0 years at the time of performed total gastrectomy (range, 35 to 75). At a
median follow-up time after surgery of 9.8 years (range, 5.0–16.7 years) and after oral vitamin B12 replacement of 8.1
years (range, 5.0–10.8 years), Of the 9 patients, 3 were started to treat by oral vitamin B12 replacement when their
serum vitamin B12 levels were detected below 180pg/ml and 6 were dispensed by oral vitamin B12 replacement for
preventive administration after surgery. The starting dosage was set for 1500µg of mecobalamin daily and it was
administered daily in three divided doses.
Results: In 3 patients of therapeutic oral vitamin B12 replacement, a mean of serum vitamin B12 level of them was
113 pg/ml (range, 50 - 160 pg/ml) before oral vitamin B12 replacement. About one month later after oral vitamin B12
replacement, a mean of serum vitamin B12 level improved to 557.3 pg/ml (range, 441 - 731 pg/ml). In 6 patients of
preventive oral vitamin B12 replacement, postoperative median follow-up time was 8.0 years (range, 5.0 - 10.1 years).
Serum vitamin B12 levels were kept within normal limits during the follow-up period. Likewise in all 9 patients, serum
vitamin B12 levels were kept within normal limits during oral vitamin B12 replacement. The median follow-up time was
8.0 years (range, 5.0 – 10.7 years).
Conclusion: Long term oral vitamin B12 replacement for patients after total gastrectomy is useful for treating and
preventing vitamin B12 deficiency. Oral vitamin B12 replacement is superior to intramuscular injection about pain,
complication and needle-stick injury.
Disclosure of Interest: None declared
409
PE060
IMPLANT SALVAGE IN BREAST RECONSTRUCTION PATIENTS: A NOVEL TECHNIQUE
F. Meybodi1, N. Sedaghat1, J. French1, E. Elder1,*
1
Westmead Breast Cancer Institute, Sydney, Australia
Introduction: Successful management of peri prosthetic infection in implant based breast reconstruction represents a
significant challenge. In order to minimise negative aesthetic and psychological effects of explantation there is a need
for techniques to achieve successful implant salvage.
Materials & Methods: In this case series we describe a novel technique utilising negative pressure wound therapy
(NPWT) with irrigation - VeraFlo™. This is an operative technique, which is used in the setting of suspected or
established peri prosthetic infection in immediate or delayed breast reconstruction. It is indicated when conservative
management, such as intravenous antibiotics and/or serial aspirations fails. It involves: (1) temporary explantation of
the breast prosthesis, (2) operative debridement and washout with application of NPWT with irrigation of the implant
pocket (3) serial fluid/tissue cultures taken at time of washout, and (4) re-implantation of the breast prosthesis once
two consecutive cultures yield no growth of organisms.
Results: This technique was utilised in four cases of suspected or established peri prosthetic infection in three
patients with immediate breast reconstruction. Indications for mastectomy were breast cancer in one patient and riskreducing surgery in two patients. Peri prosthetic infection occurred during the first-stage in three (expander / implant)
and following the second stage in one case. Cultures of fluid/tissue grew pseudomonas, streptococcus anginosis and
klebsiella oxytoca. Only one case did not yield an organism on culture. Irrigation of the implant pocket was completed
th
with normal saline in 3 cases and in the 4 case with resistant pseudomonas colonisation, a solution of 1% acetic acid
was employed. Successful implant salvage was achieved in three of four cases. In all successful cases the implant
pocket was covered with healthy, well vascularised granulation tissue. The failed salvage occurred in a patient with
previous breast and chest wall radiotherapy.
Conclusion: When conservative management fails, this operative technique involving NPWT and irrigation may be
utilised for successful implant salvage in breast reconstruction. It can accelerate forming healthy, well perfused
granulation tissue, while maintaining the breast envelope shape. Direct access to the pocket increases the accuracy of
microbiologic tests and guides appropriate antibiotic therapy.
Disclosure of Interest: None declared
410
PE061
THE NEED FOR SURGICAL EXCISION OF PAPILLARY BREAST LESION FROM CORE NEEDLE BIOPSY IN
PHRAMONGKUTKLAO HOSPITAL, THAILAND 2008-2012
J. Jaroensuk1,*, W. Vassanarisi2
1
2
Surgery, Chonburi Hospital, Chonburi, Surgery, Phramongkutklao Hospital and College of Medicine, bangkok,
Thailand
Introduction: Papillary lesion of the breast is the most common causes of nipple discharge and it is often solitary,
centrally located tumor that most commonly occurs in the fifth and sixth decades of life. There have been many
conflicting reports on the malignant potential and the factors predicted of this lesion. The need for surgical excision of
papillary lesions diagnosed on core biopsy remains controversies. This study aimed to evaluate the incidence of
malignant arise in papillary lesion from core needle biopsy and to identifying factors that predict for this, in order to
reduce unnecessary surgery without missing out an possible malignancy.
Materials & Methods: Retrospective review of 89 patients diagnosed with a papillary lesion on percutaneous core
needle biopsy was performed between 1 January 2008 and 31 July 2012. The pathological features (presented with or
without atypia) on core biopsy and the presence of malignancy in the surgical specimen were correlated with standard
clinical, radiological and pathological features.
Results: Histological underestimation occurred in 21 of 89 patients (23.6%). Malignancy was more likely when atypia
was present in the core biopsy (P < 0.05, odds ratio (OR) 10.65, 95% confidence interval (CI) 1.67–1.85). Then, a final
diagnosis of malignancy was not correlated with any clinical or radiological features (P > 0.05). The presence of atypia
was not correlated with any clinical or radiological features. However the suspicious finding on mammogram did not
allow to omitted the surgery.
Conclusion: In this study, 23.6% of patients with papillary lesion diagnosed on core biopsy were found to have a
malignancy following surgery. In practically, the nonsense of predictive factors for malignancy, we recommend
surgical excision of all papillary lesions diagnosed on core biopsy.
References:
1. Lewis JT, Hartmann LC, Vierkant RA, et al. An analysis of breast cancer risk in women with single, multiple, and
atypical papilloma. Am J Surg Pathol 2006;30:665–72.
2. Qinghui Lu, Ern Yu Tan, Bernard Ho, Juliana J. C. Chen and Patrick M. Y. Chan. Surgical excision of intraductal
breast papilloma diagnosed oncore biopsy. ANZ J Surg. 2012;82:168–172
3. Page DL, Dupont WD, Rogers LW, Rados MS. Atypical hyperplastic lesions of the female breast. A long follow-up
study. Cancer 1985;55:2698–708.
4. Page DL, Salhany KE, Jensen RA, Dupont WD. Subsequent breast carcinoma risk after biopsy with atypia in breast
papilloma. Cancer 1996;78:258–66.
5. Hartmann LC, Sellers TA, Frost MH, et al. Benign breast disease and the risk of breast cancer. N Engl J Med
2005;353(3):229–37.
6. Carter CL, Corle DK, Micozzi MS, et al. A prospective study of the development of breast cancer in 16,692 women
with benign breast disease. Am J Epidemiol 1988;128(3):467–77.
7. London SJ, Connolly JL, Schnitt SJ, et al. A prospective study of benign breast disease and the risk of breast
cancer. JAMA 1992;267(7):941–4.
8. Rizzo M, Lund MJ, Oprea G, et al. Surgical follow-up and clinical presentation of breast papillary lesions diagnosed
by ultrasound-guided core-needle biopsy. Ann Surg Oncol 2008;15(4):1040–7.
9. Gendler LS, Feldman SM, Balassanian R, et al. Association of breast cancer with papillary lesions identified at
percutaneous image-guided breast biopsy. Am J Surg 2004;188(4):365–70.
10. Valdes EK, Tartter PI, Genelus-Dominique E, et al. Significance of papillary lesions at percutaneous breast biopsy.
Ann Surg Oncol 2006;13(4):480–2.
Disclosure of Interest: None declared
411
PE062
RE-APPRAISALOF INTRA-ARTERIAL INFUSIVE CHEMOTHERAPY FOR LOCALLY ADVANCED BREAST
CANCER IN NEO-ADJUVANT SETTING
W. W. Chang1,*, T. J. Liu1
1
General Surgery , Wan Fang Hospital, Taipei Medical University , Taipei, Taiwan
Introduction: Complete pathological response (pCR) from neo-adjuvant chemotherapy(NAC) provides the beast
disease free and overall survival results for locally advanced breast cancer (LABC). In order to achieve pCR,
maximum the anticancer drug’s dose is necessary but adverse event is un-evitable. Intra-Arterial Infusive
Chemotherapy (IAIC) can supply large dose of anticancer agents at local region and it may produce less systemic
adverse events.The most proper method for drug infusion, anti-cancer drug’s dosage, staging downgrade, and the
systemic benefits needs studied.
Materials & Methods: A total 5 females with cT3-4N1M0 breast cancer were enrolled for IAIC and another 10
patients with similar staging were treated by conventional IVIC. The first 3 patients received catheter insertion at the
main trunk of elbow artery while the last 2 patient’s catheter was inserted thru the superior ulnar collateral artery of
disease side. Anthracycline, 5FU and Taxane were the anticancer agents scheduled as 4x4 settingwith modified
dosage pre-operatively. Total mastectomy and either axillary dissection (if the positive lymph node presented during
mastectomy) or sentinel lymph node dissection were performed after neo-adjuvant chemotherapy.
Results: All patients received IAIC had varied degree of tumor shrinkage before mastectomy, the more sessions of
IAIC given and the better tumor response obtained. None of IA patients had grade 4 leukopenia and needed GCSF
rescue. Three out of 5 patients’underwent SLNB only for their axillary node was negative. However, varied degree
neuro-muscular damage at disease side forearm was observed in 3 patients received IA infusion through the main
trunk of brachial artery. It is not found in last 2 cases with infusion site at upper arm.
Conclusion: IAIC did provide superiortumor control and downstage for LABC with less systemic adverse events. The
neuro-muscular damage can be avoided by insertion of IA catheter at upper arm with intermittent occlusion of arterial
flow during infusion anticancer drugs.
Disclosure of Interest: None declared
412
PE063
EVALUATION OF TREATMENT STRATEGY FOR STAGE IV BREAST CANCER PATIENTS.
T. Shien1,*, H. Doihara1, Y. Abe1, T. Nogami1, T. Iwamoto1, T. Motoki1, N. Taira1
1
Breast and endocrine surgery, OKAYAMA UNIVERSITY HOSPITAL, Okayama, Japan
Introduction: Two results of prospective studies evaluated the prognostic efficacy of primary tumor resection for
Stage IV breast cancer patients were reported. These data were different and regarded inconclusive yet. However two
clinical questions became clear. When should we recommend the primary tumor resection to Stage IV breast cancer
patients? Who should undergo the primary tumor resection to avoid the chest wall symptom? We analyzed these
clinical questions retrospectively.
Materials & Methods: We classified the timing of surgery to three categories; primary treatment (PT), after good
response to systemic therapy (good) and after progressive disease to systemic therapy (Bad). We evaluated the
prognostic impact of primary tumor resection according to these classifications. Moreover we evaluated the successful
rate of local control.
Results: We enrolled 35 Stage IV breast cancer patients who treated in Okayama University Hospital. Median OS
was 40 months. 20 (57%) patients underwent surgery. There was no significant difference between surgery and no
surgery patients. The timing of surgery were PT 7 (35%), Good 5 (25%) and Bad 8 (40%) respectively. OS of PT was
significantly worse than other timing. (p=0.0052) 3/8 cT4 patients (38%) underwent surgery for local disease control.
Conclusion: Primary tumor resection should be performed after systemic therapy. All cT4 patients didn’t need local
surgery for local control. We are enrolling patients to evaluate prognostic effect of surgery after systemic therapy
prospectively now. (JCOG1017 PRIM-BC)
References:
Disclosure of Interest: None declared
413
PE064
SURGICAL OUTCOME OF LOCALLY ADVANCED BREAST CANCER FOLLOWING NEOADJUVANT
CHEMOTHERAPY: A TEN-YEAR REVIEW
P. Y. Wong1,*, K. F. Cheung1, K. M. Chan1, W. C. Kong1, W. K. Ng1, K. Y. Sin1, C. Kwok2, L. S. Ho1
1
2
Department of Surgery, Department of Clinical Oncology, Princess Margaret Hospital, Hong Kong, Hong Kong,
Hong Kong
Introduction: The aim of this study is to determine the outcome of locally advanced breast cancer treated
with neoadjuvant chemotherapy followed by surgery.
Materials & Methods: Between 2004 and 2013, in a loco-regional hospital, data of 68 patients with locally
advanced breast cancer without distant metastasis, who were treated with neoadjuvant chemotherapy and
surgery of curative intent, were reviewed.
Results: The number of patients receiving neoajuvant chemotherapy increased annually from 2 in 2004 to 13 in 2013.
4 patients were lost to follow-up. 18 patients (26.5%) and 50 patients (73.5 %) had Stage 2 and 3 breast cancer
respectively. The mean reduction in clinical tumor size was 3.6 cm (+/- 3cm). 10 patients (14.7%) had no clinical
response after neoadjuvant chemotherapy. 10 patients (14.7%) (1 in Stage 2 and 9 in Stage 3 disease) achieved
pathologic complete response (pCR), which was significantly less likely in the ER+/Her2- subtype (p=0.045). 13
patients (19.1%) received breast conserving treatment (BCT), in which 2 patients underwent subsequent re-excision
and 1 patient underwent mastectomy due to positive margins. 1 patient of BCT group had recurrence in ipsilateral
axilla during median follow-up of 61 months. In those 10 patients undergoing neoadjuvant chemotherapy with intention
for BCT, 7 of them received BCT and 3 received mastectomy eventually (due to nipple involvement, patient
preference and loss of marker with radiological complete response respectively). Recurrence occurred in 30 patients
(44.1%) overall, with the majority of them (86.7%) having distant metastases. In contrast, in the pCR subgroup, there
was only 1 case of brain metastasis while the other 9 patients remained disease-free, suggesting that pCR is
associated with a significantly lower risk of recurrence (p=0.019). There is no significant association between
recurrence and BCT (p=0.648).
Conclusion: Neoadjuvant chemotherapy is valuable in treatment of locally advanced breast cancer to
achieve BCT and to evaluate the response to chemotherapy. In patients with favourable factors for pCR
and plan for BCT, marker insertion before neoadjuvant chemotherapy is recommended.
References: Chen AM et al. Breast conservation after neoadjuvant chemotherapy: the MD Anderson cancer center
experience. J Clin Oncol. 2004; 22(12):2303-12
Philip M. Spanheimer et al. The response of neoadjuvant chemotherapy predicts clinical outcome and increases
breast conservation in advanced breast cancer. Am J of Surg. 2013; 206: 2-7.
Hee-Chul Shin et al. Breast conservng surgery after tumor downstaging by neoadjuvant chemotherapy is oncologically
safe for Stage III breast cancer patients. Ann Surg Oncol. 2013; 20: 2582-2589.
Disclosure of Interest: None declared
414
PE065
IS TOUCH IMPRINT CYTOLOGY BY CYTOTECHNOLOGISTS RELIABLE ALTERNATIVE TO FROZEN SECTION
BY PATHOLOGISTS FOR THE INTRAOPERATIVE EVALUATION OF SENTINEL LYMPH NODES METASTASIS
IN BREAST CANCER?
H. Inari1,*, N. Suganuma1, A. Yamanaka1, K. Hasuo1, H. Iwasaki1, Y. Rino1, M. Masuda1
1
Surgery, Yokohama city university, Yokohama, Japan
Introduction: In our hospital, when pathologists of absence, cytotechnologists evaluated the intraoperative sentinel
lymph nodes (SLN) metastasis in breast cancer by touch imprint cytology (TIC). The aim of this study was to assess
the accuracy of the diagnosis of cytotechnologists by TIC. We compared the sensitivity of TIC by cytotechnologists
and the sensitivity frozen section (FS) by pathologists retrospectively.
Materials & Methods: From April 2010 to October 2014, we performed sentinel lymph node biopsy in 109
consecutive patients with breast cancer. In the intraoperative diagnosis of SLNs, 44 patients were diagnosed
according to TIC and 65 patients according to FS. The final diagnosis of SLN metastasis was made based on
conventional permanent sections using hematoxylin and eosin stain. Based on the final diagnosis, we investigated the
accuracy of intraoperative diagnosis.
Results: 125 lymph nodes from 44 patients were evaluated according to TIC, 168 lymph nodes from 65 patients were
evaluated according to FS. Among 125 lymph nodes, 21 were nodes positive according to TIC and 23 were metastatic
lymph nodes according to final diagnosis. Among 168 lymph nodes, 13 were nodes positive according to FS and 19
were metastatic lymph nodes according to final diagnosis. The sensitivity of TIC was 91%; it was 68% for FS. The
specificity of TIC and FS was 100%.
Conclusion: These findings suggest that TIC by cytotechnologists is reliable alternative to FS by pathologists for the
intraoperative evaluation of SLN metastasis in breast cancer.
Disclosure of Interest: H. Inari Salary, Royalty or Honoraria from: Not applicable, Receipt of Intellectual Property
Rights of: Not applicable, Grant/Research Support from: Not applicable, Consulting fees from: Not applicable,
Speaker’s Honorarium from: Not applicable, Ownership Interest of: Not applicable, Other Financial/Material Support
from: Not applicable, N. Suganuma Salary, Royalty or Honoraria from: Not applicable, Receipt of Intellectual Property
Rights of: Not applicable, Grant/Research Support from: Not applicable, Consulting fees from: Not applicable,
Speaker’s Honorarium from: Not applicable, Ownership Interest of: Not applicable, Other Financial/Material Support
from: Not applicable, A. Yamanaka Salary, Royalty or Honoraria from: Not applicable, Receipt of Intellectual Property
Rights of: Not applicable, Grant/Research Support from: Not applicable, Consulting fees from: Not applicable,
Speaker’s Honorarium from: Not applicable, Ownership Interest of: Not applicable, Other Financial/Material Support
from: Not applicable, K. Hasuo Salary, Royalty or Honoraria from: Not applicable, Receipt of Intellectual Property
Rights of: Not applicable, Grant/Research Support from: Not applicable, Consulting fees from: Not applicable,
Speaker’s Honorarium from: Not applicable, Ownership Interest of: Not applicable, Other Financial/Material Support
from: Not applicable, H. Iwasaki Salary, Royalty or Honoraria from: Not applicable, Receipt of Intellectual Property
Rights of: Not applicable, Grant/Research Support from: Not applicable, Consulting fees from: Not applicable,
Speaker’s Honorarium from: Not applicable, Ownership Interest of: Not applicable, Other Financial/Material Support
from: Not applicable, Y. Rino Salary, Royalty or Honoraria from: Not applicable, Receipt of Intellectual Property Rights
of: Not applicable, Grant/Research Support from: Not applicable, Consulting fees from: Not applicable, Speaker’s
Honorarium from: Not applicable, Ownership Interest of: Not applicable, Other Financial/Material Support from: Not
applicable, M. Masuda Salary, Royalty or Honoraria from: Not applicable, Receipt of Intellectual Property Rights of:
Not applicable, Grant/Research Support from: Not applicable, Consulting fees from: Not applicable, Speaker’s
Honorarium from: Not applicable, Ownership Interest of: Not applicable, Other Financial/Material Support from: Not
applicable
415
PE066
UPDATE ON RISK-REDUCING STRATEGIES UPTAKE OF BREAST AND OVARIAN CANCERS IN MALAYSIAN
BRCA MUTATION CARRIERS.
H. Sa'at1, N. A. Taib1,*, S. Y. Yoon2, S. H. Teo2, M. K. Thong3, Y. L. Woo4, C. H. Yip5, T. Hassan2 on behalf of MyBrCa
(Malaysian Breast Cancer Genetic Study) research group
1
Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, 2Cancer Research Initiatives
Foundation, Sime Darby Medical Centre, Selangor, 3Department of Pediatrics, Faculty of Medicine, 4Department of
Obstetric and Gynaecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, 5Sime Darby Medical Centre,
Selangor, Malaysia
Introduction: This study aims to describe the uptake of risk-reducing strategies (RRS) of breast and ovarian cancers
in Malaysian BRCA mutation carriers.
Materials & Methods: Between Jan 2003 and Sept 2013, 693 patients were tested for a deleterious mutation in
BRCA1 and BRCA2 as part of Malaysian Breast Cancer Genetic Study [MyBrCa]. Confirmed mutation carriers were
followed up and data documenting status of genetic test result disclosure, acceptance of genetic counselling,
attendance in risk management clinic (RMC) and the uptake of RRS were collected prospectively. The database was
then verified by the breast surgeon and genetic counsellor who managed these patients.
Results: 109 BRCA mutation carriers were initially identified, which then lead to the identification of additional twenty
relatives with positive BRCA mutation. Of these 129 mutation carriers, eighteen had passed away before result
disclosure and ten lost to follow up leaving 101 who were then followed up. Sixty-two out of eighty carriers who were
aware of their BRCA status attended the RMC to discuss on cancer risk management. Of the 49 without bilateral
breast cancer, ten (20.4%) chose to have risk-reducing contralateral mastectomy (RRM). Three had RRM based on
family history before known BRCA status. The other seven had the procedure at a median of 8 months (range 3 to 32
months) after the first result disclosure. They were at a median age of 54 (range 33 to 65) when they underwent RRM.
The rest (71.4%) opted for intensive breast surveillance while one also opted for chemoprevention using tamoxifen.
Only two not had any RRS for breast cancer as they defaulted follow-up. Of the 48 carriers without previous ovarian
cancer and other gynae surgery, 23 (48%) chose to have risk-reducing bilateral salpingo-oophorectomy (RRBSO).
Those who chose RRBSO had the procedure at a median of 17 months (range 1 to 54 months) after result disclosure.
They were at a median age of 48 (range 34 to 67) when they underwent RRBSO. Eighteen (37.5%) chose to continue
ovarian screening via annual monitoring of CA125 and/or trans-vaginal ultrasound scan. Eight not had any RRS for
ovarian cancer.
Conclusion: Different trends were seen on the uptake of RRS for breast and ovarian cancers. There was a low
uptake rate of RRM and chomeprevention as compared to RRBSO and screening. These finding should direct future
research to explore the psychosocial aspect of RRS uptake in Malaysian BRCA mutation carriers.
Disclosure of Interest: None declared
416
PE067
USE OF DOPPLER ULTRASOUND TO QUANTIFY BLOOD FLOW VOLUME IN BREAST DISEASES OF THE
NIPPLE
H. Ogata1,*, Y. Michitsuka1, T. Osaku1, F. Saito1, S. Magoshi1, S. Kanazawa1, H. Kaneko1
1
Division of Breast and Endocrine Sugery, Toho university School of medicine, Tokyo, Japan
Introduction: Background: It is often challenging to differentiate neoplastic and eczematous diseases of the breast
nipple based on clinical symptoms alone. We examined patients with breast disease characterized by nipple lesions
and attempted to determine if blood flow analysis with Doppler ultrasound and quantification of blood flow volume
were useful in differentiating neoplastic and non-neoplastic nipple lesions.
Materials & Methods: Methods: We studied 20 patients with breast disease characterized by nipple lesions: 10 with
Paget disease, 5 with atopic dermatitis, and 5 with simple eczema of the nipple. A diagnostic ultrasound system (SSA770A, Toshiba Medical) was used to visualize blood flow in the nipple area. Adobe Photoshop was then used to count
the number of pixels showing blood flow signals in the nipples on the affected and unaffected sides, and the ratio of
the pixel count on the affected side to that on the unaffected side was recorded.
Results: Results: Blood flow was greatly increased in the affected nipple of patients with Paget disease. Patients with
atopic dermatitis had a general increase in blood flow in both nipples. No increase was seen in patients with simple
eczema. The pixel count in the affected nipple was 1300–4800 in patients with Paget disease, 400–1200 in those with
atopic dermatitis, and only 150–483 in those with simple eczema. The pixel count ratio (affected side/the unaffected
side) resulted in 20.8±9.9 for patients with Paget disease, 2.4±2.1 for atopic dermatitis and 2.8±2.2 for simple eczema.
These differences showed significance (p< 0.005).
Conclusion: Conclusion: When using power Doppler imaging to evaluate blood flow in the nipples, the small display
area and focus on the body surface make visualization easy, and the results have good reproducibility. Sustained
blood flow increase of the affected nipple suggests existence of Paget disease. This information is useful in
differentiating between such patients and those with eczematous lesions in the nipple.
Disclosure of Interest: None declared
417
PE068
ONCOLOGICAL OUTCOMES AFTER NIPPLE-SPARING MASTECTOMY IN A SINGLE ITALIAN CENTER
S. Bertozzi1,*, C. Cedolini1, A. P. Londero2, M. Andretta1, S. Neri1, A. Uzzau2, P. C. Parodi2, A. Risaliti1
1
2
Department of Medical and Biological Sciences, University of Udine, 33100 Udine, Italy, Deparment of Experimental
Clinical and Medical Science, Clinic of Obstetrics and Gynecology; University of Udine, 33100 Udine, Italy., Udine,
Italy
Introduction: The introduction of skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) with
immediate reconstruction allowed an evident improvement for what concerns reconstructive surgery aesthetic results,
and as a consequence for patients psychophysical wellness. Anyway, controversies still exist about long-term
oncological safety of these two procedures. Our study aims to evaluate oncological outcomes of women who
underwent SSM and NSM.
Materials & Methods: We performed a retrospective chart review study about all patients operated of SSM and NSM
in our Clinic between January 2011 and July 2013. Main outcomes were overall survival (OS), disease-free survival
(DFS) and recurrences cumulative rate. Data was analyzed using R (version 3.1.0) and considering significant p<0.05.
Results: Among the 1836 invasive breast carcinomas included in this study, we found NSM to have a significantly
shorter DFS than traditional modified total mastectomy (MTM). Furthermore, low BMI, basal-like molecular sub-type,
extended intraductal component, and extracapsular invasion of lymph node metastasis resulted to be the most
significant predictive factors for recurrence in women operated by NSM. Moreover, breast cancers treated by BCS had
significantly longer OS and DFS than those who underwent mastectomy in general.
Conclusion: Occult nipple neoplastic involvement by negative intraoperative histological examination of subareolar
tissue may explain the higher recurrence rate among women undergoing NSM. More attention should than be paid for
those patients who present one or more risk factors for recurrence after NSM, including basal-like molecular sub-type,
extended intraductal component, and extracapsular invasion of lymph node metastasis.
References: [1] Carlson GW. Skin sparing mastectomy: anatomic and technical considerations. Am Surg.
1996;62:151–155.
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Disclosure of Interest: None declared
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