Comparative outcomes of surgical and conservative management in carotid artery dissection.

OBJECTIVES: Carotid artery dissection (CAD) is a significant cause of strokes in young individuals, leading to severe complications and socioeconomic burdens. Despite antithrombotic therapy being the primary management strategy, optimal treatment for patients with recurrent or worsening symptoms remains undefined. This study aims to describe the characteristics and evaluate the outcomes of conservative versus surgical management in CAD patients. METHODS: A total of 23 patients presenting with CAD from November 2014 to December 2021 were reviewed retrospectively. Patient demographics, vascular risk factors, symptoms, imaging results, treatment details, and follow-up information were collected and analyzed. Propensity score matching (PSM) was utilized to enhance comparability. RESULTS: The mean age of the patients was 46.4 ± 9.4 years, with a median follow-up of 12 (range 3-90) months. Of the 23 patients reviewed, seven underwent endovascular treatment or open surgery due to unresponsiveness to conservative therapy, while 16 received conservative management. All patients showed regression of symptoms. Surgical patients showed a significant improvement with a 100% patency rate during the follow-up. PS matching adjusted for baseline differences, yielding comparable groups for analysis. No significant difference between treatment approaches was observed in stroke recurrence rates, although surgical intervention showed promising outcomes in symptom resolution and stroke prevention. CONCLUSION: Both conservative and surgical management of CAD can lead to favorable outcomes. While conservative therapy remains the initial approach and proves effective, surgery appears beneficial and safe in certain cases unresponsive to conservative treatment. Further investigation through larger prospective and randomized trials is necessary to establish its safety and efficacy.

A Dedicated Algorithm For Endovascular Approach As A First-Line Treatment Option for Visceral Artery Aneurysms.

OBJECTIVES: Few data are reported in literature about visceral artery aneurysms (VAAs) management. The aim of the present study was to analyze VAAs management in a single institution, with a dedicated algorithm for endovascular approach as the first line treatment. METHODS: A single center retrospective cohort study was performed. Patients with a VAA submitted to either endovascular repair or open surgery from 2016 to 2023 were included. A dedicated algorithm was used to evaluate the endovascular approach feasibility assessing on the preoperative computed tomography angiography (CTA) the following parameters: (a) the tortuosity of the involved artery (<150°), (b) the healthy arterial diameter (>4mm), (c) the VAA proximity to the hilum and/or the presence of a bifurcation of the aneurysmatic artery, and (d) the circumferential calcium presence. An endovascular approach was chosen if (a) and (b) criteria were satisfied without (c) and (d) ones. Otherwise, it was deemed a challenging anatomy, and an open surgical treatment was considered. In the absence of (a) and/or (b) criteria open surgery was the preferred option. RESULTS: Thirty-one asymptomatic aneurysms (28 patients) were treated electively. The most frequent VAA location was the splenic artery (18 cases; 58%), followed by the renal arteries (6 cases; 19%), the common hepatic artery (5 cases; 16%), the gastroepiploic artery (1 case, 3.2%) and the pancreatoduodenal artery (1 case; 3%). Twenty-two aneurysms (71%) were initially treated by an endovascular approach (stent-graft deployment and/or transcatheter embolization) with 3 (13%) of them needing a surgical conversion. Nine aneurysms (29%) were submitted directly to a surgical treatment (aneurysm resection with or without interposition bypass) with no peri-operative and long-term complications. Technical success was 90.3%. CONCLUSIONS: Endovascular management as a first line approach is safe and effective in most cases. A preoperative dedicated algorithm is useful to identify suitable cases. Open surgery can be considered an alternative option in specific challenging anatomical situations or in case of endovascular failure.

Our Experience With 200 Cases of Inguinal Hernia Repair Using the Dynamic Self-Adjusting Prosthesis: A Case Series and Literature Review.

Introduction Inguinal hernioplasty (IH) is one of the most frequently performed surgical procedures globally. Today, a variety of surgical techniques and prosthesis types are available for this procedure. Methods At our center, we performed 200 inguinal hernioplasties using the dynamic self-adjusting prosthesis (protesi autoregolantesi dinamica, PAD) from May 1, 2022, to May 31, 2023. Our objective was to retrospectively analyze the outcomes and compare them with the current scientific literature on this surgical technique. Results Our results align with those reported by other authors using the same surgical technique. With the PAD technique, we assessed the type and frequency of adverse events up to 12 months following IH. All patients were male, with an average BMI of 26.6. Among the 200 hernias, 99 were right-sided, 101 were left-sided, 63 were direct, and 137 were indirect. The average length of hospitalization was one day. The most common postoperative complication was hematoma near the surgical site, but no prosthesis displacement was observed. In 71% of patients, analgesics were discontinued within 24 hours. The outcomes of our study are comparable to those reported by the inventor of this surgical technique. Conclusion The procedure has demonstrated safety and effectiveness and could serve as a viable alternative to traditional IH techniques.

Laparoscopic Versus Conventional Open Congenital Duodenal Obstruction Repair: A Systematic Review and Meta-analysis.

BACKGROUND: We conducted a systematic review and meta-analysis to evaluate the safety and effectiveness of laparoscopic surgery (LS) compared to open surgery (OS) for congenital duodenal obstruction (CDO). METHODS: We conducted a literature review to find studies comparing LS and OS in neonates with CDO. A meta-analysis was conducted to systematically compile and compare factors, including surgical duration, time of feeding initiation, hospital length of stay (LOS), and postoperative complications. RESULTS: Eleven studies with 1615 patients (LS: 338, OS: 1277) met inclusion criteria. Operative time was observed to be much shorter in the OS group (I2 = 97%); weighted mean difference (WMD) 60.29; 95% confidence interval (CI): 30.29 to 90.28; p < 0.0001). The LS group had a significantly shorter time to initiate feeding (I2 = 0%; WMD -3.38, 95% CI: -4.35 to -2.41; p < 0.00001), shorter time to full feeding (I2 = 0%; WMD -3.64, 95% CI: -5.06 to -2.22; p < 0.00001), and shorter LOS (I2 = 52%; WMD -3.42, 95% CI: -5.75 to -1.08; p = 0.004). There were no significantly differences in the rates of anastomotic leak (I2 = 24%; OR 0.76, 95% CI: 0.12 to 4.67; p = 0.76), anastomotic stricture (I2 = 0%; OR 1.12, 95% CI: 0.39 to 3.20; p = 0.83), postoperative ileus (I2 = 0%; OR 0.60, 95% CI: 0.21 to 1.74; p = 0.34), and overall complications between the groups (I2 = 59%; OR 0.86, 95% CI: 0.42 to 1.74; p = 0.68). The LS group, however, had a significantly decreased frequency of wound infection (I2 = 0%; OR 0.26, 95% CI: 0.08 to 0.82; p = 0.02). CONCLUSION: Despite certain limitations in our analysis, the laparoscopic approach was associated with comparable postoperative outcomes. LEVELS OF EVIDENCE: 2a. TYPE OF THE STUDY: Meta analysis.

Ultrasound-guided needle knife release for stenosing tenosynovitis of the flexor pollicis longus: a prospective randomized controlled trial.

PURPOSE: This study aimed to evaluate the efficacy and safety of ultrasound-guided needle knife release in the treatment of stenosing tenosynovitis of the flexor pollicis longus. METHODS: In this prospective trial, 60 patients with clinically and ultrasonographically confirmed stenosing tenosynovitis of the flexor pollicis longus were randomly allocated to 1 of 3 groups: ultrasound-guided needle knife release (n = 20), traditional conservative treatment (n = 20), and open surgery (n = 20). The primary outcome measure was the Quinnell grade of triggering severity. Secondary outcomes comprised pain intensity (on visual analog scale), satisfaction (5-point Likert scale), and complications. Outcomes were evaluated at baseline, 1 week, 1 month and 3 months post-intervention by blinded assessors. RESULTS: At all follow-up time points, the needle knife release group demonstrated significantly lower Quinnell grades (p < 0.05) and pain scores (p < 0.001) than the conservative treatment group; satisfaction was greater in the needle knife release group compared to the conservative treatment group at 1 month (p = 0.002) and 3 months (p < 0.001). There were no significant differences in outcomes between the needle knife release group and the open surgery group. The overall complications rate was 5% in the needle knife release group, 10% in the conservative treatment group, and 15% in the open surgery group (p = 0.574). CONCLUSION: Ultrasound-guided needle knife release is an effective and safe treatment for stenosing tenosynovitis of the flexor pollicis longus, with outcomes that are better than with traditional conservative treatment and similar to those of open surgery.

Endovascular Treatment versus Open Surgical Repair for Isolated Iliac Artery Aneurysms.

Purpose: Endovascular treatment (EVT) has been shown to be effective and safe for isolated iliac artery aneurysms (IAAs). However, concerns remain regarding the lack of consideration to recent advances in perioperative care and surgical techniques, as well as a significant number of re-interventions with EVT. This study compares the outcomes of open surgical repair (OSR) and EVT using recent clinical data. Materials and Methods: This retrospective, single-center study included patients who underwent OSR or EVT for isolated degenerative IAAs between January 2007 and December 2018. Primary outcomes were procedure time, number of transfusions during admission, length of hospital stay, complications, and number of preserved internal iliac arteries. Secondary outcomes included all-cause and aneurysm-related mortality, and re-intervention rates. Results: Fifty-eight consecutive patients underwent treatment for isolated IAAs (25 underwent OSR and 33 underwent EVT), with a median follow-up of 75 months (range: 39-133 months). Baseline characteristics were similar between the groups, except for a lower mean age in the OSR group than in the EVT group (66.0±8.2 vs. 73.1±8.6, P=0.003). Both groups had a mild risk of comorbidity severity score. Early complications (within 30 days of the procedure) occurred more frequently in the OSR group, though not statistically significant (24.0% vs. 6.1%, P=0.07). Late complications, including sac expansion and thrombotic occlusion, were significantly more common in the EVT group (15.2% vs. 0%, P=0.04). Re-intervention rate was higher in the EVT group but not statistically significant (9.1% vs. 4.0%, P=0.44). No significant differences were observed in major adverse cardiovascular events and mortality between the groups (P=0.66 and P=0.27), and there were no aneurysm-related deaths. Conclusion: For patients with mild risk factors, EVT does not offer a survival or re-intervention advantages over OSR in the treatment of isolated IAAs. However, EVT is associated with an increased risk of late complications. Although larger randomized studies are necessary, OSR may be considered the first-line treatment for isolated IAAs in younger and mild-risk patients.

Development and Validation of a Realistic Neonatal Intestinal Jejunoileal Atresia Simulator for the Training of Pediatric Surgeons.

Background: Neonatal surgical pathology presents highly technical complexity and few opportunities for training. Many of the neonatal surgical entities are not replicable in animal models. Realistic 3D models are a cost-effective and efficient alternative for training new generations of pediatric surgeons. Methods: We conceptualized, designed, and produced an anatomically realistic model for the open correction of jejunoileal atresia. We validated it with two groups of participants (experts and non-experts) through face, construct, and content validity questionnaires. Results: The model was validated by eleven experts and nine non-experts. The mean procedure time for the experts and non-experts groups was 41 and 42 min, respectively. Six non-experts and one expert did not complete the procedure by the designed time (45 min) (p = 0.02). The mean score of face validity was 3.1 out of 4. Regarding construct validity, we found statistically significant differences between groups for the correct calculation of the section length of the antimesenteric border (Nixon's technique) (p < 0.01). Concerning content validity, the mean score was 3.3 out of 4 in the experts group and 3.4 out of 4 in the non-experts group. Conclusions: The present model is a realistic and low-cost valid option for training for open correction of jejunoileal atresia. Before drawing definitive conclusions, future studies with larger sample sizes and blinded validators are needed.

Impact of robotic-assisted surgery on length of hospital stay in Paris public hospitals: a retrospective analysis.

The number of available hospital beds is decreasing in many countries. Reducing the length of hospital stay (LOS) and increasing bed turnover could improve patient flow. We evaluated whether robot-assisted surgery (RAS) had a beneficial impact on the LOS in a French hospital trust with a long-established robotic program (Assistance Publique-Hôpitaux de Paris, AP-HP). We extracted data from "Programme de Médicalisation des Systèmes d'Information" to determine the median LOS for adults in our trust after RAS versus laparoscopy and open surgery in 2021-2022 for eight target procedures, and compared data nationally and at similar academic centres (same database). We also calculated the number of hospitalisation days 'saved' using RAS. Overall, 9326 target procedures were performed at AP-HP: 3864 (41.4%) RAS, 2978 (31.9%) laparoscopies, and 2484 (26.6%) open surgeries. The median LOS for RAS was lower than laparoscopy and open surgery for all procedures, apart from hysterectomy and colectomy (equivalent to laparoscopy). Results for urological procedures at AP-HP reflected national values. The equivalent of 5390 hospitalisation days was saved in 2021-2022 using RAS instead of open surgery or laparoscopy at AP-HP; of these, 86% represented hospitalisation days saved using RAS in urological procedures. Using RAS instead of open surgery or laparoscopy (particularly in urological procedures) reduced the median LOS and may save thousands of hospitalisation days every year. This should help to increase patient turnover and facilitate patient flow.

Efficacy and Safety of Robotic Surgery vs. Open Surgery for Hilar Cholangiocarcinoma: A Comprehensive Review.

Hilar cholangiocarcinoma, a rare and aggressive bile duct malignancy, presents significant challenges in surgical management. Traditionally treated with open surgery, the emergence of robotic surgery has introduced a new dimension to surgical approaches for this condition. This review aims to systematically compare the efficacy and safety of robotic surgery versus open surgery for hilar cholangiocarcinoma. We conducted a comprehensive review of the literature, including clinical studies, case series, and comparative analyses of robotic and open surgical techniques. Data on oncological outcomes, functional recovery, survival rates, complications, and cost-effectiveness were extracted and analyzed to provide a detailed comparison of the two surgical approaches. Robotic surgery offers several potential advantages over open surgery, including reduced intraoperative blood loss, smaller incisions, and shorter recovery times. However, it requires specialized training and has a higher initial cost. Open surgery, while more established and broadly practiced, remains associated with longer recovery periods and higher complication rates. Oncological outcomes, such as R0 resection rates and survival, appear comparable between the two approaches, though robotic surgery may offer improvements in functional recovery and postoperative quality of life. Both robotic and open surgery have their merits in the treatment of hilar cholangiocarcinoma. Robotic surgery presents promising benefits in terms of reduced invasiveness and improved recovery, while open surgery continues to be a reliable and well-established option. The choice of surgical approach should be guided by patient-specific factors, surgeon expertise, and institutional resources. Further research is needed to refine surgical techniques and establish long-term outcomes, which will aid in optimizing treatment strategies for this challenging malignancy.

Evolving Approach in Nephron-Sparing Surgery: Has Anything Changed from Open Surgery to Laparoscopy?

OBJECTIVE: This study aimed to provide valuable insights into the comparative efficacy of different surgical approaches for nephron-sparing surgery (NSS) and contribute to the existing literature in this field. MATERIALS AND METHODS: This study included patients who underwent NSS for small renal masses between January 2016 and March 2024. A total of 97 patients (41 in the open approach group, 56 in the laparoscopic approach group) with demographic, radiological, intraoperative, renal functional, and oncological follow-up data were included. Three different anatomical scoring systems (R.E.N.A.L. nephrometry score, PADUA score and C-index) were utilised to assess tumour location and estimate proximity to the hilum and collecting system. RESULTS: In the open nephron-sparing surgery (ONSS) and laparoscopic nephron-sparing surgery (LNSS) groups, the mean kidney tumour diameters (SD) were 5.20 ± 2.30 and 4.90 ± 2.10, which were similar in both surgical method groups (p = 0.061). However, tumours treated with ONSS had significantly more adverse morphometric features (p < 0.05). For ONSS and LNSS groups, the mean R.E.N.A.L. nephrometry scores (SD) were 6.15 ± 2.04 and 5.2 ± 1.4 (p = 0.032), respectively; The mean PADUA scores (SD) were 7.46 ± 1.14 and 6.8 ± 1.0 (p = 0.049), respectively; And the mean C-index (SD) scores were 1.39 ± 0.4 and 1.37 ± 0.5 (p = 0.062), respectively. No significant differences were found in the mean tumour diameter (cm) (Inter Quantile Range (IQR)) distribution of both groups (p = 0.058). Despite the slight increase in transfusion rate in the LNSS group, estimated blood loss (EBL), transfusion rates, and length of hospital stay were similar in both groups. CONCLUSIONS: Although LNSS does not appear superior in terms of intraoperative blood loss, length of hospital stay and transfusion rate, it provides comparable long-term outcomes to ONSS. Our study suggests that when matched with nephrometry scores, LNSS can achieve similar outcomes to ONSS.

The difficulties and solutions in operationalising a hybrid operating room.

As the population ages and grows, health services must evolve in ways to offer versatile patient care, whilst improving patient outcomes and maintaining long-term economic viability. A facility assisting in the provision of such healthcare is the hybrid operating room (HOR): a specialised suite allowing simultaneous radiological and surgical diagnostics and therapeutics in a single episode of care. Versatile and customizable, the HOR is utilised by a broad range of subspecialties in elective and emergency settings, including (but not limited to) vascular surgery, trauma surgery and interventional radiology. Though the benefits of hybrid techniques to patient care are well known, the actual steps in operationalising the HOR can be challenging if not considered and coordinated appropriately. The intention of this narrative review is to highlight issues and suggest solutions in the design and commissioning of an HOR. Key areas in need of specific attention include stakeholder involvement, economic feasibility, suite location, workflow planning, hybrid equipment choice, and team organisation.

Oncological outcomes of minimally invasive surgery in non-endometrioid endometrial Cancer patients with varying prognostic risks: a retrospective cohort study based on the ESGO/ESTRO/ESP 2020 guidelines.

BACKGROUND: Non-endometrioid endometrial carcinomas (NEEC) are characterized by their rarity and adverse prognoses. This study evaluates the outcomes of open versus minimally invasive surgery (MIS) in NEEC patients stratified by prognostic risks according to the 2020 ESGO-ESTRO-ESP risk classification guidelines. METHODS: A retrospective analysis was performed on 99 NEEC patients who underwent initial surgery at Fujian University Cancer Hospital. Patients were categorized into two groups: those undergoing MIS and those undergoing open surgery. We compared disease-free survival (DFS) and overall survival (OS) between these groups. Cox regression analysis was employed to identify risk factors for DFS, which were further validated via bootstrap statistical methods. RESULTS: The study included 31 patients in the MIS group and 68 in the open surgery group. The demographics and clinical characteristics such as age, body mass index, comorbidities, histological subtypes, and FIGO stage were similar between groups (P > 0.05). The MIS group experienced ten recurrences (1 vaginal, 2 lymph nodes, 7 distant metastases), whereas the open surgery group had seven recurrences (1 vaginal, 3 lymph nodes, 1 pelvis, 2 distant metastases), yielding recurrence rates of 10.3% versus 25.6% (P = 0.007). Besides lymphovascular space invasion (LVSI), surgical approach was also identified as an independent prognostic factor for DFS in high-risk patients (P = 0.037, 95% CI: 1.062-7.409). The constructed nomogram demonstrated a robust predictive capability with an area under the curve (AUC) of 0.767. Survival analysis for high- and intermediate-risk patients showed no significant differences in OS between the two groups (Phigh risk = 0.275; Pintermediate-risk = 0.201). However, high-risk patients in the MIS group exhibited significantly worse DFS (P = 0.001). CONCLUSION: This investigation is the inaugural study to assess the impact of surgical approaches on NEEC patients within the framework of the latest ESGO-ESTRO-ESP risk classifications. Although MIS may offer clinical advantages, it should be approached with caution in high-risk NEEC patients due to associated poorer DFS outcomes.

A Decade of Progress: Assessing Three Revascularization Strategies for Iliac Occlusive Disease Through a 580-Case, 10-Year-Experience Literature Comparison.

INTRODUCTION:  Peripheral arterial disease (PAD) is a critical concern, particularly in the context of an aging population and escalating risk factors such as diabetes, hypertension, and smoking. PAD leads to significant morbidity and disability, imposing considerable healthcare and economic burdens. A detailed understanding of the functional outcomes of revascularization is essential as it influences the choice of therapeutic strategies. This is crucial for the patient-doctor dialogue, enabling informed decisions based on the benefits, risks, and costs associated with each option. This study specifically examines the effectiveness of various revascularization methods for iliac occlusive disease by analyzing factors such as procedural success rates, complication frequencies, long-term patency, and patient quality of life. By evaluating these characteristics, the study aims to guide surgeons in selecting the most appropriate treatment approach in modern vascular surgery. METHODS: A 10-year single-center retrospective analysis was conducted, examining 521 patients (580 interventions) from January 2009 to December 2018. Treatments included endovascular recanalization and stenting (endovascular treatment, EVT) (31.4%), hybrid surgical treatment (HST) (31.6%), and open surgical treatment (OST) (37.07%). The examined characteristics were primary patency, primary assisted patency, secondary patency, complications, and the degree of limb salvage. RESULTS: The study assessed variables such as age, gender, diabetes, hypertension, dyslipidemia, smoking status, chronic kidney disease, and anesthesiological risk (American Society of Anesthesiologists (ASA) grade). Patency rates across the three methods were 92.4%, with thrombosis observed in 7.6% of cases. Assisted primary reconstructions, identified in the analysis, were few in number. Across the three revascularization strategies, a total of 41 interventions were undertaken to preserve the patency of the index reconstruction. In cases of chronic limb-threatening ischemia (CLTI), the probability of losing patency is higher and occurs earlier. OST showed the longest patency duration (471.7±71.5 days), and EVT demonstrated consistent primary patency. Complications were the highest in OST, including five perioperative mortalities. Survival analysis revealed significant differences in patency between treatment methods, with EVT and HST showing better outcomes compared to OST, particularly in patients with CLTI. CONCLUSION: By far, this is one of the largest studies done comparing all three revascularization strategies. Endovascular, surgical, and hybrid interventions should be considered complementary elements in the vascular surgeon's toolkit. However, in the presented study, endovascular and hybrid treatment appeared to produce better outcomes compared to open surgical treatment, especially in patients with CLTI. Keeping this in mind the surgeon should be able to provide a more optimal and personalized treatment for patients with chronic lower limb ischemia.

The clinical effect of endoscopic and open surgery in the treatment of thyroid cancer and their effect on the blood coagulation state: a comparative study.

Purpose: This study was performed to compare the therapeutic efficacy of endoscopic surgery and open surgery and their effects on postoperative blood coagulation state in patients with thyroid cancer, and to provide evidence for the prevention measurement of thrombosis in the perioperative period. Methods: One hundred patients with thyroid cancer who received treatment in our hospital from January 2021 to December 2021, were randomly divided into an endoscopic group and an open surgery group, with 50 patients in each group. The patients in the open surgery group were treated by traditional open surgery, while patients in the endoscopic group accepted endoscopic surgery. The clinically therapeutic effect and blood coagulation of the 2 groups were compared. Results: Intraoperative blood loss and length of hospital stay were lower, and operative time was longer in the endoscopic group than in the open surgery group (P < 0.05). The 24-hour postoperative fibrinogen and D-dimer levels were higher in both groups than in the preoperative period, while PT was shorter (P < 0.05). There were no significant differences in postoperative complications and follow-up between the 2 groups (P > 0.05), but the incidence of complications, postoperative metastases, and thrombosis was relatively low in the endoscopic group. Conclusion: In the treatment of patients with thyroid cancer, endoscopic surgery has the advantages of less blood loss, fewer complications, and so on. Endoscopic and open surgery can lead to a hypercoagulable state, but the effect of endoscopic surgery is better than that of open surgery.

A comparison between robotic-assisted and open approaches for large ventral hernia repair-a multicenter analysis of 30 days outcomes using the ACHQC database.

INTRODUCTION: Over the last few decades, there has been an increase in the use of a minimally invasive (MIS) approach for complex hernias involving component separation. A robotic platform provides better visualization and mobilization of tissues for component separation. We aim to assess the outcomes of open and robotic-assisted approaches for large VHR utilizing the ACHQC national database. METHODS: A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was performed to include all adult patients who had primary and incisional midline ventral hernias larger than 10 cm and underwent elective open and robotic hernia repairs with mesh from January 2013 to March 2023. Univariate and multivariate analyses were performed comparing Open and Robotic approaches. RESULTS: The ACHQC database identified 5,516 patients with midline hernias larger than 10 cm who underwent VHR. The open group (OG) had 4,978 patients, and the robotic group (RG) had 538. The RG had a higher median BMI (33.3 kg/m2 (IQR 29.8-38.1) vs 32.7 (IQR 28.7-36.6) (p < 0.001). Median hernia width was 15 cm (IQR 12-18) in the OG and 12 cm in the RG (10-14) (p < 0.001). Sublay positioning of the mesh was the most common. The fascial closure was higher in the RG (524; 97% versus 4,708; 95%-p = 0.005). Median Length of Stay (LOS) was 5 days (IQR 4-7) in the OG and 2 days (IQR 1-3) in the RG (p < 0.001). The readmission rate was higher in the OG (n = 374; 7.5% vs n = 16; 3%; p < 0.001). 30-day SSI were higher in the OG (343; 6.9%% vs 14; 2.6%; p < 0.001). Logistic regression analysis identified diabetes (OR 1.6; CI 1.1-2.1; p = 0.006) and BMI (OR 1.04, CI 1.02-1.06; p < 0.001) as predictors of SSIs, while the robotic approach was protective (OR 0.35, CI 0.17-0.64; p = 0.002). For SSO, logistic regression showed BMI (OR 1.04, CI 1.03-1.06; p < 0.001) and smoking (OR 1.8, CI 1.3-2.4; p < 0.001) as predictors Robotic approach was associated with lower readmission rates (OR .04, CI 0.2-0.6; p < 0.001). CONCLUSION: A robotic approach improves early 30-day outcomes compared to an open technique for large VHR. There was no difference in SSO at 30 days.

An evidence-based model for predicting conversion to open surgery in minimally invasive distal pancreatectomy.

BACKGROUND: Intraoperative conversion to open surgery is an adverse event during minimally invasive distal pancreatectomy (MIDP), associated with poor postoperative outcomes. The aim of this study was to develop a model capable of predicting conversion in patients undergoing MIDP. METHODS: A total of 352 patients who underwent MIPD were included in this retrospective analysis and randomly assigned to training and validation cohorts. Potential risk factors related to open conversion were identified through a literature review, and data on these factors in our cohort was collected accordingly. In the training cohort, multivariate logistic regression analysis was performed to adjust the impact of confounding factors to identify independent risk factors for model building. The constructed model was evaluated using the receiver operating characteristics curve, decision curve analysis (DCA), and calibration curves. RESULTS: Following an extensive literature review, a total of ten preoperative risk factors were identified, including sex, BMI, albumin, smoker, size of lesion, tumor close to major vessels, type of pancreatic resection, surgical approach, MIDP experience, and suspicion of malignancy. Multivariate analysis revealed that sex, tumor close to major vessels, suspicion of malignancy, type of pancreatic resection (subtotal pancreatectomy or left pancreatectomy), and MIDP experience persisted as significant predictors for conversion to open surgery during MIDP. The constructed model offered superior discrimination ability compared to the existing model (area under the curve, training cohort: 0.921 vs. 0.757, P < 0.001; validation cohort: 0.834 vs. 0.716, P = 0.018). The DCA and the calibration curves revealed the clinical usefulness of the nomogram and a good consistency between the predicted and observed values. CONCLUSION: The evidence-based prediction model developed in this study outperformed the previous model in predicting conversions of MIDP. This model could contribute to decision-making processes surrounding the selection of surgical approaches and facilitate patient counseling on the conversion risk of MIDP.

AB075. When would minimally invasive spinal surgery not be preferable for metastatic spine disease?-a narrative review.

BACKGROUND: Metastatic spine tumour surgery (MSTS) is an important treatment modality of metastatic spinal disease (MSD). Open spine surgery (OSS) was previously the gold standard of treatment. However, advancements in MSTS in recent years has resulted in a current paradigm shift towards today's gold standard of minimally invasive spinal surgery (MISS) and early adjuvant RT in treating MSD patients. Nonetheless, there are still certain situations whereby MISS is not desirable or even suitable. There has also yet to be any literature describing the considerations for not using MISS in MSD in today's clinical context. We aim to bridge the gap where OSS should be considered with caution and highlight situations where MISS is preferable using the available literature and personal experience. METHODS: This narrative review was conducted using PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), The Cochrane Library and Scopus databases through August 31, 2023. Inclusion criteria for the review were studies with discussion on the type of surgery in MSTS. RESULTS: A total of 52 studies were included in this review. We discussed various advantages and situations appropriate for MISS for MSD in today's clinical context. Nonetheless, there are still various unique circumstances in which MISS may be less suitable. MISS is less feasible in patients of paediatric profile, having short stature or having had previous surgery at the level of operation. Occipitocervical and cervicothoracic location of vertebrae metastasis also makes MISS less feasible due to access and imaging difficulty. MISS for tumours which are hypersclerotic and hypervascular can also result in more difficulty for cannulation of MISS probes as well as control of bleeding respectively, and hence will be less encouraged in the above settings. CONCLUSIONS: Our review will be the first to discuss circumstances in which MISS is less applicable, despite the advantages it may confer over traditional OSS. MSTS should be individualized to the patient, depending on the experience of the surgeon. OSS is still a time-tested approach that holds weight in MSTS and should be readily utilized depending on the clinical situation.

Lessons Learned with Enhanced Recovery for Open Abdominal Aortic Aneurysm Surgery: A Long Term Regional Network Experience.

OBJECTIVE: This enhanced recovery programme (ERP) aimed to achieve early recovery for patients undergoing major surgery. Results of a standardised ERP protocol for open infrarenal abdominal aortic aneurysm (AAA) repair within a hub and spoke regional network are presented. METHODS: In this single centre prospective study (January 2004 - December 2021), consecutive AAAs (≥ 55 mm) were included in the ERP (patient discharge on post-operative day [POD] 4). The four phases of the ERP were pre-admission, pre-operative, intra-operative, and post-operative. Exclusion criteria were BMI > 35 kg/m2, functional capacity < 4 MET, previous aortic or abdominal surgery, and life expectancy < 5 years. Transperitoneal surgery was undertaken with routine AAA resection, graft interposition, and closure. RESULTS: Consecutive patients (n = 778) were enrolled into the study (mean age 72.3 ± 3.2 years; n = 712 men); 160 (20.5%) were treated in spoke hospitals. Median follow up was 78 (IQR 28, 128) months; median length of stay, procedure time, and blood loss were four days (IQR 3, 5), 190 minutes (IQR 170, 225), and 564 mL (IQR 300, 600). Infrarenal clamping and tube graft configuration were used in 96.5% (n = 751) and 72.5% (n = 564) of patients; 30 day mortality and complication rates were 0.4% (n = 3) and 9.2% (n = 72). Discharge after POD 4 occurred in 15.0%, and most significant predictors for discharge after POD 4 were blood transfusion, re-intervention, and ileus over three days. Overall survival was: 98.2% at one year, 85.0% at five years, and 59.9% at 10 years. Freedom from re-intervention was 97.9% at one year, 94.1% at five years, and 86.8% at 10 years. Short and long term outcomes were comparable between hub and spoke hospitals. CONCLUSION: The ERP protocol was associated with low short and long term mortality and complication rates. Future studies should apply the ERP protocol in other vascular centres.

Vascular anomalies of the limb and trunk in children: a retrospective comparative study of endoscopic surgery and open surgery.

BACKGROUND: Endoscopic resection has been reported for vascular anomalies (VA) previously. However, there is no study comparing endoscopic resection surgery (ERS) with open resection surgery (ORS) in children. We aimed to compare clinical and cosmetic outcomes between two approaches in pediatric VA. METHODS: Between June 2018 and June 2023, 138 pediatric VA patients undergoing ERS or ORS were retrospectively reviewed. Propensity score matching (PSM) was performed to minimize selection bias. The Scar Cosmesis Assessment and Rating (SCAR) Scale and numerical rating scale (NRS) based on patient satisfaction were used for cosmetic assessment. RESULTS: After PSM for age, depth of lesion, size of lesion, and site of surgery, 72 patients (ERS = 24, ORS = 48) were analyzed. Patients undergoing ERS had longer operative time (164.25 ± 18.46 vs. 112.85 ± 14.26 min; P < 0.001), less estimated blood loss (5.42 ± 2.15 vs. 18.04 ± 1.62 ml; P < 0.001), and shorter median hospital stay (4.50 [3.00-5.00] vs. 6.00 [5.00-6.00] days; P < 0.001). The follow-up time was 8.04 ± 1.23 month for ERS group and 8.56 ± 1.57 month for ORS group. For aesthetic results, the median overall SCAR score in ERS was lower than that in ORS (2 [1-3] vs. 5 [4-5]; P < 0.001), and the subscales of "scar spread," "dyspigmentation," "track marks or suture marks," and "overall impression" were better. The median NRS score was higher (8 [7-8] vs. 6 [5-6]; P < 0.001) and length of scars was shorter (2.18 ± 0.30 vs. 8.75 ± 1.98 cm; P < 0.001) in ERS group than those in ORS group. The incidences of total complications and recurrence showed no significant difference between two groups. CONCLUSIONS: Endoscopic surgery can be a safe and effective option for pediatric VA in the limbs and trunk. It offers the advantages of improving aesthetic outcomes and reducing postoperative wound healing time.