Complications Associated with Catheter Ablation of Atrial Fibrillation in Current Practice: Insights from a Large, Real-World Collaboration

Background: Catheter ablation is a cornerstone treatment for symptomatic atrial fibrillation (AF) with major improvements in safety over time. However, rates of adverse events with use of current techniques in a contemporary quality-focused network remain undefined. Objective(s): Across a large, real-world sample, we sought to describe (1) rates of major, adverse events associated with catheter ablation of AF and (2) patient-level factors associated with complications. Method(s): Utilizing the REAL-AF collaboration, a registry of contemporary AF ablation procedures with granular patient, procedural and follow-up data comprised of cases from over 50 operators across academic and non-academic sites, we evaluated all patients undergoing their first ablation procedure from January 2018 - June 2022. Risk-adjusted analyses were conducted to evaluate the relationship between patient factors and complications. Result(s): Among 3144 patients (age 66.1 +/- 11.0 years, 42% female, 67.1% paroxysmal, 32.9% persistent) who underwent AF ablation, procedure-related complications (n =77) were identified in 65 patients (2.1%) with multiple complications occurring in 9 patients (0.2%). Most complications (n=70, 93.5%) occurred in the peri-procedural (within 30 days) period and 6.5% (n=5) after 30 days, the latter of which all represented vascular injuries (Figure). Major complications (18 of 72 peri-procedural complications, 25.0%) are defined, detailed, and associated data reported in the Figure. Unadjusted (16.0% without CHF vs. 33.3% with CHF, p = 0.045) and risk-adjusted (OR 2.8, 95% CI 1.03-7.60, p=0.045) analyses indicated history of CHF was associated with a composite outcome of major complications. Analyses of independent complications showed those who suffered from peri-procedural stroke (n=3) were of significantly greater age (77.3 +/- 5.5 years vs. 66.1 +/- 10.9 years, p=0.035). Risk-adjusted analyses showed history of vascular disease (OR 2.9, 95% CI 1.02-8.20, p=0.045) was associated with vascular injury (n=18). From 0-695 days post-procedure, 31 deaths occurred (unknown cause: 17, COVID-19 related: 4, heart failure: 2, cardiac arrest: 2). Conclusion(s): Major complications represent rare events among those undergoing AF ablation in current practice. Risk-adjusted analyses suggest a history of CHF is associated with major complications. Similarly, older age and a history of vascular disease are associated with stroke and vascular complications, respectively. [Formula presented]Copyright © 2023

Psychological Concerns of Children Undergoing Kidney Transplantation and Their Families during the Covid-19 Pandemic

Background The current COVID-19 pandemic has been an anxious time for children and young people (CYP) with end stage kidney disease and their families particularly as they were identified as a vulnerable group. Many transplant programmes closed and reopening brought new concerns for patients and professionals. We report patient experience on being transplanted during the pandemic. Objectives To obtain a better understanding of the concerns and experiences that CYP and families have about receiving a kidney transplant during the pandemic. Methods A questionnaire was sent to patients and families of 10 paediatric patients transplanted in the first six months of reopening our transplant programme. One patient refused transplant and one lacked social support to proceed with the transplant. Results All participants felt that their questions were answered before transplantation and 75% felt well informed about the SARS-CoV-2 effects on transplantation. 62.5% reported feeling nervous 37.5% were anxious 25% scared and 12.5% relaxed about transplantation during the pandemic. The majority of participants reported surgical complications being their biggest fear;two participants were worried about catching SARS-CoV- 2. 87.5% felt that care was delivered safely in inpatient and outpatient setting. 75% of participants found shielding easy. Overall 87.5% of patients were glad to have received a kidney transplant during the pandemic with one patient struggling with feeling isolated. Conclusions Receiving a kidney transplant can be a stressful experience particularly during a pandemic. Our results show that a significant number of patients felt scared that detailed counselling of CYP and families about risks and addressing their concerns related to SARS-CoV-2 contributed to a good patient and family experience on transplantation during the pandemic. Further studies are needed to look into the longterm effects of the pandemic on this vulnerable group of patients and strategies to mitigate them.

"Inside out" - An exceptional intussusception

Introduction: We present the first case of appendiceal intussusception associated with myeloid sarcoma in a young patient. Minimally invasive techniques used along the clinical course are highlighted. Case description: A 2.5-year-old boy was admitted after three weeks of COVID-19 infection with ongoing symptoms of MIS-C. Due to constipation, distended belly and vomiting, US was done which showed ileocolic intussusception. After unsuccessful hydrostatic reduction laparoscopic exploration was performed, where the vermiform appendix was found to be thickened and partially intussuscepted into the coecum. The ileocecal region was exteriorized transumbilically. After manual reduction of the intussusception, a long, thickened, fragile appendix was removed. Histopathology revealed myeloid sarcoma. Bone marrow investigation identified acute myeloid leukemia. During the oncological treatment, laparoscopic cholecystectomy was necessary due to cholecystitis and cholelithiasis. The child recovered uneventfully in terms of surgical complications, with good cosmetic result. Conclusion(s): No similar case in childhood was found in the English literature. Unusual symptoms and radiological findings of intussusception can conceal unexpected disorders. Minimally invasive technique offered advantages in the treatment of the presented patient and can be recommended to treat intussusception or cholelithiasis, if applicable, during an ongoing oncological treatment as well.Copyright © 2023 The Authors

A rare complication of esophagoplasty in a COVID-19 reconvalescent.

Esophagoplasty in patients with esophageal cancer remains an extremely high-risk operation. This is due not only to the invasiveness of the operation, but also to the need for adequate blood supply to the gastric tube moved to the posterior mediastinum. The course of a new coronavirus infection is characterized by a high risk of thrombotic and thromboembolic complications, including after surgical interventions. The aim is to present a clinical observation of the development of a lethal complication of esophagoplasty - gastric graft necrosis in a convalescent patient with a new coronavirus infection COVID-19.Copyright © 2022 GEOTAR Media. All rights reserved.

A rare complication of esophagoplasty in a COVID-19 reconvalescent.

Esophagoplasty in patients with esophageal cancer remains an extremely high-risk operation. This is due not only to the invasiveness of the operation, but also to the need for adequate blood supply to the gastric tube moved to the posterior mediastinum. The course of a new coronavirus infection is characterized by a high risk of thrombotic and thromboembolic complications, including after surgical interventions. The aim is to present a clinical observation of the development of a lethal complication of esophagoplasty - gastric graft necrosis in a convalescent patient with a new coronavirus infection COVID-19.Copyright © 2022 GEOTAR Media. All rights reserved.

Disease clearance: A potential target for management of patients with Ulcerative Colitis

Background: Disease clearance defined by the absence of symptoms and intestinal inflammation at endoscopic and histological examination, is proposed as a target in the evaluation of the ulcerative colitis (UC) course. The purpose of this study was to evaluate disease remission on the UC evolution according to disease clearance concept. Method(s): Between January 2020 - March 2022, 79 patients with UC were evaluated clinically, laboratory testing, endoscopically and histologically. Patients positive for COVID and CDI were not included in the study. Disease remission, in accordance with the concept of disease clearance it is defined as clinical (partial Mayo score <=2), endoscopic (endoscopic Mayo score <=1) and histological (Nancy Index) remission. Disease clearance was measured at inclusion in the study and during follow-up after 12 months. Results were compared in patients who did or did not achieve disease clearance. Result(s): The patients were divided into 2 groups according to disease clearence: Group 1: 35 out of 79 patients with UC evaluated, were considered with disease clearance at the initial moment of the evaluation. Group 1 did not present complications and did not require surgical interventions during the follow-up period, compared to group 2: Nondisease clearence patients, 44 out of 79 patients (0.0% vs. 31.8%, p=0.03, OR=23.1). During follow-up, 38.6% patients (N=17 pts, Incidence Rate=0.3864) from group 2 obtained clinical remission, of which 15.9% patients obtained endoscopic remission, 6.81% patients obtained histological remission (p=0.025) and 27.2% patients were under biological therapy. A total of 27 patients from both groups required hospitalization, significantly shorter for patients with initial values of fecal calprotectin below 200 mug/mg, and without endoscopic and/or histological activity (8.57% vs. 54.54%, p=0.002, OR=0.57, RR=0.224). 51.8% patients presented severe forms of disease with surgical and non-surgical complications (35.7% vs. 64.2%, p=0.91, OR=1.07). Surgical complications include toxic megacolon (N=2 pts, 14.2%), colonic perforation (N=1 pts, 7.1%), gastrointestinal hemorrhage (N=1 pts, 7.1%) and stricture with bowel obstruction (N=1 pts, 7.1%). Non-surgical complications include gastrointestinal hemorrhage (N=6 pts, 42.8%), venous thrombosis (N=1 pts, 7.1%) and colorectal cancer (N=2 pts, 14.2%). No deaths were reported. Conclusion(s): According to the concept of disease clearance, our data indicate that UC patients in clinical, endoscopic and histological remission present a significantly lower risk of hospitalization, complications and surgical intervention.

Isolated cerebral mucormycosis in post-COVID-19 pneumonia

Background: Rhino-orbital-cerebral and isolated cerebral involvement of basal ganglia by mucormycosis are two different manifestations of CNS mucormycosis. The former variant caused by inhaled fungal spores and is common with immunosuppressive conditions. The latter form is caused by intravascular inoculation of spores as seen in intravenous drug abusers. Case report: Here we describe a case of young, non-addict patient with a history of recent mild COVID-19 pneumonia who presented with isolated cerebral mucormycosis involving bilateral basal ganglia. Discussion(s): The pulmonary vasculitis associated with COVID-19 is probably the cause of direct intravascular entry of inhaled fungal spores leading to direct isolated cerebral involvement. Such condition may rapidly turn fatal. Conclusion(s): This is the first reported case of isolated cerebral mucormycosis following post-COVID-19 infection. Early tissue diagnosis and intravenous amphotericin B is the key management.Copyright © 2022

Medical bridging therapy before pulmonary endarterectomy?

Introduction: Pulmonary endarterectomy (PEA) is the recommended treatment for patients with operable chronic thromboembolic pulmonary hypertension (CTEPH). Reducing PVR pre-surgery may lower the surgical risk, but efficacy of drug treatment in operable CTEPH has not yet been proven and surgeons are concerned that dissection may be more difficult in pre-treated patients. Methodology: A randomised, double-blind, placebo controlled, multinational prospective study was performed in patients with operable CTEPH and PVR >800 dynes.sec.cm-5 at baseline (NCT03273257). Patients were randomised to Riociguat or placebo for 3 months prior to PEA. Primary endpoint was the change in PVR from baseline to before PEA. Secondary endpoints included perioperative findings and evaluation of the PEA specimen. Planned recruitment was 88 patients over 2 years. Result(s): The study was terminated early because of slow recruitment and the COVID-19 pandemic. At the time of study cessation, 14 patients were randomised (7 in each group) and 11 patients completed PEA surgery. At diagnosis, PVR was 944.0 dynes.sec.cm-5 in the Riociguat group and 1007.5 dynes.sec.cm-5 in the control group. -5 -5 The mean change in PVR prior to PEA was -28.4% for Riociguat and -6.9% for placebo (p=0.14). Completeness of surgical clearance was as expected in all patients. In the Riociguat group ease of dissection plane was rated as easier in 1, normal in 3 and more difficult in 2. In the control group, it was rated as easier in 1 and normal in 4. There were no surgical complications or post-operative deaths and no new safety signals. Conclusion(s): Due to the premature study discontinuation and the limited sample size, we are unable to determine the impact of bridging therapy on PEA outcomes.

Outcomes of elective cancer surgery in COVID-19 survivors: An observational study

Background and Objectives: Guidelines recommend deferral of elective surgery after COVID-19. Delays in cancer surgeries may affect outcomes. We examined perioperative outcomes of elective cancer surgery in COVID-19 survivors. The primary objective was 30-day all-cause postoperative mortality. The secondary objectives were 30-day morbidity, and its association with COVID-19 severity, and duration between COVID-19 and surgery. Methods: We collected data on age, gender, comorbidities, COVID-19 severity, preoperative investigations, surgery performed, and intra and postoperative outcomes in COVID-19 survivors who underwent elective cancer surgery at a tertiary-referral cancer center. Results: Three hundred and forty-eight COVID-19 survivors presented for elective cancer surgery. Of these, 332/348 (95%) patients had mild COVID-19 and 311 (89%) patients underwent surgery. Among patients with repeat investigations, computerized tomography scan of the thorax showed the maximum new abnormalities (30/157, 19%). The 30-day all-cause mortality was 0.03% (1/311) and 30-day morbidity was 17% (54/311). On multivariable analysis, moderate versus mild COVID-19 (odds ratio [OR]: 1.95;95% confidence interval [CI]: 0.52–7.30;p = 0.32) and surgery within 7 weeks of COVID-19 (OR: 0.61;95% CI: 0.33–1.11;p = 0.10) were not associated with postoperative morbidity. Conclusions: In patients who recover from mild to moderate COVID-19, elective cancer surgery can proceed safely even within 7 weeks. Additional preoperative tests may not be indicated in these patients. © 2022 Wiley Periodicals LLC.

Outpatient Deep Brain Stimulation: Initial Experience

Introduction Since the start of the COVID-9 pandemic, inpatient hospital resources have become extremely limited. This has limited access to surgical care for patients, especially for elective surgeries. Deep brain stimulation (DBS) surgery has been known to be very safe with very low rates of serious complications but has typically been accompanied with an inpatient hospital stay. Performing DBS surgery as an outpatient procedure could preserve access to this important treatment option, even during medical scarcity. Methods From March 2020 to January of 2021, stage I DBS surgery was scheduled as outpatient surgery for 19 patients. DBS patients who were scheduled as inpatient admissions were included as a comparison. Cohorts were compared based on time until discharge, early surgical complications, readmissions, emergency department (ED) visits, as well as demographic patient characteristics. Results Eighteen patients underwent a DBS scheduled as an outpatient surgery were compared to 20 patients who were scheduled as inpatient surgeries. Only 1 patient scheduled as an outpatient surgery was admitted overnight. This was due to an asymptomatic hemorrhage seen on routine post op imaging. There were no significant differences between readmissions, ED visits, or complications between the groups. In the outpatient surgery group, there were 2 post op ED visits and no admissions. There were no symptomatic hemorrhages, surgical site infections, readmissions, or reoperations in the outpatient group. The post op admission time for the two groups was 3.72h (+/-1.11) vs 26.83h (+/-3.49) (p<0.0001). Conclusion Outpatient DBS surgery does not result in increases in readmissions or emergency visits. This could allow increased availability of DBS surgery during times of medical scarcity and lower the economic barriers to DBS surgery..

Changes in the operative management of breast cancer during the COVID pandemic-single institution experience

Aims: COVID has had a wide ranging impact on surgical practice;including staffing issues, procedural prioritisation and changes to perioperative practice. We aim to compare The operative management of breast Cancer before and during year 1 of The pandemic. Method(s): A retrospective review of primary breast Cancer Surgery in women between 23/3/2020-23/3/2021 with sub-analysis looking at wave 1 of COVID (23/3/2020-23/7/2020), compared to pre-COVID (1/1/2018-31/12/2018). Data collected include type and complexity of surgery, re-operations and complications. Result(s): Pre-COVID, 606 cancers were included, with 217 (35.8%) Simple BCS, 241(39.8%) oncoplastic BCS, 88 (14.5%) Simple mastectomies and 60 (9.9%) mastectomies with immediate reconstruction. During COVID study period, a total of 398 cancers were included, with operative number (percentages) being 104(26.1%), 176(44.2%), 83(20.9%) and 35(8.8%) respectively. During wave 1, 47 cancers were diagnosed and operated on. The operative numbers (percentages) during initial wave COVID pandemic were 9 (19.1%), 25(53.2%), 12(25.5%) and 1(2.1%) respectively. Conclusion(s): In our unit COVID led to a shift of breast Cancer operative management to more BCS and Simple mastectomies. As a unit, we were able to maintain good oncoplastic BCS service, however, reconstruction options were limited.

IDIOPATHIC TROPONEMIA AFTER TRANSCAROTID ARTERY REVASCULARIZATION

SESSION TITLE: Etiologies of Cardiovascular Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Troponin level (Tnl) is usually used as confirmation of acute myocardial infarction (AMI) and is a sensitive marker. It is usually increased within 2-3 hours after AMI. In most cases, increased in Tnl is associated with symptomatic chest pain, cardiac ischemia, chronic coronary syndromes, etc. It can also be elevated in other conditions without cardiac injuries, like critical illness: COVID infection, septic shock, acute stroke and burns. CASE PRESENTATION: A 72 y/o man with history of b/l internal carotid artery (ICA) stenosis (70% in R-ICA and 80-90% in L-ICA) underwent elective left trans-carotid artery revascularization (TCAR). He was transferred to ICU after an uneventful procedure, for monitoring. His history was significant for HTN, HLD, Meniere's disease, gout, prior CVA of L-frontal lacunar and R-PICA (posterior inferior cerebellar artery). Postop vitals: BP 114/60 mmHg, HR 65, RR 16, O2 sat 98%. Tnl increased to 1.95 and then declined (normal 0 - 0.4 ng/ml). He was AAOx4, and asymptomatic. Post-op serial EKGs: normal sinus rhythm with no ST/T wave changes. Echo: EF 60%, normal biventricular size and function. LDL <70, A1C 5.9, normal TSH, no CPK elevation. Other labs: normal, No new neurological deficits. He was continued on ASA, clopidogrel, metoprolol, amlodipine and lisinopril. His hospital stay was uneventful, and he was discharged on post-op day 3. DISCUSSION: Cardiac troponin complex has its distinct subunits according to their functions: highly conserved Ca2+ binding subunit (cTnC);actomyosin ATPase inhibitory subunit and tropomyosin binding subunit. They play the pivotal role in regulating myocardial muscle contraction and relaxation and demonstrate as sensitive biomarkers for the myocardial injuries. Interestingly, there are many other causes that lead to increased cardiac troponin level without remarkable myocardial injuries or ischemia. Elevated Tnl after TCAR procedure can also be due to its surgical complication of a chance of hypoperfusion during the procedure. Our patient's surgery was uneventful. In one randomized controlled trial, it is stated that the risk of having CVA and AMI is higher in carotid endarterectomy compared to revascularization in patients with carotid artery stenosis. Our patient did not have any post-op complication, and only had an idiopathic elevation of troponin. CONCLUSIONS: The role of Tnl plays an important role in confirmation of myocardial infarction or ischemia but it can be idiopathic. Unpublished data from our institution revealed no increase in troponin s/p TCAR after uneventful procedures. This is the first reported case presenting with elevated troponin level without any pertinent positive findings (EKG changes/symptoms). Maybe in uneventful TCAR procedure troponin should not be ordered? Reference #1: Defilippi, C.R., Tocchi, M., Parmar, R.J., Rosanio, S., Abreo, G., Potter, M.A., Runge, M.S., & Uretsky, B.F. (2000). Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. Journal of the American College of Cardiology, 35 7, 1827-34. Reference #2: Gordon AM, Homsher E, Regnier M. Regulation of contraction in striated muscle. Physiol Rev. 2000 Apr;80(2):853-924. doi: 10.1152/physrev.2000.80.2.853. PMID: 10747208. Reference #3: Brott, T.G., Hobson, R.W., Howard, G., Roubin, G.S., Clark, W.M., Brooks, W., Mackey, A., Hill, M.D., Leimgruber, P.P., Sheffet, A.J., Howard, V.J., Moore, W.S., Voeks, J., Hopkins, L.N., Cutlip, D.E., Cohen, D.J., Popma, J.J., Ferguson, R.D., Cohen, S.N., Blackshear, J.L., Silver, F.L., Mohr, J.P., Lal, B.K., & Meschia, J.F. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England journal of medicine, 363 1, 11-23. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Zin Min Htet No relevant relationships by Z nobia Khan No relevant relationships by Zin Oo

Impact of Covid-19 Measures on Surgical Site Infection Rate in Orthopaedic Patients

Aim: Rate of surgical site infections (SSI) in orthopaedic surgery is low but can have disastrous consequences. The aim of this study was to assess the impact of Covid-19 measures on the rate of SSI and subsequent readmissions in orthopaedic patients. Method: Retrospective, observational study comparing rates of SSI in orthopaedic patients who underwent surgery prior to the Covid-19 lockdown versus that of patients who underwent surgery during the lockdown period. A total of 1151 patients were identified using electronic clinical records over two different time periods: 3 months pre Covid-19 lockdown (n=680) and 3 months during the Covid-19 lockdown (n=470). Patients were followed up for 1 year following their initial procedure. Primary outcome was readmission for SSI. Results: The most commonly performed procedures were arthroplasty and manipulation under anaesthesia with 119 in lockdown vs 101 non-lockdown (p=0.001). The readmission rate was higher in the lockdown group with 61 (13%) vs 44 (6.5%) in the non-lockdown group (p <0.001). However, the majority were due to other surgical complications such as dislocations. Interestingly, the SSI rates were very similar with 24 (5%) in lockdown vs 28 (4%) in non-lockdown (p=0.472). Twenty patients (4.2%) required a secondary procedure for their SSI in the lockdown group vs 24 (3.5%) in non-lockdown (p=0.381). Mortality rate was similar at 44 (9.3%) in lockdown vs 61 (9.0%;p=0.836). Conclusion: Whilst Covid-19 precautions were associated with higher readmission rates, there was no significant difference in rate of SSI between the two groups.

The impact of the COVID-19 pandemic on the decrease in the use of intensive care units in the postoperative period of anatomic lung resections. A retrospective analysis

Objective: COVID-19 pandemic required optimization of hospital institutional flow, especially regarding the use of intensive care unit (ICU) beds. The aim of this study was to assess whether the individualization of the indication for postoperative recovery from pulmonary surgery in ICU beds was associated with more perioperative complications. Method: retrospective analysis of medical records of patients undergoing anatomic lung resections for cancer in a tertiary hospital. The sample was divided into: Group-I, composed of surgeries performed between March/2019 and February/2020, pre-pandemic, and Group-II, composed of surgeries performed between March/2020 and February/2021, pandemic period in Brazil. We analyzed demographic data, surgical risks, surgeries performed, postoperative complications, length of stay in the ICU and hospital stay. Preventive measures of COVID-19 were adopted in group-II. Results: 43 patients were included, 20 in group-I and 23 in group-II. The groups did not show statistical differences regarding baseline demographic variables. In group-I, 80% of the patients underwent a postoperative period in the ICU, compared to 21% in group-II. There was a significant difference when comparing the average length of stay in an ICU bed (46 hours in group-I versus 14 hours in group-II-p<0.001). There was no statistical difference regarding postoperative complications (p=0.44). Conclusions: the individualization of the need for ICU use in the immediate postoperative period resulted in an improvement in the institutional care flow during the COVID-19 pandemic, in a safe way, without an increase in surgical morbidity and mortality, favoring the maintenance of essential cancer treatment.

Increasing volume and the role of gynecologic oncologists in peripartum hysterectomies – A single center study of 109 cases over 7 years (008)

Objectives: To evaluate the surgical volume, surgical outcomes, and the evolving role of gynecologic oncologists in peripartum hysterectomies (PPH). Methods: We conducted an IRB-approved retrospective chart review of PPH cases performed at our institution from June 1, 2014, to June 30, 2021. Clinical-pathologic information was ed into a REDCap database. All analyses were conducted using STATA 17. Results: A total of 109 cases were performed over the 7-year period. Gynecologic oncologists (GYO) involvement in the cases increased from 33% in 2014 to 80% in 2021. The mean age was 36 (range: 23-47) years. Most patients were White (81/109, 74.3%), and the median BMI was 30.7 (range: 21-57) kg/m2. Surgical indications included placenta accreta syndrome (PAS) in 84 (77%) cases, uterine atony in ten (9.2%), uterine rupture in three (2.8%), malignancy in five (4.6%), and hemorrhage other than atony in seven cases (6.4%). Intraoperative complications included bladder injury (or intentional dissection) in eight (7.3%), ureter injury in four (3.7%), vascular injury in three (2.8%), and femoral pseudoaneurysm in one (0.9%) of the cases. Postoperative complications included urinary tract infection in 11 (10.1%), nerve injury in one (0.9%), surgical site infection in 13 (11.2%), and venous thromboembolism in five (4.6%) cases. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) usage started in 2019 with one case followed by six cases in 2020 (31.6%) and 3/16 cases in the first half of 2020 (15.8%). A higher REBOA usage in 2020 corresponded with blood products shortages during the COVID crisis.[Formula presented] Conclusions: Overall volume and complexity of peripartum hysterectomy are increasing. This trend is likely driven by an increased incidence of placenta accreta syndrome cases. Gynecologic oncologists are increasingly delegated as primary surgeons in many institutions. Fellowship training programs should strongly consider training in peripartum hysterectomy for trainees.

Stereotactic Ablative Radiotherapy Before Resection to AvoId Delay for Early-Stage LunG Cancer or OligomEts

Introduction: The COVID-19 pandemic led to worldwide barriers to access to operating rooms;some multidisciplinary thoracic oncology teams pivoted to a paradigm of stereotactic ablative radiotherapy (SABR) as a bridge to provide radical-intent treatment combining immediate SABR followed by planned surgery when surgical resource constraints ameliorated. This pragmatic approach, termed SABR-BRIDGE, was instituted with prospective data collection at four institutions (3 Canada, 1 USA);herein we present the surgical and pathological results from this approach. Methods: Eligible participants had early-stage presumed or biopsy-proven lung malignancy that would otherwise be surgically-resected. SABR was delivered using standard institutional guidelines with one of three fractionation regimens: 30-34 Gy /1 fraction, 45-55 Gy/3-5 fractions, or 60 Gy/8 fractions. Surgery was recommended at a minimum of 3 months following SABR with standardized pathologic assessment of resected tissue. A pathological complete response (pCR) was defined as absence of viable cancer, and a major pathologic response (MPR) was defined as ≤10% viable tissue. Results: Seventy-five participants were enrolled, of which 72 received SABR. Following SABR, 26 patients underwent resection, while 46 did not;reasons for not undergoing surgery included metastasis (n=2), non-cancer death (n=1), awaiting lung surgery (n=13) and patient choice given favorable post-SABR imaging response (n=30). Of 26 patients who underwent resection, 62% had a pre-treatment biopsy. The most common SABR regimens were 34 Gy /1 fraction (31%) and 48 Gy in 3-4 fractions (31%). SABR was well-tolerated, with two grade 1 toxicities (pain, 7.7%), and one grade 3 pneumonitis (3.8%). Median time-to-surgery was 4.5 months from SABR completion (range:2-17.5 months). Most had minimally-invasive surgery (n=19, 73%) with 4 patients (15%) requiring conversion to thoracotomy, and 3 (12%) had planned open operation. Surgery was reported as being more difficult because of SABR in 38% (n=10). There were two intraoperative complications (7.7%, pulmonary artery injury), and 8 patients with post-operative complications (31%, all grade 2, most commonly air leaks [n=5]). The amount of residual primary tumor ranged from 0% to 90%. Thirteen (50%) had pCR while 19 (73%) had MPR. Rates of pCR were higher in patients operated upon at earlier time points (75% if within 3 months, 50% if 3-6 months, and 33% if ≥6 months). Rates of pCR were higher in patients without pre-treatment tissue diagnosis (91% versus 20% in those without and with tissue diagnosis, respectively). In 31% (n=8) of patients, nodal disease was discovered on resection, with half being N2 (4/26=15%). Conclusions: The SABR-BRIDGE approach allowed for delivery of treatment with minimal upstaging during a period of operating room closure & high risk for patients. Surgery was well-tolerated. However, most patients who received SABR did not proceed to surgery, limiting precise estimates of pCR rates. However, the reported pCR rate is consistent with previous phase II trial data. Keywords: lung surgery, SBRT, Multi-modal therapy

SAME DAY DISCHARGE AFTER MINIMALLY INVASIVE HYSTERECTOMY IN THE COVID-19 PANDEMIC

Introduction: While same day discharge after minimally invasive hysterectomy (MIH) has demonstrated efficacy, patient's and provider's comfort and safety concerns have limited the universal transition to outpatient MIH. Beginning in March 2020, the COVID-19 pandemic led to an increased demand for hospital beds and limited the capacity for overnight admissions. Additionally, concerns over infection exposure increased patient and provider interest in limiting patient time in the hospital system. Together, these factors increased pressure for same day discharge in MIH cases. Objective: To quantify the impact of COVID-19 pandemic on same day discharges for MIH and evaluate the effect on postoperative outcomes and health care utilization. Methods: This was a retrospective cohort study of women who underwent MIH at a single institution between March 2018 and October 2021. Women over age 18 who underwent laparoscopic, vaginal, or robotic assisted hysterectomy by any gynecologic surgeon were included. Cases that converted to laparotomy or where a gynecologic surgeon was not listed as the primary surgeon were excluded. The primary objective measure was rate of same day hospital discharge. Secondary measures included length of stay and 30-day postoperative complications, readmissions, reoperations, and mortality. Continuous variables were summarized using medians (quantiles) and assessed with Wilcoxon rank tests;Categorical variables were presented using frequencies (percentages) and assessed with χ2 tests. All analyses were conducted using R version 4.1. Results: A total of 1608 women were included: 896 in the pre-pandemic cohort and 712 in the post pandemic cohort. Demographics are summarized in Table 1. The pre-pandemic cohort was more likely to have an ASA class III or IV (P < 0.01) and more likely to have a diagnosis of diabetes (P < 0.01). Surgical characteristics are described in Table 1 and Figure 1. Breakdown of surgeon subspecialty was similar between groups, endoscopic procedures were more frequent in the post-pandemic cohort (p < 0.01), and the timing in the day of cases was not different between groups. Intraoperative complications were more frequent in the pre-pandemic cohort (2.8% vs. 1.0%, P < 0.01). The post-pandemic cohort was significantly more likely to discharge on postoperative day 0 (32% vs. 54%, P < 0.01). Rates of 30-day postoperative complications were not significantly different (16.4% vs. 15.4%, P = 0.60), and there were not significant differences in postoperative transfusion (0.6% vs 1.0%, P = 0.78), readmissions (3.5% vs. 2.5%, P = 0.28), reoperations (0.8% vs. 0.8%, P = 0.89), or mortality (1 vs. 0, P = 0.37). Thirty-day postoperative emergency department visits were more frequent in the post-pandemic cohort (0.1% vs. 1.3%, P < 0.01). Conclusions: The COVID-19 pandemic was associated with an increase in same day discharge without increase in 30-day postoperative complications, although there was a significant increase in postoperative emergency room visits. Our data suggests increased utilization of same day discharge is a safe strategy for management of capacity and hospital bed constraints caused by the COVID19 pandemic (Table Presented).

Durvalumab (D) and PET-directed chemoradiation (CRT) after induction FOLFOX for esophageal adenocarcinoma: Final results

Background: Induction FOLFOX followed by PET-directed CRT prior to surgery demonstrated positive results in the CALGB 80803 study. We investigated the safety and efficacy of adding D, an anti-PD-L1 antibody, to PET-directed CRT. Methods: Patients (pts) with locally advanced esophageal/GEJ adenocarcinoma were enrolled. Pts received 2 cycles of mFOLFOX6 prior to repeat PET/CT. PET responders (≥35% reduction in SUV (PETr)) received 5-FU/capecitabine and oxaliplatin with RT to 50.4Gy, while induction PET non-responders (PETnr) received carboplatin/paclitaxel with RT. All Pts received D 1,500 mg q4W ×2 starting 2 weeks prior to CRT. Esophagectomy was planned 6-8 weeks after CRT. Pts with R0 resections received adjuvant D 1,500mg q4W ×6. The primary endpoint was the pathologic complete response (pCR) rate. Results: 36 pts were enrolled. Clinical ≥T3 disease was seen in 32 pts (88.9%, cT4 = 3) and ≥N1 in 23 (63.9%) pts. PD-L1 CPS was ≥1 in 25 (71.4%) of 35 tested with 14 (40%) ≥5. Microsatellite instability (MSI) was identified in 3 (8.3%) pts. 25 (70%) pts were PETr. Preop treatment was well tolerated with no new safety signals. Three pts had disease progression prior to surgery. pCR was identified in 8 (22.2%) pts and 22 (64.7%) had major pathologic response (MPR;ypTanyN0 + ≥90% response). Those with MSI tumors had ≥90% treatment response (1 pCR, 1: ypT1aN0 99% response, 1: ypT2N0, 90% response). 17 (73.9%) of 23 cN+ pts had ypN0 disease. MPR was associated with PD-L1 ≥1 (p = 0.03) and with a higher tumor mutational burden (TMB;p = 0.016) on MSK-IMPACT testing. Adjuvant D was commenced in 27 pts, with a median number of 6 cycles. Early discontinuation was due to risks of visits due to COVID19 (4, 15%), progressive disease (3, 11%), late surgical complications (2, 7%) and immune toxicity (1, 4%). With a median follow-up of 30 months, OS rates were 92% [95%CI: 83%-100%] and 85 % [95%CI: 74%-98%] at 12 and 24 months post induction. 12 and 24-month PFS rates were 81% [95%CI: 69%-95%] and 71% [95%CI: 58%-88%] respectively. In the 33 operated pts, 12 and 24-month disease free survival was 82% [95%CI: 70%-96%] and 78% [95%CI: 65%-94%], respectively. In addition to SUV on PET, total lesion glycolysis (TLG) was correlated with pathologic response. In cases with borderline change in SUV, TLG could predict response to treatment. One PETnr with 30.8% reduction in SUV had 88.1% reduction in TLG and pCR. Conversely, a PETr (-36.3%) who had an increase in TLG (39.3%) had only 40% treatment response on pathology. Conclusions: The addition of D to induction FOLFOX and PETdirected CRT prior to surgery is safe and appears effective with a high rate of pathologic response, as well as encouraging survival data. PD-L1 CPS≥1 and higher TMB may be associated with MPR. TLG is a novel PET variable that should be studied prospectively. Additional correlatives and comparison to a cohort treated with standard PET-directed CRT will be presented.

Quality Improvement Project to Reduce Turnaround Times to Improve Vascular Theatre Efficiency

Aims: Delays in turnaround time (TAT) have significant financial implications for the National Health Service, estimated to be as much as £347 327 per year. Considering this, we aimed to reduce the TAT by 25% in a vascular surgical theatre, via a Quality Improvement Project (QIP), as part of an MBBS component. We hypothesised that improvements in TAT would also lead to beneficial secondary effects, such as improved theatre utilisation, reduced on the day cancellations, and fewer minutes overrun. Methods: TAT was defined as the time between the last patient going to recovery (“wheels out”) to the next one entering the theatre (“wheels in”). Using the electronic theatre record system “Galaxy”, we established a baseline average TAT using data from October 2019 to January 2020. To identify the common issues underlying TAT delays, a group of three medical students undertook a four week research period, involving ad hoc staff interviews and review of postoperative debrief forms. From this, we constructed our interventions and implemented them over a six week period. Results: Our research period suggested ward-based preparation was a common reason for delay. To address this, we created interventions that focused on giving the ward staff more time, to promote “patient readiness”. An advanced warning system when sending for the patient (30 minutes prior to the end of surgery;previously, the ward was only notified when the patient was being closed) and a newly designed ward based checklist (shown in Fig. 1;the checklist allowing systematic review of tasks needed to be completed) were utilised. Baseline average TAT was 51.7 minutes and the pre-intervention theatre utilisation percentage was 86%. After a PDSA cycle using the interventions described above, we reduced the average TAT to 42.1 minutes, an 18.4% decrease. Figure 2 shows a run chart visualising these results. While the reduction did not meet our 25% target, it remains a significant one. Unfortunately, reduced TAT did not translate into significant improvement in theatre utilisation, on the day cancellations, or minutes overrun, all of which remained at the median of the pre-intervention period. However, improvements in these metrics were impeded by factors out of our control (e.g., surgical complications causing delays). These “unpreventable” delays had particularly significant impacts on our results when they occurred due to the intervention period being conducted over only one PDSA cycle (owing to the COVID-19 pandemic halting elective procedures). Conclusion: Our ward based interventions have shown they can reduce turnaround times in vascular surgery. Less idle theatre time and improved theatre utilisation will be imperative in reducing the backlog of surgeries the COVID pandemic has created. While this QIP was unable to translate reduced TAT to beneficial secondary effects, such as improved theatre utilisation, we hypothesise that with a larger sample size, reduced turnaround times will improve these long term, as there will be more opportunity for the interventions to have their effect without being obstructed by unpreventable delays. Therefore, we believe these interventions should be considered for further exploration on a larger scale to ascertain their true value. This will begin with the resumption of our second PDSA cycle, once surgeries resume [Formula presented] [Formula presented]

Efficacy and safety of emergency ureteroscopy as first-line treatment for patients with renal colic due to ureteral stones in the COVID-19 pandemic

Introduction & Objectives: Acute renal colic due to ureteral stones is a common emergency, which can be treated with conservative management, drainage of the kidney and delayed treatment, or emergency intervention. With the outbreak of COVID-19 infection and postponement of elective surgeries, emergency ureteroscopy became a valuable treatment option for acute renal colic in a single-stage setting. The objective of this study is to evaluate the efficacy and safety of emergency ureteroscopy as first-line treatment for patients with acute renal colic due to ureteral stones during the COVID-19 pandemic. Materials & Methods: A prospectively collected database of 120 patients with acute renal colic due to ureteral stone who underwent emergency ureteroscopy within 24 hours from hospitalization between March 2020 and December 2021, was reviewed. Data on patients’ preoperative characteristics, stone-free rates and complication rates was analyzed. Results: Patients’ mean age was 51.4±15.2 years. Male-to-female ratio was 73.3%/26.7%. Mean preoperative serum creatinine values were 120.1±64.1 umol/l. 33 patients (2.5%) had a solitary functioning kidney. Stone location was proximal ureter in 3 patients (27.5%), mid-ureter – in 12 (10%), distal ureter – in 73 (60.8%), distal and proximal ureter – in 2 cases (1.6%). Mean stone size was 8.1±3.3 mm. Stone-free rate after a single procedure was 95% and mean operative time – 25.1±11.5 min. Postoperative drainage was stent JJ in 34 (28.3%) and ureteral catheter for 12h – in 22 (18.3%) patients. 21 patients (17.5%) had a narrow ureter, necessitating the use of smaller caliber ureteroscope (6 Fr). In 2 patients (1.7%) the ureter could not be accessed and a stent JJ was inserted. Intraoperative complications were present in 5 cases – 1 ureteral perforation (0.8%) and 4 cases of upward stone migration (3.3%). Postoperative complications were fever in 2 patients (1.7%) and postoperative renal colic pain - in 7 (5.8%). Conclusions: The results of this prospective study suggest that emergency ureteroscopy is a safe and effective first-line treatment for acute renal colic due to ureteral stones. It offers a one-stage management, without the potential complications of obstruction and loss of renal function due to delayed treatment during the COVID-19 pandemic.